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Salluh JIF, Quintairos A, Dongelmans DA, Aryal D, Bagshaw S, Beane A, Burghi G, López MDPA, Finazzi S, Guidet B, Hashimoto S, Ichihara N, Litton E, Lone NI, Pari V, Sendagire C, Vijayaraghavan BKT, Haniffa R, Pisani L, Pilcher D. National ICU Registries as Enablers of Clinical Research and Quality Improvement. Crit Care Med 2024; 52:125-135. [PMID: 37698452 DOI: 10.1097/ccm.0000000000006050] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement. DATA SOURCES English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix. STUDY SELECTION Original research, review articles, letters, and commentaries, were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs. CONCLUSIONS ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.
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Affiliation(s)
- Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Post-Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amanda Quintairos
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Department of Critical and Intensive Care Medicine, Academic Hospital Fundación Santa Fe de Bogota, Bogota, Colombia
| | - Dave A Dongelmans
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Diptesh Aryal
- National Coordinator, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Sean Bagshaw
- Department of Medicine, Faculty of Medicine and Dentistry (Ling, Bagshaw), University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Division of Internal Medicine (Villeneuve), Department of Critical Care Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta and Grey Nuns Hospitals, Edmonton, AB, Canada
| | - Abigail Beane
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Maria Del Pilar Arias López
- Argentine Society of Intensive Care (SATI). SATI-Q Program, Buenos Aires, Argentina
- Intermediate Care Unit, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, service de réanimation, Paris, France
| | - Satoru Hashimoto
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Scottish Intensive Care Society Audit Group, United Kingdom
| | - Vrindha Pari
- Chennai Critical Care Consultants, Pvt Ltd, Chennai, India
| | - Cornelius Sendagire
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Anesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Rashan Haniffa
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Crit Care Asia, Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Luigi Pisani
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - David Pilcher
- University College Hospital, London, United Kingdom
- Department of Intensive Care, Alfred Health, Prahran, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Camberwell, Australia
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2
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Ng-Kamstra JS, Soo A, McBeth P, Rotstein O, Zuege DJ, Gregson D, Doig CJ, Stelfox HT, Niven DJ. STOP Signs: A Population-based Interrupted Time Series Analysis of Antibiotic Duration for Complicated Intraabdominal Infection Before and After the Publication of a Landmark RCT. Ann Surg 2023; 277:e984-e991. [PMID: 35129534 PMCID: PMC10082058 DOI: 10.1097/sla.0000000000005231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine if the STOP-IT randomized controlled trial changed antibiotic prescribing in patients with Complicated Intraabdominal Infection (CIAI). SUMMARY OF BACKGROUND DATA CIAI is common and causes significant morbidity. In May 2015, the STOP-IT randomized controlled trial showed equivalent outcomes between four-day and clinically determined antibiotic duration. METHODS This was a population-based retrospective cohort study using interrupted time series methods. The STOP-IT publication date was the exposure. Median duration of inpatient antibiotic prescription was the outcome. All adult patients admitted to four hospitals in Calgary, Canada between July 2012 and December 2018 with CIAI who survived at least four days following source control were included. Analysis was stratified by infectious source as appendix or biliary tract (group A) versus other (group B). RESULTS Among 4384 included patients, clinical and demographic attributes were similar before vs after publication. In Group A, median inpatient antibiotic duration was 3 days and unchanged from the beginning to the end of the study period [adjusted median difference -0.00 days, 95% confidence interval (CI) -0.37 - 0.37 days]. In Group B, antibiotic duration was shorter at the end of the study period (7.87 vs 6.73 days; -1.14 days, CI-2.37 - 0.09 days), however there was no change in trend following publication (-0.03 days, CI -0.16 - 0.09). CONCLUSIONS For appendiceal or biliary sources of CIAI, antibiotic duration was commensurate with the experimental arm of STOP-IT. For other sources, antibiotic duration was long and did not change in response to trial publication. Additional implementation science is needed to improve antibiotic stewardship.
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Affiliation(s)
- Joshua S Ng-Kamstra
- Department of Critical Care Medicine, University of Calgary, Calgary, AB
- The Queen's Medical Center, Honolulu, HI
- Department of Surgery, University of Hawaii, John A Burns School of Medicine, Honolulu, HI, USA
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary, Calgary, AB
| | - Paul McBeth
- Department of Critical Care Medicine, University of Calgary, Calgary, AB
- Department of Surgery, University of Calgary, Calgary, AB; Keenan Research Centre for Biomedical Science, St Michael's Hospital, University of Toronto, Toronto, ON
| | - Ori Rotstein
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB
| | - Danny J Zuege
- Department of Critical Care Medicine, University of Calgary, Calgary, AB
| | - Daniel Gregson
- Departments of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB; and
| | - Christopher James Doig
- Department of Critical Care Medicine, University of Calgary, Calgary, AB
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB
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3
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Pharaboz A, Kimmoun A, Gunst J, Duarte K, Merkling T, Gayat E, Mebazaa A, Glenn-Chousterman B. Association between type II diabetes mellitus and 90-day mortality in a large multicenter prospectively collected cohort. A FROG ICU post-hoc study. J Crit Care 2023; 73:154195. [PMID: 36368176 DOI: 10.1016/j.jcrc.2022.154195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/01/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Factors associated with adverse outcomes in ICU patients with type II (T2DM) are poorly defined. The main goal of this study is to determine the impact of pre-existing T2DM on 90-day mortality post ICU admission. MATERIAL Post-hoc analysis from the FROG-ICU cohort. All patients admitted to ICU who were ventilated and/or treated by a vasoactive agent for >24 h were included. Association between T2DM and 90-day mortality was analyzed in unmatched, and populations matched by propensity score (PS) method to balance confounders recorded before ICU admission. Analysis was performed in non-imputed and imputed datasets. RESULTS 2002 patients were included, and 16% had a history of T2DM. The latter were at inclusion more severely ill (SAPSII score 51(39-67) vs 48(35-61), p < 0.0001; Charlson score 2(1-3) vs 0(0-2), p < 0.0001). In the unmatched cohort, T2DM patients had a higher 90-day risk of death compared to no-DM patients (HR 1.35(1.1-1.65)). The 90-day risk of death was not significantly different T2DM and no T2DM patients after PS matching (HR: 0.81 (0.56-1.18). Results were similar with the analysis performed on imputed datasets (pooled HR: 0.95 (0.69-1.30)). CONCLUSIONS In the present study, T2DM was not associated with 90-day mortality post ICU admission.
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Affiliation(s)
- Alexandre Pharaboz
- Université de Paris, AP-HP, CHU Lariboisière, Department of Anesthesiology and Critical Care, FHU PROMICE, INSERM U942, F-CRIN-INI CRCT, Paris, France
| | - Antoine Kimmoun
- Université de Lorraine, CHRU de Nancy, Médecine Intensive et Réanimation Brabois, INSERM INSERM U942 and U1116, F-CRIN-INIC RCT, Vandœuvre-lès-Nancy, France
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven Herestraat 49, B-3000 Leuven, Belgium
| | - Kevin Duarte
- Université de Lorraine, CHRU de Nancy, INSERM CIC-P 1433, INSERM, F-CRIN-INI CRCT, Vandœuvre-lès-Nancy, France
| | - Thomas Merkling
- Université de Lorraine, CHRU de Nancy, INSERM CIC-P 1433, INSERM, F-CRIN-INI CRCT, Vandœuvre-lès-Nancy, France
| | - Etienne Gayat
- Université de Paris, AP-HP, CHU Lariboisière, Department of Anesthesiology and Critical Care, FHU PROMICE, INSERM U942, F-CRIN-INI CRCT, Paris, France
| | - Alexandre Mebazaa
- Université de Paris, AP-HP, CHU Lariboisière, Department of Anesthesiology and Critical Care, FHU PROMICE, INSERM U942, F-CRIN-INI CRCT, Paris, France
| | - Benjamin Glenn-Chousterman
- Université de Paris, AP-HP, CHU Lariboisière, Department of Anesthesiology and Critical Care, FHU PROMICE, INSERM U942, F-CRIN-INI CRCT, Paris, France.
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Sreedharan R, Martini A, Das G, Aftab N, Khanna S, Ruetzler K. Clinical challenges of glycemic control in the intensive care unit: A narrative review. World J Clin Cases 2022; 10:11260-11272. [PMID: 36387820 PMCID: PMC9649548 DOI: 10.12998/wjcc.v10.i31.11260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/15/2022] [Accepted: 09/27/2022] [Indexed: 02/05/2023] Open
Abstract
Glucose control in patient admitted to the intensive care unit has been a topic of much debate over the past 20 years. The harmful effects of uncontrolled hyperglycemia and hypoglycemia in critically ill patients is well established. Although a large clinical trial in 2001 demonstrated significant mortality and morbidity benefits with tight glucose control in this patient population, the results could not be replicated by other investigators. The “Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation” trial in 2009 established that tight glucose control was not only of no benefit, but in fact harmful due to the significant risk of hypoglycemia. The current guidelines suggest a moderate approach with the initiation of intravenous insulin therapy in critically ill patients when the blood glucose level is above 180 mg/dL. The most important factor that underpins glycemic management in intensive care unit patients is the consequent prevention of hypoglycemia. Robust glucose monitoring strategies and insulin protocols need to be implemented in order to achieve this goal.
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Affiliation(s)
- Roshni Sreedharan
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Adriana Martini
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Gyan Das
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Nida Aftab
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Sandeep Khanna
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Kurt Ruetzler
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, United States
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Gunst J, Mebis L, Wouters PJ, Hermans G, Dubois J, Wilmer A, Hoste E, Benoit D, Van den Berghe G. Impact of tight blood glucose control within normal fasting ranges with insulin titration prescribed by the Leuven algorithm in adult critically ill patients: the TGC-fast randomized controlled trial. Trials 2022; 23:788. [PMID: 36123593 PMCID: PMC9483886 DOI: 10.1186/s13063-022-06709-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background It remains controversial whether critical illness-related hyperglycemia should be treated or not, since randomized controlled trials (RCTs) have shown context-dependent outcome effects. Whereas pioneer RCTs found improved outcome by normalizing blood glucose in patients receiving early parenteral nutrition (PN), a multicenter RCT revealed increased mortality in patients not receiving early PN. Although withholding early PN has become the feeding standard, the multicenter RCT showing harm by tight glucose control in this context has been criticized for its potentially unreliable glucose control protocol. We hypothesize that tight glucose control is effective and safe using a validated protocol in adult critically ill patients not receiving early PN. Methods The TGC-fast study is an investigator-initiated, multicenter RCT. Patients unable to eat, with need for arterial and central venous line and without therapy restriction, are randomized upon ICU admission to tight (80–110 mg/dl) or liberal glucose control (only initiating insulin when hyperglycemia >215 mg/dl, and then targeting 180–215 mg/dl). Glucose measurements are performed on arterial blood by a blood gas analyzer, and if needed, insulin is only administered continuously through a central venous line. If the arterial line is no longer needed, glucose is measured on capillary blood. In the intervention group, tight control is guided by the validated LOGIC-Insulin software. In the control arm, a software alert is used to maximize protocol compliance. The intervention is continued until ICU discharge, until the patient is able to eat or no longer in need of a central venous line, whatever comes first. The study is powered to detect, with at least 80% power and a 5% alpha error rate, a 1-day difference in ICU dependency (primary endpoint), and a 1.5% increase in hospital mortality (safety endpoint), for which 9230 patients need to be included. Secondary endpoints include acute and long-term morbidity and mortality, and healthcare costs. Biological samples are collected to study potential mechanisms of organ protection. Discussion The ideal glucose target for critically ill patients remains debated. The trial will inform physicians on the optimal glucose control strategy in adult critically ill patients not receiving early PN. Trial registration ClinicalTrials.gov NCT03665207. Registered on 11 September 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06709-8.
