1
|
Bergstedt A, Hilliard B, Alabsi S, Usher MG, Peters M, Grace J, Melton GB, Beebe TJ, Pestka DL. Evaluation of a Clinical Decision Support Tool to Guide Adoption of the American Heart Association Telemetry Monitoring Practice Standards. J Am Heart Assoc 2024; 13:e031523. [PMID: 38686881 DOI: 10.1161/jaha.123.031523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND The objectives of this study were to (1) evaluate telemetry use pre- and postimplementation of clinical decision support tools to support American Heart Association practice standards for telemetry monitoring and (2) understand the factors that may contribute to variation of telemetry monitoring in practice. METHODS AND RESULTS First, we captured overall variability in telemetry use pre- and postimplementation of the clinical decision support intervention. We then conducted semistructured interviews with telemetry-ordering providers to identify key barriers and facilitators to adoption. During the study period, 399 physicians met criteria for inclusion and were divided into excessive and nonexcessive orderers. Distribution of telemetry use was bimodal. Among nonexcessive users, 24.4% of patient days were with telemetry compared with 51.6% among excessive users. On average, both excessive (6.1% reduction) and nonexcessive users (2.8% reduction) decreased telemetry use postimplementation, and these reductions were sustained over a 16-month period. Sixteen interviews were conducted. Physicians believed that the tool was successful because it caused them to more closely consider if telemetry was indicated for each patient. Physicians also voiced frustration with interruptions to their workflow, and some noted that they commonly use telemetry outside of practice standards to monitor patients who were acutely but not critically ill. CONCLUSIONS Embedding telemetry practice standards into the electronic health record in the form of clinical decision support is effective at reducing excess telemetry use. Although the intervention was well received, there are persistent barriers, such as preexisting views on telemetry and existing workflow habits, that may inhibit higher adoption of standards.
Collapse
Affiliation(s)
- Allen Bergstedt
- Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Brian Hilliard
- Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Sarah Alabsi
- Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Michael G Usher
- Department of Medicine University of Minnesota Medical School Minneapolis MN
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
| | - Maya Peters
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
| | - James Grace
- Department of Medicine University of Minnesota Medical School Minneapolis MN
| | - Genevieve B Melton
- Department of Surgery University of Minnesota Medical School Minneapolis MN
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
- Institute for Health Informatics University of Minnesota Minneapolis MN
| | - Timothy J Beebe
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
- Division of Health Policy Management, School of Public Health University of Minnesota Minneapolis MN
| | - Deborah L Pestka
- Center for Learning Health System Sciences University of Minnesota Medical School Minneapolis MN
| |
Collapse
|
2
|
Pestka DL, Boes S, Ramezani S, Peters M, Usher MG, Koopmeiners JS, Beebe TJ, Melton GB, Streib CD. Implementing Telestroke in the Inpatient Setting: Identifying Factors for Success. Stroke 2024. [PMID: 38639090 DOI: 10.1161/strokeaha.123.046024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/13/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Inpatient telestroke programs have emerged as a solution to provide timely stroke care in underserved areas, but their successful implementation and factors influencing their effectiveness remain underexplored. This study aimed to qualitatively evaluate the perspectives of inpatient clinicians located at spoke hospitals participating in a newly established inpatient telestroke program to identify implementation barriers and facilitators. METHODS This was a formative evaluation relying on semistructured qualitative interviews with 16 inpatient providers (physicians and nurse practitioners) at 5 spoke sites of a hub-and-spoke inpatient telestroke program. The Integrated-Promoting Action on Research Implementation in Health Services framework guided data analysis, focusing on the innovation, recipients, context, and facilitation aspects of implementation. Interviews were transcribed and coded using thematic analysis. RESULTS Fifteen themes were identified in the data and mapped to the Integrated-Promoting Action on Research Implementation in Health Services framework. Themes related to the innovation (the telestroke program) included easy access to stroke specialists, the benefits of limiting patient transfers, concerns about duplicating tests, and challenges of timing inpatient telestroke visits and notes to align with discharge workflow. Themes pertaining to recipients (care team members and patients) were communication gaps between teams, concern about the supervision of inpatient telestroke advanced practice providers and challenges with nurse empowerment. With regard to the context (hospital and system factors), providers highlighted familiarity with telehealth technologies as a facilitator to implementing inpatient telestroke, yet highlighted resource limitations in smaller facilities. Facilitation (program implementation) was recognized as crucial for education, standardization, and buy-in. CONCLUSIONS Understanding barriers and facilitators to implementation is crucial to determining where programmatic changes may need to be made to ensure the success and sustainment of inpatient telestroke services.
Collapse
Affiliation(s)
- Deborah L Pestka
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
| | - Samuel Boes
- Department of Neurology, University of Minnesota, Minneapolis. (S.B., S.R., C.D.S.)
| | - Solmaz Ramezani
- Department of Neurology, University of Minnesota, Minneapolis. (S.B., S.R., C.D.S.)
| | - Maya Peters
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
| | - Michael G Usher
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
| | - Joseph S Koopmeiners
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
- Division of Biostatistics and Health Data Science, School of Public Health, University of Minnesota, Minneapolis. (J.S.K.)
| | - Timothy J Beebe
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
- Division of Health Policy Management, School of Public Health, University of Minnesota, Minneapolis. (T.J.B.)
| | - Genevieve B Melton
- Center for Learning Health System Sciences, University of Minnesota Medical School, Minneapolis (D.L.P., M.P., M.G.U., J.S.K., T.J.B., G.B.M.)
- Department of Surgery, University of Minnesota, Minneapolis.(G.B.M.)
- Institute for Health Informatics, University of Minnesota, Minneapolis. (G.B.M.)
| | - Christopher D Streib
- Department of Neurology, University of Minnesota, Minneapolis. (S.B., S.R., C.D.S.)
