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Hassan EM, Jama AB, Sharaf A, Shaikh A, El Labban M, Surani S, Khan SA. Discharging patients home from the intensive care unit: A new trend. World J Clin Cases 2024; 12:5313-5319. [DOI: 10.12998/wjcc.v12.i23.5313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/07/2024] [Accepted: 06/28/2024] [Indexed: 07/05/2024] Open
Abstract
Discharging patients directly to home from the intensive care unit (ICU) is becoming a new trend. This review examines the feasibility, benefits, challenges, and considerations of directly discharging ICU patients. By analyzing available evidence and healthcare professionals' experiences, the review explores the potential impacts on patient outcomes and healthcare systems. The practice of direct discharge from the ICU presents both opportunities and complexities. While it can potentially reduce costs, enhance patient comfort, and mitigate complications linked to extended hospitalization, it necessitates meticulous patient selection and robust post-discharge support mechanisms. Implementing this strategy successfully mandates the availability of home-based care services and a careful assessment of the patient's readiness for the transition. Through critical evaluation of existing literature, this review underscores the significance of tailored patient selection criteria and comprehensive post-discharge support systems to ensure patient safety and optimal recovery. The insights provided contribute evidence-based recommendations for refining the direct discharge approach, fostering improved patient outcomes, heightened satisfaction, and streamlined healthcare processes. Ultimately, the review seeks to balance patient-centered care and effective resource utilization within ICU discharge strategies.
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Affiliation(s)
- Esraa M Hassan
- Department of Critical Care Medicine, Mayo Clinic Health system, Mankato, MN 56001, United States
| | - Abbas B Jama
- Department of Critical Care Medicine, Mayo Clinic Health system, Mankato, MN 56001, United States
| | - Ahmed Sharaf
- Department of Internal Medicine, Baptist Hospital of Southeast Texas, Beaumont, TX 77701, United States
| | - Asim Shaikh
- Department of Medicine, Aga Khan University, Karachi 74200, Sindh, Pakistan
| | - Mohamad El Labban
- Department of Internal Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Department of Medicine and Pharmacology, Texas A&M University, College Station, TX 77843, United States
- Department of Anaesthesiology, Mayo Clinic Health System, Rochester, MN 55905, United States
| | - Syed A Khan
- Department of Critical Care Medicine, Mayo Clinic Health system, Mankato, MN 56001, United States
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2
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Tran QK, Widjaja A, Plotnikova A, Yang J, Epstein J, Aquino A, Albelo F, Kowansky T, Vashee I, Austin S, Haase DJ, Esposito E. Direct Discharge from the Critical Care Resuscitation Unit: Results from a Longitudinal Assessment. Crit Care Res Pract 2023; 2023:2213185. [PMID: 37937161 PMCID: PMC10627715 DOI: 10.1155/2023/2213185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/20/2023] [Accepted: 10/07/2023] [Indexed: 11/09/2023] Open
Abstract
Background The critical care resuscitation unit (CCRU) facilitates interhospital transfer (IHT) of critically ill patients for immediate interventions. Due to these patients' acuity, it is uncommon for patients to be directly discharged home from this unit, but it does happen on occasion. Since there is no literature regarding outcomes of patients being discharged from a resuscitation unit, our study investigated these patients' outcome at greater than 12 months after being discharged directly from the CCRU. Methods We performed a retrospective cohort study of all adult patients directly discharged from the CCRU between January 01, 2017, and December 31, 2020. The primary outcome was number of ED visits or hospitalizations within 6 months. Secondary outcomes were number of ED visits or hospitalizations within 6, 12, and >12 months from CCRU discharge. Results We analyzed 145 patients' records. Mean age was 56 (standard deviation [SD] ± 19), with a majority being male (72%) and Caucasian (58%). The most common discharge destination was home (139 patients, 96% of total subjects) versus hospice (2%) or nursing facilities (2%). Most patients (55%) did not have any hospital revisits within the first 6 months of discharge, while 31% had 1-2 revisits, and 14% had ≥3 revisits. The most common discharge diagnoses were soft tissue infection (16.5%), aortic dissection (14%), and stroke (11%). Factors which were associated with a greater likelihood of any return hospital visit within 6 months receiving mechanical ventilation during CCRU stay (coefficient -2.23, 95% CI 0.01-0.87, P=0.036), while high hemoglobin on CCRU discharge was associated with no ED revisit (coeff. 0.42, 95% CI 1.15-2.06, P=0.004). Conclusions Most patients who were discharged from the CCRU did not require any hospital revisits in the first 6 months. Requiring mechanical ventilation and having soft tissue infection were associated with high unplanned hospital revisits following discharge. Further research is needed to validate these findings.
