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Song J, Topaz M, Landau AY, Klitzman RL, Shang J, Stone PW, McDonald MV, Cohen B. Natural Language Processing to Identify Home Health Care Patients at Risk for Becoming Incapacitated With No Evident Advance Directives or Surrogates. J Am Med Dir Assoc 2024; 25:105019. [PMID: 38754475 DOI: 10.1016/j.jamda.2024.105019] [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: 11/08/2023] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES Home health care patients who are at risk for becoming Incapacitated with No Evident Advance Directives or Surrogates (INEADS) may benefit from timely intervention to assist them with advance care planning. This study aimed to develop natural language processing algorithms for identifying home care patients who do not have advance directives, family members, or close social contacts who can serve as surrogate decision-makers in the event that they lose decisional capacity. DESIGN Cross-sectional study of electronic health records. SETTING AND PARTICIPANTS Patients receiving post-acute care discharge services from a large home health agency in New York City in 2019 (n = 45,390 enrollment episodes). METHODS We developed a natural language processing algorithm for identifying information documented in free-text clinical notes (n = 1,429,030 notes) related to 4 categories: evidence of close relationships, evidence of advance directives, evidence suggesting lack of close relationships, and evidence suggesting lack of advance directives. We validated the algorithm against Gold Standard clinician review for 50 patients (n = 314 notes) to calculate precision, recall, and F-score. RESULTS Algorithm performance for identifying text related to the 4 categories was excellent (average F-score = 0.91), with the best results for "evidence of close relationships" (F-score = 0.99) and the worst results for "evidence of advance directives" (F-score = 0.86). The algorithm identified 22% of all clinical notes (313,290 of 1,429,030) as having text related to 1 or more categories. More than 98% of enrollment episodes (48,164 of 49,141) included at least 1 clinical note containing text related to 1 or more categories. CONCLUSIONS AND IMPLICATIONS This study establishes the feasibility of creating an automated screening algorithm to aid home health care agencies with identifying patients at risk of becoming INEADS. This screening algorithm can be applied as part of a multipronged approach to facilitate clinician support for advance care planning with patients at risk of becoming INEADS.
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Affiliation(s)
- Jiyoun Song
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Maxim Topaz
- Columbia University School of Nursing, New York, NY, USA; Data Science Institute, Columbia University, New York, NY, USA; Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - Aviv Y Landau
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert L Klitzman
- Columbia University College of Physicians and Surgeons, New York, NY, USA; Columbia University Joseph Mailman School of Public Health, New York, NY, USA
| | - Jingjing Shang
- Columbia University School of Nursing, New York, NY, USA
| | | | | | - Bevin Cohen
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Center for Nursing Research and Innovation, Mount Sinai Health System, New York, NY, USA.
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Gramma R, Hanganu B, Arnaut O, Ioan BG. Potential Conflicts of Interest Arising from Dualism of Loyalty Imposed on Employees of Medical Institutions-Findings and Tools for Ethics Management. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1598. [PMID: 37763717 PMCID: PMC10536397 DOI: 10.3390/medicina59091598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023]
Abstract
Background and Objective: Doctors should have full loyalty to their patients, while patients should be able to trust that physicians will act only in their best interests. However, doctors may be faced with situations where they must choose between the patient's interests and those of a third party. This article presents the results of a study that aimed to identify situations of duality in the decision-making process of medical workers, which can compromise their ethical behavior. Materials and Methods: A cross-sectional study was carried out on a sample of 1070 participants, employed in 120 healthcare facilities in the Republic of Moldova. An online questionnaire was completed anonymously. Descriptive statistics for discrete data were performed by estimating absolute and relative frequencies. To perform the multivariate analysis, the logistic regression was applied. Results: A large number (74.4%) of respondents admitted that they had faced situations of conflicts of interest. Every third respondent (35.3%) had experienced ethical dilemmas when access to expensive treatments should be ensured. Every fourth respondent experienced a conflict between the patient's interests and those of the institution (26.1%) or the insurance company (23.3%). As age increases, the probability of reporting the dilemma decreases. Physicians reported such dilemmas almost 3 times more often than nurses. A low rate of staff sought support when faced with dilemmas. Half of the respondents (50.6%) preferred to discuss the problem only with a colleague, and 40.1% preferred to find solutions without anyone's help. There were significant gaps within organizations in terms of the ethical dimension of the decision-making process. Conclusions: Managers should adopt clear institutional policies and tools to identify and prevent situations of dual loyalty. Ethical support should be offered to employees facing such situations. The need to promote an institutional climate based on trust and openness becomes evident.
