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Brooks ES, Wirtalla CJ, Rosen CB, Finn CB, Kelz RR. Variation in Hospital Performance for General Surgery in Younger and Older Adults: A Retrospective Cohort Study. Ann Surg 2024; 280:261-266. [PMID: 38126756 DOI: 10.1097/sla.0000000000006184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To compare hospital surgical performance in older and younger patients. BACKGROUND In-hospital mortality after surgical procedures varies widely among hospitals. Prior studies suggest that failure-to-rescue rates drive this variation for older adults, but the generalizability of these findings to younger patients remains unknown. METHODS We performed a retrospective cohort study of patients ≥18 years undergoing one of 10 common and complex general surgery operations in 16 states using the Healthcare Cost and Utilization Projects State Inpatient Databases (2016-2018). Patients were split into 2 populations: patients with Medicare ≥65 (older adult) and non-Medicare <65 (younger adult). Hospitals were sorted into quintiles using risk-adjusted in-hospital mortality rates for each age population. Correlations between hospitals in each mortality quintile across age populations were calculated. Complication and failure-to-rescue rates were compared across the highest and lowest mortality quintiles in each age population. RESULTS We identified 579,582 patients treated in 732 hospitals. The mortality rate was 3.6% among older adults and 0.7% among younger adults. Among older adults, high- relative to low-mortality hospitals had similar complication rates (32.0% vs 29.8%; P = 0.059) and significantly higher failure-to-rescue rates (16.0% vs 4.0%; P < 0.001). Among younger adults, high-relative to low-mortality hospitals had higher complications (15.4% vs 12.1%; P < 0.001) and failure-to-rescue rates (8.3% vs 0.7%; P < 0.001). The correlation between observed-to-expected mortality ratios in each age group was 0.385 ( P < 0.001). CONCLUSIONS High surgical mortality rates in younger patients may be driven by both complication and failure-to-rescue rates. There is little overlap between low-mortality hospitals in the older and younger adult populations. Future work must delve into the root causes of this age-based difference in hospital-level surgical outcomes.
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Affiliation(s)
- Ezra S Brooks
- General Surgery Residency, Department of Surgery, Brigham and Women's Hospital
| | - Christopher J Wirtalla
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Claire B Rosen
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Caitlin B Finn
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
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Pallarès N, Inouzhe H, Straw S, Safdar N, Fernández D, Cortés J, Rodríguez L, Videla S, Barrio I, Witte KK, Carratalà J, Tebé C. Development and validation of a model to predict ceiling of care in COVID-19 hospitalized patients. BMC Palliat Care 2024; 23:173. [PMID: 39010044 PMCID: PMC11250965 DOI: 10.1186/s12904-024-01490-8] [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: 09/14/2023] [Accepted: 06/17/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Therapeutic ceiling of care is the maximum level of care deemed appropiate to offer to a patient based on their clinical profile and therefore their potential to derive benefit, within the context of the availability of resources. To our knowledge, there are no models to predict ceiling of care decisions in COVID-19 patients or other acute illnesses. We aimed to develop and validate a clinical prediction model to predict ceiling of care decisions using information readily available at the point of hospital admission. METHODS We studied a cohort of adult COVID-19 patients who were hospitalized in 5 centres of Catalonia between 2020 and 2021. All patients had microbiologically proven SARS-CoV-2 infection at the time of hospitalization. Their therapeutic ceiling of care was assessed at hospital admission. Comorbidities collected at hospital admission, age and sex were considered as potential factors for predicting ceiling of care. A logistic regression model was used to predict the ceiling of care. The final model was validated internally and externally using a cohort obtained from the Leeds Teaching Hospitals NHS Trust. The TRIPOD Checklist for Prediction Model Development and Validation from the EQUATOR Network has been followed to report the model. RESULTS A total of 5813 patients were included in the development cohort, of whom 31.5% were assigned a ceiling of care at the point of hospital admission. A model including age, COVID-19 wave, chronic kidney disease, dementia, dyslipidaemia, heart failure, metastasis, peripheral vascular disease, chronic obstructive pulmonary disease, and stroke or transient ischaemic attack had excellent discrimination and calibration. Subgroup analysis by sex, age group, and relevant comorbidities showed excellent figures for calibration and discrimination. External validation on the Leeds Teaching Hospitals cohort also showed good performance. CONCLUSIONS Ceiling of care can be predicted with great accuracy from a patient's clinical information available at the point of hospital admission. Cohorts without information on ceiling of care could use our model to estimate the probability of ceiling of care. In future pandemics, during emergency situations or when dealing with frail patients, where time-sensitive decisions about the use of life-prolonging treatments are required, this model, combined with clinical expertise, could be valuable. However, future work is needed to evaluate the use of this prediction tool outside COVID-19.