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Affiliation(s)
- Quincy K. Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Austin Widjaja
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anya Plotnikova
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jerry Yang
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jacob Epstein
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alexa Aquino
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Fernando Albelo
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Taylor Kowansky
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Isha Vashee
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel Austin
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J. Haase
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Esposito
- The R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Roumeliotis N, Desforges J, French ME, Dupre-Roussel J, Fiest KM, Lau VI, Lacroix J, Carnevale FA. Patient and Family Experience With Discharge Directly Home From the Pediatric ICU. Hosp Pediatr 2023; 13:954-960. [PMID: 37667850 DOI: 10.1542/hpeds.2023-007332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
BACKGROUND Children are increasingly discharged directly from the PICU. Transitions have been recognized as a period of increased patient and caregiver stress and risk of adverse events. No study has evaluated patient and caregiver outcomes after direct discharge from the PICU. This study aimed to explore the family's experiences with discharge directly home (DDH) from the PICU. METHODS This exploratory mixed-methods study was conducted in the PICU of the Institution is Sainte-Justine Hospital from February to July 2021. We included families of children expected to be DDH within 12 hours. Semistructured interviews were conducted at discharge, followed by telephone interviews 7 and 28 days post-PICU discharge. We measured comfort on a 5-point Likert scale and screened for anxiety using the Generalized Anxiety Disorder-7 tool. RESULTS Families of 25 patients were interviewed. Thematic analysis of the interviews revealed several themes, such as feeling stress and anxiety, feeling confident, anticipating home care, and needing support. These findings complemented the quantitative findings; the median comfort score was 4 (comfortable) (interquartile range 4-5) and 8 (interquartile range 4-12) for the Generalized Anxiety Disorder-7 on the day of discharge, with 16 reporting clinically significant anxiety. In the 28-day study period, 2 patients were readmitted and 6 had visited the emergency department. CONCLUSIONS Despite feelings of anxiety, many families felt comfortable with DDH from the PICU. Increasing our understanding of the patient and family experiences of discharge from the PICU will help to better support these patients and their families during transition.
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Affiliation(s)
| | | | | | | | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Jacques Lacroix
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Franco A Carnevale
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
- Pediatric ICU, Montreal Children's Hospital, Montreal, Quebec, Canada
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Siddiqui S, Kelly L, Bosch N, Law A, Patel LA, Perkins N, Armaignac DL, Zabolotskikh I, Christie A, Krishna Mohan S, Deo N, Bansal V, Kumar VK, Gajic O, Kashyap R, Domecq JP, Boman K, Walkey A, Banner-Goodspeed V, Schaefer MS. Discharge Disposition and Loss of Independence Among Survivors of COVID-19 Admitted to Intensive Care: Results From the SCCM Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS). J Intensive Care Med 2023; 38:931-938. [PMID: 37157813 PMCID: PMC10183337 DOI: 10.1177/08850666231174375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES To describe incidence and risk factors of loss of previous independent living through nonhome discharge or discharge home with health assistance in survivors of intensive care unit (ICU) admission for coronavirus disease 2019 (COVID-19). DESIGN Multicenter observational study including patients admitted to the ICU from January 2020 till June 30, 2021. HYPOTHESIS We hypothesized that there is a high risk of nonhome discharge in patients surviving ICU admission due to COVID-19. SETTING Data were included from 306 hospitals in 28 countries participating in the SCCM Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 registry. PATIENTS Previously independently living adult ICU survivors of COVID-19. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was nonhome discharge. Secondary outcome was the requirement of health assistance among patients who were discharged home. Out of 10 820 patients, 7101 (66%) were discharged alive; 3791 (53%) of these survivors lost their previous independent living status, out of those 2071 (29%) through nonhome discharge, and 1720 (24%) through discharge home requiring health assistance. In adjusted analyses, loss of independence on discharge among survivors was predicted by patient age ≥ 65 years (adjusted odds ratio [aOR] 2.78, 95% confidence interval [CI] 2.47-3.14, P < .0001), former and current smoking status (aOR 1.25, 95% CI 1.08-1.46, P = .003 and 1.60 (95% CI 1.18-2.16), P = .003, respectively), substance use disorder (aOR 1.52, 95% CI 1.12-2.06, P = .007), requirement for mechanical ventilation (aOR 4.17, 95% CI 3.69-4.71, P < .0001), prone positioning (aOR 1.19, 95% CI 1.03-1.38, P = .02), and requirement for extracorporeal membrane oxygenation (aOR 2.28, 95% CI 1.55-3.34, P < .0001). CONCLUSIONS More than half of ICU survivors hospitalized for COVID-19 are unable to return to independent living status, thereby imposing a significant secondary strain on health care systems worldwide.
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Affiliation(s)
- Shahla Siddiqui
- Center for Anesthesia Research
Excellence (CARE), Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical
Center, and Harvard Medical School, Boston, MA, USA
| | - Lauren Kelly
- Center for Anesthesia Research
Excellence (CARE), Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical
Center, and Harvard Medical School, Boston, MA, USA
| | | | - Anica Law
- Boston University School of
Medicine, Boston, MA, USA
| | - Love A Patel
- Allina Health (Abbott Northwestern
Hospital), Minneapolis, MN, USA
| | | | | | | | - Amy Christie
- Atrium Health Navicent the Medical
Center, Macon, GA, USA
| | | | - Neha Deo
- Mayo Clinic Rochester, Rochester, MN,
USA
| | | | | | | | | | | | - Karen Boman
- Society of Critical Care
Medicine, Mount Prospect, IL, USA
| | - Allan Walkey
- Boston University School of
Medicine, Boston, MA, USA
| | - Valerie Banner-Goodspeed
- Center for Anesthesia Research
Excellence (CARE), Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical
Center, and Harvard Medical School, Boston, MA, USA
| | - Maximilian Sebastian Schaefer
- Center for Anesthesia Research
Excellence (CARE), Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical
Center, and Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology,
Duesseldorf University Hospital, Duesseldorf, Germany
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Safety Outcomes of Direct Discharge Home From ICUs: An Updated Systematic Review and Meta-Analysis (Direct From ICU Sent Home Study). Crit Care Med 2023; 51:127-135. [PMID: 36519986 PMCID: PMC9750104 DOI: 10.1097/ccm.0000000000005720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the impact of direct discharge home (DDH) from ICUs compared with ward transfer on safety outcomes of readmissions, emergency department (ED) visits, and mortality. DATA SOURCES We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature from inception until March 28, 2022. STUDY SELECTION Randomized and nonrandomized studies of DDH patients compared with ward transfer were eligible. DATA EXTRACTION We screened and extracted studies independently and in duplicate. We assessed risk of bias using the Newcastle-Ottawa Scale for observational studies. A random-effects meta-analysis model and heterogeneity assessment was performed using pooled data (inverse variance) for propensity-matched and unadjusted cohorts. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS Of 10,228 citations identified, we included six studies. Of these, three high-quality studies, which enrolled 49,376 patients in propensity-matched cohorts, could be pooled using meta-analysis. For DDH from ICU, compared with ward transfers, there was no difference in the risk of ED visits at 30-day (22.4% vs 22.7%; relative risk [RR], 0.99; 95% CI, 0.95-1.02; p = 0.39; low certainty); hospital readmissions at 30-day (9.8% vs 9.6%; RR, 1.02; 95% CI, 0.91-1.15; p = 0.71; very low-to-low certainty); or 90-day mortality (2.8% vs 2.6%; RR, 1.06; 95% CI, 0.95-1.18; p = 0.29; very low-to-low certainty). There were no important differences in the unmatched cohorts or across subgroup analyses. CONCLUSIONS Very low-to-low certainty evidence from observational studies suggests that DDH from ICU may have no difference in safety outcomes compared with ward transfer of selected ICU patients. In the future, this research question could be further examined by randomized control trials to provide higher certainty data.