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Affiliation(s)
- Jan Gunst
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Liese Mebis
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Pieter J Wouters
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hermans
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Medical Intensive Care unit, Clinical Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jasperina Dubois
- Department of Anesthesiology and Intensive Care Medicine, Jessa Hospitals, Hasselt, Belgium
| | - Alexander Wilmer
- Medical Intensive Care unit, Clinical Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Eric Hoste
- Department of Intensive Care Medicine, University Hospitals Ghent, Ghent, Belgium
| | - Dominique Benoit
- Department of Intensive Care Medicine, University Hospitals Ghent, Ghent, Belgium
| | - Greet Van den Berghe
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium. .,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
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Sypes EE, Leigh JP, Stelfox HT, Niven DJ. Context, Culture, and the Complexity of De-Implementing Low-Value Care Comment on "Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands". Int J Health Policy Manag 2022; 11:1592-1594. [PMID: 35174681 PMCID: PMC9808337 DOI: 10.34172/ijhpm.2022.6968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 01/22/2022] [Indexed: 01/12/2023] Open
Abstract
Low-value care contributes to poor quality of care and wasteful spending in healthcare systems. In Verkerk and colleagues' recent qualitative study, interviews with low-value care experts from Canada, the United States, and the Netherlands identified a broad range of nationally relevant social, system, and knowledge factors that promote ongoing use of low-value care. These factors highlight the complexity of the problem that is persistent use of low-value care and how it is heavily influenced by public and medical culture as well as healthcare system features. This commentary discusses how these findings integrate within current low-value care and de-implementation literature and uses specific low-value care examples to highlight the importance of considering context, culture, and clinical setting when considering how to apply these factors to future de-implementation initiatives.
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Affiliation(s)
- Emma E. Sypes
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Henry T. Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Daniel J. Niven
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
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7
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Roberts DJ, Sypes EE, Nagpal SK, Niven D, Mamas M, McIsaac DI, van Walraven C, Shorr R, Graham ID, Stelfox HT, Grimshaw J. Evidence for overuse of cardiovascular healthcare services in high-income countries: protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e053920. [PMID: 35393307 PMCID: PMC8991042 DOI: 10.1136/bmjopen-2021-053920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Overuse of cardiovascular healthcare services, defined as the provision of low-value (ineffective, harmful, cost-ineffective) tests, medications and procedures, may be common and associated with increased patient harm and health system inefficiencies and costs. We seek to systematically review the evidence for overuse of different cardiovascular healthcare services in high-income countries. METHODS AND ANALYSIS We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2010 onwards. Two investigators will independently review titles and abstracts and full-text studies. We will include published English-language studies conducted in high-income countries that enrolled adults (mean/median age ≥18 years) and reported the incidence or prevalence of overuse of cardiovascular tests, medications or procedures; adjusted risk factors for overuse; or adjusted associations between overuse and outcomes (reported estimates of morbidity, mortality, costs or lengths of hospital stay). Acceptable methods of defining low-value care will include literature review and multidisciplinary iterative panel processes, healthcare services with reproducible evidence of a lack of benefit or harm, or clinical practice guideline or Choosing Wisely recommendations. Two investigators will independently extract data and evaluate study risk of bias in duplicate. We will calculate summary estimates of the incidence and prevalence of overuse of different cardiovascular healthcare services across studies unstratified and stratified by country; method of defining low-value care; the percentage of included females, different races, and those with low and high socioeconomic status or cardiovascular risk; and study risks of bias using random-effects models. We will also calculate pooled estimates of adjusted risk factors for overuse and adjusted associations between overuse and outcomes overall and stratified by country using random-effects models. We will use the Grading of Recommendations, Assessment, Development and Evaluation to determine certainty in estimates. ETHICS AND DISSEMINATION No ethics approval is required for this study as it deals with published data. Results will be presented at meetings and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021257490.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emma E Sypes
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Daniel I McIsaac
- Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Carl van Walraven
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeremy Grimshaw
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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8
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de Grood C, Sypes EE, Niven DJ, Clement F, FitzGerald EA, Kupsch S, King-Hunter S, Stelfox HT, Parsons Leigh J. Patient and family involvement in Choosing Wisely initiatives: a mixed methods study. BMC Health Serv Res 2022; 22:457. [PMID: 35392900 PMCID: PMC8991491 DOI: 10.1186/s12913-022-07861-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 03/29/2022] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Patients are important stakeholders in reducing low-value care, yet mechanisms for optimizing their involvement in low-value care remain unclear. To explore the role of patients in the development and implementation of Choosing Wisely recommendations to reduce low-value care and to assess the likelihood that existing patient resources will change patient health behaviour. METHODS Three phased mixed-methods study: 1) content analysis of all publicly available Choosing Wisely clinician lists and patient resources from the United States of America and Canada. Quantitative data was summarized with frequencies and free text comments were analyzed with qualitative thematic content analysis; 2) semi-structured telephone interviews with a purposive sample of representatives of professional societies who created Choosing Wisely clinician lists and members of the public (including patients and family members). Interviews were transcribed verbatim, and two researchers conducted qualitative template analysis; 3) evaluation of Choosing Wisely patient resources. Two public partners were identified through the Calgary Critical Care Research Network and independently answered two free text questions "would this change your health behaviour" and "would you discuss this material with a healthcare provider". Free text data was analyzed by two researchers using thematic content analysis. RESULTS From the content analysis of 136 Choosing Wisely clinician lists, six reported patient involvement in their development. From 148 patient resource documents that were mapped onto a conceptual framework (Inform, Activate, Collaborate) 64% described patient engagement at the level of Inform (educating patients). From 19 interviews stakeholder perceptions of patient involvement in reducing low-value care were captured by four themes: 1) impact of perceived power dynamics on the discussion of low-value care in the clinical interaction, 2) how to communicate about low-value care, 3) perceived barriers to patient involvement in reducing low-value care, and 4) suggested strategies to engage patients and families in Choosing Wisely initiatives. In the final phase of work in response to the question "would this change your health behaviour" two patient partners agreed 'yes' on 27% of patient resources. CONCLUSIONS Opportunities exist to increase patient and family participation in initiatives to reduce low-value care.
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Affiliation(s)
- Chloe de Grood
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Emma E Sypes
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Emily A FitzGerald
- Faculty of Health, School of Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shelly Kupsch
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shelly King-Hunter
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry T Stelfox
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeanna Parsons Leigh
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. .,Faculty of Health, School of Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada.
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9
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Leigh JP, Sypes EE, Straus SE, Demiantschuk D, Ma H, Brundin-Mather R, de Grood C, FitzGerald EA, Mizen S, Stelfox HT, Niven DJ. Determinants of the de-implementation of low-value care: a multi-method study. BMC Health Serv Res 2022; 22:450. [PMID: 35387673 PMCID: PMC8985316 DOI: 10.1186/s12913-022-07827-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/23/2022] [Indexed: 11/26/2022] Open
Abstract
Background There is an urgent need to understand the determinants (i.e., barriers and facilitators) of de-implementation. The purpose of this study was to develop a comprehensive list of determinants of the de-implementation of low-value care from the published literature and to compare this list to determinants identified by a group of stakeholders with lived experience with de-implementation. Methods This was a two-phase multi-method study. First, a systematic review examined published barriers and facilitators to de-implementation. Articles were identified through searches within electronic databases, reference lists and the grey literature. Citations were screened independently and in duplicate and included if they were: 1) written in English; and 2) described a barrier or facilitator to de-implementation of any clinical practice in adults (age ≥ 18 years). ‘Raw text’ determinants cited within included articles were extracted and synthesized into a list of representative determinants using conventional content analysis. Second, semi-structured interviews were conducted with decision-makers (unit managers and medical directors) and healthcare professionals working in adult critical care medicine to explore the overlap between the determinants found in the systematic review to those experienced in critical care medicine. Thematic content analysis was used to identify key themes emerging from the interviews. Results In the systematic review, reviewers included 172 articles from 35,368 unique citations. From 437 raw text barriers and 280 raw text facilitators, content analysis produced 29 distinct barriers and 24 distinct facilitators to de-implementation. Distinct barriers commonly cited within raw text included ‘lack of credible evidence to support de-implementation’ (n = 90, 21%), ‘entrenched norms and clinicians’ resistance to change (n = 43, 21%), and ‘patient demands and preferences’ (n = 28, 6%). Distinct facilitators commonly cited within raw text included ‘stakeholder collaboration and communication’ (n = 43, 15%), and ‘availability of credible evidence’ (n = 33, 12%). From stakeholder interviews, 23 of 29 distinct barriers and 20 of 24 distinct facilitators from the systematic review were cited as key themes relevant to de-implementation in critical care. Conclusions The availability and quality of evidence that identifies a clinical practice as low-value, as well as healthcare professional willingness to change, and stakeholder collaboration are common and important determinants of de-implementation and may serve as targets for future de-implementation initiatives. Trial registration The systematic review was registered in PROSPERO CRD42016050234. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07827-4.
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Affiliation(s)
- Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Emma E Sypes
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Canada
| | | | - Henry Ma
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Rebecca Brundin-Mather
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Chloe de Grood
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Emily A FitzGerald
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Sara Mizen
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada.
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10
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Sankar A, Swanson KM, Zhou J, Jena AB, Ross JS, Shah ND, Karaca-Mandic P. Association of Fluoroquinolone Prescribing Rates With Black Box Warnings from the US Food and Drug Administration. JAMA Netw Open 2021; 4:e2136662. [PMID: 34851398 PMCID: PMC8637256 DOI: 10.1001/jamanetworkopen.2021.36662] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE In 2013 and 2016, the US Food and Drug Administration (FDA) issued warnings and recommended limited use of fluoroquinolones for patients with certain acute conditions. It is not clear how prescribers have responded to these warnings. OBJECTIVE To analyze changes in prescribing of fluoroquinolones after the 2013 and 2016 FDA warnings and to examine the physician characteristics associated with these changes. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used Medicare administrative claims data on Medicare fee-for-service beneficiaries and OneKey data on physicians and their organizations from January 1, 2011, to December 31, 2017. The sample was restricted to outpatient visits for sinusitis, bronchitis, and uncomplicated urinary tract infections. An interrupted time series approach was used to analyze the changes in the prescription rate after each FDA warning. Data analysis was performed between January 1, 2011, and December 31, 2017. INTERVENTIONS Two FDA black box warnings released in August 2013 and July 2016. MAIN OUTCOMES AND MEASURES The main outcome was an indicator for fluoroquinolone prescriptions in 3 periods: before the 2013 warning (baseline period), after the 2013 warning but before the 2016 warning (postwarning period 1), and after the 2016 warning (postwarning period 2). RESULTS The sample comprised 1 238 397 unique patients with a total of 2 720 071 outpatient acute care visits. Of this sample, 848 360 were women (68.5%), and the mean (SD) age was 69.7 (12.6) years. The immediate prescribing levels of fluoroquinolones in postwarning period 1 increased by 3.42 percentage points (95% CI, 3.23-3.62; P < .001) and declined by -0.77 percentage points (95% CI, -1.00 to -0.54; P < .001) in postwarning period 2. The prescribing trend increased by 0.08 percentage points per month (95% CI, 0.08-0.10; P < .001) in postwarning period 1 and 0.06 percentage points per month (95% CI, 0.04-0.08; P < .001) in postwarning period 2. In postwarning period 1, the prescribing levels for physicians who were affiliated with hospitals with a top 10th percentile case mix index vs those without such affiliation decreased by -1.13 percentage points (95% CI, -1.92 to -0.34; P = .005), whereas the levels for primary care physicians declined by -1.34 percentage points (95% CI, -1.78 to -0.88; P < .001) compared with non-primary care physicians in postwarning period 2. Physicians at teaching hospitals were the only ones who showed a decline in prescribing trend in postwarning period 1. CONCLUSIONS AND RELEVANCE This cross-sectional study found an overall decline in prescribing of fluoroquinolones after the release of FDA warnings. Understanding the association of physician and organizational characteristics with fluoroquinolone prescribing behavior may ultimately help to identify mechanisms to improve de-adoption.