| |
Collapse
|
3
|
Byrd TF, Southwell B, Ravishankar A, Tran T, Kc A, Phelan T, Melton-Meaux GB, Usher MG, Scheppmann D, Switzer S, Simon G, Tignanelli CJ. Validation of a Proprietary Deterioration Index Model and Performance in Hospitalized Adults. JAMA Netw Open 2023; 6:e2324176. [PMID: 37486632 PMCID: PMC10366696 DOI: 10.1001/jamanetworkopen.2023.24176] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
Importance The Deterioration Index (DTI), used by hospitals for predicting patient deterioration, has not been extensively validated externally, raising concerns about performance and equitable predictions. Objective To locally validate DTI performance and assess its potential for bias in predicting patient clinical deterioration. Design, Setting, and Participants This retrospective prognostic study included 13 737 patients admitted to 8 heterogenous Midwestern US hospitals varying in size and type, including academic, community, urban, and rural hospitals. Patients were 18 years or older and admitted between January 1 and May 31, 2021. Exposure DTI predictions made every 15 minutes. Main Outcomes and Measures Deterioration, defined as the occurrence of any of the following while hospitalized: mechanical ventilation, intensive care unit transfer, or death. Performance of the DTI was evaluated using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC). Bias measures were calculated across demographic subgroups. Results A total of 5 143 513 DTI predictions were made for 13 737 patients across 14 834 hospitalizations. Among 13 918 encounters, the mean (SD) age of patients was 60.3 (19.2) years; 7636 (54.9%) were female, 11 345 (81.5%) were White, and 12 392 (89.0%) were of other ethnicity than Hispanic or Latino. The prevalence of deterioration was 10.3% (n = 1436). The DTI produced AUROCs of 0.759 (95% CI, 0.756-0.762) at the observation level and 0.685 (95% CI, 0.671-0.700) at the encounter level. Corresponding AUPRCs were 0.039 (95% CI, 0.037-0.040) at the observation level and 0.248 (95% CI, 0.227-0.273) at the encounter level. Bias measures varied across demographic subgroups and were 14.0% worse for patients identifying as American Indian or Alaska Native and 19.0% worse for those who chose not to disclose their ethnicity. Conclusions and Relevance In this prognostic study, the DTI had modest ability to predict patient deterioration, with varying degrees of performance at the observation and encounter levels and across different demographic groups. Disparate performance across subgroups suggests the need for more transparency in model training data and reinforces the need to locally validate externally developed prediction models.
Collapse
Affiliation(s)
- Thomas F Byrd
- Department of Medicine, University of Minnesota, Minneapolis
- Institute for Health Informatics, University of Minnesota, Minneapolis
| | | | | | - Travis Tran
- Department of Medicine, University of Minnesota, Minneapolis
| | - Abhinab Kc
- University of Minnesota Medical School, University of Minnesota, Minneapolis
| | - Tom Phelan
- Fairview Health Services, Minneapolis, Minnesota
| | - Genevieve B Melton-Meaux
- Institute for Health Informatics, University of Minnesota, Minneapolis
- Department of Surgery, University of Minnesota, Minneapolis
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis
| | - Michael G Usher
- Department of Medicine, University of Minnesota, Minneapolis
- Institute for Health Informatics, University of Minnesota, Minneapolis
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis
| | - Daren Scheppmann
- Institute for Health Informatics, University of Minnesota, Minneapolis
| | - Sean Switzer
- Department of Medicine, University of Minnesota, Minneapolis
| | - Gyorgy Simon
- Department of Medicine, University of Minnesota, Minneapolis
- Institute for Health Informatics, University of Minnesota, Minneapolis
| | - Christopher J Tignanelli
- Institute for Health Informatics, University of Minnesota, Minneapolis
- Department of Surgery, University of Minnesota, Minneapolis
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis
| |
Collapse
|
4
|
Ikramuddin F, Melnik T, Ingraham NE, Nguyen N, Siegel L, Usher MG, Tignanelli CJ, Morse L. Predictors of discharge disposition and mortality following hospitalization with SARS-CoV-2 infection. PLoS One 2023; 18:e0283326. [PMID: 37053224 PMCID: PMC10101512 DOI: 10.1371/journal.pone.0283326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/07/2023] [Indexed: 04/14/2023] Open
Abstract
IMPORTANCE The SARS-CoV-2 pandemic has overwhelmed hospital capacity, prioritizing the need to understand factors associated with type of discharge disposition. OBJECTIVE Characterization of disposition associated factors following SARS-CoV-2. DESIGN Retrospective study of SARS-CoV-2 positive patients from March 7th, 2020, to May 4th, 2022, requiring hospitalization. SETTING Midwest academic health-system. PARTICIPANTS Patients above the age 18 years admitted with PCR + SARS-CoV-2. INTERVENTION None. MAIN OUTCOMES Discharge to home versus PAC (inpatient rehabilitation facility (IRF), skilled-nursing facility (SNF), long-term acute care (LTACH)), or died/hospice while hospitalized (DH). RESULTS We identified 62,279 SARS-CoV-2 PCR+ patients; 6,248 required hospitalizations, of whom 4611(73.8%) were discharged home, 985 (15.8%) to PAC and 652 (10.4%) died in hospital (DH). Patients discharged to PAC had a higher median age (75.7 years, IQR: 65.6-85.1) compared to those discharged home (57.0 years, IQR: 38.2-69.9), and had longer mean length of stay (LOS) 14.7 days, SD: 14.0) compared to discharge home (5.8 days, SD: 5.9). Older age (RRR:1.04, 95% CI:1.041-1.055), and higher Elixhauser comorbidity index [EI] (RRR:1.19, 95% CI:1.168-1.218) were associated with higher rate of discharge to PAC versus home. Older age (RRR:1.069, 95% CI:1.060-1.077) and higher EI (RRR:1.09, 95% CI:1.071-1.126) were associated with more frequent DH versus home. Blacks, Asians, and Hispanics were less likely to be discharged to PAC (RRR, 0.64 CI 0.47-0.88), (RRR 0.48 CI 0.34-0.67) and (RRR 0.586 CI 0.352-0.975). Having alpha variant was associated with less frequent PAC discharge versus home (RRR 0.589 CI 0.444-780). The relative risks for DH were lower with a higher platelet count 0.998 (CI 0.99-0.99) and albumin levels 0.342 (CI 0.26-0.45), and higher with increased CRP (RRR 1.006 CI 1.004-1.007) and D-Dimer (RRR 1.070 CI 1.039-1.101). Increased albumin had lower risk to PAC discharge (RRR 0.630 CI 0.497-0.798. An increase in D-Dimer (RRR1.033 CI 1.002-1.064) and CRP (RRR1.002 CI1.001-1.004) was associated with higher risk of PAC discharge. A breakthrough (BT) infection was associated with lower likelihood of DH and PAC. CONCLUSION Older age, higher EI, CRP and D-Dimer are associated with PAC and DH discharges following hospitalization with COVID-19 infection. BT infection reduces the likelihood of being discharged to PAC and DH.
Collapse
Affiliation(s)
- Farha Ikramuddin
- Department of Rehabilitation Medicine, Division of PM&R, University of Minnesota, Minneapolis, MN, United States of America
| | - Tanya Melnik
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN, United States of America
| | - Nicholas E Ingraham
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN, United States of America
| | - Nguyen Nguyen
- Department of Rehabilitation Medicine, Division of PM&R, University of Minnesota, Minneapolis, MN, United States of America
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States of America
| | - Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota Division of Acute Care Surgery, Minneapolis, MN, United States of America
| | - Leslie Morse
- Department of Rehabilitation Medicine, Division of PM&R, University of Minnesota, Minneapolis, MN, United States of America
| |
Collapse
|
5
|
Lim S, Tignanelli CJ, Hoertel N, Boulware DR, Usher MG. Prevalence of medical contraindications to nirmatrelvir/ritonavir in a cohort of hospitalized and non-hospitalized patients with COVID-19. Open Forum Infect Dis 2022; 9:ofac389. [PMID: 36000003 PMCID: PMC9384640 DOI: 10.1093/ofid/ofac389] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/01/2022] [Indexed: 11/21/2022] Open
Abstract
This analysis describes the prevalence of contraindications to nirmatrelvir/ritonavir among 66 007 patients with coronavirus disease 2019 in a large health care system. A possible contradiction was present in 9830 patients (14.8%), with the prevalence of contraindications increasing with higher acuity of illness.