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6
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Daoust D, Dodin P, Sy E, Lau V, Roumeliotis N. Prevalence and Readmission Rates of Discharge Directly Home From the PICU: A Systematic Review. Pediatr Crit Care Med 2023; 24:62-71. [PMID: 36594800 DOI: 10.1097/pcc.0000000000003114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Critically ill patients are increasingly being discharged directly home from PICU as opposed to discharged home, via the ward. The objective was to assess the prevalence, safety, and satisfaction of discharge directly home from PICUs. DATA SOURCES We searched PubMed, Medline, EMBASE, PsycINFO, and CINAHL for studies published between January 1991 and June 2021. STUDY SELECTION We included observational or randomized studies, of children up to 18 years old, that reported on the prevalence, safety, or satisfaction of discharge directly home from the PICU, compared with the ward. Safety outcomes included readmission, unplanned visits to hospital, and any adverse events. We excluded case series, reviews, and studies discharging patients to other facilities. DATA EXTRACTION Two independent reviewers evaluated 88 full-text articles; five studies met eligibility (362,868 patients). Only one study had discharge directly home as a primary outcome. DATA SYNTHESIS Prevalence of discharge directly to home from the PICU ranged from less than 1% to 23% (random effects proportion 7.7 [95% CI, 1.3-18.6]). Readmissions to the PICU (only safety outcome) were significantly lower in the discharge directly home group compared with the ward group, in two of three studies (p < 0.0001). No studies reported on patient or family satisfaction. CONCLUSIONS The prevalence of discharge directly home from the PICU ranges from 1% to 23%. PICU readmission rates do not appear to increase after discharge directly home. Caution is needed in the interpretation of the results, given the significant heterogeneity of the included studies. Further high-quality studies are needed to evaluate the safety of discharge directly home from the PICU and support families in this transition.
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Affiliation(s)
- Daphne Daoust
- Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Philippe Dodin
- Medical Librarian, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, QC, Canada
| | - Eric Sy
- Department of Medicine, College of Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Vincent Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nadia Roumeliotis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
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7
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Gal DB, Kwiatkowski DM, Cribb Fabersunne C, Kipps AK. Direct Discharge to Home From the Pediatric Cardiovascular ICU. Pediatr Crit Care Med 2022; 23:e199-e207. [PMID: 35044343 DOI: 10.1097/pcc.0000000000002883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe direct discharge to home from the cardiovascular ICU. DESIGN Mixed-methods including retrospective Pediatric Cardiac Critical Care Consortium and Pediatric Acute Care Cardiology Collaborative data and survey. SETTING Tertiary pediatric heart center. PATIENTS Patients less than 25 years old, with a cardiovascular ICU stay of greater than 24 hours and direct discharge to home from January 1, 2016, to December 8, 2020, were included. Select data describing patients discharged from acute care internally and nationally from Pediatric Acute Care Cardiology Collaborative sites were compared with the direct discharge to home cohort. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Encounter- and patient-specific characteristics. Seven-day and 30-day readmission and 30-day mortality served as surrogate safety markers. A survey of cardiovascular ICU frontline providers assessed comfort and skills related to direct discharge to home.There were 364 direct discharge to home encounters that met inclusion criteria. The majority of direct discharge to home encounters were associated with a surgery or procedure (305; 84%). There were 27 encounters (7.4%) for medical technology-dependent patients requiring direct discharge to home. Unplanned 7-day readmissions among direct discharge to home patients was 1.9% compared with 4.6% (p = 0.04) of patients discharged from acute care internally. Readmission among those discharged from acute care internally did not differ from those at Pediatric Acute Care Cardiology Collaborative sites nationally. Frontline cardiovascular ICU providers had mixed levels of confidence in technical aspects and low levels of confidence in logistics of direct discharge to home. CONCLUSIONS Cardiovascular ICU direct discharge to home was not associated with increased unplanned readmissions compared with patients discharged from acute care and may be safe in select patients. Frontline cardiovascular ICU providers feel time constraints challenge direct discharge to home. Further research is needed to identify patient characteristics associated with safe direct discharge to home and systems needed to support this practice.Summary statistics are described using proportions or medians with interquartile ranges (IQRs) and were performed using Microsoft Excel (Microsoft, Redmond, WA). Two-sample tests of proportions were used to compare readmission frequency of the DDH cohort compared with internal and national PAC3 data using STATA Version 15 (StataCorp, College Station, TX).
