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Wang B, Han D, Hu X, Chen J, Liu Y, Wu J. Perioperative liberal drinking management promotes postoperative gastrointestinal function recovery after gynecological laparoscopic surgery: A randomized controlled trial. J Clin Anesth 2024; 97:111539. [PMID: 38945059 DOI: 10.1016/j.jclinane.2024.111539] [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: 03/17/2024] [Revised: 06/17/2024] [Accepted: 06/22/2024] [Indexed: 07/02/2024]
Abstract
STUDY OBJECTIVE This study aims to evaluate the effect of perioperative liberal drinking management, including preoperative carbohydrate loading (PCL) given 2 h before surgery and early oral feeding (EOF) at 6 h postoperatively, in enhancing postoperative gastrointestinal function and improving outcomes in gynecologic patients. The hypotheses are that the perioperative liberal drinking management accelerates the recovery of gastrointestinal function, enhances dietary tolerance throughout hospitalization, and ultimately reduces the length of hospitalization. DESIGN A prospective randomized controlled trial. SETTING Operating room and gynecological ward in Wuhan Union Hospital. PATIENTS We enrolled 210 patients undergoing elective gynecological laparoscopic surgery, and 157 patients were included in the final analysis. INTERVENTIONS Patients were randomly allocated in a 1:1:1 ratio into three groups, including the control, PCL, and PCL-EOF groups. The anesthetists and follow-up staff were blinded to group assignment. MEASUREMENTS The primary outcome was the postoperative Intake, Feeling nauseated, Emesis, Examination, and Duration of symptoms (I-FEED) score (range 0 to 14, higher scores worse). Secondary outcomes included the incidence of I-FEED scores >2, and other additional indicators to monitor postoperative gastrointestinal function, including time to first flatus, time to first defecation, time to feces Bristol grade 3-4, and time to tolerate diet. Additionally, we collected other ERAS recovery indicators, including the incidence of PONV, complications, postoperative pain score, satisfaction score, and the quality of postoperative functional recovery at discharge. MAIN RESULTS The PCL-EOF exhibited significantly enhanced gastrointestinal function recovery compared to control group and PCL group (p < 0.05), with the lower I-FEED score (PCL: 0[0,1] vs. PCL-EOF: 0[0,0] vs. control: 1[0,2]) and the reduced incidence of I-FEED >2 (PCL:8% vs. PCL-EOF: 2% vs. control:21%). Compared to the control, the intervention of PCL-EOF protected patients from the incidence of I-FEED score > 2 [HR:0.09, 95%CI (0.01-0.72), p = 0.023], and was beneficial in promoting the patient's postoperative first flatus [PCL-EOF: HR:3.33, 95%CI (2.14-5.19),p < 0.001], first defecation [PCL-EOF: HR:2.76, 95%CI (1.83-4.16), p < 0.001], Bristol feces grade 3-4 [PCL-EOF: HR:3.65, 95%CI (2.36-5.63), p < 0.001], first fluid diet[PCL-EOF: HR:2.76, 95%CI (1.83-4.16), p < 0.001], and first normal diet[PCL-EOF: HR:6.63, 95%CI (4.18-10.50), p < 0.001]. Also, the length of postoperative hospital stay (PCL-EOF: 5d vs. PCL: 6d and control: 6d, p < 0.001), the total cost (PCL-EOF: 25052 ± 3650y vs. PCL: 27914 ± 4684y and control: 26799 ± 4775y, p = 0.005), and postoperative VAS pain score values [POD0 (PCL-EOF: 2 vs. control: 4 vs. PCL: 4, p < 0.001), POD1 (PCL-EOF: 1 vs. control: 3 vs. PCL: 2, p < 0.001), POD2 (PCL-EOF: 1 vs. control:2 vs. PCL: 1, p < 0.001), POD3 (PCL-EOF: 0 vs. control: 1 vs. PCL: 1, p < 0.001)] were significantly reduced in PCL-EOF group. CONCLUSIONS Our primary endpoint, I-FEED score demonstrated significant reduction with perioperative liberal drinking, serving as a protective intervention against I-FEED>2. Gastrointestinal recovery metrics, such as time to first flatus and defecation, also showed substantial improvements. Furthermore, the intervention enhanced postoperative dietary tolerance and expedited early recovery. TRIAL REGISTRATION ChiCTR2300071047(https://www.chictr.org.cn/).
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Affiliation(s)
- Beibei Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, China.
| | - Dong Han
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, China
| | - Xinyue Hu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, China
| | - Jing Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, China
| | - Yuwei Liu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, China
| | - Jing Wu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education, China
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Iddagoda MT, Trevenen M, Meaton C, Etherton-Beer C, Flicker L. Identifying factors predicting outcomes after major trauma in older patients: Prognostic systematic review and meta-analysis. J Trauma Acute Care Surg 2024; 97:478-487. [PMID: 38523141 DOI: 10.1097/ta.0000000000004320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Trauma is the most common cause of morbidity and mortality in older people, and it is important to determine the predictors of outcomes after major trauma in older people. METHODS MEDLINE, Embase, and Web of Science were searched, and manual search of relevant papers since 1987 to February 2023 was performed. Random-effects meta-analyses were performed. The primary outcome of interest was mortality, and secondary outcomes were medical complications, length of stay, discharge destination, readmission, and intensive care requirement. RESULTS Among 6,064 studies in the search strategy, 136 studies qualified the inclusion criteria. Forty-three factors, ranging from demographics to patient factors, admission measurements, and injury factors, were identified as potential predictors. Mortality was the commonest outcome investigated, and increasing age was associated with increased risk of in-hospital mortality (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07) along with male sex (OR, 1.40; 95% CI, 1.24-1.59). Comorbidities of heart disease (OR, 2.59; 95% CI, 1.41-4.77), renal disease (OR, 2.52; 95% CI, 1.79-3.56), respiratory disease (OR, 1.40; 95% CI, 1.09-1.81), diabetes (OR, 1.35; 95% CI, 1.03-1.77), and neurological disease (OR, 1.42; 95% CI, 0.93-2.18) were also associated with increased in-hospital mortality risk. Each point increase in the Glasgow Coma Scale lowered the risk of in-hospital mortality (OR, 0.85; 95% CI, 0.76-0.95), while each point increase in Injury Severity Score increased the risk of in-hospital mortality (OR, 1.07; 95% CI, 1.04-1.09). There were limited studies and substantial variability in secondary outcome predictors; however, medical comorbidities, frailty, and premorbid living condition appeared predictive for those outcomes. CONCLUSION This review was able to identify potential predictors for older trauma patients. The identification of these factors allows for future development of risk stratification tools for clinicians. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level III.
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Affiliation(s)
- Mayura Thilanka Iddagoda
- From the Perioperative Service (M.T.I., C.M., C.E.-B., L.F.), Royal Perth Hospital; and University of Western Australia (M.T.I., M.T., C.E.-B., L.F.), Perth, Australia
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Clements NA, Philips P, Egger ME, McMasters KM, Scoggins CR, Martin RCG. Combined pre-operative risk score predicts pancreatic leak after pancreatic resection. Surg Endosc 2024; 38:742-756. [PMID: 38049669 DOI: 10.1007/s00464-023-10602-z] [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: 05/20/2023] [Accepted: 11/14/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is a major complication following pancreatectomy and is currently difficult to predict pre-operatively. This study aims to validate pre-operative risk factors and develop a novel combined score for the prediction of POPF in the pre-operative setting. METHODS Data were collected from 2016 to 2021 for radiologic main pancreatic duct diameter (MPD), body mass index (BMI), physical status classified by American Society of Anesthesiologists (ASA), polypharmacy, mean platelet ratio (MPR), comorbidity-polypharmacy score (CPS), and a novel Combined Pancreatic Leak Prediction Score (CPLPS) (derived from MPD diameter, BMI, and CPS) were obtained from pre-operative data and analyzed for their independent association with POPF occurrence. RESULTS In total, 166 patients who underwent pancreatectomy with pancreatic leak (Grade A, B, and C) occurring in 51(30.7%) of patients. Pre-operative radiologic MPD diameter < 4 mm (p < 0.001), < 5 mm (p < 0.001), < 6 mm (p = 0.001), BMI ≥ 25 (p = 0.009), and ≥ 30 (p = 0.017) were independently associated with the occurrence of pancreatic leak. CPLPS was also predictive of pancreatic leak following pancreatectomy on univariate (p = 0.005) and multivariate analysis (p = 0.036). CONCLUSION MPD and BMI were independent risk factors predictive for the development of pancreatic leak. CPLPS, was an independent predictor of pancreatic leak following pancreatectomy and could be used to help guide surgical decision making and patient counseling.
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Affiliation(s)
- Noah A Clements
- The Hiram C. Polk, Jr., MD, Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Prejesh Philips
- The Hiram C. Polk, Jr., MD, Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Michael E Egger
- The Hiram C. Polk, Jr., MD, Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Kelly M McMasters
- The Hiram C. Polk, Jr., MD, Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Charles R Scoggins
- The Hiram C. Polk, Jr., MD, Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, 40292, USA
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway, Louisville, KY, 40202, USA.