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Affiliation(s)
- Rodica Gramma
- Doctoral School, State University of Medicine and Pharmacy Nicolae Testemițanu, 2004 Chisinau, Moldova; (R.G.); (O.A.)
| | - Bianca Hanganu
- 3rd Medical Sciences Department, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Oleg Arnaut
- Doctoral School, State University of Medicine and Pharmacy Nicolae Testemițanu, 2004 Chisinau, Moldova; (R.G.); (O.A.)
| | - Beatrice Gabriela Ioan
- 3rd Medical Sciences Department, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
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Beil M, van Heerden PV, de Lange DW, Szczeklik W, Leaver S, Guidet B, Flaatten H, Jung C, Sviri S, Joskowicz L. Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care. BMC Med Inform Decis Mak 2023; 23:1. [PMID: 36609257 PMCID: PMC9818057 DOI: 10.1186/s12911-022-02094-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/23/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making. METHODS Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions. RESULTS Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree. CONCLUSIONS Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required. TRIAL REGISTRATION VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).
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Affiliation(s)
- Michael Beil
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - P. Vernon van Heerden
- grid.9619.70000 0004 1937 0538Department of Anaesthesia, Intensive Care and Pain Medicine, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan W. de Lange
- grid.7692.a0000000090126352Department of Intensive Care Medicine, University Medical Centre, University Utrecht, Utrecht, The Netherlands
| | - Wojciech Szczeklik
- grid.5522.00000 0001 2162 9631Department of Intensive Care, Jagiellonian University Medical College, Kraków, Poland
| | - Susannah Leaver
- grid.451349.eIntensive Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Bertrand Guidet
- grid.50550.350000 0001 2175 4109Service de Réanimation Médicale, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Hans Flaatten
- grid.412008.f0000 0000 9753 1393Intensive Care, Department of Clinical Medicine, Haukeland Universitetssjukehus, Bergen, Norway
| | - Christian Jung
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Sigal Sviri
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Leo Joskowicz
- grid.9619.70000 0004 1937 0538School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
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Kopanczyk R, Lester J, Long MT, Kossbiel BJ, Hess AS, Rozycki A, Nunley DR, Habib A, Taylor A, Awad H, Bhatt AM. The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:47. [PMID: 36676669 PMCID: PMC9867461 DOI: 10.3390/medicina59010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jesse Lester
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Briana J. Kossbiel
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aaron S. Hess
- Department of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Alan Rozycki
- Department of Pharmacology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Alim Habib
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Ashley Taylor
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Barnato AE, Johnson GR, Birkmeyer JD, Skinner JS, O'Malley AJ, Birkmeyer NJO. Advance Care Planning and Treatment Intensity Before Death Among Black, Hispanic, and White Patients Hospitalized with COVID-19. J Gen Intern Med 2022; 37:1996-2002. [PMID: 35412179 PMCID: PMC9002036 DOI: 10.1007/s11606-022-07530-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/29/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Black and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access. OBJECTIVE To examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19. DESIGN Retrospective cohort analysis of manually abstracted electronic medical records. PATIENTS 7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020 MAIN MEASURES: Advance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR). KEY RESULTS Adjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9-1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6-1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)). CONCLUSIONS Hospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.
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Affiliation(s)
- Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH, USA
| | | | - John D Birkmeyer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Sound Physicians, Tacoma, WA, USA
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Economics, Dartmouth College, Hanover, NH, USA
| | - Allistair James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Nancy J O Birkmeyer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
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Tleyjeh IM, Kashour T, Mandrekar J, Petitti DB. Overlooked Shortcomings of Observational Studies of Interventions in Coronavirus Disease 2019: An Illustrated Review for the Clinician. Open Forum Infect Dis 2021; 8:ofab317. [PMID: 34377723 PMCID: PMC8339279 DOI: 10.1093/ofid/ofab317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/09/2021] [Indexed: 11/13/2022] Open
Abstract
The rapid spread of severe acute respiratory syndrome coronavirus 2 infection across the globe triggered an unprecedented increase in research activities that resulted in an astronomical publication output of observational studies. However, most studies failed to apply fully the necessary methodological techniques that systematically deal with different biases and confounding, which not only limits their scientific merit but may result in harm through misleading information. In this article, we address a few important biases that can seriously threaten the validity of observational studies of coronavirus disease 2019 (COVID-19). We focus on treatment selection bias due to patients’ preference on goals of care, medical futility and disability bias, survivor bias, competing risks, and the misuse of propensity score analysis. We attempt to raise awareness and to help readers assess shortcomings of observational studies of interventions in COVID-19.