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Affiliation(s)
- Dana B Gal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - David M Kwiatkowski
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - Camila Cribb Fabersunne
- San Francisco Department of Public Health, Division of Maternal and Child Health, San Francisco, CA
| | - Alaina K Kipps
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
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McPeake J, Bateson M, Christie F, Robinson C, Cannon P, Mikkelsen M, Iwashyna TJ, Leyland AH, Shaw M, Quasim T. Hospital re-admission after critical care survival: a systematic review and meta-analysis. Anaesthesia 2022; 77:475-485. [PMID: 34967011 DOI: 10.1111/anae.15644] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 12/22/2022]
Abstract
Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3-21.2%) at 30 days; 31.0% (95%CI: 24.3-38.6%) at 90 days; 29.6% (95%CI: 24.5-35.2%) at six months; and 53.3% (95%CI: 44.4-62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation.
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Affiliation(s)
- J McPeake
- Intensive Care Unit, Glasgow Royal Infirmary and School of Medicine, Dentistry and Nursing, University of Glasgow, UK
| | - M Bateson
- University of the West of Scotland, Glasgow, UK
| | - F Christie
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - C Robinson
- Belfast Health and Social Care Trust, Belfast, UK
| | - P Cannon
- University of Glasgow Library, Glasgow, UK
| | - M Mikkelsen
- Center for Clinical Epidemiology and Biostatistics, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - T J Iwashyna
- Centre for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - A H Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - M Shaw
- Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - T Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.,Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK
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9
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Sy E, Gupta C, Shahab Z, Fortin N, Kassir S, Mailman JF, Lau VI. Long-term Safety of Directly Discharging Patients Home from the ICU Compared to Ward Transfer. J Intensive Care Med 2022; 37:1344-1352. [PMID: 35350921 DOI: 10.1177/08850666221090459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate the long-term safety of directly discharging intensive care unit (ICU) survivors to their home. Methods: A retrospective observational cohort of 341 ICU survivors who were directly discharged home from the ICU ("direct discharge") or discharged home ≤72 hours after ICU transfer to the ward ("ward transfer") was conducted in Regina, Saskatchewan ICUs between September 1, 2016 and September 30, 2018. The primary outcome was 90-day hospital readmission. Secondary outcomes included 30-day, 90-day, and 365-day emergency department (ED) visits, 30-day and 365-day hospital readmissions, and 365-day mortality. All outcomes were evaluated by multivariable Cox regression after adjustment for demographic and clinical characteristics. Results: Of 341 survivors (25.5% of total ICU visits), 148 (43.4%) patients were direct discharges and 193 (56.6%) were ward transfers. The median age was 46 years (interquartile range, 34-62), 38.4% were female, and 61.8% resided in Regina. Compared to the ward transfer cohort, more patients in the direct discharge cohort had at least one 90-day hospital readmission (30.4% versus 17.1% of patients, adjusted hazard ratio 2.09, 95% confidence interval 1.28-3.40, P = .003), after adjustment. Additionally, there were more 90-day ED visits (P = .045), and 30-day (P = .049) and 365-day hospital readmissions (P = .03), after adjustment. Conclusions: In Saskatchewan, direct discharge compared to ward transfer was associated with an increase in 90-day hospital readmissions, and potentially other clinical outcomes. Further study is necessary.