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Grandi A, Bertoglio L, Lepidi S, Kölbel T, Mani K, Budtz-Lilly J, DeMartino R, Scali S, Hanna L, Troisi N, Calvagna C, D’Oria M. Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms: A Scoping Review. J Clin Med 2023; 12:5505. [PMID: 37685573 PMCID: PMC10488165 DOI: 10.3390/jcm12175505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA). MATERIALS AND METHODS A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)? RESULTS The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies. CONCLUSIONS The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events.
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Affiliation(s)
- Alessandro Grandi
- Department of Vascular Medicine, University Heart and Vascular Center, 20251 Hamburg, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, 25123 Brescia, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart and Vascular Center, 20251 Hamburg, Germany
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 751 05 Uppsala, Sweden
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL 32610, USA
| | - Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London SW7 5NH, UK
| | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
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Maki H, Wakabayashi H, Maeda K, Nakamichi M, Kubota K, Momosaki R. Impact of the Comorbidity Polypharmacy Score on Clinical Outcome in Patients with Hip Fracture undergoing surgery Using Real-World Data. ANNALS OF CLINICAL EPIDEMIOLOGY 2023; 5:88-94. [PMID: 38504727 PMCID: PMC10944981 DOI: 10.37737/ace.23012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 06/01/2023] [Indexed: 03/21/2024]
Abstract
BACKGROUND The Comorbidity Polypharmacy Score (CPS) is calculated by the number of drugs carried plus the number of comorbidities on admission and divided into three categories (minor, 0-7; moderate, 8-14; and severe, 15+). This study investigates whether CPS can predict the clinical outcomes in older patients with hip fractures undergoing surgery. METHODS This retrospective longitudinal study used a multicenter hospital-based database containing the Diagnosis Procedure Combination. Consecutive patients with hip fractures (ICD-10 codes S720 and S721) who were aged ≥65 years between April 2014 and August 2020 were included. We evaluated the predictive association between the CPS and Barthel Index (BI) efficiency. The primary outcome was defined as the BI efficiency, and the secondary outcome was the length of hospital stay. RESULTS We enrolled 11,564 patients, and 80.5% of them were female. The mean age was 83.9 ± 6.5 years. The BI efficiency was the lowest in the CPS severe group with a median [interquartile range] of 0.67 [0.10, 1.43]. The length of hospital stay was the highest in the CPS severe group, with a median of 35 [21, 58]. Additionally, multiple linear regression analysis revealed that the CPS was independently associated with the BI efficiency (β = -0.100, 95% CI: -0.040, -0.029; P < 0.001) and the length of hospital stay (β = 0.047, 95% CI: 0.199, 0.366; P < 0.001). CONCLUSIONS An increased CPS score is associated with low BI efficiency and longer length of hospital stay in patients with hip fractures.
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Affiliation(s)
- Hiroki Maki
- Department of Pharmacy, Kofu Municipal Hospital
| | - Hidetaka Wakabayashi
- Department of Rehabilitation Medicine, Tokyo Women’s Medical University Hospital
| | - Keisuke Maeda
- Department of Geriatric Medicine, Hospital, National Center for Geriatrics and Gerontology
| | | | - Kazumi Kubota
- Department of Healthcare Information Management, The University of Tokyo Hospital
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Mie University Graduate School of Medicine
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Chua MT, Pan DST, Lee MZ, Thajudeen MZ, Rahman MMF, Sheth IA, Ong VYK, Tang JZY, Wee CPJ, Kuan WS. Comparing Comorbidity Polypharmacy Score and Charlson Comorbidity Index in predicting outcomes in older trauma patients. Injury 2023; 54:1113-1118. [PMID: 36822915 DOI: 10.1016/j.injury.2023.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/04/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND The Charlson Comorbidity Index (CCI) and Comorbidity Polypharmacy Score (CPS) may potentially risk-stratify older trauma patients more accurately than traditional trauma severity scores. We aim to evaluate if CCI or CPS are better predictors of mortality and discharge venue in such patients. METHODS We conducted a retrospective study using registry data from two tertiary trauma centres. Patients aged 65 years and above who presented to the emergency departments (EDs) between January 2011 and December 2015 with traumatic injuries were included. Charts were reviewed for demographics, injury mechanism and severity, discharge outcomes, and types of comorbidities and medications used. Primary outcome was overall mortality; secondary outcomes included ED disposition and hospital discharge venue. Discriminatory power of the score(s) were compared using area under the receiver operating characteristic (AUROC) curve. RESULTS There were 2,750 patients, with overall female predominance (56.7%, 1,560/2,750) and median age of 78 years (interquartile range [IQR] 72 to 84 years). Median CCI score was 1 (IQR 0 to 2) and median CPS was 8 (IQR 4 to 12). Overall mortality was 9.4% (259/2,750). Every 1-point increase in CCI score resulted in increased odds of death by 16% (adjusted odds ratio 1.16, 95% confidence interval 1.07 to 1.26, p<0.001). Addition of CCI to the Injury Severity Score (ISS) increased the discriminatory power for mortality (AUROC for ISS = 0.832; AUROC for ISS with CCI = 0.843). Every 1-point increase in CCI was significantly associated with decreased odds of admission to a rehab facility by 8%. CPS did not predict mortality and discharge venue. CONCLUSION CCI, but not CPS, was a predictor of mortality. A higher CCI was associated with decreased odds of discharge to a subacute facility, likely related to underlying rehabilitation potential. Further studies should be undertaken to explore an integrated scoring system that considers injury severity, comorbidities, and polypharmacy.
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Affiliation(s)
- Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Darius Shaw Teng Pan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Ming Zhou Lee
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | | | | | | | - Victor Yeok Kein Ong
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jonathan Zhe Ying Tang
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Harcombe H, Barson D, Samaranayaka A, Davie G, Wyeth E, Derrett S, McBride P. Predictors of hospital readmission after trauma: A retrospective cohort study in New Zealand. Injury 2023:S0020-1383(23)00252-8. [PMID: 36931967 DOI: 10.1016/j.injury.2023.03.009] [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: 10/10/2022] [Revised: 02/27/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Understanding predictors of hospital readmission following major trauma is important as readmissions are costly and some are potentially avoidable. This study describes the incidence of, and sociodemographic, injury-related and treatment-related factors predictive of, hospital readmission related to: a) all-causes, b) the index trauma injury, and c) subsequent injury events in the 30 days and 12 months following discharge for major trauma patients nationally in New Zealand. METHODS Data from the New Zealand Trauma Registry (NZTR) was linked with Ministry of Health hospital discharge data. Hospital readmissions were examined for all patients entered into the NZTR for an injury event between 1 January and 31 December 2018. Readmissions were examined for the 12-months following the discharge date for participant's index trauma injury. RESULTS Of 1986 people, 42% had ≥1 readmission in the 12 months following discharge; 15% within 30 days. Seven percent had ≥1 readmission related to the index trauma within 30 days of discharge; readmission was 3.43 (95% CI 1.87, 6.29) times as likely if the index trauma was self-inflicted compared to unintentional, and 1.64 (95% CI 1.15, 2.34) times as likely if the index trauma involved intensive care unit admission. Those admitted to hospital for longer for their index trauma were less likely to be readmitted due to their index trauma injury within 30 days compared to those admitted for 0-1 day. Seventeen percent were readmitted for a subsequent injury event within 12 months, with readmission more likely for older people (>65 years), those with comorbidities, Māori compared with non-Māori and those with higher trauma injury severity. CONCLUSION A substantial proportion of people are readmitted after discharge for major trauma. Factors identified in this study will be useful to consider when developing interventions to reduce preventable readmissions including those related to the index trauma injury, readmissions from other causes and subsequent injury-related readmissions. Further research specifically examining planned and unplanned readmissions is warranted.
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Affiliation(s)
- Helen Harcombe
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Dave Barson
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Ari Samaranayaka
- Biostatistics Centre, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Gabrielle Davie
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Emma Wyeth
- Ngāi Tahu Māori Health Research Unit, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Sarah Derrett
- Ngāi Tahu Māori Health Research Unit, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Paul McBride
- Health Quality & Safety Commission, PO Box 25496, Wellington, 6146, New Zealand.