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Affiliation(s)
- Imad M Tleyjeh
- Infectious Diseases Section, Department of Medical Specialties, King Fahad Medical City, Riyadh, Saudi Arabia.,Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.,Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Tarek Kashour
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Jay Mandrekar
- Department of Biostatistics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Diana B Petitti
- Department of Biomedical Informatics, University of Arizona College of Medicine, Phoenix, Arizona, USA
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Tleyjeh PIM, Tlayjeh H. Perceived efficacy of hydroxychloroquine in observational studies: Results of the confounding effect of "goals of care". Int J Antimicrob Agents 2021; 57:106308. [PMID: 33609717 PMCID: PMC7888988 DOI: 10.1016/j.ijantimicag.2021.106308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/01/2020] [Accepted: 12/12/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Prof Imad M Tleyjeh
- Infectious Diseases Section, Department of Medical Specialties King Fahad Medical City, Riyadh, Saudi Arabia; Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; Department of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; College of Medicine, Al Faisal University, Riyadh, Saudi Arabia.
| | - Haytham Tlayjeh
- Department of Intensive Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Deaths following withdrawal of life-sustaining therapy: Opportunities for quality improvement? J Trauma Acute Care Surg 2020; 89:743-751. [PMID: 32697448 DOI: 10.1097/ta.0000000000002892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mortality is an important trauma center outcome. With many patients initially surviving catastrophic injuries and a growing proportion of geriatric patients, many deaths might occur following withdrawal of life-sustaining therapy (WLST). We utilized the American College of Surgeons Trauma Quality Improvement Program database to explore whether deaths following WLST might be preventable and to evaluate the impact of excluding patients who died following WLST on hospital performance. METHODS A retrospective cohort study was conducted using data derived from American College of Surgeons Trauma Quality Improvement Program. Adult trauma patients treated at Levels I and II centers in 2016 were included. Three cohorts of deceased patients were created to assess differences in hospital performance. The first included all deaths, the second included only those who died without WLST, and the third included deaths without WLST and deaths with WLST where death was preceded by a major complication. Hospitals were ranked based on their observed-to-expected mortality ratio calculated using each of the three decedent cohorts. Outcomes included absolute change in hospital ranking and change in performance outlier status between cohorts. RESULTS We identified 275,939 patients treated at 447 centers who met inclusion criteria. Overall mortality was 6.9% (n = 19,145). Withdrawal of life-sustaining therapy preceded 43.6% (n = 8,343) of deaths and 23% (n = 1,920) of these patients experienced a major complication before death. The median absolute change in hospital performance rank between the first and second cohort was 58 (p < 0.001), between the first and third cohort was 44 (p < 0.001), and between the second and third cohort was 23 (p < 0.001). Hospital performance outlier status changed significantly between cohorts. CONCLUSION The exclusion of patients who die following WLST from benchmarking efforts leads to a major change in hospital ranks. Potentially preventable deaths, such as those following a major complication, should not be excluded. LEVEL OF EVIDENCE Epidemiological study, level III.
