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Sexton MT, Kim A, McGonigle T, Mihalko S, Vandekar SN, Brummel NE, Patel MB, Dittus RS, Heckers S, Pandharipande PP, Ely EW, Wilson JE. In-hospital catatonia, delirium, and coma and mortality: Results from the delirium and catatonia prospective cohort investigation. Schizophr Res 2024; 263:223-228. [PMID: 37580182 PMCID: PMC10843668 DOI: 10.1016/j.schres.2023.07.031] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Catatonia, a form of acute brain dysfunction typically linked with severe affective and psychotic disorders, occurs in critical illness with delirium and coma. Delirium and coma are associated with mortality, though catatonia's relationship with mortality is unclear. We aim to describe whether catatonia, delirium, and coma are associated with mortality. METHODS We enrolled a convenience cohort of critically ill adults (N = 378) at an academic medical center. We assessed catatonia, delirium, and coma using the Bush-Francis Catatonia Rating Scale, the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively. We tested the associations between previous day brain dysfunction state occurrence with in-hospital and one-year mortality using multivariable time-dependent risk models. Additionally, we tested the association between brain dysfunction duration and one-year mortality. RESULTS Catatonia was not associated with death on the day after diagnosis during hospitalization, and neither previous catatonia occurrence nor duration was associated with one-year mortality. Delirium was not associated with death on any day following diagnosis during hospitalization, and neither previous delirium occurrence nor duration was associated with one-year mortality. The occurrence of coma was associated with death on any day after diagnosis during hospitalization (HR 2.30,CI 1.19-4.44,p = 0.014), as well as through one year following hospital discharge (HR 1.68,CI 1.09-2.59,p = 0.02). CONCLUSIONS Coma, but neither catatonia nor delirium, was associated with future day in-hospital and one-year mortality. More research is needed to understand catatonia's clinical impact. Delirium results differ from existing literature likely due to cohort demographics and size. Coma results highlight the prognostic significance of suppressed arousal while critically ill.
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Affiliation(s)
- Morgan T Sexton
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Ahra Kim
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Trey McGonigle
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Sarasota Mihalko
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America
| | - Simon N Vandekar
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Division of Acute Care Surgery, Departments of Surgery, Neurosurgery, and Hearing and Speech Sciences, Section of Surgical Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America
| | - Robert S Dittus
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America; Department of Medicine, Division of General Internal Medicine and Public Health, Center for Health Services Research and Quality Aging, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Stephan Heckers
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Division of Anesthesiology Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America; Division of Allergy, Pulmonary and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States of America; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States of America; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America.
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2
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Wilson JE, Sealock J, Straub P, Raman R, Kipp AM, Dittus RS, Heckers S, Ely W, Davis LK. Exploring genetic risk for catatonia in a genome wide association study and polygenic risk score analysis. Schizophr Res 2024; 263:178-190. [PMID: 37517919 PMCID: PMC10822029 DOI: 10.1016/j.schres.2023.07.015] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Catatonia is an under-recognized disorder characterized by psychomotor (increased, decreased, or abnormal) changes, affective symptoms, and disturbance of volition, which may arise in the setting of decompensated psychiatric or non-psychiatric medical disorders. Genetic studies of catatonia are limited, and to the best of our knowledge no prior genome wide association studies of catatonia have been performed to date. METHODS First we performed a genome wide association study of catatonia regardless of etiology (psychiatric or non-psychiatric). Secondarily we evaluated whether there was an elevated genetic risk profile for predisposing psychiatric disorders (schizophrenia spectrum disorder, bipolar affective disorder, etc.) in patients with catatonia. We used a matched case control design and applied polygenic risk scores to evaluate for a shared polygenetic contribution to catatonia from common psychiatric phenotypes that show a high prevalence of catatonia in their decompensated states. RESULTS Anxiety, bipolar affective disorder, schizophrenia spectrum disorder and cross disorder polygenic risk scores were significantly associated with catatonia case status in both unadjusted and adjusted logistic regression models for the European Ancestry set even after correcting for multiple comparisons. Depression, Alzheimer's, Autism Spectrum Disorder and Obsessive Disorder polygenic risk scores were not significantly associated with catatonia status in participants of European Ancestry. In the African Ancestry set, no psychiatric polygenic risk scores were significantly associated with catatonia status in either the unadjusted or adjusted regression models. CONCLUSIONS Even after controlling for relevant covariates, anxiety, bipolar affective disorder, schizophrenia spectrum disorder and cross disorders were significantly associated with catatonia status suggesting that there might be a shared genetic risk for those disorders amongst patients with catatonia.