Collapse
Affiliation(s)
- Sarah Lim
- Minnesota Department of Health , St. Paul, MN , USA
| | | | - Nicolas Hoertel
- Université de Paris, AP-HP, Hôpital Corentin-Celton, DMU Psychiatrie et Addictologie, INSERM U1266, Institut de Psychiatrie et Neuroscience de Paris , F-75014 Paris , France
| | - David R Boulware
- Department of Medicine, University of Minnesota , Minneapolis, MN , USA
| | - Michael G Usher
- Department of Medicine, University of Minnesota , Minneapolis, MN , USA
| |
Collapse
|
6
|
Usher MG, Tignanelli CJ, Hilliard B, Kaltenborn ZP, Lupei MI, Simon G, Shah S, Kirsch JD, Melton GB, Ingraham NE, Olson AP, Baum KD. Responding to COVID-19 Through Interhospital Resource Coordination: A Mixed-Methods Evaluation. J Patient Saf 2022; 18:287-294. [PMID: 34569998 PMCID: PMC8940726 DOI: 10.1097/pts.0000000000000916] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The COVID-19 pandemic stressed hospital operations, requiring rapid innovations to address rise in demand and specialized COVID-19 services while maintaining access to hospital-based care and facilitating expertise. We aimed to describe a novel hospital system approach to managing the COVID-19 pandemic, including multihospital coordination capability and transfer of COVID-19 patients to a single, dedicated hospital. METHODS We included patients who tested positive for SARS-CoV-2 by polymerase chain reaction admitted to a 12-hospital network including a dedicated COVID-19 hospital. Our primary outcome was adherence to local guidelines, including admission risk stratification, anticoagulation, and dexamethasone treatment assessed by differences-in-differences analysis after guideline dissemination. We evaluated outcomes and health care worker satisfaction. Finally, we assessed barriers to safe transfer including transfer across different electronic health record systems. RESULTS During the study, the system admitted a total of 1209 patients. Of these, 56.3% underwent transfer, supported by a physician-led System Operations Center. Patients who were transferred were older (P = 0.001) and had similar risk-adjusted mortality rates. Guideline adherence after dissemination was higher among patients who underwent transfer: admission risk stratification (P < 0.001), anticoagulation (P < 0.001), and dexamethasone administration (P = 0.003). Transfer across electronic health record systems was a perceived barrier to safety and reduced quality. Providers positively viewed our transfer approach. CONCLUSIONS With standardized communication, interhospital transfers can be a safe and effective method of cohorting COVID-19 patients, are well received by health care providers, and have the potential to improve care quality.
Collapse
Affiliation(s)
- Michael G. Usher
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota Medical School
- Institute for Health Informatics, University of Minnesota
| | - Brian Hilliard
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Zachary P. Kaltenborn
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | | | - Gyorgy Simon
- Institute for Health Informatics, University of Minnesota
| | - Surbhi Shah
- Division of Hematology and Oncology, Department of Medicine
| | - Jonathan D. Kirsch
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Genevieve B. Melton
- Department of Surgery, University of Minnesota Medical School
- Institute for Health Informatics, University of Minnesota
| | - Nicholas E. Ingraham
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Andrew P.J. Olson
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Karyn D. Baum
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| |
Collapse
|
7
|
Abdelwahab N, Ingraham NE, Nguyen N, Siegel L, Silverman G, Sahoo HS, Pakhomov S, Morse LR, Billings J, Usher MG, Melnik TE, Tignanelli CJ, Ikramuddin F. Predictors of Post-Acute Sequelae of COVID-19 Development and Rehabilitation: A Retrospective Study. Arch Phys Med Rehabil 2022; 103:2001-2008. [PMID: 35569640 PMCID: PMC9098397 DOI: 10.1016/j.apmr.2022.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 04/08/2022] [Accepted: 04/13/2022] [Indexed: 12/02/2022]
Abstract
Objective To examine the frequency of postacute sequelae of SARS-CoV-2 (PASC) and the factors associated with rehabilitation utilization in a large adult population with PASC. Design Retrospective study. Setting Midwest hospital health system. Participants 19,792 patients with COVID-19 from March 10, 2020, to January 17, 2021. Intervention Not applicable. Main Outcome Measures Descriptive analyses were conducted across the entire cohort along with an adult subgroup analysis. A logistic regression was performed to assess factors associated with PASC development and rehabilitation utilization. Results In an analysis of 19,792 patients, the frequency of PASC was 42.8% in the adult population. Patients with PASC compared with those without had a higher utilization of rehabilitation services (8.6% vs 3.8%, P<.001). Risk factors for rehabilitation utilization in patients with PASC included younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-1.00; P=.01). In addition to several comorbidities and demographics factors, risk factors for rehabilitation utilization solely in the inpatient population included male sex (OR, 1.24; 95% CI, 1.02-1.50; P=.03) with patients on angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers 3 months prior to COVID-19 infections having a decreased risk of needing rehabilitation (OR, 0.80; 95% CI, 0.64-0.99; P=.04). Conclusions Patients with PASC had higher rehabilitation utilization. We identified several clinical and demographic factors associated with the development of PASC and rehabilitation utilization.
Collapse
Affiliation(s)
- Nermine Abdelwahab
- Department of Medicine, University of Minnesota, Division of General Internal Medicine, Minneapolis, MN.