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Affiliation(s)
- Ashwini Sankar
- Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis
- Department of Economics, Macalester College, St Paul, Minnesota
| | - Kristi M. Swanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Jiani Zhou
- School of Public Health, University of Minnesota, Minneapolis
| | - Anupam Bapu Jena
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Joseph S. Ross
- Yale University, Yale School of Medicine, New Haven, Connecticut
| | - Nilay D. Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Pinar Karaca-Mandic
- Carlson School of Management, Department of Finance, University of Minnesota, Minneapolis
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11
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12
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Roberts DJ, Faris PD, Ball CG, Kirkpatrick AW, Moore EE, Feliciano DV, Rhee P, D'Amours S, Stelfox HT. Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia. World J Emerg Surg 2021; 16:53. [PMID: 34649583 PMCID: PMC8515656 DOI: 10.1186/s13017-021-00396-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy. Methods A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy. Results Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39–40.27], level-1 verification status (OR = 6.02; 95% CI 2.01–18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20–2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01–1.58) in the last year. Conclusions The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00396-7.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Room A-280, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. .,The Ottawa Hospital Trauma Program, The Ottawa Hospital, Ottawa, ON, Canada. .,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada. .,The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
| | - Peter D Faris
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Health Services Statistical and Analytic Methods, Data and Analytics (DIMR), Alberta Health Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Chad G Ball
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Department of Oncology, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Andrew W Kirkpatrick
- Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Ernest E Moore
- Department of Surgery, School of Medicine and the Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - David V Feliciano
- Department of Surgery and Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Peter Rhee
- Department of Surgery, Westchester Medical Center, Section of Trauma and Acute Care Surgery, New York Medical College, Valhalla, NY, USA
| | - Scott D'Amours
- South Western Sydney Clinical School, UNSW, Sydney, NSW, Australia.,Acute Care Surgery Unit, Liverpool Hospital, Liverpool, NSW, Australia
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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13
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Willingness to Treat with Therapies of Unknown Effectiveness in Severe COVID-19: A Survey of Intensivist Physicians. Ann Am Thorac Soc 2021; 19:633-639. [PMID: 34543580 PMCID: PMC8996269 DOI: 10.1513/annalsats.202105-594oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Little is known about how physicians develop their beliefs about new treatments or update their beliefs in the face of new clinical evidence. These issues are particularly salient in the context of the COVID-19 pandemic, which created rapid demand for novel therapies in the absence of robust evidence. OBJECTIVE To identify psychological traits associated with physicians' willingness to treat with unproven therapies and willingness to update their treatment preferences in the setting of new evidence in the context of COVID-19. METHODS We administered a longitudinal e-mail survey to United States physicians board-certified in intensive care medicine in April and May, 2020 (phase one); and October and November, 2020 (phase two). We assessed five psychological traits potentially related to evidence-uptake: need for cognition, evidence skepticism, need for closure, risk tolerance, and research engagement. We then examined the relationship between these traits and physician preferences for pharmacological treatment for a hypothetical patient with severe COVID-19 pneumonia. RESULTS There were 592 responses to the phase one survey, conducted prior to publication of trial data. At this time physicians were most willing to treat with macrolide antibiotics (50.5%), followed by antimalaria agents (36.1%), corticosteroids (24.5%), antiretroviral agents (22.6%), and angiotensin inhibitors (4.4%). Greater evidence skepticism (relative risk, RR=1.40, 95% CI: 1.30 - 1.52, p<0.001), greater need for closure (RR=1.19, 95% CI: 1.06 - 1.34, p=0.003), and greater risk tolerance (RR=1.17, 95% CI: 1.08 - 1.26, p<0.001) were associated with an increased willingness to treat; while greater need for cognition (RR: 0.85, 95% CI: 0.75 - 0.96, p=0.010) and greater research engagement (RR=0.91, 95% CI: 0.88 - 0.95, p<.0001) were associated with decreased willingness to treat. In phase two, most physicians updated their beliefs after publication of trial data about antimalarial agents and corticosteroids. Physicians with greater evidence skepticism more likely to persist in their beliefs. CONCLUSIONS Psychological traits associated with clinical decisions in the setting of uncertain evidence may provide insight into strategies to better align clinical practice with published evidence.
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14
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Lane-Fall MB, Christakos A, Russell GC, Hose BZ, Dauer ED, Greilich PE, Hong Mershon B, Potestio CP, Pukenas EW, Kimberly JR, Stephens-Shields AJ, Trotta RL, Beidas RS, Bass EJ. Handoffs and transitions in critical care-understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial. Implement Sci 2021; 16:63. [PMID: 34130725 PMCID: PMC8204062 DOI: 10.1186/s13012-021-01131-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings. METHODS The Handoffs and Transitions in Critical Care-Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU). DISCUSSION The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04571749 . Date of registration: October 1, 2020.
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Affiliation(s)
| | - Athena Christakos
- 3400 Spruce Street 6th Floor Dulles Building, Philadelphia, PA 19104 USA
| | - Gina C. Russell
- 3400 Civic Center Boulevard, Building 421, Philadelphia, PA 19104 USA
| | - Bat-Zion Hose
- 423 Guardian Drive, 333 Blockley Hall, Philadelphia, PA 19104 USA
| | | | | | | | | | | | - John R. Kimberly
- 3620 Locust Walk, 2109 Steinberg-Dietrich Hall, Philadelphia, PA 19104 USA
| | | | | | | | - Ellen J. Bass
- Drexel University, 3675 Market Street, Suite 1000, Philadelphia, PA 19104 USA
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15
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Young JQ, Holmboe ES, Frank JR. Competency-Based Assessment in Psychiatric Education: A Systems Approach. Psychiatr Clin North Am 2021; 44:217-235. [PMID: 34049645 DOI: 10.1016/j.psc.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Medical education programs are failing to meet the health needs of patients and communities. Misalignments exist on multiple levels, including content (what trainees learn), pedagogy (how trainees learn), and culture (why trainees learn). To address these challenges effectively, competency-based assessment (CBA) for psychiatric medical education must simultaneously produce life-long learners who can self-regulate their own growth and trustworthy processes that determine and accelerate readiness for independent practice. The key to effectively doing so is situating assessment within a carefully designed system with several, critical, interacting components: workplace-based assessment, ongoing faculty development, learning analytics, longitudinal coaching, and fit-for-purpose clinical competency committees.
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Affiliation(s)
- John Q Young
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and the Zucker Hillside Hospital at Northwell Health, Glen Oaks, NY, USA.
| | - Eric S Holmboe
- Accreditation Council for Graduate Medical Education, 401 North Michigan Avenue, Chicago, IL 60611, USA
| | - Jason R Frank
- Royal College of Physicians and Surgeons of Canada, 774 Echo Drive, Ottawa, Ontario K15 5NB, Canada; Education, Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
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16
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Gershengorn HB. International Variation in Intubation and Extubation Practices and Adverse Events Among Critically Ill Patients Receiving Mechanical Ventilation. JAMA 2021; 325:1157-1159. [PMID: 33755055 DOI: 10.1001/jama.2021.1178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
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17
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Everhart A, Desai NR, Dowd B, Herrin J, Higuera L, Jeffery MM, Jena AB, Ross JS, Shah ND, Smith LB, Karaca-Mandic P. Physician variation in the de-adoption of ineffective statin and fibrate therapy. Health Serv Res 2021; 56:919-931. [PMID: 33569804 DOI: 10.1111/1475-6773.13630] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To describe physicians' variation in de-adopting concurrent statin and fibrate therapy for type 2 diabetic patients following a reversal in clinical evidence. DATA SOURCES We analyzed 2007-2015 claims data from OptumLabs® Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data. STUDY DESIGN We modeled fibrate use among Medicare Advantage and commercially insured type 2 diabetic statin users before and after the publication of the ACCORD lipid trial, which found statins and fibrates were no more effective than statins alone in reducing cardiovascular events among type 2 diabetic patients. We modeled fibrate use trends with physician random effects and physician characteristics such as age and specialty. DATA EXTRACTION We identified patient-year-quarters with one year of continuous insurance enrollment, type 2 diabetes diagnoses, and fibrate use. We designated the physician most responsible for patients' diabetes care based on evaluation and management visits and prescriptions of glucose-lowering drugs. PRINCIPAL FINDINGS Fibrate use increased by 0.12 percentage points per quarter among commercial patients (95% CI, 0.10 to 0.14) and 0.17 percentage points per quarter among Medicare Advantage patients (95% CI, 0.13 to 0.20) before the trial and then decreased by 0.16 percentage points per quarter among commercial patients (95% CI, -0.18 to -0.15) and 0.05 percentage points per quarter among Medicare Advantage patients (95% CI, -0.06 to -0.03) after the trial. However, 45% of physicians treating commercial patients and 48% of physicians treating Medicare Advantage patients had positive trends in prescribing following the trial. Physicians' characteristics did not explain their variation (pseudo R2 = 0.000). CONCLUSION On average, physicians decreased fibrate prescribing following the ACCORD lipid trial. However, many physicians increased prescribing following the trial. Observable physician characteristics did not explain variations in prescribing. Future research should examine whether physicians vary similarly in other de-adoption settings.
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Affiliation(s)
- Alexander Everhart
- University of Minnesota, Minneapolis, Minnesota, USA.,OptumLabs Visiting Fellow, Eden Prairie, Minnesota, USA
| | - Nihar R Desai
- Yale School of Medicine, Charlottesville, Virginia, USA
| | - Bryan Dowd
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeph Herrin
- Yale School of Medicine, Charlottesville, Virginia, USA
| | - Lucas Higuera
- University of Minnesota, Minneapolis, Minnesota, USA.,Medtronic Plc, Mounds View, Minnesota, USA
| | | | - Anupam B Jena
- Harvard Medical School, Boston, Massachusetts, USA.,Massachusetts General Hospital, Boston, Massachusetts, USA.,National Bureau of Economic Research, Cambridge, Massachusetts, USA
| | - Joseph S Ross
- Yale School of Medicine, Charlottesville, Virginia, USA
| | | | | | - Pinar Karaca-Mandic
- University of Minnesota, Minneapolis, Minnesota, USA.,National Bureau of Economic Research, Cambridge, Massachusetts, USA
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18
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Bosch NA, Fantasia KL, Modzelewski KL, Alexanian SM, Walkey AJ. Guideline-Concordant Insulin Infusion Initiation Among Critically Ill Patients With Sepsis. Endocr Pract 2021; 27:552-560. [PMID: 33549815 DOI: 10.1016/j.eprac.2021.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/06/2021] [Accepted: 01/28/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Our objective was to benchmark rates of guideline-concordant insulin infusion initiation, identify factors associated with guideline-concordant insulin practices, and examine the association between hospital-level guideline concordance and mortality among critically ill patients with sepsis. METHODS We performed a multicenter retrospective cohort study of intensive care patients with sepsis who were eligible for insulin infusion initiation according to American Diabetes Association and Surviving Sepsis guidelines (persistent blood sugar ≥180 mg/dL). We then identified patients who were initiated on insulin infusions within 24 hours of eligibility. We examined patient- and hospital-level factors associated with guideline-concordant insulin infusion initiation and explored the association between the hospital-level proportion of patients who received guideline-concordant insulin infusions and hospital mortality. RESULTS Among 5453 guideline-eligible patients with sepsis, 13.4% were initiated on insulin infusions. Factors most strongly associated with guideline-concordant insulin infusion initiation were mechanical ventilation and hospital of admission. The hospital-level proportion of patients who received guideline-concordant insulin infusions were not associated with mortality. Among 1501 intensive care unit patients with sepsis who were started on insulin infusions, 37.0% were initiated at a blood glucose level below 180 mg/dL, the guideline-recommended starting threshold. CONCLUSION Guideline-concordant insulin infusion initiation was uncommon among patients with sepsis admitted to U.S. intensive care units and was determined in large part by hospital of admission. The degree to which hospitals were guideline-concordant were not associated with mortality.