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Affiliation(s)
- N Pallarès
- Biostatistics Support and Research Unit, Germans Trias I Pujol Research Institute and Hospital (IGTP), Campus Can RutiCarretera de Can RutiCamí de Les Escoles S/N, Barcelona, Badalona, 08916, Spain
- Department of Basic Clinical Practice, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - H Inouzhe
- Basque Center for Applied Mathematics, BCAM, Bilbao, Spain
| | - S Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - N Safdar
- Department of Internal Medicine, St James's University Hospitals, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
- Department of Internal Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, USA
| | - D Fernández
- Department of Statistics and Operations Research, Universitat Politècnica de, Catalunya/BarcelonaTech, Barcelona, Spain
- Institute of Mathematics of UPC - BarcelonaTech (IMTech), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III (CIBERSAM), Madrid, Spain
| | - J Cortés
- Department of Statistics and Operations Research, Universitat Politècnica de, Catalunya/BarcelonaTech, Barcelona, Spain
| | - L Rodríguez
- Basque Center for Applied Mathematics, BCAM, Bilbao, Spain
| | - S Videla
- Department of Clinical Pharmacology, Bellvitge University Hospital, Barcelona, Spain
- Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - I Barrio
- Basque Center for Applied Mathematics, BCAM, Bilbao, Spain
- Department of Mathematics, University of the Basque Country UPV/EHU, Leioa, Spain
| | - K K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - J Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - C Tebé
- Biostatistics Support and Research Unit, Germans Trias I Pujol Research Institute and Hospital (IGTP), Campus Can RutiCarretera de Can RutiCamí de Les Escoles S/N, Barcelona, Badalona, 08916, Spain.
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain.
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Warner BE, Lound A, Grailey K, Vindrola-Padros C, Wells M, Brett SJ. Perspectives of healthcare professionals and older patients on shared decision-making for treatment escalation planning in the acute hospital setting: a systematic review and qualitative thematic synthesis. EClinicalMedicine 2023; 62:102144. [PMID: 37588625 PMCID: PMC10425683 DOI: 10.1016/j.eclinm.2023.102144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023] Open
Abstract
Background Shared Decision-Making (SDM) between patients and clinicians is increasingly considered important. Treament Escalation Plans (TEP) are individualised documents outlining life-saving interventions to be considered in the event of clinical deterioration. SDM can inform subjective goals of care in TEP but it remains unclear how much it is considered beneficial by patients and clinicians. We aimed to synthesise the existing knowledge of clinician and older patient (generally aged ≥65 years) perspectives on patient involvement in TEP in the acute setting. Methods Systematic database search was performed in MEDLINE, EMBASE, PsycInfo and CINAHL databases as well as grey literature from database inception to June 8, 2023, using the Sample (older patients, clinicians, acute setting; studies relating to patients whose main diagnosis was cancer or single organ failure were excluded as these conditions may have specific TEP considerations), Phenomenon of Interest (Treatment Escalation Planning), Design (any including interview, observational, survey), Evaluation (Shared Decision-Making), Research type (qualitative, quantitative, mixed methods) tool. Primary data (published participant quotations, field notes, survey results) and descriptive author comments were extracted and qualitative thematic synthesis was performed to generate analytic themes. Quality assessment was made using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess overall confidence in each thematic finding according to methodology, coherence, adequacy and relevance of the contributing studies. The study protocol was registered on PROSPERO, CRD42022361593. Findings Following duplicate exclusion there were 1916 studies screened and ultimately 13 studies were included, all from European and North American settings. Clinician-orientated themes were: treatment escalation is a medical decision (high confidence); clinicians want the best for their patients amidst uncertainty (high confidence); involving patients and families in decisions is not always meaningful and can involve conflict (high confidence); treatment escalation planning exists within the clinical environment, organisation and society (moderate confidence). Patient-orientated themes were: patients' relationships with Treatment Escalation Planning are complex (low confidence); interactions with doctors are important but communication is not always easy (moderate confidence); patients are highly aware of their families when considering TEP (moderate confidence). Interpretation Based on current evidence, TEP decisions appear dominated by clinicians' perspectives, motivated by achieving the best for patients and challenged by complex decisions, communication and environmental factors; older patients' perspectives have seldom been explored, but their input on decisions may be modest. Presenting the context and challenge of SDM during professional education may allow reflection and a more nuanced approach. Future research should seek to understand what approach to TEP decision-making patients and clinicians consider to be optimum in the acute setting so that a mutually acceptable standard can be defined in policy. Funding HCA International and the NIHR Imperial Biomedical Research Centre.