| | - Nicholas E Ingraham
- Department of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN
| | - Nguyen Nguyen
- Department of Rehabilitation Medicine, University of Minnesota, Division of PM&R, Minneapolis, MN
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Greg Silverman
- Department of Surgery, University of Minnesota Division of Acute Care Surgery, Minneapolis, MN
| | - Himanshu Shekhar Sahoo
- Department of Surgery, University of Minnesota Division of Acute Care Surgery, Minneapolis, MN; Department of Electrical and Computer Engineering, University of Minnesota, Minneapolis, MN
| | - Serguei Pakhomov
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN
| | - Leslie R Morse
- Department of Rehabilitation Medicine, University of Minnesota, Division of PM&R, Minneapolis, MN
| | - Joanne Billings
- Department of Medicine, University of Minnesota, Division of Pulmonary and Critical Care, Minneapolis, MN
| | - Michael G Usher
- Department of Medicine, University of Minnesota, Division of General Internal Medicine, Minneapolis, MN
| | - Tanya E Melnik
- Department of Medicine, University of Minnesota, Division of General Internal Medicine, Minneapolis, MN
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota Division of Acute Care Surgery, Minneapolis, MN; Institute for Health Informatics, University of Minnesota, Minneapolis, MN
| | - Farha Ikramuddin
- Department of Rehabilitation Medicine, University of Minnesota, Division of PM&R, Minneapolis, MN
| |
Collapse
|
8
|
Lupei MI, Li D, Ingraham NE, Baum KD, Benson B, Puskarich M, Milbrandt D, Melton GB, Scheppmann D, Usher MG, Tignanelli CJ. A 12-hospital prospective evaluation of a clinical decision support prognostic algorithm based on logistic regression as a form of machine learning to facilitate decision making for patients with suspected COVID-19. PLoS One 2022; 17:e0262193. [PMID: 34986168 PMCID: PMC8730444 DOI: 10.1371/journal.pone.0262193] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/20/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To prospectively evaluate a logistic regression-based machine learning (ML) prognostic algorithm implemented in real-time as a clinical decision support (CDS) system for symptomatic persons under investigation (PUI) for Coronavirus disease 2019 (COVID-19) in the emergency department (ED). METHODS We developed in a 12-hospital system a model using training and validation followed by a real-time assessment. The LASSO guided feature selection included demographics, comorbidities, home medications, vital signs. We constructed a logistic regression-based ML algorithm to predict "severe" COVID-19, defined as patients requiring intensive care unit (ICU) admission, invasive mechanical ventilation, or died in or out-of-hospital. Training data included 1,469 adult patients who tested positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) within 14 days of acute care. We performed: 1) temporal validation in 414 SARS-CoV-2 positive patients, 2) validation in a PUI set of 13,271 patients with symptomatic SARS-CoV-2 test during an acute care visit, and 3) real-time validation in 2,174 ED patients with PUI test or positive SARS-CoV-2 result. Subgroup analysis was conducted across race and gender to ensure equity in performance. RESULTS The algorithm performed well on pre-implementation validations for predicting COVID-19 severity: 1) the temporal validation had an area under the receiver operating characteristic (AUROC) of 0.87 (95%-CI: 0.83, 0.91); 2) validation in the PUI population had an AUROC of 0.82 (95%-CI: 0.81, 0.83). The ED CDS system performed well in real-time with an AUROC of 0.85 (95%-CI, 0.83, 0.87). Zero patients in the lowest quintile developed "severe" COVID-19. Patients in the highest quintile developed "severe" COVID-19 in 33.2% of cases. The models performed without significant differences between genders and among race/ethnicities (all p-values > 0.05). CONCLUSION A logistic regression model-based ML-enabled CDS can be developed, validated, and implemented with high performance across multiple hospitals while being equitable and maintaining performance in real-time validation.
Collapse
Affiliation(s)
- Monica I. Lupei
- Division of Critical Care, Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Danni Li
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Nicholas E. Ingraham
- Division of Pulmonary and Critical Care, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Karyn D. Baum
- Division of General Internal Medicine, Department of Medicine, Section of Hospital Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Bradley Benson
- Division of General Internal Medicine, Department of Medicine, Section of Hospital Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - David Milbrandt
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Genevieve B. Melton
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Daren Scheppmann
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Michael G. Usher
- Division of General Internal Medicine, Department of Medicine, Section of Hospital Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
- Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, United States of America
- Division of Critical Care and Acute Care Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| |
Collapse
|
9
|
Ingraham NE, Purcell LN, Karam BS, Dudley RA, Usher MG, Warlick CA, Allen ML, Melton GB, Charles A, Tignanelli CJ. Racial and Ethnic Disparities in Hospital Admissions from COVID-19: Determining the Impact of Neighborhood Deprivation and Primary Language. J Gen Intern Med 2021; 36:3462-3470. [PMID: 34003427 PMCID: PMC8130213 DOI: 10.1007/s11606-021-06790-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/01/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite past and ongoing efforts to achieve health equity in the USA, racial and ethnic disparities persist and appear to be exacerbated by COVID-19. OBJECTIVE Evaluate neighborhood-level deprivation and English language proficiency effect on disproportionate outcomes seen in racial and ethnic minorities diagnosed with COVID-19. DESIGN Retrospective cohort study SETTING: Health records of 12 Midwest hospitals and 60 clinics in Minnesota between March 4, 2020, and August 19, 2020 PATIENTS: Polymerase chain reaction-positive COVID-19 patients EXPOSURES: Area Deprivation Index (ADI) and primary language MAIN MEASURES: The primary outcome was COVID-19 severity, using hospitalization within 45 days of diagnosis as a marker of severity. Logistic and competing-risk regression models assessed the effects of neighborhood-level deprivation (using the ADI) and primary language. Within race, effects of ADI and primary language were measured using logistic regression. RESULTS A total of 5577 individuals infected with SARS-CoV-2 were included; 866 (n = 15.5%) were hospitalized within 45 days of diagnosis. Hospitalized patients were older (60.9 vs. 40.4 years, p < 0.001) and more likely to be male (n = 425 [49.1%] vs. 2049 [43.5%], p = 0.002). Of those requiring hospitalization, 43.9% (n = 381), 19.9% (n = 172), 18.6% (n = 161), and 11.8% (n = 102) were White, Black, Asian, and Hispanic, respectively. Independent of ADI, minority race/ethnicity was associated with COVID-19 severity: Hispanic patients (OR 3.8, 95% CI 2.72-5.30), Asians (OR 2.39, 95% CI 1.74-3.29), and Blacks (OR 1.50, 95% CI 1.15-1.94). ADI was not associated with hospitalization. Non-English-speaking (OR 1.91, 95% CI 1.51-2.43) significantly increased odds of hospital admission across and within minority groups. CONCLUSIONS Minority populations have increased odds of severe COVID-19 independent of neighborhood deprivation, a commonly suspected driver of disparate outcomes. Non-English-speaking accounts for differences across and within minority populations. These results support the ongoing need to determine the mechanisms that contribute to disparities during COVID-19 while also highlighting the underappreciated role primary language plays in COVID-19 severity among minority groups.