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Pollock BD, Herrin J, Neville MR, Dowdy SC, Moreno Franco P, Shah ND, Ting HH. Association of Do-Not-Resuscitate Patient Case Mix With Publicly Reported Risk-Standardized Hospital Mortality and Readmission Rates. JAMA Netw Open 2020; 3:e2010383. [PMID: 32662845 PMCID: PMC7361656 DOI: 10.1001/jamanetworkopen.2020.10383] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The Centers for Medicare and Medicaid Services's (CMS's) 30-day risk-standardized mortality rate (RSMR) and risk-standardized readmission rate (RSRR) models do not adjust for do-not-resuscitate (DNR) status of hospitalized patients and may bias Hospital Readmissions Reduction Program (HRRP) financial penalties and Overall Hospital Quality Star Ratings. OBJECTIVE To identify the association between hospital-level DNR prevalence and condition-specific 30-day RSMR and RSRR and the implications of this association for HRRP financial penalty. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study obtained patient-level data from the Medicare Limited Data Set Inpatient Standard Analytical File and hospital-level data from the CMS Hospital Compare website for all consecutive Medicare inpatient encounters from July 1, 2015, to June 30, 2018, in 4484 US hospitals. Hospitalized patients had a principal diagnosis of acute myocardial infarction (AMI), heart failure (HF), stroke, pneumonia, or chronic obstructive pulmonary disease (COPD). Incoming acute care transfers, discharges against medical advice, and patients coming from or discharged to hospice were among those excluded from the analysis. EXPOSURES Present-on-admission (POA) DNR status was defined as an International Classification of Diseases, Ninth Revision diagnosis code of V49.86 (before October 1, 2015) or as an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of Z66 (beginning October 1, 2015). Hospital-level prevalence of POA DNR status was calculated for each of the 5 conditions. MAIN OUTCOMES AND MEASURES Hospital-level 30-day RSMRs and RSRRs for 5 condition-specific cohorts (mortality cohorts: AMI, HF, stroke, pneumonia, and COPD; readmission cohorts: AMI, HF, pneumonia, and COPD) and HRRP financial penalty status (yes or no). RESULTS Included in the study were 4 884 237 inpatient encounters across condition-specific 30-day mortality cohorts (patient mean [SD] age, 78.8 [8.5] years; 2 608 182 women [53.4%]) and 4 450 378 inpatient encounters across condition-specific 30-day readmission cohorts (patient mean [SD] age, 78.6 [8.5] years; 2 349 799 women [52.8%]). Hospital-level median (interquartile range [IQR]) prevalence of POA DNR status in the mortality cohorts varied: 11% (7%-16%) for AMI, 13% (7%-23%) for HF, 14% (9%-22%) for stroke, 17% (9%-26%) for pneumonia, and 10% (5%-18%) for COPD. For the readmission cohorts, the hospital-level median (IQR) POA DNR prevalence was 9% (6%-15%) for AMI, 12% (6%-22%) for HF, 16% (8%-24%) for pneumonia, and 9% (4%-17%) for COPD. The 30-day RSMRs were significantly higher for hospitals in the highest quintiles vs the lowest quintiles of DNR prevalence (eg, AMI: 12.9 [95% CI, 12.8-13.1] vs 12.5 [95% CI, 12.4-12.7]; P < .001). The inverse was true among the readmission cohorts, with the highest quintiles of DNR prevalence exhibiting the lowest RSRRs (eg, AMI: 15.3 [95% CI, 15.1-15.5] vs 15.9 [95% CI, 15.7-16.0]; P < .001). A 1% absolute increase in risk-adjusted hospital-level DNR prevalence was associated with greater odds of avoiding HRRP financial penalty (odds ratio, 1.06; 95% CI, 1.04-1.08; P < .001). CONCLUSIONS AND RELEVANCE This cross-sectional study found that the lack of adjustment in CMS 30-day RSMR and RSRR models for POA DNR status of hospitalized patients may be associated with biased readmission penalization and hospital-level performance.