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Affiliation(s)
- Nicholas A Bosch
- Boston University School of Medicine, Department of Medicine, The Pulmonary Center, Boston, Massachusetts.
| | - Kathryn L Fantasia
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston, Massachusetts
| | - Katherine L Modzelewski
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston, Massachusetts
| | - Sara M Alexanian
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston, Massachusetts
| | - Allan J Walkey
- Boston University School of Medicine, Department of Medicine, The Pulmonary Center, Boston, Massachusetts
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19
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Gantner D, Bragge P, Finfer S, Gabbe B, Varma D, Webb S, Waterson S, Saxena M, Rengarajoo P, Reade MC, Coates T, Thomas P, Cooper J. Management of Australian Patients with Severe Traumatic Brain Injury: Are Potentially Harmful Treatments Still Used? J Neurotrauma 2020; 37:2686-2693. [PMID: 32731848 DOI: 10.1089/neu.2020.7152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical trials have shown that intravenous albumin and decompressive craniectomy to treat early refractory intracranial hypertension can cause harm in patients with severe traumatic brain injury (TBI). The extent to which these treatments remain in use is unknown. We conducted a multi-center retrospective cohort study of adult patients with severe TBI admitted to five neurotrauma centers across Australia between April 2013 and March 2015. Patients were identified from local trauma and intensive care unit (ICU) registries and followed until hospital discharge. Main outcome measures were the administration of intravenous albumin, and decompressive craniectomy for intracranial hypertension. Analyses were predominantly descriptive. There were 303 patients with severe TBI, of whom a minority received albumin (6.9%) or underwent early decompressive craniectomy for treatment of refractory intracranial hypertension complicating diffuse TBI (2.3%). The median (intequartile range [IQR]) age was 35 (24, 58), and most injuries were caused by road traffic accidents (57.4%) or falls (25.1%). Overall, 34.3% of patients died while in the hospital and the remainder were discharged to rehabilitation (44.6%), other health care facilities (4.6%), or home (16.5%). There were no patient characteristics significantly associated with use of albumin or craniectomy. Intravenous albumin and craniectomy for treatment of intracranial hypertension were used infrequently in Australian neurotrauma centers, indicating alignment between best available evidence and practice.
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Affiliation(s)
- Dashiell Gantner
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Simon Finfer
- Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia.,The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dinesh Varma
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Steve Webb
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sharon Waterson
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Manoj Saxena
- Department of Intensive Care, Bankstown Hospital, Sydney, New South Wales, Australia
| | - Parveta Rengarajoo
- Department of Intensive Care, Bankstown Hospital, Sydney, New South Wales, Australia
| | - Michael C Reade
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Tom Coates
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Piers Thomas
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
| | - Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
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20
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Vail EA, Wunsch H, Pinto R, Bosch NA, Walkey AJ, Lindenauer PK, Gershengorn HB. Use of Hydrocortisone, Ascorbic Acid, and Thiamine in Adults with Septic Shock. Am J Respir Crit Care Med 2020; 202:1531-1539. [PMID: 32706593 DOI: 10.1164/rccm.202005-1829oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: In December 2016, a single-center study describing significant improvements in mortality among a small group of patients with severe sepsis and septic shock treated with hydrocortisone, high-dose ascorbic acid, and thiamine (HAT therapy) was published online.Objectives: This study aims to describe the administration of HAT therapy among U.S. adults with septic shock before and after study publication and to compare outcomes between patients who received and did not receive HAT therapy.Methods: We performed a retrospective cohort study of 379 acute care hospitals in the Premier Healthcare Database including patients discharged from October 1, 2015, to September 30, 2018. Exposure was quarter year of hospital discharge; postpublication was defined as January 2017 onward (July 2017 for effectiveness analyses). The primary outcome was receipt of HAT at least once during hospitalization. We conducted unadjusted segmented regression analyses to examine temporal trends in HAT administration. In patients with early septic shock, we compared the association of early HAT therapy (within 2 d of hospitalization) with hospital mortality using multivariable modeling and propensity score matching.Measurements and Main Results: Among 338,597 patients, 3,574 (1.1%) received HAT therapy, 98.7% in the postpublication period. HAT administration increased from 0.03% of patients (95% confidence interval [CI], 0.02-0.04) before publication to 2.65% (95% CI, 2.46-2.83) in the last quarter, with a significant step up in use after December 2016 (P < 0.001). Receipt of early HAT was associated with higher hospital mortality (28.2% vs. 19.7%; P < 0.001; adjusted odds ratio, 1.17 [95% CI, 1.02-1.33]; primary propensity-matched model adjusted odds ratio, 1.19 [95% CI, 1.02-1.40]).Conclusions: Publication of a single-center retrospective study was associated with significantly increased administration of HAT. Among patients with early septic shock, receipt of HAT was not associated with mortality benefit.
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Affiliation(s)
- Emily A Vail
- Department of Anesthesiology, University of Texas Health San Antonio, San Antonio, Texas
| | - Hannah Wunsch
- Department of Anesthesiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- Department of Anesthesiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas A Bosch
- Division of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston University, Boston, Massachusetts
| | - Allan J Walkey
- Division of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston University, Boston, Massachusetts
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida; and.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
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21
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Fenster ME, Hersh AL, Srivastava R, Keren R, Wilkes J, Coon ER. Trends in Use of Postdischarge Intravenous Antibiotic Therapy for Children. J Hosp Med 2020; 15:731-733. [PMID: 32966197 PMCID: PMC9514303 DOI: 10.12788/jhm.3422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/31/2020] [Indexed: 11/20/2022]
Abstract
Children with complicated appendicitis, osteomyelitis, and complicated pneumonia have historically been treated with postdischarge intravenous antibiotics (PD-IV) using peripherally inserted central catheters (PICCs). Recent studies have shown no advantage and increased complications of PD-IV, compared with oral therapy, and the extent to which use of PD-IV has since changed for these conditions is not known. We used a national children's hospital database to evaluate trends in PD-IV during 2000-2018 for each of these three conditions. PD-IV decreased from 13% to 2% (risk ratio [RR], 0.15; 95% CI, 0.14-0.16) for complicated appendicitis, 61% to 22% (RR, 0.41; 95% CI, 0.39-0.43) for osteomyelitis, and 29% to 19% (RR, 0.63; 95% CI, 0.58-0.69) for complicated pneumonia. Despite these overall reductions, substantial variation in PD-IV use by hospital remains in 2018.
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Affiliation(s)
- Michael E Fenster
- Department of PediatricsUniversity of Utah School of MedicineSalt Lake CityUtah
| | - Adam L Hersh
- Department of PediatricsUniversity of Utah School of MedicineSalt Lake CityUtah
| | - Rajendu Srivastava
- Department of PediatricsUniversity of Utah School of MedicineSalt Lake CityUtah
- Intermountain HealthcareSalt Lake CityUtah
| | - Ron Keren
- Division of General PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvania
| | | | - Eric R Coon
- Department of PediatricsUniversity of Utah School of MedicineSalt Lake CityUtah
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22
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Gershengorn HB. Early adoption of critical care interventions is unjustifiable without concomitant effectiveness study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:649. [PMID: 33208179 PMCID: PMC7672161 DOI: 10.1186/s13054-020-03382-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Rosenstiel Medical Science Building, Rm. 7043B, 1600 NW 10th Avenue, Miami, FL, 33136, USA. .,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
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23
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Yoo HJ, Suh EE, Shim J. Effectiveness of blood glucose control protocol for open heart surgery patients. J Adv Nurs 2020; 77:275-285. [PMID: 33016410 DOI: 10.1111/jan.14592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 07/30/2020] [Accepted: 08/07/2020] [Indexed: 12/01/2022]
Abstract
AIMS To evaluate the effectiveness of a tailored blood glucose control protocol for postoperative cardiac surgery patients treated in intensive care. DESIGN Retrospective study. METHODS Data for the control group (non-tailored protocol) were collected from medical records at a tertiary hospital in Seoul, Korea between April-July 2015. Data for the experimental group (tailored protocol) were obtained from medical records between April-July 2016. After adjusting the target blood glucose range, eliminating single-dose insulin administration and extending the blood glucose measurement time interval, data for blood glucose measurements, time for reaching and maintaining target blood glucose, mean number of daily blood glucose measurements and insulin dose adjustments for the experimental group were collected. RESULTS In the experimental group (where the target blood glucose rate was increased) the hypoglycaemia rate and the variation in blood glucose decreased significantly compared with the control group. In particular, the experimental group maintained relatively stable blood glucose levels by retaining a small variation range in glucose, regardless of the presence of diabetes. Time required for maintaining target blood glucose, mean number of daily blood glucose measurements and insulin dose adjustments per patient decreased. CONCLUSION The tailored protocol contributes to the safe and effective control of blood glucose in critical care patients after cardiac surgery and to the efficiency of nurses administering it. IMPACT This study has two significant impacts. The application of the tailored protocol has a positive impact on patients' blood glucose management, a critical component of treatment for postoperative cardiac patients in intensive care units. It also has a positive impact on the efficiency of nurses applying it. The results of this study are thus expected to facilitate successful implementation of clinical protocols for critical care after heart surgery.