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Affiliation(s)
- Eric Sy
- Department of Critical Care, 7234Saskatchewan Health Authority, Regina General Hospital, Regina, Saskatchewan, Canada.,College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Chiraag Gupta
- College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada.,Research Department, 7234Saskatchewan Health Authority, Wascana Rehabilitation Centre, Regina, Saskatchewan, Canada
| | - Zunaira Shahab
- College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada.,Department of Medicine, 7235University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nathan Fortin
- College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Sandy Kassir
- Research Department, 7234Saskatchewan Health Authority, Wascana Rehabilitation Centre, Regina, Saskatchewan, Canada
| | - Jonathan F Mailman
- Department of Critical Care, 7234Saskatchewan Health Authority, Regina General Hospital, Regina, Saskatchewan, Canada.,College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada.,Department of Pharmacy Services, 7234Saskatchewan Health Authority, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 3C1.12 Walter C Mackenzie Centre, Edmonton, Alberta, Canada
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10
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Outcomes After Direct Discharge Home From Critical Care Units: A Population-Based Cohort Analysis. Crit Care Med 2022; 50:1256-1264. [PMID: 35275594 DOI: 10.1097/ccm.0000000000005533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare health service use and clinical outcomes for patients with and without direct discharge to home (DDH) from ICUs in Ontario. DESIGN Population-based, observational, cohort study using propensity scoring to match patients who were DDH to those not DDH and a preference-based instrumental variable (IV) analysis using ICU-level DDH rate as the IV. SETTING ICUs in Ontario. PATIENTS Patients discharged home from a hospitalization either directly or within 48 hours of care in an ICU between April 1, 2015, and March 31, 2017. INTERVENTION DDH from ICU. MEASUREMENTS AND MAIN RESULTS Among 76,737 patients in our cohort, 46,859 (61%) were DDH from the ICU. In the propensity matched cohort, the odds for our primary outcome of hospital readmission or emergency department (ED) visit within 30 days were not significantly different for patients DDH (odds ratio [OR], 1.00; 95% CI, 0.96-1.04), and there was no difference in mortality at 90 days for patients DDH (OR, 1.08; 95% CI, 0.97-1.21). The effect on hospital readmission or ED visits was similar in the subgroup of patients discharged from level 2 (OR, 0.98; 95% CI, 0.92-1.04) and level 3 ICUs (OR, 1.02; 95% CI, 0.96-1.09) and in the subgroups with cardiac conditions (OR, 1.03; 95% CI, 0.96-1.12) and noncardiac conditions (OR, 0.98; 95% CI, 0.94-1.03). Similar results were obtained in the IV analysis (coefficient for hospital readmission or ED visit within 30 d = -0.03 ± 0.03 (SE); p = 0.3). CONCLUSIONS There was no difference in outcomes for patients DDH compared with ward transfer prior to discharge when two approaches were used to minimize confounding within a large health systemwide observational cohort. We did not evaluate how patients are selected for DDH. Our results suggest that with careful patient selection, this practice might be feasible for routine implementation to ensure efficient and safe use of limited healthcare resources.
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Sy E, Parvez S, Kassir S, Donnelly R, Gupta C, Mailman JF, Lau VI. Canadian healthcare provider perceptions of discharging patients directly home from the intensive care unit. Can J Anaesth 2021; 68:1840-1842. [PMID: 34553307 DOI: 10.1007/s12630-021-02107-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/23/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Eric Sy
- Department of Critical Care, Saskatchewan Health Authority, Regina General Hospital, Regina, SK, Canada. .,College of Medicine, University of Saskatchewan, Regina General Hospital, Regina, SK, Canada.