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Affiliation(s)
- Benjamin D. Pollock
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
- Department of Quality, Experience, and Affordability, Mayo Clinic, Rochester, Minnesota
| | - Jeph Herrin
- Flying Buttress Associates, Charlottesville, Virginia
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew R. Neville
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
- Department of Quality, Experience, and Affordability, Mayo Clinic, Rochester, Minnesota
| | - Sean C. Dowdy
- Department of Quality, Experience, and Affordability, Mayo Clinic, Rochester, Minnesota
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Pablo Moreno Franco
- Department of Quality, Experience, and Affordability, Mayo Clinic, Rochester, Minnesota
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Nilay D. Shah
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Henry H. Ting
- Department of Quality, Experience, and Affordability, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Validation of the V49.86 Code for Do-Not-Resuscitate Status in Hospitalized Patients at a Single Academic Medical Center. Ann Am Thorac Soc 2019; 15:1234-1237. [PMID: 29944385 DOI: 10.1513/annalsats.201804-257rl] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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11
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Philpotts YF, Ma X, Anderson MR, Hua M, Baldwin MR. Health Insurance and Disparities in Mortality among Older Survivors of Critical Illness: A Population Study. J Am Geriatr Soc 2019; 67:2497-2504. [PMID: 31449681 DOI: 10.1111/jgs.16138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/24/2019] [Accepted: 07/20/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The 1.5 million Medicare beneficiaries who survive intensive care each year have a high post-hospitalization mortality rate. We aimed to determine whether mortality after critical illness is higher for Medicare beneficiaries with Medicaid compared with those with commercial insurance. DESIGN A retrospective cohort study from 2010 through 2014 with 1 year of follow-up using the New York Statewide Planning and Research Cooperative System database. SETTING A New York State population-based study of older (age ≥65 y) survivors of intensive care. PARTICIPANTS Adult Medicare beneficiaries age 65 years or older who were hospitalized with intensive care at a New York State hospital and survived to discharge. INTERVENTION None. MEASUREMENT Mortality in the first year after hospital discharge. RESULTS The study included 340 969 Medicare beneficiary survivors of intensive care with a mean (standard deviation) age of 77 (8) years; 20% died within 1 year. There were 152 869 (45%) with commercial insurance, 78 577 (23%) with Medicaid, and 109 523 (32%) with Medicare alone. Compared with those with commercial insurance, those with Medicare alone had a similar 1-year mortality rate (adjusted hazard ratio [aHR] = 1.01; 95% confidence interval [CI] = .99-1.04), and those with Medicaid had a 9% higher 1-year mortality rate (aHR = 1.09; 95% CI = 1.05-1.12). Among those discharged home, the 1-year mortality rate did not vary by insurance coverage, but among those discharged to skilled-care facilities (SCFs), the 1-year mortality rate was 16% higher for Medicaid recipients (aHR = 1.16; 95% CI = 1.12-1.21; P for interaction <.001). CONCLUSIONS Older adults with Medicaid insurance have a higher 1-year post-hospitalization mortality compared with those with commercial insurance, especially among those discharged to SCFs. Future studies should investigate care disparities at SCFs that may mediate these higher mortality rates. J Am Geriatr Soc 67:2497-2504, 2019.
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Affiliation(s)
- Yoland F Philpotts
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Xiaoyue Ma
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - May Hua
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Matthew R Baldwin
- Division of Pulmonary, Allergy, and Critical Care, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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12
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Darby JL, Davis BS, Barbash IJ, Kahn JM. An administrative model for benchmarking hospitals on their 30-day sepsis mortality. BMC Health Serv Res 2019; 19:221. [PMID: 30971244 PMCID: PMC6458755 DOI: 10.1186/s12913-019-4037-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/24/2019] [Indexed: 12/29/2022] Open
Abstract
Background Given the increased attention to sepsis at the population level there is a need to assess hospital performance in the care of sepsis patients using widely-available administrative data. The goal of this study was to develop an administrative risk-adjustment model suitable for profiling hospitals on their 30-day mortality rates for patients with sepsis. Methods We conducted a retrospective cohort study using hospital discharge data from general acute care hospitals in Pennsylvania in 2012 and 2013. We identified adult patients with sepsis as determined by validated diagnosis and procedure codes. We developed an administrative risk-adjustment model in 2012 data. We then validated this model in two ways: by examining the stability of performance assessments over time between 2012 and 2013, and by examining the stability of performance assessments in 2012 after the addition of laboratory variables measured on day one of hospital admission. Results In 2012 there were 115,213 sepsis encounters in 152 hospitals. The overall unadjusted mortality rate was 18.5%. The final risk-adjustment model had good discrimination (C-statistic = 0.78) and calibration (slope and intercept of the calibration curve = 0.960 and 0.007, respectively). Based on this model, hospital-specific risk-standardized mortality rates ranged from 12.2 to 24.5%. Comparing performance assessments between years, correlation in risk-adjusted mortality rates was good (Pearson’s correlation = 0.53) and only 19.7% of hospitals changed by more than one quintile in performance rankings. Comparing performance assessments after the addition of laboratory variables, correlation in risk-adjusted mortality rates was excellent (Pearson’s correlation = 0.93) and only 2.6% of hospitals changed by more than one quintile in performance rankings. Conclusions A novel claims-based risk-adjustment model demonstrated wide variation in risk-standardized 30-day sepsis mortality rates across hospitals. Individual hospitals’ performance rankings were stable across years and after the addition of laboratory data. This model provides a robust way to rank hospitals on sepsis mortality while adjusting for patient risk. Electronic supplementary material The online version of this article (10.1186/s12913-019-4037-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jennifer L Darby
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Billie S Davis
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ian J Barbash
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jeremy M Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA. .,Critical Care Medicine and Health Policy & Management, University of Pittsburgh, Scaife Hall Room 602-B, 3550 Terrace Street, Pittsburgh, PA, 15221, USA.