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Affiliation(s)
- Hye Jin Yoo
- Department of Nursing, Asan Medical center, Seoul, South Korea
| | - Eunyoung E Suh
- College of Nursing and Research Institute of Nursing Science, Seoul National University, Seoul, South Korea
| | - JaeLan Shim
- College of Medicine, Department of Nursing, Dongguk University, Gyeongju, South Korea
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24
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Kheirbek T, Jikaria N, Murray B, Martin TJ, Lueckel SN, Stephen AH, Monaghan SF, Adams CA. Unjustified Administration in Liberal Use of Tranexamic Acid in Trauma Resuscitation. J Surg Res 2020; 258:125-131. [PMID: 33010557 DOI: 10.1016/j.jss.2020.08.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 07/16/2020] [Accepted: 08/25/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Early administration of tranexamic acid (TXA) has been widely implemented for the treatment of presumed hyperfibrinolysis in hemorrhagic shock. We aimed to characterize the liberal use of TXA and whether unjustified administration was associated with increased venous thrombotic events (VTEs). METHODS We identified injured patients who received TXA between January 2016 and January 2018 by querying our Level 1 trauma center's registry. We retrospectively reviewed medical records and radiologic images to classify whether patients had a hemorrhagic injury that would have benefited from TXA (justified) or not (unjustified). RESULTS Ninety-five patients received TXA for traumatic injuries, 42.1% were given by emergency medical services. TXA was considered unjustified in 35.8% of the patients retrospectively and in 52% of the patients when given by emergency medical services. Compared with unjustified administration, patients in the justified group were younger (47.6 versus 58.4; P = 0.02), more hypotensive in the field (systolic blood pressure: 107 ± 31 versus 137 ± 32 mm Hg; P < 0.001) and in the emergency department (systolic blood pressure: 97 ± 27 versus 128 ± 27; P < 0.001), and more tachycardic in emergency department (heart rate: 99 ± 29 versus 88 ± 19; P = 0.04). The justified group also had higher injury severity score (median 24 versus 11; P < 0.001), was transfused more often (81.7% versus 20.6%; P < 0.001), and had higher in-hospital mortality (39.3% versus 2.9%; P < 0.001), but there was no difference in the rate of VTE (8.2% versus 5.9%). CONCLUSIONS Our results highlight a high rate of unjustified administration, especially in the prehospital setting. Hypotension and tachycardia were indications of correct use. Although we did not observe a difference in VTE rates between the groups, though, our study was underpowered to detect a difference. Cautious implementation of TXA in resuscitation protocols is encouraged in the meantime. Nonetheless, adverse events associated with unjustified TXA administration should be further evaluated.
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Affiliation(s)
- Tareq Kheirbek
- Department of Surgery, Brown University, Alpert School of Medicine, Providence, Rhode Island.
| | - Neil Jikaria
- Department of Surgery, Brown University, Alpert School of Medicine, Providence, Rhode Island
| | - Brett Murray
- Department of Surgery, Brown University, Alpert School of Medicine, Providence, Rhode Island
| | - Thomas J Martin
- Department of Surgery, Brown University, Alpert School of Medicine, Providence, Rhode Island
| | - Stephanie N Lueckel
- Department of Surgery, Brown University, Alpert School of Medicine, Providence, Rhode Island
| | - Andrew H Stephen
- Department of Surgery, Brown University, Alpert School of Medicine, Providence, Rhode Island
| | - Sean F Monaghan
- Department of Surgery, Brown University, Alpert School of Medicine, Providence, Rhode Island
| | - Charles A Adams
- Department of Surgery, Brown University, Alpert School of Medicine, Providence, Rhode Island
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25
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Smith LB, Desai NR, Dowd B, Everhart A, Herrin J, Higuera L, Jeffery MM, Jena AB, Ross JS, Shah ND, Karaca-Mandic P. Patient and provider-level factors associated with changes in utilization of treatments in response to evidence on ineffectiveness or harm. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2020; 20:299-317. [PMID: 32350680 PMCID: PMC7725279 DOI: 10.1007/s10754-020-09282-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/20/2020] [Indexed: 06/11/2023]
Abstract
High-quality health care not only includes timely access to effective new therapies but timely abandonment of therapies when they are found to be ineffective or unsafe. Little is known about changes in use of medications after they are shown to be ineffective or unsafe. In this study, we examine changes in use of two medications: fenofibrate, which was found to be ineffective when used with statins among patients with Type 2 diabetes (ACCORD lipid trial); and dronedarone, which was found to be unsafe in patients with permanent atrial fibrillation (PALLAS trial). We examine the patient and provider characteristics associated with a decline in use of these medications. Using Medicare fee-for-service claims from 2008 to 2013, we identified two cohorts: patients with Type 2 diabetes using statins (7 million patient-quarters), and patients with permanent atrial fibrillation (83 thousand patient-quarters). We used interrupted time-series regression models to identify the patient- and provider-level characteristics associated with changes in medication use after new evidence emerged for each case. After new evidence of ineffectiveness emerged, fenofibrate use declined by 0.01 percentage points per quarter (95% CI - 0.02 to - 0.01) from a baseline of 6.9 percent of all diabetes patients receiving fenofibrate; dronedarone use declined by 0.13 percentage points per quarter (95% CI - 0.15 to - 0.10) from a baseline of 3.8 percent of permanent atrial fibrillation patients receiving dronedarone. For dronedarone, use declined more quickly among patients dually-enrolled in Medicare and Medicaid compared to Medicare-only patients (P < 0.001), among patients seen by male providers compared to female providers (P = 0.01), and among patients seen by cardiologists compared to primary care providers (P < 0.001).
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Affiliation(s)
- Laura Barrie Smith
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, USA
| | - Nihar R Desai
- Cardiovascular Medicine, Yale School of Medicine, New Haven, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, USA
| | - Bryan Dowd
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, USA
| | - Alexander Everhart
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, USA
| | - Jeph Herrin
- Cardiovascular Medicine, Yale School of Medicine, New Haven, USA
| | - Lucas Higuera
- Health Economics and Outcomes Research - Cardiac Rhythm and Heart Failure, Medtronic, Minneapolis, USA
| | - Molly Moore Jeffery
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
- Emergency Medicine Research, Mayo Clinic, Rochester, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, USA
- Department of Medicine, Massachusetts General Hospital, Boston, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, USA
- General Internal Medicine, Yale School of Medicine, New Haven, USA
- Health Policy and Management, Yale School of Public Health, New Haven, USA
| | - Nilay D Shah
- Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Pinar Karaca-Mandic
- National Bureau of Economic Research, Cambridge, MA, USA.
- Carlson School of Management, University of Minnesota, Minneapolis, MN, USA.
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26
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Yap T, Affandi JS, Reid CM, Xu D. Translating research evidence into clinical practice: a reminder of important clinical lessons in management of resistant hypertension through a case study in general practice. BMJ Case Rep 2020; 13:e235007. [PMID: 32606122 PMCID: PMC7328755 DOI: 10.1136/bcr-2020-235007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2020] [Indexed: 11/04/2022] Open
Abstract
A case of a 59-year-old man with resistant hypertension, despite 8 months of non-pharmacological and pharmacological management up to maximal doses of triple antihypertensive therapy. Review of the literature found a study that reported improved blood pressure control with bedtime dosing of antihypertensive treatment. Changing to bedtime dosage of antihypertensives resulted in significant improvement in blood pressure control to below target levels. This highlights the importance of the clinicians' awareness and implementation of research findings and hence delivery of best evidence-based care.
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Affiliation(s)
- Timothy Yap
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Jacquita S Affandi
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Christopher M Reid
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Dan Xu
- Department of General Practice, Curtin University Bentley Campus, Perth, Western Australia, Australia
- Department of Medical Education, Sun Yan-sen University of Medical Sciences, Guangzhou, China
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27
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Prone positioning in non-intubated patients with COVID-19: raising the bar. THE LANCET RESPIRATORY MEDICINE 2020; 8:744-745. [PMID: 32569584 PMCID: PMC7304963 DOI: 10.1016/s2213-2600(20)30269-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 01/13/2023]
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28
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Ewusie JE, Soobiah C, Blondal E, Beyene J, Thabane L, Hamid JS. Methods, Applications and Challenges in the Analysis of Interrupted Time Series Data: A Scoping Review. J Multidiscip Healthc 2020; 13:411-423. [PMID: 32494150 PMCID: PMC7231782 DOI: 10.2147/jmdh.s241085] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/17/2020] [Indexed: 12/02/2022] Open
Abstract
Objective Interrupted time series (ITS) designs are robust quasi-experimental designs commonly used to evaluate the impact of interventions and programs implemented in healthcare settings. This scoping review aims to 1) identify and summarize existing methods used in the analysis of ITS studies conducted in health research, 2) elucidate their strengths and limitations, 3) describe their applications in health research and 4) identify any methodological gaps and challenges. Design Scoping review. Data Sources Searches were conducted in MEDLINE, JSTOR, PUBMED, EMBASE, CINAHL, Web of Science and the Cochrane Library from inception until September 2017. Study Selection Studies in health research involving ITS methods or reporting on the application of ITS designs. Data Extraction Screening of studies was completed independently and in duplicate by two reviewers. One reviewer extracted the data from relevant studies in consultations with a second reviewer. Results of the review were presented with respect to methodological and application areas, and data were summarized using descriptive statistics. Results A total of 1389 articles were included, of which 98.27% (N=1365) were application papers. Segmented linear regression was the most commonly used method (26%, N=360). A small percentage (1.73%, N=24) were methods papers, of which 11 described either the development of novel methods or improvement of existing methods, 7 adapted methods from other areas of statistics, while 6 provided comparative assessment of conventional ITS methods. Conclusion A significantly increasing trend in ITS use over time is observed, where its application in health research almost tripled within the last decade. Several statistical methods are available for analyzing ITS data. Researchers should consider the types of data and validate the required assumptions for the various methods. There is a significant methodological gap in ITS analysis involving aggregated data, where analyses involving such data did not account for heterogeneity across patients and hospital settings.
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Affiliation(s)
- Joycelyne E Ewusie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Charlene Soobiah
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
| | - Erik Blondal
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
| | - Joseph Beyene
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Jemila S Hamid
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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29
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Sypes EE, de Grood C, Whalen-Browne L, Clement FM, Parsons Leigh J, Niven DJ, Stelfox HT. Engaging patients in de-implementation interventions to reduce low-value clinical care: a systematic review and meta-analysis. BMC Med 2020; 18:116. [PMID: 32381001 PMCID: PMC7206676 DOI: 10.1186/s12916-020-01567-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/18/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Many decisions regarding health resource utilization flow through the patient-clinician interaction. Thus, it represents a place where de-implementation interventions may have considerable effect on reducing the use of clinical interventions that lack efficacy, have risks that outweigh benefits, or are not cost-effective (i.e., low-value care). The objective of this systematic review with meta-analysis was to determine the effect of de-implementation interventions that engage patients within the patient-clinician interaction on use of low-value care. METHODS MEDLINE, EMBASE, and CINAHL were searched from inception to November 2019. Gray literature was searched using the CADTH tool. Studies were screened independently by two reviewers and were included if they (1) described an intervention that engaged patients in an initiative to reduce low-value care, (2) reported the use of low-value care with and without the intervention, and (3) were randomized clinical trials (RCTs) or quasi-experimental designs. Studies describing interventions solely focused on clinicians or published in a language other than English were excluded. Data was extracted independently in duplicate and pertained to the low-value clinical intervention of interest, components of the strategy for patient engagement, and study outcomes. Quality of included studies was assessed using the Cochrane Risk of Bias tool for RCTs and a modified Downs and Black checklist for quasi-experimental studies. Random effects meta-analysis (reported as risk ratio, RR) was used to examine the effect of de-implementation interventions on the use of low-value care. RESULTS From 6736 unique citations, 9 RCTs and 13 quasi-experimental studies were included in the systematic review. Studies mostly originated from the USA (n = 13, 59%), targeted treatments (n = 17, 77%), and took place in primary care (n = 10, 45%). The most common intervention was patient-oriented educational material (n = 18, 82%), followed by tools for shared decision-making (n = 5, 23%). Random effects meta-analysis demonstrated that de-implementation interventions that engage patients within the patient-clinician interaction led to a significant reduction in low-value care in both RCTs (RR 0.74; 95% CI 0.66-0.84) and quasi-experimental studies (RR 0.61; 95% CI 0.43-0.87). There was significant inter-study heterogeneity; however, intervention effects were consistent across subgroups defined by low-value practice and patient-engagement strategy. CONCLUSIONS De-implementation interventions that engage patients within the patient-clinician interaction through patient-targeted educational materials or shared decision-making tools are effective in decreasing the use of low-value care. Clinicians and policymakers should consider engaging patients within initiatives that seek to reduce low-value care. REGISTRATION Open Science Framework (https://osf.io/6fsxm).