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Affiliation(s)
- Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, USA; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Julia Sealock
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter Straub
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, USA; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron M Kipp
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Robert S Dittus
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, USA; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA; Center for Health Services Research and the Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephan Heckers
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, USA; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wes Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, USA; Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, USA; Division of Allergy, Pulmonary and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lea K Davis
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center Nashville, Nashville, TN, USA
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Lewis JA, Samuels LR, Weems J, Park D, Winter R, Lindsell CJ, Callaway-Lane C, Audet C, Slatore CG, Wiener RS, Dittus RS, Kripalani S, Yankelevitz DF, Henschke CI, Moghanaki D, Matheny ME, Vogus TJ, Roumie CL, Spalluto LB. The Association of Organizational Readiness With Lung Cancer Screening Utilization. Am J Prev Med 2023; 65:844-853. [PMID: 37224985 PMCID: PMC10592591 DOI: 10.1016/j.amepre.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 02/07/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Lung cancer screening is widely underutilized. Organizational factors, such as readiness for change and belief in the value of change (change valence), may contribute to underutilization. The aim of this study was to evaluate the association between healthcare organizations' preparedness and lung cancer screening utilization. METHODS Investigators cross-sectionally surveyed clinicians, staff, and leaders at10 Veterans Affairs from November 2018 to February 2021 to assess organizational readiness to implement change. In 2022, investigators used simple and multivariable linear regression to evaluate the associations between facility-level organizational readiness to implement change and change valence with lung cancer screening utilization. Organizational readiness to implement change and change valence were calculated from individual surveys. The primary outcome was the proportion of eligible Veterans screened using low-dose computed tomography. Secondary analyses assessed scores by healthcare role. RESULTS The overall response rate was 27.4% (n=1,049), with 956 complete surveys analyzed: median age of 49 years, 70.3% female, 67.6% White, 34.6% clinicians, 61.1% staff, and 4.3% leaders. For each 1-point increase in median organizational readiness to implement change and change valence, there was an associated 8.4-percentage point (95% CI=0.2, 16.6) and a 6.3-percentage point increase in utilization (95% CI= -3.9, 16.5), respectively. Higher clinician and staff median scores were associated with increased utilization, whereas leader scores were associated with decreased utilization after adjusting for other roles. CONCLUSIONS Healthcare organizations with higher readiness and change valence utilized more lung cancer screening. These results are hypothesis generating. Future interventions to increase organizations' preparedness, especially among clinicians and staff, may increase lung cancer screening utilization.
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Affiliation(s)
- Jennifer A Lewis
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Medical Service, VA Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, Tennessee; Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.
| | - Lauren R Samuels
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacy Weems
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel Park
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Winter
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carol Callaway-Lane
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Medical Service, VA Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn Audet
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Christopher G Slatore
- Center to Improve Veteran Involvement in Care (CIVIC), Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon; Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon; VA National Center for Lung Cancer Screening (NCLCS), Veterans Health Administration, Washington, District of Columbia
| | - Renda Soylemez Wiener
- VA National Center for Lung Cancer Screening (NCLCS), Veterans Health Administration, Washington, District of Columbia; Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts; The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts
| | - Robert S Dittus
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David F Yankelevitz
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Claudia I Henschke
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York; VA Phoenix Health Care System, Phoenix, Arizona
| | - Drew Moghanaki
- Radiation Oncology Service, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael E Matheny
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee
| | - Christianne L Roumie
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Lucy B Spalluto
- VA Tennessee Valley Health Care System Geriatric Research Education and Clinical Center (GRECC), Veterans Health Administration, Nashville, Tennessee; Vanderbilt-Ingram Cancer Center, Nashville, Tennessee; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
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4
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Lewis JA, Bonnet K, Schlundt DG, Byerly S, Lindsell CJ, Henschke CI, Yankelevitz DF, York SJ, Hendler F, Dittus RS, Vogus TJ, Kripalani S, Moghanaki D, Audet CM, Roumie CL, Spalluto LB. Rural barriers and facilitators of lung cancer screening program implementation in the veterans health administration: a qualitative study. Front Health Serv 2023; 3:1209720. [PMID: 37674596 PMCID: PMC10477991 DOI: 10.3389/frhs.2023.1209720] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/04/2023] [Indexed: 09/08/2023]