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Affiliation(s)
- Bronwen E. Warner
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
| | - Adam Lound
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
| | - Kate Grailey
- Centre for Health Policy, Institute for Global Health Innovation, Department of Surgery and Cancer, Imperial College London, UK
| | | | - Mary Wells
- Department of Surgery and Cancer, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Stephen J. Brett
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
- Department of Intensive Care Medicine, Imperial College Healthcare NHS Trust London, London, UK
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research, University of Sheffield, Regent Court, Sheffield S1 4DA, UK
| | - Gordon Fuller
- Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Simon Conroy
- Central and North West London NHS Foundation Trust, London, UK
| | - Clint Hendrikse
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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da Silva MDAP, Corradi-Perini C. The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review. Indian J Palliat Care 2023; 29:234-242. [PMID: 37700891 PMCID: PMC10493695 DOI: 10.25259/ijpc_292_2022] [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: 12/08/2022] [Accepted: 01/27/2023] [Indexed: 09/14/2023] Open
Abstract
Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword 'clinical decision-making' AND 'terminal care' OR 'end-of-life care' and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.
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Affiliation(s)
| | - Carla Corradi-Perini
- Bioethics Graduate Program, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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Teto terapêutico e a adequação do tratamento no Serviço de Urgência – estudo retrospectivo. SCIENTIA MEDICA 2022. [DOI: 10.15448/1980-6108.2022.1.41370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Introdução: no Serviço de Urgência vive-se um antagonismo constante pela sua natureza direcionada para a patologia aguda e a prestação de cuidados paliativos de qualidade. O nosso estudo tem como objetivo avaliar se a definição de teto terapêutico leva a diferenças na adequação da marcha diagnóstica e terapêutica instituída.Material e métodos: análise retrospetiva descritiva monocêntrica dos doentes que morreram nos primeiros seis meses de 2018 no serviço de urgência do Hospital do Espírito Santo de Évora.Resultados: compararam-se os três grupos de doentes o que não foi definido qualquer teto terapêutico, com o grupo em que iniciaram medidas paliativas e o grupo em que se tomou a Decisão de Não Reanimar. Verificou-se que não existem diferenças significativa entre as idades, o local de residência e as comorbilidades e, com exceção da demência (p= 0,006), existe sim uma diferença no grau de dependência nas atividades da vida diária (p<0,001). Verificou-se que não existem diferenças entre número ou tipo de exames complementares de diagnóstico, mas há algumas diferenças na terapêutica instituída já que no grupo dos doentes em cuidados paliativos a terapêutica com morfina (p<0,001), butilescopolamina (p=0,001) e paracetamol (p=0,004) foi mais frequente. A ventilação invasiva só ocorreu no grupo de doentes sem definição de teto terapêutico (p<0,001), enquanto a oxigénioterapia foi mais frequente nos grupos em Decisão de Não Reanimar ou em cuidados paliativos (p<0,001).Discussão e conclusão: os médicos do serviço de urgência reconhecem que os seus doentes estão em final de vida, adequando parcialmente a terapêutica com vista ao controlo de sintomas, dor e secreções.
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Torr L, Mortimore G. The management and diagnosis of rhabdomyolysis-induced acute kidney injury: a case study. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:844-852. [PMID: 36094035 DOI: 10.12968/bjon.2022.31.16.844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Rhabdomyolysis is characterised by a rapid dissolution of damaged or injured skeletal muscle that can be the result of a multitude of mechanisms. It can range in severity from mild to severe, leading to multi-organ failure and death. Rhabdomyolysis causes muscular cellular breakdown, which can cause fatal electrolyte imbalances and metabolic acidosis, as myoglobin, creatine phosphokinase, lactate dehydrogenase and other electrolytes move into the circulation; acute kidney injury can follow as a severe complication. This article reflects on the case of a person who was diagnosed with rhabdomyolysis and acute kidney injury after a fall at home. Understanding the underpinning mechanism of rhabdomyolysis and the associated severity of symptoms may improve early diagnosis and treatment initiation.