Collapse
Affiliation(s)
- Nicholas E. Ingraham
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN USA
| | - Laura N. Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, NC USA
| | - Basil S. Karam
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI USA
| | - R. Adams Dudley
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN USA
| | - Michael G. Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN USA
| | | | - Michele L. Allen
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN USA
| | - Genevieve B. Melton
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN USA
- Department of Surgery, University of Minnesota, Minneapolis, MN USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, NC USA
- School of Public Health, University of North Carolina, Chapel Hill, NC USA
| | - Christopher J. Tignanelli
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN USA
- Department of Surgery, University of Minnesota, Minneapolis, MN USA
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN USA
| |
Collapse
|
10
|
Usher MG, Tourani R, Simon G, Tignanelli C, Jarabek B, Strauss CE, Waring SC, Klyn NAM, Kealey BT, Tambyraja R, Pandita D, Baum KD. Overcoming gaps: regional collaborative to optimize capacity management and predict length of stay of patients admitted with COVID-19. JAMIA Open 2021; 4:ooab055. [PMID: 34350391 PMCID: PMC8327377 DOI: 10.1093/jamiaopen/ooab055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/12/2021] [Accepted: 07/06/2021] [Indexed: 11/21/2022] Open
Abstract
Objective Ensuring an efficient response to COVID-19 requires a degree of inter-system coordination and capacity management coupled with an accurate assessment of hospital utilization including length of stay (LOS). We aimed to establish optimal practices in inter-system data sharing and LOS modeling to support patient care and regional hospital operations. Materials and Methods We completed a retrospective observational study of patients admitted with COVID-19 followed by 12-week prospective validation, involving 36 hospitals covering the upper Midwest. We developed a method for sharing de-identified patient data across systems for analysis. From this, we compared 3 approaches, generalized linear model (GLM) and random forest (RF), and aggregated system level averages to identify features associated with LOS. We compared model performance by area under the ROC curve (AUROC). Results A total of 2068 patients were included and used for model derivation and 597 patients for validation. LOS overall had a median of 5.0 days and mean of 8.2 days. Consistent predictors of LOS included age, critical illness, oxygen requirement, weight loss, and nursing home admission. In the validation cohort, the RF model (AUROC 0.890) and GLM model (AUROC 0.864) achieved good to excellent prediction of LOS, but only marginally better than system averages in practice. Conclusion Regional sharing of patient data allowed for effective prediction of LOS across systems; however, this only provided marginal improvement over hospital averages at the aggregate level. A federated approach of sharing aggregated system capacity and average LOS will likely allow for effective capacity management at the regional level.
Collapse
Affiliation(s)
- Michael G Usher
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Roshan Tourani
- Department of Medicine, Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Gyorgy Simon
- Department of Medicine, Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Christopher Tignanelli
- Department of Medicine, Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota, USA.,Division of Acute Care Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Bryan Jarabek
- Department of Informatics, M Health Fairview, Minneapolis, Minnesota, USA
| | - Craig E Strauss
- Minneapolis Heart Institute Center for Healthcare Delivery Innovation, Minneapolis Heart Institute, Allina Health, Minneapolis, Minnesota, USA
| | - Stephen C Waring
- Essentia Institute of Rural Health, Essential Health, Duluth, Minnesota, USA
| | - Niall A M Klyn
- Information Services, Essentia Health, Duluth, Minnesota, USA
| | - Burke T Kealey
- Internal Medicine, HealthPartners, St. Paul, Minnesota, USA
| | - Rabindra Tambyraja
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Deepti Pandita
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Karyn D Baum
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| |
Collapse
|
11
|
Ingraham NE, King S, Proper J, Siegel L, Zolfaghari EJ, Murray TA, Vakayil V, Sheka A, Feng R, Guzman G, Roy SS, Muddappa D, Usher MG, Chipman JG, Tignanelli CJ, Pendleton KM. Morbidity and Mortality Trends of Pancreatitis: An Observational Study. Surg Infect (Larchmt) 2021; 22:1021-1030. [PMID: 34129395 DOI: 10.1089/sur.2020.473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Pancreatitis accounts for more than $2.5 billion of healthcare costs and remains the most common gastrointestinal (GI) admission. Few contemporary studies have assessed temporal trends of incidence, complications, management, and outcomes for acute pancreatitis in hospitalized patients at the national level. Methods: We used data from one of the largest hospital-based databases available in the United States, the Healthcare Cost and Utilization Project's (HCUP) State Inpatient Database, from 10 states between 2008 and 2015. We included patients with a diagnosis of acute pancreatitis (ICD-9 CM 577.0). Patient- and hospital-level data were used to estimate incidence and inpatient mortality rates. Results: From 80,736,256 hospitalizations, 929,914 (1.15%) cases of acute pancreatitis were identified, 186,226 (20.2%) of which were caused by gallbladder disease). The median age was 53 years (interquartile range [IQR], 41-67) and 50.8% were men. In-hospital mortality was 2.5% and crude mortality rates declined from 2.9% to 2.0% over the study period. Admission year remained significant after adjusting for patient demographics and comorbidities (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.89-0.90; p < 0.001). Gallbladder disease was associated with decreased odds of mortality (OR, 0.60; 95% CI, 0.57-0.62). Median length of stay was four days (IQR, 2-7) and decreased over time. The rates of surgical and endoscopic interventions were highest in 2011 (peak incidence of 16.1% and 9.5%, respectively) and have been decreasing since. Surgical providers were, on average, more likely than medical providers to perform surgery in both those with and without gallbladder disease etiology (gallbladder disease OR, 7.11; 95% CI, 5.46-9.25; non-gallbladder disease OR, 20.50; 95% CI, 16.81-25.01), endoscopy (gallbladder disease OR, 1.22; 95% CI, 0.87-1.72; non-gallbladder disease OR, 1.60; 95% CI, 1.18-2.16), or both (gallbladder disease OR, 7.00; 95% CI, 5.22-9.37; non-gallbladder disease OR, 8.85; 95% CI, 5.61-13.96). Conclusions: The incidence of pancreatitis, from 2008 to 2015, has increased whereas inpatient mortality (i.e., case fatality) has decreased. Understanding temporal trends in outcomes and management along with provider, hospital, and regional variation can better identify areas for future research and collaboration in managing these patients.
Collapse
Affiliation(s)
- Nicholas E Ingraham
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Samantha King
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Victor Vakayil
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adam Sheka
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ruoying Feng
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gabriel Guzman
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Samit Sunny Roy
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Dhannanjay Muddappa
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA.,Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathryn M Pendleton
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
12
|
Kaltenborn Z, Paul K, Kirsch JD, Aylward M, Rogers EA, Rhodes MT, Usher MG. Super fragmented: a nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers. BMC Health Serv Res 2021; 21:338. [PMID: 33853590 PMCID: PMC8045386 DOI: 10.1186/s12913-021-06323-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background Super-utilizers with 4 or more admissions per year frequently receive low-quality care and disproportionately contribute to healthcare costs. Inpatient care fragmentation (admission to multiple different hospitals) in this population has not been well described. Objective To determine the prevalence of super-utilizers who receive fragmented care across different hospitals and to describe associated risks, costs, and health outcomes. Research design We analyzed inpatient data from the Health Care Utilization Project’s State Inpatient and Emergency Department database from 6 states from 2013. After identifying hospital super-utilizers, we stratified by the number of different hospitals visited in a 1-year period. We determined how patient demographics, costs, and outcomes varied by degree of fragmentation. We then examined how fragmentation would influence a hospital’s ability to identify super-utilizers. Subjects Adult patients with 4 or more inpatient stays in 1 year. Measures Patient demographics, cost, 1-year hospital reported mortality, and probability that a single hospital could correctly identify a patient as a super-utilizer. Results Of the 167,515 hospital super-utilizers, 97,404 (58.1%) visited more than 1 hospital in a 1-year period. Fragmentation was more likely among younger, non-white, low-income, under-insured patients, in population-dense areas. Patients with fragmentation were more likely to be admitted for chronic disease management, psychiatric illness, and substance abuse. Inpatient fragmentation was associated with higher yearly costs and lower likelihood of being identified as a super-utilizer. Conclusions Inpatient care fragmentation is common among super-utilizers, disproportionately affects vulnerable populations. It is associated with high yearly costs and a decreased probability of correctly identifying super-utilizers. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06323-5.