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Inappropriate Prescriptions in Older People-Translation and Adaptation to Portuguese of the STOPP/START Screening Tool. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116896. [PMID: 35682479 PMCID: PMC9180165 DOI: 10.3390/ijerph19116896] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/26/2022] [Accepted: 06/02/2022] [Indexed: 02/04/2023]
Abstract
Inappropriate prescribing, which encompasses the prescription of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), is a common problem for older people. The STOPP/START tool enables general practitioners, who are the main prescribers, to identify and reduce the incidence of PIMs and PPOs and appraise an older patient’s prescribed drugs during the diagnosis process to improve the clinical care quality. This study aimed to translate and validate the STOPP/START screening tool to enable its use by Portuguese physicians. A translation-back translation method including the validation of the obtained Portuguese version was used. Intra- and inter-rater reliability and agreement analyses were used in the validation process. A dataset containing the information of 334 patients was analyzed by one GP twice within a 2-week interval, while a dataset containing the information of 205 patients was independently analyzed by three GPs. Intra-rater reliability assessment led to a Kappa coefficient (κ) of 0.70 (0.65−0.74) for the STOPP criteria and 0.60 (0.52−0.68) for the START criteria, considered to be substantial and moderate values, respectively. The results of the inter-rater reliability rating were almost perfect for all combinations of raters (κ > 0.93). The version of the STOPP/START criteria translated into Portuguese represents an improvement in managing the medications prescribed to the elderly. It provides clinicians with a screening tool for detecting potentially inappropriate prescribing in patients older than 65 years old that is reliable and easy to use.
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Chilakapati S, Burton MD, Adogwa O. Preoperative Polypharmacy in Geriatric Patients is Associated with Increased 90-Day All-Cause Hospital Readmission After Surgery for Adult Spinal Deformity Patients. World Neurosurg 2022; 164:e404-e410. [PMID: 35552032 DOI: 10.1016/j.wneu.2022.04.137] [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: 03/18/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To investigate the effect of preoperative polypharmacy (PP) on 90-day all-cause readmission rate in older adults undergoing corrective surgery for ASD. METHODS Older adults with a diagnosis of ASD undergoing spinal surgery at a quaternary medical center from January 2016 to March 2019 were enrolled in this study. Patients were dichotomized into two groups stratified by the number of preoperative prescription medications; with PP defined as 5 or more prescription medications. The primary outcome measure was 90-day all-cause readmission rate. Secondary outcomes included postoperative changes in health-related quality of life measures. RESULTS Among 161 patients (mean [SD], 69.59[8.79] years), 97 patients were included in PP cohort and 64 in non-polypharmacy (non-PP) cohort. Both groups were balanced at baseline. The duration of hospital (5.82[1.93] vs. 6.50[4.00] days), mean number of fusion levels, and duration of surgery was statistically similar between both groups (p>0.05). There was no difference in the proportion of patients discharged directly home (31.25% vs. 40.42%, p=0.36). 90-day all-cause readmission rate was 3-fold higher in the PP cohort compared with the non-PP cohort. After adjusting for preoperative patient optimization, ASA grade, surgical invasiveness, smoking, depression and baseline functional disability, older adults with PP had a 9.79 increased odds of 90-day all-cause hospital readmission (p=0.04). Change in HRQOL measures were similar between both groups. CONCLUSION This study's findings indicate that despite preoperative optimization, older adults exposed to polypharmacy are at a significantly increased risk of hospital readmission within 90-days of surgery.
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Affiliation(s)
- Sai Chilakapati
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX
| | - Michael D Burton
- Department of Neuroscience, University of Texas Dallas, Richardson, TX
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Cincinnati School of Medicine, Cincinnati, OH.
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10
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El Abd A, Schwab C, Clementz A, Fernandez C, Hindlet P. Safety of Elderly Fallers: Identifying Associated Risk Factors for 30-Day Unplanned Readmissions Using a Clinical Data Warehouse. J Patient Saf 2022; 18:230-236. [PMID: 34419990 DOI: 10.1097/pts.0000000000000893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospital readmissions are a major problem in the older people as they are frequent, costly, and life-threatening. Falls among older adults are the leading cause of injury, deaths, and emergency department visits for trauma. OBJECTIVE The main objective was to determine risk factors associated with a 30-day readmission after index hospital admission for fall-related injuries. METHODS A retrospective nested case-control study was conducted. Data from elderly patients initially hospitalized for fall-related injuries in 2019, in 11 of the Greater Paris University Hospitals and discharged home, were retrieved from the clinical data warehouse. Cases were admission of elderly patients who subsequently experienced a readmission within 30 days after discharge from the index admission. Controls were admission of elderly patients who were not readmitted to hospital. RESULTS Among 670 eligible index admissions, 127 (18.9%) were followed by readmission within 30 days after discharge. After multivariate analysis, men sex (odds ratio [OR] = 2.29, 95% confidence interval [CI] = 1.45-3.61), abnormal concentration of C-reactive protein, and anemia (OR = 2.22, 95% CI = 1.28-3.85; OR = 1.85, 95% CI = 1.11-3.11, respectively) were associated with a higher risk of readmission. Oppositely, having a traumatic injury at index admission decreased this risk (OR = 0.47, 95% CI = 0.28-0.81). CONCLUSIONS Reducing early unplanned readmission is crucial, especially in elderly patients susceptible to falls. Our results indicate that the probability of unplanned readmission is higher for patients with specific characteristics that should be taken into consideration in interventions designed to reduce this burden.
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Affiliation(s)
- Asmae El Abd
- From the GHU AP-HP.Sorbonne Université, Hôpital Saint Antoine, Service Pharmacie, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris
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11
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Pazan F, Wehling M. Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences. Eur Geriatr Med 2021; 12:443-452. [PMID: 33694123 PMCID: PMC8149355 DOI: 10.1007/s41999-021-00479-3] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 02/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The number of older adults has been constantly growing around the globe. Consequently, multimorbidity and related polypharmacy have become an increasing problem. In the absence of an accepted agreement on the definition of polypharmacy, data on its prevalence in various studies are not easily comparable. Besides, the evidence on the potential adverse clinical outcomes related to polypharmacy is limited though polypharmacy has been linked to numerous adverse clinical outcomes. This narrative review aims to find and summarize recent publications on definitions, epidemiology and clinical consequences of polypharmacy. METHODS The MEDLINE database was used to identify recent publications on the definition, prevalence and clinical consequences of polypharmacy using their respective common terms and their variations. Systematic reviews and original studies published between 2015 and 2020 were included. RESULTS One hundred and forty-three definitions of polypharmacy and associated terms were found. Most of them are numerical definitions. Its prevalence ranges from 4% among community-dwelling older people to over 96.5% in hospitalized patients. In addition, numerous adverse clinical outcomes were associated with polypharmacy. CONCLUSION The term polypharmacy is imprecise, and its definition is yet subject to an ongoing debate. The clinically oriented definitions of polypharmacy found in this review such as appropriate or necessary polypharmacy are more useful and relevant. Regardless of the definition, polypharmacy is highly prevalent in older adults, particularly in nursing home residents and hospitalized patients. Approaches to increase the appropriateness of polypharmacy can improve clinical outcomes in older adults.
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Affiliation(s)
- Farhad Pazan
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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12
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Kayyali R, Funnell G, Odeh B, Sharma A, Katsaros Y, Nabhani-Gebara S, Pierscionek B, Wells JS, Chang J. Investigating the characteristics and needs of frequently admitting hospital patients: a cross-sectional study in the UK. BMJ Open 2020; 10:e035522. [PMID: 32878751 PMCID: PMC7470484 DOI: 10.1136/bmjopen-2019-035522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES This study forms the user requirements phase of the OPTIMAL project, which, through a predictive model and supportive intervention, aims to decrease early hospital readmissions. This phase aims to investigate the needs and characteristics of patients who had been admitted to hospital ≥2 times in the past 12 months. SETTING This was a cross-sectional study involving patients from Croydon University Hospital (CUH), London, UK. PARTICIPANTS A total of 347 patients responded to a postal questionnaire, a response rate of 12.7%. To meet the inclusion criteria, participants needed to be aged ≥18 and have been admitted ≥2 times in the previous 12 months (August 2014-July 2015) to CUH. PRIMARY AND SECONDARY OUTCOMES To profile patients identified as frequent admitters to assess gaps in care at discharge or post-discharge. Additionally, to understand the patients' experience of admission, discharge and post-discharge care. RESULTS The range of admissions in the past 12 months was 2-30, with a mean of 2.8. At discharge 72.4% (n=231/347) were not given a contact for out-of-hours help. Regression analysis identified patient factors that were significantly associated with frequent admissions (>2 in 12 months), which included age (p=0.008), being in receipt of care (p=0.005) and admission due to a fall (p=0.01), but not receiving polypharmacy. Post-discharge, 41.8% (n=145/347) were concerned about being readmitted to the hospital. In the first 30 days after discharge, over half of patients (54.5% n=189/347) had no contact from a healthcare professional. CONCLUSION Considering that social care needs were more of a determinant of admission risk than medical needs, rectifying the lack of integration, communication and the under-utilisation of existing patient services could prevent avoidable problems during the transition of care and help decrease the likelihood of hospital readmission.