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13
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Turnbull AE, Chessare CM, Coffin RK, Needham DM. More than one in three proxies do not know their loved one's current code status: An observational study in a Maryland ICU. PLoS One 2019; 14:e0211531. [PMID: 30699212 PMCID: PMC6353188 DOI: 10.1371/journal.pone.0211531] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/16/2019] [Indexed: 12/21/2022] Open
Abstract
Rationale The majority of ICU patients lack decision-making capacity at some point during their ICU stay. However the extent to which proxy decision-makers are engaged in decisions about their patient’s care is challenging to quantify. Objectives To assess 1)whether proxies know their patient’s actual code status as recorded in the electronic medical record (EMR), and 2)whether code status orders reflect ICU patient preferences as reported by proxy decision-makers. Methods We enrolled proxy decision-makers for 96 days starting January 4, 2016. Proxies were asked about the patient’s goals of care, preferred code status, and actual code status. Responses were compared to code status orders in the EMR at the time of interview. Characteristics of patients and proxies who correctly vs incorrectly identified actual code status were compared, as were characteristics of proxies who reported a preferred code status that did vs did not match actual code status. Measurements and main results Among 111 proxies, 42 (38%) were incorrect or unsure about the patient’s actual code status and those who were correct vs. incorrect or unsure were similar in age, race, and years of education (P>0.20 for all comparisons). Twenty-nine percent reported a preferred code status that did not match the patient’s code status in the EMR. Matching preferred and actual code status was not associated with a patient’s age, gender, income, admission diagnosis, or subsequent in-hospital mortality or with proxy age, gender, race, education level, or relation to the patient (P>0.20 for all comparisons). Conclusions More than 1 in 3 proxies is incorrect or unsure about their patient’s actual code status and more than 1 in 4 proxies reported that a preferred code status that did not match orders in the EMR. Proxy age, race, gender and education level were not associated with correctly identifying code status or code status concordance.
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Affiliation(s)
- Alison E. Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Caroline M. Chessare
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Rachel K. Coffin
- Medical Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
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14
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Seo Y, Shin S. The Relationship among Attitudes toward the Withdrawal of Life-sustaining Treatment, Death Anxiety, and Death Acceptance among Hospitalized Elderly Cancer Patients. ASIAN ONCOLOGY NURSING 2019. [DOI: 10.5388/aon.2019.19.3.142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- YeonMi Seo
- Department of Nursing, Asan Medical Center, Seoul, Korea
| | - Sujin Shin
- College of Nursing, Ewha Womans University, Seoul, Korea
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15
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Turnbull AE, Sahetya SK, Biddison ELD, Hartog CS, Rubenfeld GD, Benoit DD, Guidet B, Gerritsen RT, Tonelli MR, Curtis JR. Competing and conflicting interests in the care of critically ill patients. Intensive Care Med 2018; 44:1628-1637. [PMID: 30046872 DOI: 10.1007/s00134-018-5326-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/16/2018] [Indexed: 12/26/2022]
Abstract
Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician's sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient's best interest and discusses steps that could help minimize the impact of these factors on patient care.