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Affiliation(s)
- Emma E Sypes
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Chloe de Grood
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Liam Whalen-Browne
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Canada
| | - Daniel J Niven
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada.
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada.
| | - Henry T Stelfox
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Canada
- O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
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30
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Understanding the public's role in reducing low-value care: a scoping review. Implement Sci 2020; 15:20. [PMID: 32264926 PMCID: PMC7137456 DOI: 10.1186/s13012-020-00986-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/23/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Low-value care initiatives are rapidly growing; however, it is not clear how members of the public should be involved. The objective of this scoping review was to systematically examine the literature describing public involvement in initatives to reduce low-value care. METHODS Evidence sources included MEDLINE, EMBASE, and CINAHL databases from inception to November 26, 2019, grey literature (CADTH Tool), reference lists of included articles, and expert consultation. Citations were screened in duplicate and included if they referred to the public's perception and/or involvement in reducing low-value care. Public included patients or citizens without any advanced healthcare knowledge. Low-value care included medical tests or treatments that lack efficacy, have risks that exceed benefit, or are not cost-effective. Extracted data pertained to study characteristics, low-value practice, clinical setting, and level of public involvement (i.e., patient-clinician interaction, research, or policy-making). RESULTS The 218 included citations were predominantly original research (n = 138, 63%), published since 2010 (n = 192, 88%), originating from North America (n = 146, 67%). Most citations focused on patient engagement within the patient-clinician interaction (n = 156, 72%), using tools that included shared decision-making (n = 66, 42%) and patient-targeted educational materials (n = 72, 46%), and reported both reductions in low-value care and improved patient perceptions regarding low-value care. Fewer citations examined public involvement in low-value care policy-making (n = 33, 15%). Among citations that examined perspectives regarding public involvement in initiatives to reduce low-value care (n = 10, 5%), there was consistent support for the utility of tools applied within the patient-clinician interaction and less consistent support for involvement in policy-making. CONCLUSIONS Efforts examining public involvement in low-value care concentrate within the patient-clinician interaction, wherein patient-oriented educational materials and shared decision-making tools have been commonly studied and are associated with reductions in low-value care. This contrasts with inclusion of the public in low-value care policy decisions wherein tools to promote engagement are less well-developed and involvement not consistently viewed as valuable. TRIAL REGISTRATION Open Science Framework (https://osf.io/6fsxm).
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31
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Money NM, Schroeder AR, Quinonez RA, Ho T, Marin JR, Morgan DJ, Dhruva SS, Coon ER. 2019 Update on Pediatric Medical Overuse: A Systematic Review. JAMA Pediatr 2020; 174:375-382. [PMID: 32011675 DOI: 10.1001/jamapediatrics.2019.5849] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Medical overuse is common in pediatrics and may lead to unnecessary care, resource use, and patient harm. Timely scrutiny of established and emerging practices can identify areas of overuse and empower clinicians to reconsider the balance of harms and benefits of the medical care that they provide. A literature review was conducted to identify the most important areas of pediatric medical overuse in 2018. OBSERVATIONS Consistent with prior methods, a structured MEDLINE search and manual table of contents review of selected pediatric journals for the 2018 literature was conducted identifying articles pertaining to pediatric medical overuse. The structured MEDLINE search consisted of a PubMed search for articles with the Medical Subject Headings term health services misuse or medical overuse or article titles containing the term unnecessary, inappropriate, overutilization, or overuse. Articles containing the term overuse injury or overuse injuries were excluded, along with articles not published in English and those not constituting original research. The same search was performed using Embase with the additional Emtree term unnecessary procedure. Each article was evaluated by 3 independent raters for quality of methods, magnitude of potential harm, and number of patients potentially harmed. Ten articles were identified based on scores and appraisal of overall potential harm. This year's review identified both established and emerging practices that may warrant deimplementation. Examples of such established practices include antibiotic prophylaxis for urinary tract infections, routine opioid prescriptions, prolonged antibiotic courses for latent tuberculosis, and routine intensive care admission and pharmacologic therapy for neonatal abstinence syndrome. Emerging practices that merit greater inspection and discouragement of widespread adoption include postdischarge nurse-led home visits, probiotics for gastroenteritis, and intensive cardiac screening programs for athletes. CONCLUSIONS AND RELEVANCE This year's review highlights established and emerging practices that represent medical overuse in the pediatric setting. Deimplementation of disproven practices and careful examination of emerging practices are imperative to prevent unnecessary resource use and patient harm.
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Affiliation(s)
- Nathan M Money
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Ricardo A Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Timmy Ho
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jennifer R Marin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Daniel J Morgan
- University of Maryland School of Medicine, Baltimore.,VA Maryland Health Care System, Baltimore
| | - Sanket S Dhruva
- University of California, San Francisco School of Medicine, San Francisco.,San Francisco VA Medical Center, San Francisco, California
| | - Eric R Coon
- Department of Pediatrics, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City
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Wang X, Du X, Yang H, Bucholz E, Downing N, Spertus JA, Masoudi FA, Li J, Guan W, Gao Y, Hu S, Bai X, Krumholz HM, Li X. Use of intravenous magnesium sulfate among patients with acute myocardial infarction in China from 2001 to 2015: China PEACE-Retrospective AMI Study. BMJ Open 2020; 10:e033269. [PMID: 32220910 PMCID: PMC7170603 DOI: 10.1136/bmjopen-2019-033269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE In 2001, Chinese guidelines for the care of acute myocardial infarction (AMI) included a new recommendation against the routine use of magnesium. We studied temporal trends and institutional variation in the use of intravenous magnesium sulfate in nationally representative samples of individuals hospitalised with AMI in China between 2001 and 2015. METHODS In an observational study (China PEACE-Retrospective Study) of AMI care, we used a two-stage, random sampling strategy to create a nationally representative sample of 28 208 patients with AMI at 162 Chinese hospitals in 2001, 2006, 2011 and 2015. The main outcome is use of intravenous magnesium sulfate over time. RESULTS We identified 24 418 patients admitted for AMI, without hypokalaemia, in the four study years. Over time, there was a significant initial decrease in intravenous magnesium sulfate use, from 32.1% in 2001 to 17.1% in 2015 (p<0.001 for trend). The decline was greater in the Eastern (from 33.3% to 16.5%) and Western (from 34.8% to 17.2%) regions, as compared with the Central region (from 25.9% to 18.1%), with little difference between rural and urban areas. The proportion of hospitals using intravenous magnesium sulfate did not change over time (from 81.3% to 77.9%). The median ORs, representing hospital-level variation, were 6.03 in 2001, 3.86 in 2006, 4.26 in 2011 and 4.72 in 2015. Intravenous magnesium sulfate use was associated with cardiac arrest at admission and receipt of reperfusion therapy, but no hospital-specific characteristics. CONCLUSIONS Despite recommendations against its use, intravenous magnesium sulfate is used in about one in six patients with AMI in China. Our findings highlight the need for more efficient mechanisms to stop using ineffective therapies to improve patients' outcomes and reduce medical waste. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT01624883).
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Affiliation(s)
- Xianqiang Wang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue Du
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Yang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Emily Bucholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Nicholas Downing
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - John A Spertus
- Cardiovascular Outcomes Research, St. Luke's Mid America Heart Institute and the University of Missouri, Kansas City, Missouri, USA
| | - Fredrick A Masoudi
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jing Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenchi Guan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Gao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuang Hu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueke Bai
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Xi Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Association of multiple glycemic parameters at intensive care unit admission with mortality and clinical outcomes in critically ill patients. Sci Rep 2019; 9:18498. [PMID: 31811218 PMCID: PMC6897941 DOI: 10.1038/s41598-019-55080-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/15/2019] [Indexed: 12/14/2022] Open
Abstract
The aim of the present study was to investigate the association of multiple glycemic parameters at intensive care unit (ICU) admission with outcomes in critically ill patients. Critically ill adults admitted to ICU were included prospectively in the study and followed for 180 days until hospital discharge or death. Patients were assessed for glycemic gap, hypoglycemia, hyperglycemia, glycemic variability, and stress hyperglycemia ratio (SHR). A total of 542 patients were enrolled (30% with preexisting diabetes). Patients with glycemic gap >80 mg/dL had increased need for renal replacement therapy (RRT; 37.7% vs. 23.7%, p = 0.025) and shock incidence (54.7% vs. 37.4%, p = 0.014). Hypoglycemia was associated with increased mortality (54.8% vs. 35.8%, p = 0.004), need for RRT (45.1% vs. 22.3%, p < 0.001), mechanical ventilation (MV; 72.6% vs. 57.5%, p = 0.024), and shock incidence (62.9% vs. 35.8%, p < 0.001). Hyperglycemia increased mortality (44.3% vs. 34.9%, p = 0.031). Glycemic variability >40 mg/dL was associated with increased need for RRT (28.3% vs. 14.4%, p = 0.002) and shock incidence (41.4% vs.31.2%, p = 0.039). In this mixed sample of critically ill subjects, including patients with and without preexisting diabetes, glycemic gap, glycemic variability, and SHR were associated with worse outcomes, but not with mortality. Hypoglycemia and hyperglycemia were independently associated with increased mortality.
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Lack of Regulations and Conflict of Interest Transparency of New Hernia Surgery Technologies. J Surg Res 2019; 247:445-452. [PMID: 31668430 DOI: 10.1016/j.jss.2019.09.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/22/2019] [Accepted: 09/25/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Medical devices introduced to market through the 510K process often have limited research of low quality and substantial conflict of interest (COI). By the time high-quality safety and effectiveness research is performed, thousands of patients may have already been treated by the device. Our aim was to systematically review the trends of outcomes, research quality, and financial relationships of published studies related to de-adopted meshes for ventral hernia repair. MATERIALS AND METHODS Literature was systematically reviewed using PubMed to obtain all published studies related to three de-adopted meshes: C-QUR, Physiomesh, and meshes with polytetrafluoroethylene. Primary outcome was change in cumulative percentage of subjects with positive published outcomes. Secondary outcome was percentage of published manuscript with COI. RESULTS A total of 723 articles were screened, of which, 129 were analyzed and included a total of 8081 subjects. Percentage of subjects with positive outcomes decreased over time for all groups: (1) C-QUR from 100% in 2009 to 22% in 2018, (2) Physiomesh from 100% in 2011 to 20% in 2018, and (3) polytetrafluoroethylene from 100% in 1979 to 49% in 2018. Authors of only 20% of articles self-reported no COI, most representing later publications and were more likely to show neutral or negative results. CONCLUSIONS Among three de-adopted meshes, early publications demonstrated overly optimistic results followed by disappointing outcomes. Skepticism over newly introduced, poorly proven therapies is essential to prevent adoption of misleading practices and products. Devices currently approved under the 510K processes should undergo blinded, randomized controlled trials before introduction to the market.
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Cheng A, Nadkarni VM, Mancini MB, Hunt EA, Sinz EH, Merchant RM, Donoghue A, Duff JP, Eppich W, Auerbach M, Bigham BL, Blewer AL, Chan PS, Bhanji F. Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 138:e82-e122. [PMID: 29930020 DOI: 10.1161/cir.0000000000000583] [Citation(s) in RCA: 189] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.
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Stelfox HT, Bourgault AM, Niven DJ. De-implementing low value care in critically ill patients: a call for action-less is more. Intensive Care Med 2019; 45:1443-1446. [PMID: 31396643 DOI: 10.1007/s00134-019-05694-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/11/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 5A1, Canada.
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada.