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Affiliation(s)
- Reem Kayyali
- Pharmacy, Kingston University Faculty of Science Engineering and Computing, Kingston Upon Thames, Surrey, UK
| | - Gill Funnell
- Pharmacy, Kingston University Faculty of Science Engineering and Computing, Kingston Upon Thames, Surrey, UK
| | - Bassel Odeh
- Pharmacy, Kingston University Faculty of Science Engineering and Computing, Kingston Upon Thames, Surrey, UK
| | | | | | - Shereen Nabhani-Gebara
- Pharmacy, Kingston University Faculty of Science Engineering and Computing, Kingston Upon Thames, Surrey, UK
| | - Barbara Pierscionek
- School of Life Sciences and Education, Staffordshire University, Stoke-on-Trent, Staffordshire, UK
| | - Joshua Sterling Wells
- Pharmacy, Kingston University Faculty of Science Engineering and Computing, Kingston Upon Thames, Surrey, UK
| | - John Chang
- Research and Development, Croydon University Hospital, London, UK
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13
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Khanh LN, Helenowski IB, Hoel AW, Ho KJ. The Comorbidity-Polypharmacy Score is an Objective and Practical Predictor of Outcomes and Mortality after Vascular Surgery. Ann Vasc Surg 2020; 69:206-216. [PMID: 32502672 DOI: 10.1016/j.avsg.2020.05.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The comorbidity-polypharmacy score (CPPS) was developed to quantify the severity of comorbidities of patients with geriatric trauma. CPPS is the sum of the number of medications and comorbidities, and is thus objective, user-friendly, and potentially adaptable to many clinical situations. We sought to understand if CPPS associates with outcomes and mortality after common vascular surgery procedures. METHODS This is a retrospective single-center study. A total of 466 patients who underwent carotid endarterectomy, infrainguinal bypass, percutaneous lower extremity revascularization, or endovascular abdominal aortic aneurysm repair at a single medical center were included. CPPS were classified as mild, moderate, severe, and morbid based on scores of 0-7, 8-15, 15-21, and ≥21, respectively. End points were reinterventions, 30-day readmission, and mortality. We used chi-squared tests to analyze differences in categorical variables; Kruskal-Wallis tests to analyze differences in continuous variables; Kaplan-Meier estimation and Cox proportional hazard modeling to examine survival data; and receiver operator characteristic (ROC) curve analyses to assess sensitivity and specificity. RESULTS The mean preoperative CPPS was 14.1 ± 6.1. Higher CPPS were associated with longer hospital and postoperative length of stay (P < 0.001). Severe and morbid CPPS categories had higher rates of ICU admission, reintervention, and 30-day readmission which did not reach statistical significance after correction for multiple comparisons. CPPS was independently associated with 1- and 5-year mortality in a multivariable Cox model (hazard ratio = 2.2, 95% confidence interval: 1.3-3.3). ROC analysis revealed C-statistics of 0.81 and 0.72 for 1-year and 5-year all-cause mortality, respectively (P < 0.001). CONCLUSIONS CPPS is a simple and pragmatic clinical tool for quantifying risk of postoperative outcomes and mortality after common vascular surgery procedures. Further investigation is needed to validate the use of CPPS in enhancing existing predictors of patient outcomes and in serving as an adjunctive tool for determining resource allocation and discharge planning in patients who underwent vascular surgery.
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Affiliation(s)
- Linh Ngo Khanh
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Irene B Helenowski
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew W Hoel
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Karen J Ho
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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14
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Hodosevich Z, Wheeler KK, Shi J, Coffey R, Bailey JK, Jones LM, Thakkar RK, Fabia RB, Groner JI, Xiang H. Incidence of Unplanned 30-Day Readmissions in Adult Burn Patients in the United States. J Burn Care Res 2020. [PMID: 29534188 DOI: 10.1093/jbcr/iry008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This study characterizes adult burn readmissions in the United States using a nationally representative hospital inpatient sample. Readmission rates, diagnoses, and risk factors are discussed. We analyzed the 2013 and 2014 Nationwide Readmission Database for adult burn patients. The data were weighted to estimate national 30-day readmission rates. Principal readmission diagnoses were sorted into burn-specific or other readmission categories. We used multivariable logistic regression to assess the effects of patient and hospital stay risk factors on readmissions. An estimated 42,957 U.S. adult burn patients were discharged between January and November of 2013 and 2014. Of these patients, an estimated 3203 had unscheduled readmissions within 30 days (all-cause readmission rate: 7.5%, 95% CI: 6.7-8.2). An estimated 55.4 per cent of unplanned readmissions were for burn-specific principal readmission diagnoses. Burn-specific readmission was associated with burn severity and increased with both patient age and the number of comorbidities. Patients whose length of stay was less than 1 day per % total body surface area (%TBSA) burned had higher readmission risk (Adjusted odds ratio = 2.10, 95% CI = 1.48-2.99). The results of logistic regression models were similar for burn-specific readmissions and all-cause readmissions. In a nationally representative sample of adult burn patients, 4.1 per cent had unplanned 30-day readmissions for burn-specific reasons; 7.5 per cent were readmitted for any reason. Patient comorbidities and discharge before 1 day per %TBSA from the hospital impact readmission risk. Healthcare providers can use this information to identify at-risk patients, modify their treatment plans, and prevent readmissions.
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Affiliation(s)
- Zachary Hodosevich
- The Ohio State University College of Medicine, Columbus, Ohio.,Center for Injury Research and Policy, Nationwide Children's Hospital, Columbus, Ohio.,Center for Pediatric Trauma Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Krista K Wheeler
- Center for Injury Research and Policy, Nationwide Children's Hospital, Columbus, Ohio.,Center for Pediatric Trauma Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Junxin Shi
- Center for Injury Research and Policy, Nationwide Children's Hospital, Columbus, Ohio.,Center for Pediatric Trauma Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Rebecca Coffey
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - J Kevin Bailey
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Larry M Jones
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rajan K Thakkar
- The Ohio State University College of Medicine, Columbus, Ohio.,Center for Pediatric Trauma Research, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Renata B Fabia
- The Ohio State University College of Medicine, Columbus, Ohio.,Center for Pediatric Trauma Research, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Jonathan I Groner
- The Ohio State University College of Medicine, Columbus, Ohio.,Center for Pediatric Trauma Research, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Henry Xiang
- The Ohio State University College of Medicine, Columbus, Ohio.,Center for Injury Research and Policy, Nationwide Children's Hospital, Columbus, Ohio.,Center for Pediatric Trauma Research, Nationwide Children's Hospital, Columbus, Ohio
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15
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Lester E, Dykstra M, Grant C, Fawcett V, Tsang B, Widder S. High-risk medications in older patients with trauma: a cross-sectional study of risk mitigation. Can J Surg 2019; 62:100-104. [PMID: 30907565 DOI: 10.1503/cjs.017117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background The Beers Criteria for Potentially Inappropriate Medication Use inOlder Adults is a framework that can assess the nature of high-risk medication use. The objective of this study was to use the Beers Criteria to assess the prevalence and nature of polypharmacy, the magnitude of medication changes during the hospital stay and the impact of Beers Criteria medications on outcomes in older patients with trauma. Methods We used the Alberta Trauma Registry to conduct a retrospective review of patients aged 65 years or older with major trauma (Injury Severity Score ≥ 12) who were admitted to a level 1 trauma centre between January 2013 and December 2014. We analyzed changes in medication prescriptions during the hospital stay using descriptive statistics and assessed the association between Beers Criteria medications and relevant outcomes using multivariable regression analysis. Results There was no significant change in the number of Beers Criteria medications prescribed before and after admission. The adjusted odds ratio for 30-day mortality for each additional Beers Criteria medication prescribed was 2.02 (95% confidence interval [CI] 1.16–3.51) versus 1.24 (95% CI 1.04–1.59) for each additional medication of any type. The corresponding adjusted incidence rate ratios for length of stay were 1.15 (95% CI 1.03–1.30) versus 1.05 (95% CI 1.01–1.10). Conclusion Beers Criteria medications were not discontinued during trauma admissions. Using the Beers Criteria as a process indicator for quality improvement in trauma care may provide interdisciplinary trauma teams an opportunity to audit patient medications and stop potentially harmful medications in a vulnerable population.