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Affiliation(s)
- Leah Torr
- Acute Kidney Injury Specialist Nurse, Royal Derby Hospital, University Hospitals of Derby and Burton Foundation Trust, Derby
| | - Gerri Mortimore
- Associate Professor in Advanced Clinical Practice, University of Derby, Derby
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Cognitive biases, environmental, patient and personal factors associated with critical care decision making: A scoping review. J Crit Care 2021; 64:144-153. [PMID: 33906103 DOI: 10.1016/j.jcrc.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/31/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Cognitive biases and factors affecting decision making in critical care can potentially lead to life-threatening errors. We aimed to examine the existing evidence on the influence of cognitive biases and factors on decision making in critical care. MATERIALS AND METHODS We conducted a scoping review by searching MEDLINE for articles from 2004 to November 2020. We included studies conducted in physicians that described cognitive biases or factors associated with decision making. During the study process we decided on the method to summarize the evidence, and based on the obtained studies a descriptive summary of findings was the best fit. RESULTS Thirty heterogenous studies were included. Four main biases or factors were observed, e.g. cognitive biases, personal factors, environmental factors, and patient factors. Six (20%) studies reported biases associated with decision making comprising omission-, status quo-, implicit-, explicit-, outcome-, and overconfidence bias. Nineteen (63%) studies described personal factors, twenty-two (73%) studies described environmental factors, and sixteen (53%) studies described patient factors. CONCLUSIONS The current evidence on cognitive biases and factors is heterogenous, but shows they influence clinical decision. Future studies should investigate the prevalence of cognitive biases and factors in clinical practice and their impact on clinical outcomes.
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Sacks B, Mughal HN, Ahluwalia A, Rudran B, Parmar KR. The BOAST recommendations for care of the older or frail orthopaedic trauma patient. Br J Hosp Med (Lond) 2020; 81:1-8. [PMID: 32730158 DOI: 10.12968/hmed.2020.0028] [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: 11/11/2022]
Abstract
Safe and effective care for the elderly or physiologically frail patient in cases of trauma requires a multidisciplinary perioperative approach. This article expands upon the British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines for the management of the older or frail orthopaedic trauma patient. Optimisation of the patient is key to a successful surgical outcome, because these patients often have significant comorbidities involving bone health, nutrition, cognitive function and cardiovascular stability. This article discusses the evidence base for tailoring the management of these patients and the importance of doing so in an ageing population. It considers the requisite preoperative procedures and investigations, guidelines for specific cases such as comatose patients or those with complex fractures, and ceiling of care discussions, and then focuses on the postoperative period, including physiotherapy, rehabilitation goals and medical management.
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Affiliation(s)
- Ben Sacks
- Department of Colorectal Surgery, University College London Hospital, London, UK
| | | | - Aashish Ahluwalia
- Department of Trauma and Orthopaedics, Hillingdon Hospital, London, UK
| | - Branavan Rudran
- Department of Trauma and Orthopaedics, Hillingdon Hospital, London, UK
| | - Kishan R Parmar
- Department of Trauma and Orthopaedics, Hillingdon Hospital, London, UK
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Greenhalgh T, Choon Huat Koh G, Car J. Covid-19: avaliação remota em Atenção Primária à Saúde. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2020. [DOI: 10.5712/rbmfc15(42)2461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
O que você precisa saber? A maioria dos pacientes com Covid-19 podem ser manejados remotamente com aconselhamento de manejo de sintomas e autoisolamento; Apesar da maioria das consultas poderem ser feitas por telefone, a imagem de vídeo fornece pistas adicionais visuais e a presença terapêutica do profissional de saúde para o paciente; Falta de ar é um sintoma preocupante, embora, hoje, não há ferramenta validada para avaliá-la remotamente;Aconselhamento sobre rede de segurança para o paciente é crucial, uma vez que, alguns pacientes deterioram muito a sua condição de saúde em 2 semanas, mais comumente por pneumonia.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Gerald Choon Huat Koh
- Saw Swee Hock School of Public Health, Yong Loo Lin School of Medicine, National University of Singapore
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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