Collapse
Affiliation(s)
- Zach Kaltenborn
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Koushik Paul
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA
| | - Jonathan D Kirsch
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA
| | - Michael Aylward
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Elizabeth A Rogers
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Michael T Rhodes
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | - Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, 420 Delaware St. SE MMC 741, Minneapolis, MN, 55455, USA.
| |
Collapse
|
13
|
Lusczek ER, Ingraham NE, Karam BS, Proper J, Siegel L, Helgeson ES, Lotfi-Emran S, Zolfaghari EJ, Jones E, Usher MG, Chipman JG, Dudley RA, Benson B, Melton GB, Charles A, Lupei MI, Tignanelli CJ. Characterizing COVID-19 clinical phenotypes and associated comorbidities and complication profiles. PLoS One 2021; 16:e0248956. [PMID: 33788884 PMCID: PMC8011766 DOI: 10.1371/journal.pone.0248956] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/09/2021] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Heterogeneity has been observed in outcomes of hospitalized patients with coronavirus disease 2019 (COVID-19). Identification of clinical phenotypes may facilitate tailored therapy and improve outcomes. The purpose of this study is to identify specific clinical phenotypes across COVID-19 patients and compare admission characteristics and outcomes. METHODS This is a retrospective analysis of COVID-19 patients from March 7, 2020 to August 25, 2020 at 14 U.S. hospitals. Ensemble clustering was performed on 33 variables collected within 72 hours of admission. Principal component analysis was performed to visualize variable contributions to clustering. Multinomial regression models were fit to compare patient comorbidities across phenotypes. Multivariable models were fit to estimate associations between phenotype and in-hospital complications and clinical outcomes. RESULTS The database included 1,022 hospitalized patients with COVID-19. Three clinical phenotypes were identified (I, II, III), with 236 [23.1%] patients in phenotype I, 613 [60%] patients in phenotype II, and 173 [16.9%] patients in phenotype III. Patients with respiratory comorbidities were most commonly phenotype III (p = 0.002), while patients with hematologic, renal, and cardiac (all p<0.001) comorbidities were most commonly phenotype I. Adjusted odds of respiratory, renal, hepatic, metabolic (all p<0.001), and hematological (p = 0.02) complications were highest for phenotype I. Phenotypes I and II were associated with 7.30-fold (HR:7.30, 95% CI:(3.11-17.17), p<0.001) and 2.57-fold (HR:2.57, 95% CI:(1.10-6.00), p = 0.03) increases in hazard of death relative to phenotype III. CONCLUSION We identified three clinical COVID-19 phenotypes, reflecting patient populations with different comorbidities, complications, and clinical outcomes. Future research is needed to determine the utility of these phenotypes in clinical practice and trial design.
Collapse
Affiliation(s)
- Elizabeth R. Lusczek
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
| | - Nicholas E. Ingraham
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN, United States of America
| | - Basil S. Karam
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States of America
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States of America
| | - Erika S. Helgeson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States of America
| | - Sahar Lotfi-Emran
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN, United States of America
| | - Emily J. Zolfaghari
- University of Minnesota Medical School, Minneapolis, MN, United States of America
| | - Emma Jones
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
| | - Michael G. Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Jeffrey G. Chipman
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
| | - R. Adams Dudley
- Department of Medicine, Division of Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN, United States of America
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States of America
| | - Bradley Benson
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Genevieve B. Melton
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States of America
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, NC, United States of America
- School of Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Monica I. Lupei
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, United States of America
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States of America
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN, United States of America
| |
Collapse
|
14
|
Dutta N, Ingraham NE, Usher MG, Fox C, Tignanelli CJ, Bramante CT. We Should Do More to Offer Evidence-Based Treatment for an Important Modifiable Risk Factor for COVID-19: Obesity. J Prim Care Community Health 2021; 12:2150132721996283. [PMID: 33648370 PMCID: PMC7930643 DOI: 10.1177/2150132721996283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Observational studies, from multiple countries, repeatedly demonstrate an association between obesity and severe COVID-19, which is defined as need for hospitalization, intensive care unit admission, invasive mechanical ventilation (IMV) or death. Meta-analysis of studies from China, USA, and France show odds ratio (OR) of 2.31 (95% CI 1.3-4.1) for obesity and severe COVID-19. Other studies show OR of 12.1 (95% CI 3.25-45.1) for mortality and OR of 7.36 (95% CI 1.63-33.14) for need for IMV for patients with body mass index (BMI) ≥ 35 kg/m2. Obesity is the only modifiable risk factor that is not routinely treated but treatment can lead to improvement in visceral adiposity, insulin sensitivity, and mortality risk. Increasing the awareness of the association between obesity and COVID-19 risk in the general population and medical community may serve as the impetus to make obesity identification and management a higher priority.
Collapse
Affiliation(s)
| | | | | | - Claudia Fox
- University of Minnesota, Minneapolis, MN, USA
| | | | | |
Collapse
|
15
|
Ingraham NE, Purcell LN, Karam BS, Dudley RA, Usher MG, Warlick CA, Allen ML, Melton GB, Charles A, Tignanelli CJ. Racial/Ethnic Disparities in Hospital Admissions from COVID-19 and Determining the Impact of Neighborhood Deprivation and Primary Language. medRxiv 2020. [PMID: 32909015 DOI: 10.1101/2020.09.02.20185983] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Despite past and ongoing efforts to achieve health equity in the United States, persistent disparities in socioeconomic status along with multilevel racism maintain disparate outcomes and appear to be amplified by COVID-19. Objective Measure socioeconomic factors and primary language effects on the risk of COVID-19 severity across and within racial/ethnic groups. Design Retrospective cohort study. Setting Health records of 12 Midwest hospitals and 60 clinics in the U.S. between March 4, 2020 to August 19, 2020. Patients PCR+ COVID-19 patients. Exposures Main exposures included race/ethnicity, area deprivation index (ADI), and primary language. Main Outcomes and Measures The primary outcome was COVID-19 severity using hospitalization within 45 days of diagnosis. Logistic and competing-risk regression models (censored at 45 days and accounting for the competing risk of death prior to hospitalization) assessed the effects of neighborhood-level deprivation (using the ADI) and primary language. Within race effects of ADI and primary language were measured using logistic regression. Results 5,577 COVID-19 patients were included, 866 (n=15.5%) were hospitalized within 45 days of diagnosis. Hospitalized patients were older (60.9 vs. 40.4 years, p<0.001) and more likely to be male (n=425 [49.1%] vs. 2,049 [43.5%], p=0.002). Of those requiring hospitalization, 43.9% (n=381), 19.9% (n=172), 18.6% (n=161), and 11.8% (n=102) were White, Black, Asian, and Hispanic, respectively. Independent of ADI, minority race/ethnicity was associated with COVID-19 severity; Hispanic patients (OR 3.8, 95% CI 2.72-5.30), Asians (OR 2.39, 95% CI 1.74-3.29), and Blacks (OR 1.50, 95% CI 1.15-1.94). ADI was not associated with hospitalization. Non-English speaking (OR 1.91, 95% CI 1.51-2.43) significantly increased odds of hospital admission across and within minority groups. Conclusions Minority populations have increased odds of severe COVID-19 independent of neighborhood deprivation, a commonly suspected driver of disparate outcomes. Non-English-speaking accounts for differences across and within minority populations. These results support the continued concern that racism contributes to disparities during COVID-19 while also highlighting the underappreciated role primary language plays in COVID-19 severity across and within minority groups.