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Affiliation(s)
- Erica Lester
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Mark Dykstra
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Chantalle Grant
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Vanessa Fawcett
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Bonnie Tsang
- From the Department of Surgery, University of Alberta, Edmonton, Alta
| | - Sandy Widder
- From the Department of Surgery, University of Alberta, Edmonton, Alta
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16
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Guidet B, de Lange DW, Boumendil A, Leaver S, Watson X, Boulanger C, Szczeklik W, Artigas A, Morandi A, Andersen F, Zafeiridis T, Jung C, Moreno R, Walther S, Oeyen S, Schefold JC, Cecconi M, Marsh B, Joannidis M, Nalapko Y, Elhadi M, Fjølner J, Flaatten H. The contribution of frailty, cognition, activity of daily life and comorbidities on outcome in acutely admitted patients over 80 years in European ICUs: the VIP2 study. Intensive Care Med 2019; 46:57-69. [PMID: 31784798 PMCID: PMC7223711 DOI: 10.1007/s00134-019-05853-1] [Citation(s) in RCA: 189] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/01/2019] [Indexed: 12/21/2022]
Abstract
Purpose Premorbid conditions affect prognosis of acutely-ill aged patients. Several lines of evidence suggest geriatric syndromes need to be assessed but little is known on their relative effect on the 30-day survival after ICU admission. The primary aim of this study was to describe the prevalence of frailty, cognition decline and activity of daily life in addition to the presence of comorbidity and polypharmacy and to assess their influence on 30-day survival. Methods Prospective cohort study with 242 ICUs from 22 countries. Patients 80 years or above acutely admitted over a six months period to an ICU between May 2018 and May 2019 were included. In addition to common patients’ characteristics and disease severity, we collected information on specific geriatric syndromes as potential predictive factors for 30-day survival, frailty (Clinical Frailty scale) with a CFS > 4 defining frail patients, cognitive impairment (informant questionnaire on cognitive decline in the elderly (IQCODE) with IQCODE ≥ 3.5 defining cognitive decline, and disability (measured the activity of daily life with the Katz index) with ADL ≤ 4 defining disability. A Principal Component Analysis to identify co-linearity between geriatric syndromes was performed and from this a multivariable model was built with all geriatric information or only one: CFS, IQCODE or ADL. Akaike’s information criterion across imputations was used to evaluate the goodness of fit of our models. Results We included 3920 patients with a median age of 84 years (IQR: 81–87), 53.3% males). 80% received at least one organ support. The median ICU length of stay was 3.88 days (IQR: 1.83–8). The ICU and 30-day survival were 72.5% and 61.2% respectively. The geriatric conditions were median (IQR): CFS: 4 (3–6); IQCODE: 3.19 (3–3.69); ADL: 6 (4–6); Comorbidity and Polypharmacy score (CPS): 10 (7–14). CFS, ADL and IQCODE were closely correlated. The multivariable analysis identified predictors of 1-month mortality (HR; 95% CI): Age (per 1 year increase): 1.02 (1.–1.03, p = 0.01), ICU admission diagnosis, sequential organ failure assessment score (SOFA) (per point): 1.15 (1.14–1.17, p < 0.0001) and CFS (per point): 1.1 (1.05–1.15, p < 0.001). CFS remained an independent factor after inclusion of life-sustaining treatment limitation in the model. Conclusion We confirm that frailty assessment using the CFS is able to predict short-term mortality in elderly patients admitted to ICU. Other geriatric syndromes do not add improvement to the prediction model. Since CFS is easy to measure, it should be routinely collected for all elderly ICU patients in particular in connection to advance care plans, and should be used in decision making. Electronic supplementary material The online version of this article (10.1007/s00134-019-05853-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Saint Antoine Hospital, AP-HP, Hôpital Saint-Antoine, service de réanimation, F75012, Paris, France.
| | - Dylan W de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Ariane Boumendil
- AP-HP, Hôpital Saint-Antoine, service de réanimation, F75012, Paris, France
| | - Susannah Leaver
- Research Lead Critical Care Directorate St George's Hospital, London, UK
| | | | - Carol Boulanger
- Chair NAHP Section ESICM, Intensive Care Unit, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Wojciech Szczeklik
- Intensive Care and Perioperative Medicine Division, Jagiellonian University Medical College, Kraków, Poland
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Sabadell and Critical Care Department, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sagrado Corazon-General de Cataluña University Hospitals, Quiron Salud, Barcelona, Spain
| | - Alessandro Morandi
- Department of Rehabilitation Hospital Ancelle di Cremona Italy, Geriatric Research Group, Brescia, Italy
| | - Finn Andersen
- Department of Anaesthesia and Intensive Care, NTNU, Dep of Circulation and Medical Imaging, Ålesund Hospital, Trondheim, Ålesund, Norway
| | | | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Rui Moreno
- Faculdade de Ciências Médicas de Lisboa (Nova Médical School), Unidade de Cuidados Intensivos Neurocríticos e Trauma. Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Sten Walther
- Linkoping University Hospital, Linkoping, Sweden
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC Ghent University Hospital, Ghent, Belgium
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, Bern, Switzerland
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni 56, 20089, Rozzano, MI, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Rozzano, MI, Italy
| | - Brian Marsh
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Yuriy Nalapko
- European Wellness International, ICU, Luhansk, Ukraine
| | | | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Flaatten
- Dep. of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
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17
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Mizokami F, Mizuno T, Kanamori K, Oyama S, Nagamatsu T, Lee JK, Kobayashi T. Clinical medication review type III of polypharmacy reduced unplanned hospitalizations in older adults: A meta‐analysis of randomized clinical trials. Geriatr Gerontol Int 2019; 19:1275-1281. [DOI: 10.1111/ggi.13796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 08/22/2019] [Accepted: 09/26/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Fumihiro Mizokami
- Department of PharmacyNational Center for Geriatrics and Gerontology Obu Japan
| | - Tomohiro Mizuno
- Analytical PharmacologyMeijo University Graduate School of Pharmacy Nagoya Japan
- Center for Innovation in Clinical Pharmacy Education and ResearchMeijo University Nagoya Japan
| | - Koichiro Kanamori
- Analytical PharmacologyMeijo University Graduate School of Pharmacy Nagoya Japan
| | - Sakiko Oyama
- Analytical PharmacologyMeijo University Graduate School of Pharmacy Nagoya Japan
| | - Tadashi Nagamatsu
- Analytical PharmacologyMeijo University Graduate School of Pharmacy Nagoya Japan
| | - Jeannie K Lee
- Department of Pharmacy Practice & ScienceUniversity of Arizona College of Pharmacy Tucson Arizona USA
| | - Tomoharu Kobayashi
- Department of PharmacyNational Center for Geriatrics and Gerontology Obu Japan
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18
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Hall C, Essler S, Dandashi J, Corrigan M, Muñoz-Maldonado Y, Juergens A, Wieters S, Drigalla D, Regner JL. Impact of frailty and anticoagulation status on readmission and mortality rates following falls in patients over 80. Proc (Bayl Univ Med Cent) 2019; 32:181-186. [PMID: 31191123 DOI: 10.1080/08998280.2018.1550468] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/05/2018] [Accepted: 11/08/2018] [Indexed: 01/19/2023] Open
Abstract
Falls are the leading cause of trauma-related mortality in geriatric patients. We hypothesized that frailty and anticoagulation status are risk factors for readmission and mortality following falls in patients >80 years. A retrospective review was performed on patients over 80 years old who presented to our level 1 trauma center for a fall and underwent a computed tomography of the head between January 2014 and January 2016. Frailty was assessed via the Rockwood Frailty Score. Clinical outcomes were death, readmission, recurrent falls, and delayed intracranial hemorrhage. Of 803 fall-related encounters, 173 patients over 80 years old were identified for inclusion. The 30-day readmission rate was 17.5% and was associated with an increased 6-month mortality (P = 0.01). One-year and 2-year mortality rates were 28% and 47%, respectively. Frailty was the strongest predictor of 6-month and overall mortality (P < 0.01). Anticoagulation status did not significantly influence these outcomes. The recurrent fall rate was 21%, and delayed intracranial hemorrhage did not occur in this study. Mortality of octogenarians after a fall is most influenced by patient frailty. Acknowledgment of frailty, risk of recurrent falls, and increased mortality should direct goals of care for geriatric trauma patients.