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Affiliation(s)
- Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA. .,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. .,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA
| | - E Lee Daugherty Biddison
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA
| | - Christiane S Hartog
- Department for Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany.,Department of Anaesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Kreischa, Germany.,Patient- and Family-Centered Care, Klinik Bavaria, Kreischa, Germany
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Bertrand Guidet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France.,Sorbonne Universités, Université Pierre et Marie Curie, Paris, France.,Institut National de la Santé et de la Recherche Médicale (INSERM), UMR S 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
| | - Rik T Gerritsen
- Department of Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Mark R Tonelli
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
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16
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Gannon WD, Lederer DJ, Biscotti M, Javaid A, Patel NM, Brodie D, Bacchetta M, Baldwin MR. Outcomes and Mortality Prediction Model of Critically Ill Adults With Acute Respiratory Failure and Interstitial Lung Disease. Chest 2018; 153:1387-1395. [PMID: 29353024 PMCID: PMC6026289 DOI: 10.1016/j.chest.2018.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/07/2017] [Accepted: 01/02/2018] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND We aimed to examine short- and long-term mortality in a mixed population of patients with interstitial lung disease (ILD) with acute respiratory failure, and to identify those at lower vs higher risk of in-hospital death. METHODS We conducted a single-center retrospective cohort study of 126 consecutive adults with ILD admitted to an ICU for respiratory failure at a tertiary care hospital between 2010 and 2014 and who did not undergo lung transplantation during their hospitalization. We examined associations of ICU-day 1 characteristics with in-hospital and 1-year mortality, using Poisson regression, and examined survival using Kaplan-Meier curves. We created a risk score for in-hospital mortality, using a model developed with penalized regression. RESULTS In-hospital mortality was 66%, and 1-year mortality was 80%. Those with connective tissue disease-related ILD had better short-term and long-term mortality compared with unclassifiable ILD (adjusted relative risk, 0.6; 95% CI, 0.3-0.9; and relative risk, 0.6; 95% CI, 0.4-0.9, respectively). Our prediction model includes male sex, interstitial pulmonary fibrosis diagnosis, use of invasive mechanical ventilation and/or extracorporeal life support, no ambulation within 24 h of ICU admission, BMI, and Simplified Acute Physiology Score-II. The optimism-corrected C-statistic was 0.73, and model calibration was excellent (P = .99). In-hospital mortality rates for the low-, moderate-, and high-risk groups were 33%, 65%, and 96%, respectively. CONCLUSIONS We created a risk score that classifies patients with ILD with acute respiratory failure from low to high risk for in-hospital mortality. The score could aid providers in counseling these patients and their families.
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Affiliation(s)
- Whitney D Gannon
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY
| | - David J Lederer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Mauer Biscotti
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY
| | - Azka Javaid
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY
| | - Nina M Patel
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY
| | - Matthew Bacchetta
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY
| | - Matthew R Baldwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY.
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17
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Kahn JM, Davis BS, Le TQ, Yabes JG, Chang CCH, Angus DC. Variation in mortality rates after admission to long-term acute care hospitals for ventilator weaning. J Crit Care 2018; 46:6-12. [PMID: 29627660 DOI: 10.1016/j.jcrc.2018.03.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/18/2018] [Accepted: 03/18/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE We sought to examine variation in long-term acute care hospital (LTACH) quality based on 90-day in-hospital mortality for patients admitted for weaning from mechanical ventilation. METHODS We developed an administrative risk-adjustment model using data from Medicare claims. We validated the administrative model against a clinical model using data from LTACHs participating in a 2002 to 2003 clinical registry. We then used our validated administrative model to assess national variation in 90-day in-hospital mortality rates in LTACHs from 2013. RESULTS The administrative risk-adjustment model was derived using data from 9447 patients admitted to 221 LTACHs in 2003. The model had good discrimination (C statistic=0.72) and calibration. Compared to a clinically derived model using data from 1163 patients admitted to 14 LTACHs, the administrative model generated similar performance estimates. National variation in risk-adjusted mortality was assessed using data from 20,453 patients admitted to 380 LTACHs in 2013. LTACH-specific risk-adjusted mortality rates varied from 8.4% to 48.1% (median: 24.2%, interquartile range: 19.7%-30.7%). CONCLUSIONS LTACHs vary widely in mortality rates, underscoring the need to better understand the sources of this variation and improve the quality of care for patients requiring long-term ventilator weaning.
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Affiliation(s)
- Jeremy M Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States.
| | - Billie S Davis
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tri Q Le
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
| | - Jonathan G Yabes
- Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
| | - Chung-Chou H Chang
- Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
| | - Derek C Angus
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
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