| | - Sehar Parvez
- College of Medicine, University of Saskatchewan, Regina General Hospital, Regina, SK, Canada
| | - Sandy Kassir
- Research Department, Saskatchewan Health Authority, Wascana Rehabilitation Centre, Regina, SK, Canada
| | - Ryan Donnelly
- College of Medicine, University of Saskatchewan, Regina General Hospital, Regina, SK, Canada
| | - Chiraag Gupta
- College of Medicine, University of Saskatchewan, Regina General Hospital, Regina, SK, Canada.,Research Department, Saskatchewan Health Authority, Wascana Rehabilitation Centre, Regina, SK, Canada
| | - Jonathan F Mailman
- College of Medicine, University of Saskatchewan, Regina General Hospital, Regina, SK, Canada.,Department of Pharmacy Services, Saskatchewan Health Authority, Regina General Hospital, Regina, SK, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Patel PM, Fiorella MA, Zheng A, McDonnell L, Yasuoka M, Yoo EJ. Characteristics and Outcomes of Patients Discharged Directly Home From a Medical Intensive Care Unit: A Retrospective Cohort Study. J Intensive Care Med 2020; 36:1431-1435. [PMID: 32954949 DOI: 10.1177/0885066620960637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the safety of directly discharging patients home from the medical intensive care unit (MICU). MATERIALS AND METHODS Single-center retrospective observational study of consecutive MICU direct discharges to home from an urban university hospital between June, 1, 2017, and June 30, 2019. RESULTS Of 1061 MICU discharges, 331 (31.2%) patients were eligible for analysis. Patients were divided into 2 groups based on duration of wait-time (< or ≥24 hours) between ward transfer order and ultimate hospital discharge. Most patients (68.2%) were discharged in <24 hours. Patients who waited for a floor bed for ≥24 hours prior to discharge had longer hospital length-of-stay (LOS, median 3.83 versus 2.00 days) and ICU LOS (median 3.51 versus 1.74 days). Overall, 44 (13.3%) direct MICU discharges were readmitted to the hospital within 30-days, but there was no difference in this outcome or in 30-day mortality when comparing the 2 wait-time groups. CONCLUSIONS The practice of directly discharging MICU patients home does not negatively influence patient outcomes. Patients who overstay in the ICU after being deemed transfer-ready are unlikely to be benefiting from critical care, but impact hospital throughput and resource utilization. Prospective investigation into this practice may provide further confirmation of its feasibility and safety.
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Affiliation(s)
- Preeyal M Patel
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michele A Fiorella
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ann Zheng
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lauren McDonnell
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mina Yasuoka
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Erika J Yoo
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Martin CM, Lam M, Allen B, Richard L, Lau V, Ball IM, Wunsch H, Fowler RA, Scales DC. Determinants of Direct Discharge Home From Critical Care Units: A Population-Based Cohort Analysis. Crit Care Med 2020; 48:475-483. [PMID: 32205593 DOI: 10.1097/ccm.0000000000004178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe trends and patient and system factors associated with direct discharge from critical care to home in a large health system. DESIGN Population-based cohort study of direct discharge to home rates annually over 10 years. We used a multivariable, multilevel random-effects regression model to analyze current factors associated with direct discharge home in a subcohort from the most recent 2 years. SETTING One hundred seventy-four ICUs in 101 hospitals in Ontario. PATIENTS All patients discharged from an ICU between April 1, 2007, and March 31, 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 237,200 patients (21.1%) were discharged directly home from an ICU. The rate of direct discharge to home increased from 18.6% in 2007 to 23.1% in 2017 (annual increase of 1.02; 95% CI, 1.02-1.03). There were marked variations in rates of direct discharge to home across all critical care units. For medical and surgical units, the median odds ratio was 1.76 (95% CI, 1.59-1.92). In these units, direct discharge to home was associated with younger age (odds ratio, 0.36; 95% CI, 0.34-0.39 for age 80-105 vs age 18-39), fewer comorbidities (odds ratio, 1.74; 95% CI, 1.63-1.85 for Charlson comorbidity index of 0 vs 2), diagnoses of overdose/poisoning (odds ratio, 1.35; 95% CI, 1.23-1.47) and diabetic complications (odds ratio, 1.35; 95% CI, 1.2-1.51), and admission after a same-day procedure (odds ratio, 2.82; 95% CI, 2.46-3.23 compared with emergency department). ICU occupancy was inversely associated with direct discharge to home with an odds ratio of 0.88 (95% CI, 0.87-0.88) for each 10% increase. CONCLUSIONS High rates of direct discharge to home with evidence of significant practice variation combined with identifiable patient characteristics suggest that further evaluation of this increasingly common transition in care is warranted.