Abstract
Introduction To assess healthcare professionals' perceptions of rural barriers and facilitators of lung cancer screening program implementation in a Veterans Health Administration (VHA) setting through a series of one-on-one interviews with healthcare team members. Methods Based on measures developed using Reach Effectiveness Adoption Implementation Maintenance (RE-AIM), we conducted a cross-sectional qualitative study consisting of one-on-one semi-structured telephone interviews with VHA healthcare team members at 10 Veterans Affairs medical centers (VAMCs) between December 2020 and September 2021. An iterative inductive and deductive approach was used for qualitative analysis of interview data, resulting in the development of a conceptual model to depict rural barriers and facilitators of lung cancer screening program implementation. Results A total of 30 interviews were completed among staff, providers, and lung cancer screening program directors and a conceptual model of rural barriers and facilitators of lung cancer screening program implementation was developed. Major themes were categorized within institutional and patient environments. Within the institutional environment, participants identified systems-level (patient communication, resource availability, workload), provider-level (attitudes and beliefs, knowledge, skills and capabilities), and external (regional and national networks, incentives) barriers to and facilitators of lung cancer screening program implementation. Within the patient environment, participants revealed patient-level (modifiable vulnerabilities) barriers and facilitators as well as ecological modifiers (community) that influence screening behavior. Discussion Understanding rural barriers to and facilitators of lung cancer screening program implementation as perceived by healthcare team members points to opportunities and approaches for improving lung cancer screening reach, implementation and effectiveness in VHA rural settings.
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Affiliation(s)
- Jennifer A. Lewis
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
- Qualitative Research Core, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David G. Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
- Qualitative Research Core, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susan Byerly
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Claudia I. Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States
- Veterans Health Administration—Phoenix VA Health Care System, Radiology Service, Phoenix, AZ, United States
| | - David F. Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States
| | - Sally J. York
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Fred Hendler
- Rex Robley VA Medical Center, Medicine Service, Louisville, KY, United States
| | - Robert S. Dittus
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Timothy J. Vogus
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN, United States
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Drew Moghanaki
- Veterans Health Administration—Greater Los Angeles Veterans Affairs Medical Center, Radiation Oncology Service, Los Angeles, CA, United States
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Carolyn M. Audet
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christianne L. Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lucy B. Spalluto
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
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5
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Johnson W, Kraft K, Chotai P, Lynch R, Dittus RS, Goldberg D, Ye F, Doby B, Schaubel DE, Shah MB, Karp SJ. Variability in Organ Procurement Organization Performance by Individual Hospital in the United States. JAMA Surg 2023; 158:404-409. [PMID: 36753195 PMCID: PMC9909569 DOI: 10.1001/jamasurg.2022.7853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/23/2022] [Indexed: 02/09/2023]
Abstract
Importance Availability of organs inadequately addresses the need of patients waiting for a transplant. Objective To estimate the true number of donor patients in the United States and identify inefficiencies in the donation process as a way to guide system improvement. Design, Setting, and Participants A retrospective cross-sectional analysis was performed of organ donation across 13 different hospitals in 2 donor service areas covered by 2 organ procurement organizations (OPOs) in 2017 and 2018 to compare donor potential to actual donors. More than 2000 complete medical records for decedents were reviewed as a sample of nearly 9000 deaths. Data were analyzed from January 1, 2017, to December 31, 2018. Exposure Deaths of causes consistent with donation according to medical record review, ventilated patient referrals, center acceptance practices, and actual deceased donors. Main Outcomes and Measures Potential donors by medical record review vs actual donors and OPO performance at specific hospitals. Results Compared with 242 actual donors, 931 potential donors were identified at these hospitals. This suggests a deceased donor potential of 3.85 times (95% CI, 4.23-5.32) the actual number of donors recovered. There was a surprisingly wide variability in conversion of potential donor patients into actual donors among the hospitals studied, from 0% to 51.0%. One OPO recovered 18.8% of the potential donors, whereas the second recovered 48.2%. The performance of the OPOs was moderately related to referrals of ventilated patients and not related to center acceptance practices. Conclusions and Relevance In this cross-sectional study of hospitals served by 2 OPOs, wide variation was found in the performance of the OPOs, especially at individual hospitals. Addressing this opportunity could greatly increase the organ supply, affirming the importance of recent efforts from the federal government to increase OPO accountability and transparency.