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Affiliation(s)
- Chad Hall
- Department of Surgery, Baylor Scott & White Medical CenterTempleTexas
| | - Shannon Essler
- Department of Emergency Medicine, Baylor Scott & White Medical CenterTempleTexas
| | | | | | | | - Andrew Juergens
- Department of Emergency Medicine, Baylor Scott & White Medical CenterTempleTexas
| | - Scott Wieters
- Department of Emergency Medicine, Baylor Scott & White Medical CenterTempleTexas
| | - Dorian Drigalla
- Department of Emergency Medicine, Baylor Scott & White Medical CenterTempleTexas
| | - Justin L Regner
- Department of Surgery, Baylor Scott & White Medical CenterTempleTexas
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19
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McGowan K, Acton C, Ivanovski S, Johnson NW, Ware RS. Systemic comorbidities are associated with medication‐related osteonecrosis of the jaws: Case–control study. Oral Dis 2019; 25:1107-1115. [DOI: 10.1111/odi.13046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Kelly McGowan
- School of Dentistry and Oral Health Griffith University Southport Queensland Australia
- School of Dentistry University of Queensland Herston Queensland Australia
| | - Caroline Acton
- Oral & Maxillofacial Surgery Department Royal Brisbane and Women’s Hospital Herston Queensland Australia
| | - Saso Ivanovski
- School of Dentistry University of Queensland Herston Queensland Australia
| | - Newell W. Johnson
- School of Dentistry and Oral Health Griffith University Southport Queensland Australia
- Menzies Health Institute QueenslandGriffith University Southport Queensland Australia
- Dental Institute King’s College London London UK
| | - Robert S. Ware
- Menzies Health Institute QueenslandGriffith University Southport Queensland Australia
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20
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Wong TH, Wong YJ, Lau ZY, Nadkarni N, Lim GH, Seow DCC, Ong MEH, Tan KB, Nguyen HV, Wong CH. Not All Falls Are Equal: Risk Factors for Unplanned Readmission in Older Patients After Moderate and Severe Injury—A National Cohort Study. J Am Med Dir Assoc 2019; 20:201-207.e3. [DOI: 10.1016/j.jamda.2018.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
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21
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Russell AM, Smith SG, Bailey SC, Belter LT, Pandit AU, Hedlund LA, Bojarski EA, Rush SR, Wolf MS. Older Adult Preferences of Mobile Application Functionality Supporting Medication Self-Management. JOURNAL OF HEALTH COMMUNICATION 2018; 23:1064-1071. [PMID: 30526400 DOI: 10.1080/10810730.2018.1554728] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Health systems and insurers alike are increasingly interested in leveraging mHealth (mobile health) tools to support patient health-related behaviors including medication adherence. However, these tools are not widely used by older patients. This study explores patient preferences for functionality in a smartphone application (app) that supports medication self-management among older adults with multiple chronic conditions. We conducted six discussion groups in Chicago, Miami, and Denver (N = 46). English-speaking older adults (55 and older) who owned smartphones and took five or more prescription medicines were invited to participate. Discussions covered familiarity with and use of current apps and challenges with taking multidrug regimens. Participants reviewed a range of possible mobile app functions and were asked to give feedback regarding the acceptability and desirability of each to support medication management. Very few participants (n = 3) reported current use of a mobile app for medication support, although all were receptive. Challenges to medication use were forgetfulness, fear of adverse events, and managing medication information from multiple sources. Desired features included (1) a list and consolidated schedule of medications, (2) identification and warning of unsafe medication interactions, (3) reminder alerts to take medicine, and (4) the ability record when medications were taken. Features relating to refill ordering, pharmacy information, and comparing costs for medication were not considered to be as important for an app.
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Affiliation(s)
- Andrea M Russell
- a Division of General Internal Medicine , Feinberg School of Medicine at Northwestern University , Chicago , IL , USA
| | - Samuel G Smith
- b Leeds Institute of Health Sciences , University of Leeds , Leeds , UK
| | - Stacy C Bailey
- c Division of Pharmaceutical Outcomes and Policy , UNC Eshelman School of Pharmacy , Chapel Hill , NC , USA
| | - Lisa T Belter
- a Division of General Internal Medicine , Feinberg School of Medicine at Northwestern University , Chicago , IL , USA
| | - Anjali U Pandit
- a Division of General Internal Medicine , Feinberg School of Medicine at Northwestern University , Chicago , IL , USA
| | - Laurie A Hedlund
- a Division of General Internal Medicine , Feinberg School of Medicine at Northwestern University , Chicago , IL , USA
| | - Elizabeth A Bojarski
- a Division of General Internal Medicine , Feinberg School of Medicine at Northwestern University , Chicago , IL , USA
| | - Steven R Rush
- d UnitedHealth Group Health Literacy Innovations Program , United HealthCare Services Inc , Minneapolis , MN , USA
| | - Michael S Wolf
- a Division of General Internal Medicine , Feinberg School of Medicine at Northwestern University , Chicago , IL , USA
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22
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Gnädinger M, Herzig L, Ceschi A, Conen D, Staehelin A, Zoller M, Puhan MA. Chronic conditions and multimorbidity in a primary care population: a study in the Swiss Sentinel Surveillance Network (Sentinella). Int J Public Health 2018; 63:1017-1026. [PMID: 29786762 PMCID: PMC6245242 DOI: 10.1007/s00038-018-1114-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 05/08/2018] [Accepted: 05/10/2018] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To provide estimates of the prevalence of chronic conditions in Swiss primary care. METHODS In total, 175 general practitioners (GP) or pediatricians (PED) reporting to the Swiss Sentinel Surveillance Network collected morbidity data. RESULTS In 26,853 patient contacts, mean (± SD) age was 55.8 ± 21.6 or 6.1 ± 5.7 years (in GPs vs. PEDs, respectively) and 47% were males. In GP patients, median Thurgau Morbidity Index was 2 (IQR 1-3). The median numbers of chronic conditions and permanently used prescribed drugs were 2 (0-5) and 2 (1-4), respectively; in PEDs medians were 0. Out of all patients, 16.7 and 7.0% of the PED patients were hospitalized during the previous year; patients cared by family/proxies or community nurses were hospitalized significantly more often than patients living in homes (50.1 vs. 35.4%, OR 1.41, p < 0.001). Out of patients over 80 years of age, 51.5% were care dependent and 45.5% of the patients over 90 years were living in homes for the elderly. CONCLUSIONS In a representative sample of Swiss primary care patients, a substantial part shows multimorbidity with a high prevalence of chronic diseases, multiple drug treatment, and care dependency. These data may serve to be compared with other patient groups or other primary care systems. Trial registration www.clinicaltrials.gov NCT0229537, national study registry www.kofam.ch SNCTP000001207.
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Affiliation(s)
- Markus Gnädinger
- Institute of Primary Care, University of Zurich, Zurich, Switzerland.
| | - Lilli Herzig
- Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
- Swiss Sentinel Surveillance Network (Sentinella), Swiss Federal Office of Public Health, Bern, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Dieter Conen
- Patientensicherheit Schweiz, Zurich, Switzerland
| | - Alfred Staehelin
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
- Swiss Sentinel Surveillance Network (Sentinella), Swiss Federal Office of Public Health, Bern, Switzerland
| | - Marco Zoller
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
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23
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Theou O, Squires E, Mallery K, Lee JS, Fay S, Goldstein J, Armstrong JJ, Rockwood K. What do we know about frailty in the acute care setting? A scoping review. BMC Geriatr 2018; 18:139. [PMID: 29898673 PMCID: PMC6000922 DOI: 10.1186/s12877-018-0823-2] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/22/2018] [Indexed: 12/21/2022] Open
Abstract
Background The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in frailty research. Methods This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015. Results Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured frailty. Among the 204 articles that did measure frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used frailty tools to predict adverse health outcomes. In 74% of the cases frailty predicted the outcome examined, typically mortality and length of stay. Conclusions Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring frailty. There was great variability in tools used and more recently published studies were more likely to use established frailty tools. Overall, frailty appears to be a good predictor of adverse health outcomes. For frailty to be implemented in clinical practice frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined. Electronic supplementary material The online version of this article (10.1186/s12877-018-0823-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olga Theou
- Department of Medicine, Dalhousie University, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada. .,Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.
| | - Emma Squires
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Kayla Mallery
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Jacques S Lee
- Sunnybrook Health Service, 2075 Bayview Avenue, BG-04, Toronto, ON, M4N 3M5, Canada
| | - Sherri Fay
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
| | - Judah Goldstein
- Emergency Health Services, 239 Brownlow Avenue, Suite 300, Dartmouth, NS, B3B 2B2, Canada
| | - Joshua J Armstrong
- Department of Health Sciences, Lakehead University, 955 Oliver Road, Thunder Bay, ON, P7B 5E1, Canada
| | - Kenneth Rockwood
- Geriatric Medicine, QEII Health Sciences Centre, Nova Scotia Health Authority, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada.,Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Camp Hill Veterans' Memorial Building, 5955 Veterans' Memorial Lane, Halifax, NS, B3H 2E1, Canada
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24
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Wheeler KK, Shi J, Xiang H, Thakkar RK, Groner JI. US pediatric trauma patient unplanned 30-day readmissions. J Pediatr Surg 2018; 53:765-770. [PMID: 28844536 PMCID: PMC5803463 DOI: 10.1016/j.jpedsurg.2017.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/22/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE We sought to determine readmission rates and risk factors for acutely injured pediatric trauma patients. METHODS We produced 30-day unplanned readmission rates for pediatric trauma patients using the 2013 National Readmission Database (NRD). RESULTS In US pediatric trauma patients, 1.7% had unplanned readmissions within 30days. The readmission rate for patients with index operating room procedures was no higher at 1.8%. Higher readmission rates were seen in patients with injury severity scores (ISS)=16-24 (3.4%) and ISS ≥25 (4.9%). Higher rates were also seen in patients with LOS beyond a week, severe abdominal and pelvic region injuries (3.0%), crushing (2.8%) and firearm injuries (4.5%), and in patients with fluid and electrolyte disorders (3.9%). The most common readmission principal diagnoses were injury, musculoskeletal/integumentary diagnoses and infection. Nearly 39% of readmitted patients required readmission operative procedures. Most common were operations on the musculoskeletal system (23.9% of all readmitted patients), the integumentary system (8.6%), the nervous system (6.6%), and digestive system (2.5%). CONCLUSIONS Overall, the readmission rate for pediatric trauma patients was low. Measures of injury severity, specifically length of stay, were most useful in identifying those who would benefit from targeted care coordination resources. LEVEL OF EVIDENCE This is a Level III retrospective comparative study.