Collapse
|
16
|
Usher MG, Fanning C, Fang VW, Carroll M, Parikh A, Joseph A, Herrigel D. Insurance Coverage Predicts Mortality in Patients Transferred Between Hospitals: a Cross-Sectional Study. J Gen Intern Med 2018; 33:2078-2084. [PMID: 30276655 PMCID: PMC6258597 DOI: 10.1007/s11606-018-4687-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/30/2018] [Accepted: 07/22/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized. OBJECTIVE To identify the association between insurance coverage and mortality of patients transferred between hospitals. DESIGN We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers. SETTING Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers. PATIENTS The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals. MEASUREMENTS Adjusted inpatient mortality and 24-h mortality, stratified by insurance status. RESULTS Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p = 0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p = 0.026), and earlier in their hospital course (3.9 vs 2.0 days, p = 0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95% CI 1.13-1.36, p < 0.001) and higher mortality within 24 h (OR 1.33 95% CI 1.11-1.60, p < 0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses. LIMITATIONS This is an observational study where transfer appropriateness cannot be directly assessed. CONCLUSIONS Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.
Collapse
Affiliation(s)
- Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Christine Fanning
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Vivian W Fang
- Department of Accounting, Carlson School of Management, University of Minnesota, Minneapolis, MN, USA
| | - Madeline Carroll
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Amay Parikh
- Department of Medicine, Divisions of Nephrology and Critical Care, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anne Joseph
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Dana Herrigel
- Department of Hospital Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| |
Collapse
|
17
|
Usher MG, Fanning C, Wu D, Muglia C, Balonze K, Kim D, Parikh A, Herrigel D. Information handoff and outcomes of critically ill patients transferred between hospitals. J Crit Care 2016; 36:240-245. [PMID: 27591388 DOI: 10.1016/j.jcrc.2016.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 08/02/2016] [Accepted: 08/05/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE Patients transferred between hospitals are at high risk of adverse events and mortality. This study aims to identify which components of the transfer handoff process are important predictors of adverse events and mortality. MATERIALS AND METHODS We conducted a retrospective, observational study of 335 consecutive patient transfers to 3 intensive care units at an academic tertiary referral center. We assessed the relationship between handoff documentation completeness and patient outcomes. The primary outcome was in-hospital mortality. Secondary outcomes included adverse events, duplication of labor, disposition error, and length of stay. RESULTS Transfer documentation was frequently absent with overall completeness of 58.3%. Adverse events occurred in 42% of patients within 24 hours of arrival, with an overall in-hospital mortality of 17.3%. Higher documentation completeness was associated with reduced in-hospital mortality (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.02 to 0.38; P = .002), reduced adverse events (coefficient, -2.08; 95% CI, -2.76 to -1.390; P < .001), and reduced duplication of labor (OR, 0.19; 95% CI, 0.04 to 0.88; P = .033) when controlling for severity of illness. CONCLUSIONS Documentation completeness is associated with improved outcomes and resource utilization in patients transferred between hospitals.
Collapse
Affiliation(s)
- Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN 55455.
| | - Christine Fanning
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Di Wu
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Christine Muglia
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Karen Balonze
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Deborah Kim
- Department of Medicine, Division of Pulmonary and Critical Care, Boston University School of Medicine, Boston, MA 02118
| | - Amay Parikh
- Department of Medicine, Divisions of Nephrology and Critical Care, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Dana Herrigel
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| |
Collapse
|
18
|
Frieler RA, Ray JJ, Meng H, Ramnarayanan SP, Usher MG, Su EJ, Berger S, Pinsky DJ, Lawrence DA, Wang MM, Mortensen RM. Myeloid mineralocorticoid receptor during experimental ischemic stroke: effects of model and sex. J Am Heart Assoc 2012; 1:e002584. [PMID: 23316294 PMCID: PMC3541615 DOI: 10.1161/jaha.112.002584] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 08/08/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Mineralocorticoid receptor (MR) antagonists have protective effects in the brain during experimental ischemic stroke, and we have previously demonstrated a key role for myeloid MR during stroke pathogenesis. In this study, we explore both model- and sex-specific actions of myeloid MR during ischemic stroke. METHODS AND RESULTS The MR antagonist eplerenone significantly reduced the infarct size in male (control, 99.5 mm(3); eplerenone, 74.2 mm(3); n=8 to 12 per group) but not female (control, 84.0 mm(3); eplerenone, 83.7 mm(3); n=6 to 7 per group) mice after transient (90-minute) middle cerebral artery occlusion. In contrast to MR antagonism, genetic ablation of myeloid MR in female mice significantly reduced infarct size (myeloid MR knockout, 9.4 mm(3) [5.4 to 36.6]; control, 66.0 mm(3) [50.0 to 81.4]; n=6 per group) after transient middle cerebral artery occlusion. This was accompanied by reductions in inflammatory gene expression and improvement in neurological function. In contrast to ischemia-reperfusion, myeloid MR-knockout mice were not protected from permanent middle cerebral artery occlusion. The infarct size and inflammatory response after permanent occlusion showed no evidence of protection by myeloid MR knockout in photothrombotic and intraluminal filament models of permanent occlusion. CONCLUSIONS These studies demonstrate that MR antagonism is protective in male but not female mice during transient middle cerebral artery occlusion, whereas genetic ablation of myeloid MR is protective in both male and female mice. They also highlight important mechanistic differences in the role of myeloid cells in different models of stroke and confirm that specific myeloid phenotypes play key roles in stroke protection.