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Affiliation(s)
- Wali Johnson
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathryn Kraft
- Division of Abdominal Transplant Surgery, University of Kentucky, Lexington
| | - Pranit Chotai
- Division of Transplantation, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - Raymond Lynch
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Robert S. Dittus
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare Center, Nashville
| | - David Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brianna Doby
- Department of Public Health Sciences, New Mexico State University, College of Health, Education, and Social Transformation, Las Cruces
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Malay B. Shah
- Division of Abdominal Transplant Surgery, University of Kentucky, Lexington
| | - Seth J. Karp
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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6
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Connell J, Oldham M, Pandharipande P, Dittus RS, Wilson A, Mart M, Heckers S, Ely EW, Wilson JE. Malignant Catatonia: A Review for the Intensivist. J Intensive Care Med 2023; 38:137-150. [PMID: 35861966 DOI: 10.1177/08850666221114303] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Catatonia is a clinical syndrome characterized by psychomotor, neurological and behavioral changes. The clinical picture of catatonia ranges from akinetic stupor to severe motoric excitement. Catatonia can occur in the setting of a primary psychiatric condition such as bipolar disorder or secondary to a general medical illness like autoimmune encephalitis. Importantly, it can co-occur with delirium or coma. Malignant catatonia describes catatonia that presents with clinically significant autonomic abnormalities including change in temperature, blood pressure, heart rate, and respiratory rate. It is a life-threatening form of acute brain dysfunction that has several motoric manifestations and occurs secondary to a primary psychiatric condition or a medical cause. Many of the established predisposing and precipitating factors for catatonia such as exposure to neuroleptic medications or withdrawal states are common in the setting of critical illness. Catatonia typically improves with benzodiazepines and treatment of its underlying psychiatric or medical conditions, with electroconvulsive therapy reserved for catatonia refractory to benzodiazepines or for malignant catatonia. However, some forms of catatonia, such as catatonia secondary to a general medical condition or catatonia comorbid with delirium, may be less responsive to traditional treatments. Prompt recognition and treatment of catatonia are crucial because malignant catatonia may be fatal without treatment. Given the high morbidity and mortality associated with malignant catatonia, intensivists should familiarize themselves with this important and under-recognized condition.
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Affiliation(s)
- Jennifer Connell
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,12327Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mark Oldham
- University of Rochester Medical Center, Rochester, NY, USA
| | - Pratik Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Division of Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert S Dittus
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda Wilson
- Department of Psychiatry and Behavioral Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Mart
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephan Heckers
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Department of Psychiatry and Behavioral Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wes Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Department of Psychiatry and Behavioral Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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7
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Strayer TE, Spalluto LB, Burns A, Lindsell CJ, Henschke CI, Yankelevitz DF, Moghanaki D, Dittus RS, Vogus TJ, Audet C, Kripalani S, Roumie CL, Lewis JA. Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study adaptations in lung cancer screening delivery in the Veterans Health Administration: a cohort study. Implement Sci Commun 2023; 4:5. [PMID: 36635719 PMCID: PMC9836333 DOI: 10.1186/s43058-022-00388-x] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 12/20/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Lung cancer screening is a complex clinical process that includes identification of eligible individuals, shared decision-making, tobacco cessation, and management of screening results. Adaptations to the delivery process for lung cancer screening in situ are understudied and underreported, with the potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for a systematic enumeration of adaptations to implementation of evidence-based practices. We applied FRAME to study adaptations in lung cancer screening delivery processes implemented by lung cancer screening programs in a Veterans Health Administration (VHA) Enterprise-Wide Initiative. METHODS We prospectively conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMCs) between 2019 and 2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, documented, and mapped to FRAME categories. RESULTS We conducted a total of 16 interviews across 10 VHA lung cancer screening programs (n=6 in year 1, n=10 in year 2) to collect adaptations. In year 1 (2020), six programs were operational and eligible. Of these, three reported adaptations to their screening process that were planned or in response to COVID-19. In year 2 (2021), all 10 programs were operational and eligible. Programs reported 14 adaptations in year 2. These adaptations were planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to the identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 60% of programs to improve the data collection and tracking of Veterans in the screening process. CONCLUSIONS Using FRAME, we found that adaptations occurred primarily in the areas of patient identification and communication of results due to increased workload. These findings highlight navigator time and resource considerations for sustainability and scalability of existing and future lung cancer screening programs as well as potential areas for future intervention.