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Affiliation(s)
- Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | | | | | | | - Vincent Lau
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Rob A Fowler
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
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Look Homeward, Intensivist. Crit Care Med 2019; 46:1015-1016. [PMID: 29762403 DOI: 10.1097/ccm.0000000000003140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Lau VI, Priestap F, Lam JNH, Basmaji J, Ball IM. Clinical Predictors for Unsafe Direct Discharge Home Patients From Intensive Care Units. J Intensive Care Med 2018; 35:1067-1073. [PMID: 30477391 DOI: 10.1177/0885066618811810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To describe factors (demographics and clinical characteristics) that predict patients who are at an increased risk of adverse events or unplanned return visits to a health-care facility following discharge direct to home (DDH) from intensive care units (ICUs). METHODS Prospective cohort study of all adult patients who survived their stay in our medical-surgical-trauma ICU between February 2016 and 2017 and were discharged directly home. Patients were followed for 8 weeks postdischarge. Univariable and multivariable logistic regression analyses were performed to identify factors associated with adverse events or unplanned return visits to a health-care facility following DDH from ICU. RESULTS A total of 129 DDH patients were enrolled and completed the 8-week follow-up. We identified 39 unplanned return visits (URVs). There was 0% mortality at 8 weeks postdischarge. Eight potential predictors of hospital URVs (P < .2) were identified in the univariable analysis: prior substance abuse (odds ratio [OR] of URV of 2.50 [95% confidence interval: 1.08-5.80], hepatitis (OR: 6.92 [1.68-28.48]), sepsis (OR: 11.03 [1.19-102.29]), admission nine equivalents of nursing manpower score (NEMS) <24 (OR: 2.28 [1.03-5.04], no fixed address (OR: 22.9 [1.2-437.3]), ICU length of stay (LOS) <2 days (OR: 2.95 [1.28-6.78]), home discharge within London, Ontario (OR: 2.44 [1.00-5.92]), and left against medical advice (AMA; OR: 6.06 [2.04-17.98]). CONCLUSIONS Our study identified 8 covariates that were potential predictors of URV: prior substance abuse, hepatitis, sepsis, admission NEMS <24, no fixed address, ICU LOS <2 days, home discharge within London, Ontario, and left AMA. The practice of direct discharges home from the ICU would benefit from adequately powered multicenter study in order to construct a clinical prediction model (that would require further testing and validation).
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Affiliation(s)
- Vincent Issac Lau
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Fran Priestap
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Joyce N H Lam
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - John Basmaji
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Basmaji J, Lau V, Lam J, Priestap F, Ball IM. Lessons learned and new directions regarding Discharge Direct from Adult Intensive Care Units Sent Home (DISH): A narrative review. J Intensive Care Soc 2018; 20:165-170. [PMID: 31037110 DOI: 10.1177/1751143718794123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose To perform a narrative review of the literature regarding the discharge of patients directly to home (DDH) from the intensive care unit, and to identify patient characteristics and clinical outcomes associated with this practice. Methods We searched MEDLINE and EMBASE from 1946 to present. We also manually searched the references of relevant articles. A two-step review process with three independent reviewers was used to identify relevant articles based on predetermined inclusion/exclusion criteria. Results Four studies were included in the final review. Two studies were retrospective and two studies were prospective that shared data from the same patient cohort. All were single center studies. Two of the four studies outlined clinical outcomes associated with DDH. Conclusions This study highlights the relative dearth in the literature regarding the increasingly common practice of DDH, underscores the importance of further studies in this area, and identifies future important foci of research.
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Affiliation(s)
- John Basmaji
- Department of Medicine, Western University, London, ON, Canada
| | - Vincent Lau
- Department of Medicine, Western University, London, ON, Canada
| | - Joyce Lam
- Department of Medicine, Western University, London, ON, Canada
| | - Fran Priestap
- Department of Medicine, Western University, London, ON, Canada
| | - Ian M Ball
- Department of Medicine, Western University, London, ON, Canada
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