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Affiliation(s)
- Krista K. Wheeler
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
| | - Junxin Shi
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210
| | - Rajan K. Thakkar
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210,Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
| | - Jonathan I. Groner
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210,Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
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25
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Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr 2017; 17:230. [PMID: 29017448 PMCID: PMC5635569 DOI: 10.1186/s12877-017-0621-2] [Citation(s) in RCA: 1562] [Impact Index Per Article: 223.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 10/02/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Multimorbidity and the associated use of multiple medicines (polypharmacy), is common in the older population. Despite this, there is no consensus definition for polypharmacy. A systematic review was conducted to identify and summarise polypharmacy definitions in existing literature. METHODS The reporting of this systematic review conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. MEDLINE (Ovid), EMBASE and Cochrane were systematically searched, as well as grey literature, to identify articles which defined the term polypharmacy (without any limits on the types of definitions) and were in English, published between 1st January 2000 and 30th May 2016. Definitions were categorised as i. numerical only (using the number of medications to define polypharmacy), ii. numerical with an associated duration of therapy or healthcare setting (such as during hospital stay) or iii. Descriptive (using a brief description to define polypharmacy). RESULTS A total of 1156 articles were identified and 110 articles met the inclusion criteria. Articles not only defined polypharmacy but associated terms such as minor and major polypharmacy. As a result, a total of 138 definitions of polypharmacy and associated terms were obtained. There were 111 numerical only definitions (80.4% of all definitions), 15 numerical definitions which incorporated a duration of therapy or healthcare setting (10.9%) and 12 descriptive definitions (8.7%). The most commonly reported definition of polypharmacy was the numerical definition of five or more medications daily (n = 51, 46.4% of articles), with definitions ranging from two or more to 11 or more medicines. Only 6.4% of articles classified the distinction between appropriate and inappropriate polypharmacy, using descriptive definitions to make this distinction. CONCLUSIONS Polypharmacy definitions were variable. Numerical definitions of polypharmacy did not account for specific comorbidities present and make it difficult to assess safety and appropriateness of therapy in the clinical setting.
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Affiliation(s)
- Nashwa Masnoon
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia Australia
- Department of Pharmacy, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, South Australia Australia
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia Australia
| | - Gillian E. Caughey
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, South Australia Australia
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26
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Shulzhenko N, Zens T, Beems M, Haines K, Agarwal SK. Reply to: Threshold of number of rib fractures in elderly blunt trauma: A simple or complex matter of numbers? Surgery 2017; 162:1343-1344. [PMID: 28709647 DOI: 10.1016/j.surg.2017.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 05/10/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - Tiffany Zens
- University of Wisconsin Department of Surgery, Madison, WI
| | - Megan Beems
- University of Wisconsin Department of Surgery, Madison, WI
| | - Krista Haines
- University of Wisconsin Department of Surgery, Madison, WI
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27
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Le Pogam MA, Quantin C, Reich O, Tuppin P, Fagot-Campagna A, Paccaud F, Peytremann-Bridevaux I, Burnand B. Geriatric Patient Safety Indicators Based on Linked Administrative Health Data to Assess Anticoagulant-Related Thromboembolic and Hemorrhagic Adverse Events in Older Inpatients: A Study Proposal. JMIR Res Protoc 2017; 6:e82. [PMID: 28495660 PMCID: PMC5445236 DOI: 10.2196/resprot.7562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/13/2017] [Accepted: 04/14/2017] [Indexed: 11/13/2022] Open
Abstract
Background Frail older people with multiple interacting conditions, polypharmacy, and complex care needs are particularly exposed to health care-related adverse events. Among these, anticoagulant-related thromboembolic and hemorrhagic events are particularly frequent and serious in older inpatients. The growing use of anticoagulants in this population and their substantial risk of toxicity and inefficacy have therefore become an important patient safety and public health concern worldwide. Anticoagulant-related adverse events and the quality of anticoagulation management should thus be routinely assessed to improve patient safety in vulnerable older inpatients. Objective This project aims to develop and validate a set of outcome and process indicators based on linked administrative health data (ie, insurance claims data linked to hospital discharge data) assessing older inpatient safety related to anticoagulation in both Switzerland and France, and enabling comparisons across time and among hospitals, health territories, and countries. Geriatric patient safety indicators (GPSIs) will assess anticoagulant-related adverse events. Geriatric quality indicators (GQIs) will evaluate the management of anticoagulants for the prevention and treatment of arterial or venous thromboembolism in older inpatients. Methods GPSIs will measure cumulative incidences of thromboembolic and bleeding adverse events based on hospital discharge data linked to insurance claims data. Using linked administrative health data will improve GPSI risk adjustment on patients’ conditions that are present at admission and will capture in-hospital and postdischarge adverse events. GQIs will estimate the proportion of index hospital stays resulting in recommended anticoagulation at discharge and up to various time frames based on the same electronic health data. The GPSI and GQI development and validation process will comprise 6 stages: (1) selection and specification of candidate indicators, (2) definition of administrative data-based algorithms, (3) empirical measurement of indicators using linked administrative health data, (4) validation of indicators, (5) analyses of geographic and temporal variations for reliable and valid indicators, and (6) data visualization. Results Study populations will consist of 166,670 Swiss and 5,902,037 French residents aged 65 years and older admitted to an acute care hospital at least once during the 2012-2014 period and insured for at least 1 year before admission and 1 year after discharge. We will extract Swiss data from the Helsana Group data warehouse and French data from the national health insurance information system (SNIIR-AM). The study has been approved by Swiss and French ethics committees and regulatory organizations for data protection. Conclusions Validated GPSIs and GQIs should help support and drive quality and safety improvement in older inpatients, inform health care stakeholders, and enable international comparisons. We discuss several limitations relating to the representativeness of study populations, accuracy of administrative health data, methods used for GPSI criterion validity assessment, and potential confounding bias in comparisons based on GQIs, and we address these limitations to strengthen study feasibility and validity.
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Affiliation(s)
- Marie-Annick Le Pogam
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Catherine Quantin
- Biostatistics and Bioinformatics (DIM), Dijon University Hospital and University of Bourgogne Franche-Comté, Dijon, France.,Inserm, CIC 1432, Clinical epidemiology / clinical trials unit, Dijon University Hospital, Dijon, France.,Inserm, UMR 1181, B2PHI: Biostatistics, Biomathematics, PHarmacoepidemiology and Infectious diseases, Institut Pasteur and Université de Versailles St-Quentin-en-Yvelines, Université Paris-Saclay, Paris, France
| | - Oliver Reich
- Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland
| | - Philippe Tuppin
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
| | - Anne Fagot-Campagna
- Caisse Nationale d'Assurance Maladie des Travailleurs Salariés, Paris, France
| | - Fred Paccaud
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
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28
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Lin MJ, Baky F, Housley BC, Kelly N, Pletcher E, Balshi JD, Stawicki SP, Evans DC. Temporal variability of readmission determinants in postoperative vascular surgery patients. J Postgrad Med 2017; 62:216-222. [PMID: 27763477 PMCID: PMC5105205 DOI: 10.4103/0022-3859.188548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Introduction: Clinical information continues to be limited regarding changes in the temporal risk profile for readmissions during the initial postoperative year in vascular surgery patients. We set out to describe the associations between demographics, clinical outcomes, comorbidity indices, and hospital readmissions in a sample of patients undergoing common extremity revascularization or dialysis access (ERDA) procedures. We hypothesized that factors independently associated with readmission will evolve from “short-term” to “long-term” determinants at 30-, 180-, and 360-day postoperative cutoff points. Methods: Following IRB approval, medical records of patients who underwent ERDA at two institutions were retrospectively reviewed between 2008 and 2014. Abstracted data included patient demographics, procedural characteristics, the American Society of Anesthesiologists score, Goldman Criteria for perioperative cardiac assessment, the Charlson comorbidity index, morbidity, mortality, and readmission (at 30-, 180-, and 360-days). Univariate analyses were performed for readmissions at each specified time point. Variables reaching statistical significance of P < 0.20 were included in multivariate analyses for factors independently associated with readmission. Results: A total of 450 of 744 patients who underwent ERDA with complete medical records were included. Patients underwent either an extremity revascularization (e.g. bypass or endarterectomy, 406/450) or a noncatheter dialysis access procedure (44/450). Sample characteristics included 262 (58.2%) females, mean age 61.4 ± 12.9 years, 63 (14%) emergent procedures, and median operative time 164 min. Median hospital length of stay (index admission) was 4 days. Cumulative readmission rates at 30-, 180-, and 360-day were 12%, 27%, and 35%, respectively. Corresponding mortality rates were 3%, 7%, and 9%. Key factors independently associated with 30-, 180-, and 360-day readmissions evolved over the study period from comorbidity and morbidity-related issues in the short-term to cardiovascular and graft patency issues in the long-term. Any earlier readmission elevated the risk of subsequent readmission. Conclusions: We noted important patterns in the temporal behavior of hospital readmission risk in patients undergoing ERDA. Although factors independently associated with readmission were not surprising (e.g. comorbidity profile, cardiovascular status, and graft patency), the knowledge of temporal trends described in this study may help determine clinical risk profiles for individual patients and guide readmission reduction strategies. These considerations will be increasingly important in the evolving paradigm of value-based healthcare.