Collapse
Affiliation(s)
- Ryan A Frieler
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Usher MG, Duan SZ, Ivaschenko CY, Frieler RA, Berger S, Schütz G, Lumeng CN, Mortensen RM. Myeloid mineralocorticoid receptor controls macrophage polarization and cardiovascular hypertrophy and remodeling in mice. J Clin Invest 2010; 120:3350-64. [PMID: 20697155 DOI: 10.1172/jci41080] [Citation(s) in RCA: 288] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 06/30/2010] [Indexed: 12/12/2022] Open
Abstract
Inappropriate excess of the steroid hormone aldosterone, which is a mineralocorticoid receptor (MR) agonist, is associated with increased inflammation and risk of cardiovascular disease. MR antagonists are cardioprotective and antiinflammatory in vivo, and evidence suggests that they mediate these effects in part by aldosterone-independent mechanisms. Here we have shown that MR on myeloid cells is necessary for efficient classical macrophage activation by proinflammatory cytokines. Macrophages from mice lacking MR in myeloid cells (referred to herein as MyMRKO mice) exhibited a transcription profile of alternative activation. In vitro, MR deficiency synergized with inducers of alternatively activated macrophages (for example, IL-4 and agonists of PPARgamma and the glucocorticoid receptor) to enhance alternative activation. In vivo, MR deficiency in macrophages mimicked the effects of MR antagonists and protected against cardiac hypertrophy, fibrosis, and vascular damage caused by L-NAME/Ang II. Increased blood pressure and heart rates and decreased circadian variation were observed during treatment of MyMRKO mice with L-NAME/Ang II. We conclude that myeloid MR is an important control point in macrophage polarization and that the function of MR on myeloid cells likely represents a conserved ancestral MR function that is integrated in a transcriptional network with PPARgamma and glucocorticoid receptor. Furthermore, myeloid MR is critical for blood pressure control and for hypertrophic and fibrotic responses in the mouse heart and aorta.
Collapse
Affiliation(s)
- Michael G Usher
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan 48109-5622, USA
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Abstract
PURPOSE OF REVIEW Peroxisome proliferator-activated receptors (PPARs) are a family of nuclear receptors activated by nutrient molecules and their derivatives. Their role has been increasingly recognized to be important in hypertension, metabolic disorders and cardiovascular disease, including atherosclerosis. Control of innate inflammatory processes mostly through alteration of monocyte/macrophage phenotype promises to be a unifying paradigm in understanding the pleiotropic effects of PPAR agonists. RECENT FINDINGS Although PPAR-gamma was the first to be described as an anti-inflammatory agent, both PPAR-alpha and PPAR-delta are now known to have similar effects as well. Inflammation is an important part of the damage caused by hypertensive diseases. PPARs have now been recognized as important determinants of macrophage polarization. Monocyte precursors of classical and alternatively activated macrophages are being defined as important changes in progression of cardiovascular disease associated with metabolic syndrome including hypertension, hyperlipidemia and obesity. SUMMARY A major unifying role for PPARs in hypertension and its complications through modification of the innate immune system and inflammation is increasingly likely. PPAR agonists may be beneficial, alone or in combination with other drugs that modify the inflammatory response, in treating hypertension, atherosclerosis and metabolic derangements associated with obesity.
Collapse
Affiliation(s)
- Sheng Zhong Duan
- Nephrology Division, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109-0622, USA
| | | | | |
Collapse
|
21
|
Abstract
Peroxisome proliferator-activated receptor (PPAR)-γ is a nuclear receptor and transcription factor in the steroid superfamily. PPAR-γ agonists, the thiazolidinediones, are clinically used to treat type 2 diabetes. In addition to its function in adipogenesis and increasing insulin sensitivity, PPAR-γ also plays critical roles in the vasculature. In vascular endothelial cells, PPAR-γ activation inhibits endothelial inflammation by suppressing inflammatory gene expression and therefore improves endothelial dysfunction. In vascular smooth muscle cells, PPAR-γ activation inhibits proliferation and migration and promotes apoptosis. In macrophages, PPAR-γ activation suppresses inflammation by regulating gene expression and increases cholesterol uptake and efflux. A recurring theme in many cell types is the modulation of the innate immunity system particularly through altering the activity of the nuclear factor κB. This system is likely to be even more prominent in modulating disease in vascular cells. The effects of PPAR-γ in the vascular cells translate into the beneficial function of this transcription factor in vascular disorders, including hypertension and atherosclerosis. Both human genetic studies and animal studies using transgenic mice have demonstrated the importance of PPAR-γ in these disorders. However, recent clinical studies have raised significant concerns about the cardiovascular side effects of thiazolidinediones, particularly rosiglitazone. Weighing the potential benefit and harm of PPAR-γ activation and exploring the functional mechanisms may provide a balanced view on the clinical use of these compounds and new approaches to the future therapeutics of vascular disorders associated with diabetes.
Collapse
Affiliation(s)
- Sheng Zhong Duan
- From the Departments of Molecular and Integrative Physiology (S.Z.D., M.G.U., R.M.M.), Pharmacology (R.M.M.), and Internal Medicine (R.M.M.), Metabolism Endocrinology and Diabetes Division, University of Michigan Medical School, Ann Arbor
| | - Michael G. Usher
- From the Departments of Molecular and Integrative Physiology (S.Z.D., M.G.U., R.M.M.), Pharmacology (R.M.M.), and Internal Medicine (R.M.M.), Metabolism Endocrinology and Diabetes Division, University of Michigan Medical School, Ann Arbor
| | - Richard M. Mortensen
- From the Departments of Molecular and Integrative Physiology (S.Z.D., M.G.U., R.M.M.), Pharmacology (R.M.M.), and Internal Medicine (R.M.M.), Metabolism Endocrinology and Diabetes Division, University of Michigan Medical School, Ann Arbor
| |
Collapse
|
22
|
Ivashchenko CY, Duan SZ, Usher MG, Mortensen RM. PPAR-gamma knockout in pancreatic epithelial cells abolishes the inhibitory effect of rosiglitazone on caerulein-induced acute pancreatitis. Am J Physiol Gastrointest Liver Physiol 2007; 293:G319-26. [PMID: 17463185 DOI: 10.1152/ajpgi.00056.2007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Peroxisome proliferator-activated receptor-gamma (PPAR-gamma) agonists, such as the thiazolidinediones (TZDs), decrease acute inflammation in both pancreatic cell lines and mouse models of acute pancreatitis. Since PPAR-gamma agonists have been shown to exert some of their actions independent of PPAR-gamma, the role of PPAR-gamma in pancreatic inflammation has not been directly tested. Furthermore, the differential role of PPAR-gamma in endodermal derivatives (acini, ductal cells, and islets) as opposed to the endothelial or inflammatory cells is unknown. To determine whether the effects of a TZD, rosiglitazone, on caerulein-induced acute pancreatitis are dependent on PPAR-gamma in the endodermal derivatives, we created a cell-type specific knock out of PPAR-gamma in pancreatic acini, ducts, and islets. PPAR-gamma knockout animals show a greater response in some inflammatory genes after caerulein challenge. The anti-inflammatory effect of rosiglitazone on edema, macrophage infiltration, and expression of the proinflammatory cytokines is significantly decreased in pancreata of the knockout animals compared with control animals. However, rosiglitazone retains its effect in the lungs of the pancreatic-specific PPAR-gamma knockout animals, likely due to direct anti-inflammatory effect on lung parenchyma. These data show that the PPAR-gamma in the pancreatic epithelia and islets is important in suppressing inflammation and is required for the anti-inflammatory effects of TZDs in acute pancreatitis.
Collapse
Affiliation(s)
- C Y Ivashchenko
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, 1150 W. Medical Center Drive, Ann Arbor, MI 48109, USA
| | | | | | | |
Collapse
|