- Alberta Health Services, Alberta, Canada.
| | - Annette M Bourgault
- College of Nursing, Academic Health Sciences Center, University of Central Florida, Orlando, FL, USA
- Orlando Health, Orlando, FL, USA
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 5A1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Alberta Health Services, Alberta, Canada
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Shifting to triple value healthcare: Reflections from England. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2019; 130:2-7. [PMID: 29402597 DOI: 10.1016/j.zefq.2018.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Increasing need and demand because of growing and aging populations combined with stagnant or decreasing resources being invested into healthcare globally mean that a radical shift is needed to ensure that healthcare systems can meet current and future challenges. Quality-, safety- and efficiency-improvement approaches have been used as means to address many problems in healthcare and while they are essential and necessary, they are not sufficient to meet our current challenges. To build resilient and sustainable healthcare systems, we need a shift to focus on triple value healthcare, which will help healthcare professionals improve outcomes at the process, patient and population levels while also optimising resource utilisation. Here we present a brief history of the Quality and Evidence-based Healthcare model and then describe how value emerged as a predominant theme in England. We then highlight the four solutions that we, as part of the RightCare programme, designed and refined in the English NHS to turn theory into practice: We end with a description of how triple value is being introduced into Germany and steps that can be taken to facilitate its adoption.
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Desveaux L, Saragosa M, Kithulegoda N, Ivers NM. Family Physician Perceptions of Their Role in Managing the Opioid Crisis. Ann Fam Med 2019; 17:345-351. [PMID: 31285212 PMCID: PMC6827657 DOI: 10.1370/afm.2413] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 02/01/2019] [Accepted: 03/03/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We examined the perspectives of family physicians (FPs) on opioid prescribing and management of chronic pain to better understand the barriers to safer prescribing in primary care and differences in perspectives that may be potential drivers of practice variation. METHODS We used an exploratory qualitative study design. Semistructured interviews were conducted in June and July 2017 with 22 FPs in Ontario and coded inductively. Thematic analysis was used to identify themes, and a framework analysis explored the influence of physician demographics on prescribing experience. RESULTS Three key themes emerged: the discrepancy between FPs' training and current practice, the tension between the FP's role and patient and system expectations, and the influence of length of time in practice and strength of therapeutic relationships on perspectives on opioid prescribing. There was an overarching sentiment among participants that FPs are unsupported in their efforts to manage chronic pain. More years in practice (≥15 years) seems to influence practice patterns by increasing trust in therapeutic relationships and decreasing reliance on emergent guidelines (vs clinical experience). CONCLUSION Number of years in practice influences FPs' response to emergent evidence, requiring initiatives to include strategies tailored to individual beliefs. Initiatives must move beyond dissemination and education to equip FPs with the skills they need to navigate emotionally charged conversations. External pressures and misaligned system and patient expectations place FPs at the center of a challenging situation, which may result in a higher risk of burnout compared with that of their specialist colleagues.
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Affiliation(s)
- Laura Desveaux
- Women's College Research Institute, Toronto, Canada .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Abstract
OBJECTIVE To determine whether women treated by older physicians are more likely to undergo episiotomy. DATA SOURCES/STUDY SETTING Hospital discharge data from Pennsylvania for the period 1994 to 2010. STUDY DESIGN We examined the impact of the year in which physicians started delivering babies (a proxy for age) in Pennsylvania on episiotomy rates using a linear probability model with hospital fixed effects. DATA COLLECTION/EXTRACTION METHODS Using diagnosis and procedure codes, we identified women delivering vaginally (N = 1 658 327) and determined the proportion who had an episiotomy. PRINCIPAL FINDINGS The average physician-level episiotomy rate declined from 54 percent in 1994 to 13 percent in 2010. Rates declined among older and younger physicians, but, at any point in time, women treated by older physicians were more likely to have an episiotomy. A 10-year difference in physician age is associated with a 6 percentage point increase in episiotomy rates. CONCLUSIONS Results indicate that older physicians, who entered practice when episiotomy was common, were slow to adjust their practices in response to evidence showing that routine episiotomy is unnecessary.
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Affiliation(s)
- David H. Howard
- Department of Health Policy and ManagementEmory UniversityAtlantaGeorgia
| | - Jason Hockenberry
- Department of Health Policy and ManagementEmory UniversityAtlantaGeorgia
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van Egmond S, Wakkee M, van Rengen A, Bastiaens M, Nijsten T, Lugtenberg M. Factors influencing current low-value follow-up care after basal cell carcinoma and suggested strategies for de-adoption: a qualitative study. Br J Dermatol 2019; 180:1420-1429. [PMID: 30597525 PMCID: PMC6850416 DOI: 10.1111/bjd.17594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Providing follow-up to patients with low-risk basal cell carcinoma (BCC) can be considered as low-value care. However, dermatologists still provide substantial follow-up care to this patient group, for reasons not well understood. OBJECTIVES To identify factors influencing current BCC follow-up practices among dermatologists and suggested strategies to de-adopt this low-value care. In addition, views of patients regarding follow-up care were explored. METHODS A qualitative study was conducted consisting of 18 semistructured interviews with dermatologists and three focus groups with a total of 17 patients with low-risk BCC who had received dermatological care. The interviews focused on current follow-up practices, influencing factors and suggested strategies to de-adopt the follow-up care. The focus groups discussed preferred follow-up schedules and providers, as well as the content of follow-up. All (group) interviews were transcribed verbatim and analysed by two researchers using ATLAS.ti software. RESULTS Factors influencing current follow-up care practices among dermatologists included complying with patients' preferences, lack of trust in general practitioners (GPs), financial incentives and force of habit. Patients reported varying needs regarding periodic follow-up visits, preferred to be seen by a dermatologist and indicated a need for improved information provision. Suggested strategies by dermatologists to de-adopt the low-value care encompassed educating patients with improved information, educating GPs to increase trust of dermatologists, realizing appropriate financial reimbursement and informing dermatologists about the low value of care. CONCLUSIONS A mixture of factors appear to contribute to current follow-up practices after low-risk BCC. In order to de-adopt this low-value care, strategies should be aimed at dermatologists and GPs, and also patients.
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Affiliation(s)
- S. van Egmond
- Department of DermatologyErasmus MC Cancer InstituteRotterdamthe Netherlands
- Department of Public HealthErasmus MC University Medical CenterRotterdamthe Netherlands
| | - M. Wakkee
- Department of DermatologyErasmus MC Cancer InstituteRotterdamthe Netherlands
| | - A. van Rengen
- Department of DermatologyMohs KliniekenDordrechtthe Netherlands
| | - M.T. Bastiaens
- Department of DermatologyElisabeth‐TweeSteden HospitalTilburgthe Netherlands
| | - T. Nijsten
- Department of DermatologyErasmus MC Cancer InstituteRotterdamthe Netherlands
| | - M. Lugtenberg
- Department of DermatologyErasmus MC Cancer InstituteRotterdamthe Netherlands
- Department of Public HealthErasmus MC University Medical CenterRotterdamthe Netherlands
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Fernández-Méndez R, Rodríguez-Villar S, Méndez PF, Windle R, Adams GG. Methodology for the analysis and comparison of protocols for glycaemic control in intensive care. J Eval Clin Pract 2019; 25:251-259. [PMID: 30311352 DOI: 10.1111/jep.13047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/31/2018] [Indexed: 01/06/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The practice of glycaemic control of critically ill patients admitted to intensive care units (ICUs) is guided by clinical management protocols, designed locally by the ICUs. These protocols differ significantly in their aims and methods. The aim of this study was to develop a standardized methodology for the systematic and objective analysis and comparison of protocols for glycaemic control implemented in any ICU. METHOD The protocols for glycaemic control implemented in seven ICUs of a UK-based ICU network were analysed using techniques of inductive content analysis, through an open coding process and the framework method. This involved the identification and classification of protocol instructions for glycaemic control, as well as of the processes and decisions pertaining to each of these instructions. These were used to develop a framework for the structured and systematic description and comparison of the protocols' contents, and to develop a technique for the protocols' graphic visualization. RESULTS The following elements were identified or developed: (1) 35 quantifiable variables and 11 non-quantifiable subjects that could be present in an ICU protocol for glycaemic control, to be used as a framework for the description and comparison of contents; (2) a technique for condensing a protocol into a single, comprehensive flowchart; (3) using these flowcharts, a method for assessing the complexity and comprehensiveness of the protocols. CONCLUSIONS The methodology developed in this study will allow for any future work analysing the contents of glycaemic control protocols to be carried out in a structured and standardized way. This may be done either as a standalone study, or as the essential first step in any investigation on the impact of new protocols. In turn, the methodology will facilitate the performance of regional, national, and international comparisons, demonstrating the usefulness of this study at a global scale.
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Affiliation(s)
- Rocío Fernández-Méndez
- Faculty of Medicine and Health Sciences, University of Nottingham, Medical School (West Block), NG7 2RD, Nottingham, UK
| | | | - Pablo F Méndez
- Department of Ecology, Estación Biológica de Doñana, Seville, Spain
| | - Richard Windle
- Faculty of Medicine and Health Sciences, University of Nottingham, Medical School (West Block), NG7 2RD, Nottingham, UK
| | - Gary George Adams
- Faculty of Medicine and Health Sciences, University of Nottingham, Medical School (West Block), NG7 2RD, Nottingham, UK
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Bertoletti L, Murgier M, Stelfox HT. Direct oral anticoagulants for venous thromboembolism prophylaxis in critically ill patients: where do we go from here? Intensive Care Med 2019; 45:549-551. [PMID: 30911805 DOI: 10.1007/s00134-019-05605-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, 42055, Saint-Etienne, France
- INSERM, CHU Saint-Etienne, CIC-1408, 42055, Saint-Etienne, France
| | - Martin Murgier
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, 42055, Saint-Etienne, France
- Service de Médecine Intensive et Réanimation, CHU de St-Etienne, Saint-Etienne, France
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Alberta Health Services, Calgary, AB, Canada.
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Sauro K, Bagshaw SM, Niven D, Soo A, Brundin-Mather R, Parsons Leigh J, Cook DJ, Stelfox HT. Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study. BMJ Open 2019; 9:e024159. [PMID: 30878979 PMCID: PMC6429967 DOI: 10.1136/bmjopen-2018-024159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices. DESIGN (1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers. SETTING Data were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers. PARTICIPANTS Participants included 6946 ICU admissions and 309 healthcare providers from the same ICUs. MAIN OUTCOME MEASURES (1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices. RESULTS LMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively). CONCLUSIONS Despite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar.
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Affiliation(s)
- Khara Sauro
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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Fernández-Méndez R, Harvey DJR, Windle R, Adams GG. The practice of glycaemic control in intensive care units: A multicentre survey of nursing and medical professionals. J Clin Nurs 2019; 28:2088-2100. [PMID: 30653767 DOI: 10.1111/jocn.14774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/07/2018] [Accepted: 01/07/2019] [Indexed: 12/14/2022]
Abstract
AIMS AND OBJECTIVES To determine the views of nurses and physicians working in intensive care units (ICU) about the aims of glycaemic control and use of their protocols. BACKGROUND Evidence about the optimal aims and methods for glycaemic control in ICU is controversial, and current local protocols guiding practice differ between ICUs, both nationally and internationally. The views of professionals on glycaemic control can influence their practice. DESIGN Cross-sectional, multicentre, survey-based study. METHODS An online short survey was sent to all physicians and nurses of seven ICUs, including questions on effective glycaemic control, treatment of hypoglycaemia and deviations from protocols' instructions. STROBE reporting guidelines were followed. RESULTS Over half of the 40 respondents opined that a patient spending <75% admission time within the target glycaemic levels constituted poor glycaemic control. Professionals with more than 5 years of experience were more likely to rate a patient spending 50%-74% admission time within target glycaemic levels as poor than less experienced colleagues. Physicians were more likely to rate a patient spending <50% admission time within target as poor than nurses. There was general agreement on how professionals would rate most deviations from their protocols. Nurses were more likely to rate insulin infusions restarted late and incorrect dosage of rescue glucose as major deviations than physicians. Most professionals agreed on when they would treat hypoglycaemia. CONCLUSIONS When surveyed on various aspects of glycaemic control, ICU nurses and physicians often agreed, although there were certain areas of disagreement, in which their profession and level of experience seemed to play a role. RELEVANCE TO CLINICAL PRACTICE Differing views on glycaemic control amongst professionals may affect their practice and, thus, could lead to health inequalities. Clinical leads and the multidisciplinary ICU team should assess and, if necessary, address these differing opinions.