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Affiliation(s)
- M J Lin
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - F Baky
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - B C Housley
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - N Kelly
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - E Pletcher
- Temple University School of Medicine - St. Luke's University Hospital Campus, Bethlehem, PA, USA
| | - J D Balshi
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - S P Stawicki
- Department of Surgery; Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - D C Evans
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
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29
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Joseph B, Toosizadeh N, Orouji Jokar T, Heusser MR, Mohler J, Najafi B. Upper-Extremity Function Predicts Adverse Health Outcomes among Older Adults Hospitalized for Ground-Level Falls. Gerontology 2016; 63:299-307. [PMID: 27941328 DOI: 10.1159/000453593] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/19/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite National Surgical Quality Improvement guidelines to integrate frailty into surgical elder assessments, a quick, accurate, and simple frailty assessment tool suitable for busy clinical settings is still not available. Recently, we have demonstrated that a simple upper-extremity function (UEF) test based on wearable sensors could identify frailty with high agreement with conventional assessments by testing 20-s repetitive elbow flexion and extension. OBJECTIVE We examined whether UEF parameters are sensitive for predicting adverse health outcomes in bedbound older adults admitted to hospital due to ground-level fall injuries. STUDY DESIGN Frailty was assessed in 101 eligible older adults (age: 79 ± 9 years) admitted to a trauma setting using the UEF test at the time of admission. All participants were followed up for 2 months using phone calls and chart reviews. The measured health outcomes included (1) discharge disposition (favorable: discharge home or rehabilitation; unfavorable: discharge to skilled nursing facility or death), (2) hospital length of stay, (3) 30-day readmission, (4) 60-day readmission, and (5) 30-day prospective falls. Multivariate analyses were used to identify independent predictors of adverse health outcomes based on participants' demographic parameters (i.e., age, gender, and body mass index [BMI]) and UEF index. RESULTS Based on the UEF frailty status, 53 (52%) of the participants were frail and 48 (48%) were non-frail. Among all adverse health outcomes, age was only a significant predictor of 30-day prospective falls (p = 0.023). On the other hand, the UEF index was a significant predictor of all measured outcomes except hospital length of stay (p < 0.010). Among the UEF parameters, those indicating slowness, weakness, and exhaustion had the highest effect sizes to predict an unfavorable discharge disposition (p < 0.010; effect size = 0.65-0.92). CONCLUSION The results of this study suggest that a 20-s UEF test is practical in the trauma setting and could be used as a quick measure for predicting adverse events and outcomes among bedbound patients after discharge. Assessing frailty using UEF may assist in objective triage, treatment, and post-discharge decision-making with regard to geriatric trauma patients.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA
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Mubang RN, Stoltzfus JC, Cohen MS, Hoey BA, Stehly CD, Evans DC, Jones C, Papadimos TJ, Grell J, Hoff WS, Thomas P, Cipolla J, Stawicki SP. Comorbidity-Polypharmacy Score as Predictor of Outcomes in Older Trauma Patients: A Retrospective Validation Study. World J Surg 2016; 39:2068-75. [PMID: 25809063 DOI: 10.1007/s00268-015-3041-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Traditional injury severity assessment is insufficient in estimating the morbidity and mortality risk for older (≥45 years) trauma patients. Commonly used tools involve complex calculations or tables, do not consider all comorbidities, and often rely on data that are not available early in the trauma patient's hospitalization. The comorbidity-polypharmacy score (CPS), a sum of all pre-injury medications and comorbidities, was found in previous studies to independently predict morbidity and mortality in this older patient population. However, these studies are limited by relatively small sample sizes. Consequently, we sought to validate previous research findings in a large, administrative dataset. METHODS A retrospective study of patients ages≥45 years was performed using an administrative trauma database from St. Luke's University Hospital's Level I Trauma Center. The study period was from 1 January 2008 to 31 December 2013. Abstracted data included patient demographics, injury mechanism and severity [injury characteristics and severity score (ISS)], Glasgow coma scale (GCS), hospital and intensive care unit lengths of stay (HLOS and ILOS, respectively), morbidity, post-discharge destination, and in-hospital mortality. Univariate analyses were conducted with mortality, all-cause morbidity, and discharge destination as primary end-points. Variables reaching statistical significance (p≤0.20) were included in a multivariate logistic regression model. Data are presented as adjusted odds ratios (AORs), with p<0.05 denoting statistical significance. RESULTS A total of 5863 patient records were analyzed. Average patient age was 68.5±15.3 years (52% male, 89% blunt mechanism, mean GCS 14.3). Mean HLOS and ILOS increased significantly with increasing CPS (p<0.01). Independent predictors of mortality included age (AOR 1.05, p<0.01), CPS (per-unit AOR 1.08, p<0.02), GCS (AOR 1.43 per-unit decrease, p<0.01), and ISS (per-unit 1.08, p<0.01). Independent predictors of all-cause morbidity included age (AOR 1.02, p<0.01), GCS (AOR per-unit decrease 1.08, p<0.01), ISS (per-unit AOR 1.09, p<0.01), and CPS (per-unit AOR 1.04, p<0.01). CPS did not independently predict need for discharge to a facility. CONCLUSIONS This study confirms that CPS is an independent predictor of all-cause morbidity and mortality in older trauma patients. However, CPS was not independently associated with need for discharge to a facility. Prospective multicenter studies are needed to evaluate the use of CPS as a predictive and interventional tool, with special focus on correlations between specific pre-existing conditions, pharmacologic interactions, and morbidity/mortality patterns.
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Affiliation(s)
- Ronnie N Mubang
- Department of Surgery, St Luke's University Health Network, 801 Ostrum Street, NW2 Administration, Bethlehem, PA, 18015, USA
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31
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Birriel TJ, Uchino R, Barry N, Butryn T, Sabol DM, Valenza PL, Stawicki SP. Adverse drug reactions in the era of multi-morbidity and polypharmacy. J Basic Clin Pharm 2015; 6:122-3. [PMID: 26692740 PMCID: PMC4660485 DOI: 10.4103/0976-0105.168052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- T Javier Birriel
- St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Reina Uchino
- St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Noran Barry
- St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Tracy Butryn
- St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Donna M Sabol
- St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Pamela L Valenza
- St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
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Stawicki SP, Kalra S, Jones C, Justiniano CF, Papadimos TJ, Galwankar SC, Pappada SM, Feeney JJ, Evans DC. Comorbidity polypharmacy score and its clinical utility: A pragmatic practitioner's perspective. J Emerg Trauma Shock 2015; 8:224-31. [PMID: 26604529 PMCID: PMC4626940 DOI: 10.4103/0974-2700.161658] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 02/23/2015] [Indexed: 12/11/2022] Open
Abstract
Modern medical management of comorbid conditions has resulted in escalating use of multiple medications and the emergence of the twin phenomena of multimorbidity and polypharmacy. Current understanding of how the polypharmacy in conjunction with multimorbidity influences trauma outcomes is limited, although it is known that trauma patients are at increased risk for medication-related adverse events. The comorbidity-polypharmacy score (CPS) is a simple clinical tool that quantifies the overall severity of comorbidities using the polypharmacy as a surrogate for the "intensity" of treatment necessary to adequately control chronic medical conditions. Easy to calculate, CPS is derived by counting all known pre-injury comorbid conditions and medications. CPS has been independently associated with mortality, increased risk for complications, lower functional outcomes, readmissions, and longer hospital stays. In addition, CPS may help identify older trauma patients at risk of post-emergency department undertriage. The goal of this article was to review and refine the rationale for CPS and to provide an evidence-based outline of its potential clinical applications.
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Affiliation(s)
- Stanislaw P. Stawicki
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Sarathi Kalra
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Christian Jones
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Carla F. Justiniano
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas J. Papadimos
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sagar C. Galwankar
- Department of Emergency Medicine, University of Florida, Jacksonville, Ohio, USA
| | - Scott M. Pappada
- Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - John J. Feeney
- Division of Performance Assessment & Augmentation, Aptima, Inc., Fairborn, Ohio, USA
| | - David C. Evans
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
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