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Affiliation(s)
| | | | - Richard Windle
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Gary George Adams
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
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A multicentre controlled pre-post trial of an implementation science intervention to improve venous thromboembolism prophylaxis in critically ill patients. Intensive Care Med 2019; 45:211-222. [PMID: 30707246 DOI: 10.1007/s00134-019-05532-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/14/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To test whether a multicomponent intervention would increase the use of low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for venous thromboembolism (VTE) prophylaxis in critically ill patients and change patient outcomes and healthcare utilization. METHODS Controlled pre-post trial of 12,342 adults admitted to 11 ICUs (five intervention, six control) May 1, 2015 to April 30, 2017 with no contraindication to pharmacological prophylaxis and an ICU stay longer than 24 h. Models were developed to examine temporal changes in ICU VTE prophylaxis (primary outcome), VTE, major bleeding, heparin-induced thrombocytopenia (HIT), death and hospital costs. RESULTS The use of LMWH increased from 45.9% to 78.3% of patient days in the intervention group and from 37.9% to 53.3% in the control group, an absolute increase difference of 17.0% (32.4% vs. 15.4%, p = 0.001). Changes in the administration of UFH were inversely related to those of LMWH. There were no significant differences in the adjusted odds of VTE (ratio of odds ratios [rOR] 1.13, 95% CI 0.51-2.46) or major bleeding (rOR 1.22, 95% CI 0.97-1.54) post-implementation of the intervention (compared to pre-implementation) between the intervention group and the control group. HIT was uncommon in both groups (n = 20 patients). There were no significant changes for ICU and hospital mortality, length of stay and costs. Results were similar when stratified according to reason for ICU admission, patient weight and kidney function. CONCLUSIONS A multicomponent intervention changed practice, but not clinical and economic outcomes. The benefit of implementing LMWH for VTE prophylaxis under real-world conditions is uncertain.
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Jitschin R, Böttcher M, Saul D, Lukassen S, Bruns H, Loschinski R, Ekici AB, Reis A, Mackensen A, Mougiakakos D. Inflammation-induced glycolytic switch controls suppressivity of mesenchymal stem cells via STAT1 glycosylation. Leukemia 2019; 33:1783-1796. [PMID: 30679801 DOI: 10.1038/s41375-018-0376-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/19/2018] [Accepted: 12/07/2018] [Indexed: 02/06/2023]
Abstract
Mesenchymal stem cells (MSCs) represent key contributors to tissue homeostasis and promising therapeutics for hyperinflammatory conditions including graft-versus-host disease. Their immunomodulatory effects are controlled by microenvironmental signals. The MSCs' functional response towards inflammatory cues is known as MSC-"licensing" and includes indoleamine 2,3-dioxygenase (IDO) upregulation. MSCs use tryptophan-depleting IDO to suppress T-cells. Increasing evidence suggests that several functions are (co-)determined by the cells' metabolic commitment. MSCs are capable of both, high levels of glycolysis and of oxidative phosphorylation. Although several studies have addressed alterations of the immune regulatory phenotype elicited by inflammatory priming metabolic mechanisms controlling this process remain unknown. We demonstrate that inflammatory MSC-licensing causes metabolic shifts including enhanced glycolysis and increased fatty acid oxidation. Yet, only interfering with glycolysis impacts IDO upregulation and impedes T-cell-suppressivity. We identified the Janus kinase (JAK)/signal transducer and activator of transcription (STAT)1 pathway as a regulator of both glycolysis and IDO, and show that enhanced glucose turnover is linked to abundant STAT1 glycosylation. Inhibiting the responsible O-acetylglucosamine (O-GlcNAc) transferase abolishes STAT1 activity together with IDO upregulation. Our data suggest that STAT1-O-GlcNAcylation increases its stability towards degradation thus sustaining downstream effects. This pathway could represent a target for interventions aiming to enhance the MSCs' immunoregulatory potency.
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Affiliation(s)
- R Jitschin
- Department of Medicine 5 for Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - M Böttcher
- Department of Medicine 5 for Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - D Saul
- Department of Medicine 5 for Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - S Lukassen
- Institute of Human Genetics, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - H Bruns
- Department of Medicine 5 for Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - R Loschinski
- Department of Medicine 5 for Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - A B Ekici
- Institute of Human Genetics, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - A Reis
- Institute of Human Genetics, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - A Mackensen
- Department of Medicine 5 for Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - D Mougiakakos
- Department of Medicine 5 for Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054, Erlangen, Germany.
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Diebel LN, Liberati DM, Martin JV. Acute hyperglycemia increases sepsis related glycocalyx degradation and endothelial cellular injury: A microfluidic study. Am J Surg 2019; 217:1076-1082. [PMID: 30635208 DOI: 10.1016/j.amjsurg.2018.12.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 11/16/2018] [Accepted: 12/29/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hyperglycemia promotes vascular inflammation; however its effect on endothelial dysfunction in sepsis is unknown. Microfluidic devices (MFD) may closely mimic the in vivo endothelial cell microenvironment. We hypothesized that stress glucose concentrations would increase sepsis related endothelial injury/activation. METHODS Human umbilical vein endothelial cell (HUVEC) monolayers were established in microfluidic channels. TNF was added followed by glucose. Endothelial glycocalyx (EG) integrity was indexed by shedding of the EG components as well as thickness. Endothelial cell (EC) injury/activation was indexed by soluble biomarkers. Intracellular reactive oxygen species (ROS) was by fluorescence. RESULTS TNF increased glycocalyx degradation and was associated with biomarkers of EC injury. These vascular barrier derangements were further increased by hyperglycemia. This may be related to increase ROS species generated followed by the combined insults. CONCLUSION MFD technology may be a useful platform to study endothelial barrier function and stress conditions and allow preclinical assessment of potential therapies.
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Affiliation(s)
- Lawrence N Diebel
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI, USA.
| | - David M Liberati
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI, USA.
| | - Jonathan V Martin
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI, USA.
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Admon AJ, Hyzy RC. Truth survival: on de-adoption of practices in critical care. THE LANCET RESPIRATORY MEDICINE 2018; 5:166-168. [PMID: 28266324 DOI: 10.1016/s2213-2600(17)30052-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 01/19/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Andrew J Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA
| | - Robert C Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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Stoudt K, Chawla S. Don't Sugar Coat It: Glycemic Control in the Intensive Care Unit. J Intensive Care Med 2018; 34:889-896. [PMID: 30309291 DOI: 10.1177/0885066618801748] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Stress hyperglycemia is the transient increase in blood glucose as a result of complex hormonal changes that occur during critical illness. It has been described in the critically ill for nearly 200 years; patient harm, including increases in morbidity, mortality, and lengths of stay, has been associated with hyperglycemia, hypoglycemia, and glucose variability. However, there remains a contentious debate regarding the optimal glucose ranges for this population, most notably within the past 15 years. Recent landmark clinical trials have dramatically changed the treatment of stress hyperglycemia in the intensive care unit (ICU). Earlier studies suggested that tight glucose control improved both morbidity and mortality for ICU patients, but later studies have suggested potential harm related to the development of hypoglycemia. Multiple trials have tried to elucidate potential glucose target ranges for special patient populations, including those with diabetes, trauma, sepsis, cardiac surgery, and brain injuries, but there remains conflicting evidence for most of these subpopulations. Currently, most international organizations recommend targeting moderate blood glucose concentration to levels <180 mg/dL for all patients in the intensive care unit. In this review, the history of stress hyperglycemia and its treatment will be discussed including optimal glucose target ranges, devices for monitoring blood glucose, and current professional organizations' recommendations regarding glucose control in the ICU.
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Affiliation(s)
- Kara Stoudt
- Department of Anesthesiology & Critical Care Medicine, Critical Care Medicine Service, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Sanjay Chawla
- Department of Anesthesiology & Critical Care Medicine, Critical Care Medicine Service, Memorial Sloan Kettering Cancer Center, NY, USA
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Gershengorn HB, Wunsch H, Scales DC, Rubenfeld GD. Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation. JAMA Netw Open 2018; 1:e181119. [PMID: 30646104 PMCID: PMC6324260 DOI: 10.1001/jamanetworkopen.2018.1119] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Guidelines from December 2011 recommended against obtaining daily chest radiographs (CXRs) for patients requiring mechanical ventilation (MV). Daily CXR use for patients receiving MV in US hospitals is unknown and, if high, may represent an opportunity to reduce low-value care and unnecessary radiation. OBJECTIVES To determine frequency of daily CXR use for US patients receiving MV, assess variability across hospitals, and evaluate whether use has decreased over time. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of hospitalized adults (aged ≥18 years) receiving MV for 3 days or longer. Mechanical ventilation was defined by having an International Classification of Diseases, Ninth Revision, Clinical Modification code of 96.7x and an MV charge on more than 1 hospital day. Hospital discharges in the Premier Perspectives database were examined from July 1, 2008, to December 31, 2014. Data analysis was conducted from July 28, 2017, to December 13, 2017. EXPOSURES Hospital discharge date (quarter of the year) and hospital in which patients received MV. MAIN OUTCOMES AND MEASURES The outcome was daily CXR use (up to 7 days) during MV. We used standard statistics to describe CXR use, multilevel multivariable regression modeling with adjusted median odds ratio (OR) to evaluate variability by hospital, and multivariable piecewise regression (breakpoint: fourth quarter of 2011) with adjusted OR to evaluate time trends and response to guideline recommendations. RESULTS The primary cohort included 512 518 patients receiving MV (mean [SD] age, 63.0 [16.1] years; 46% female) in 416 hospitals, of whom 321 093 (63%) received daily CXRs. Wide variability was seen across hospitals; hospitals performed daily CXRs on a median of 66% of patients (interquartile range, 50%-77%; full range, 12%-97%). The adjusted median OR was 2.43 (95% CI, 2.29-2.59), suggesting the same patient had 2.43-fold higher odds of receiving a daily CXR if admitted to a higher- vs lower-use hospital; the odds of receiving daily CXRs were unchanged through quarter 3 of 2011 (adjusted OR, 1.00; 95% CI, 0.99-1.01), after which there was a 3% relative reduction in the odds of daily CXR use per quarter (adjusted OR, 0.97; 95% CI, 0.96-0.98). CONCLUSIONS AND RELEVANCE Three-fifths of US patients receiving MV also received daily CXRs from 2008 to 2014, although use declined slowly after new guidelines were published. The hospital at which a patient received care was associated with the odds of daily CXR receipt.
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Affiliation(s)
- Hayley B. Gershengorn
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
- Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Hannah Wunsch
- Department of Anesthesiology, Columbia University Medical College, New York, New York
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Damon C. Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gordon D. Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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