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Affiliation(s)
- Thomas E Strayer
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lucy B Spalluto
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Abby Burns
- Veterans Health Administration-Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Claudia I Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Veterans Health Administration - Phoenix VA Health Care System, Phoenix, AZ, USA
| | - David F Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Drew Moghanaki
- Veterans Health Administration - Greater Los Angeles Veterans Affairs Medical Center, Los Angeles, CA, USA
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Robert S Dittus
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN, USA
| | - Carolyn Audet
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christianne L Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer A Lewis
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA.
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC) and Medicine Service, Nashville, TN, USA.
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave, Suite 1200, Nashville, TN, 37203, USA.
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8
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Reasoner K, Pellegrino R, Gettler E, Johnson MC, Hulgan T, Roumie CL, Grijalva CG, Dittus RS, Staub MB. 1778. Veterans’ Perceptions and Categorial Constructs Regarding Antibiotics for Upper Respiratory Tract Infections (URIs). Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1408] [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] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
To reduce antibiotic prescribing, antimicrobial stewards must understand patient knowledge, attitudes, and perceptions (KAP) around antibiotics for URIs. Validated patient KAP surveys are scarce and for Veteran patients, nonexistent. We aimed to explore if published results of an exploratory factor analysis (EFA) of a KAP survey in emergency department (ED) patients and an online sample would approximate results in outpatient Veterans.
Methods
After cognitive testing in Veterans and healthcare providers, we omitted 13 of the 46 questions from the published KAP survey deemed confusing or with low factor loadings. We mailed the 33-item survey to Veterans seen for URI at 18 Veterans Affairs clinics from January 2018 to December 2019. We excluded Veterans not evaluated in-person, with documented dementia, or who died prior to study start. We excluded surveys with > 3 unanswered questions.
We used principal component factor analysis (PCFA) with orthogonal varimax rotation (Fig. 1) to assess Veteran responses and Cronbach’s alpha to assess each factor’s internal consistency. We removed questions to reach alpha of >0.7 (Fig. 2). We repeated PCFA and compared results to published EFA factors and loadings for the ED patients and online sample.
Results
Of 1329 eligible Veterans invited, 474 (36%) returned the survey; 407 met inclusion criteria (Table 1). PCFA of Veterans’ responses yielded 7 Factors (Fig 2). Like ED patients and the online sample, Veteran responses about side effects clustered together. Veteran responses about “antibiotics help” and “antibiotics don’t hurt” clustered together like ED patients. They grouped separately in the online sample. Veteran responses about safety and efficacy (Factors 3 & 5) and knowledge about viruses and bacteria, (Factors 4 & 5) clustered separately (Fig. 2). For ED patients and the online sample, safety and efficacy and virus and bacteria responses clustered together, respectively (Fig. 1).
Conclusion
While Veterans did share some KAPs around antibiotics for URIs with ED patients and the online sample, this study shows they also have distinct views. Further testing in Veteran and non-Veteran populations should validate and assess reliability of this survey as an antimicrobial stewardship tool.
Disclosures
Carlos G. Grijalva, MD, MPH, AHRQ: Grant/Research Support|Campbell Alliance/Syneos Health: Grant/Research Support|CDC: Grant/Research Support|FDA: Grant/Research Support|Merck: Advisor/Consultant|NIH: Grant/Research Support|Pfizer: Advisor/Consultant|Sanofi: Grant/Research Support|Sanofi-Pasteur: Advisor/Consultant Milner B. Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds.
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Affiliation(s)
| | | | - Erin Gettler
- Duke University Medical Center , Durham, North Carolina
| | | | - Todd Hulgan
- Vanderbilt University Medical Center , Nashville, Tennessee
| | | | | | | | - Milner B Staub
- Vanderbilt University Medical Center , Nashville, Tennessee
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9
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Lewis JA, Samuels LR, Denton J, Matheny ME, Maiga A, Slatore CG, Grogan E, Kim J, Sherrier RH, Dittus RS, Massion PP, Keohane L, Roumie CL, Nikpay S. The Association of Health Care System Resources With Lung Cancer Screening Implementation. Chest 2022; 162:701-711. [PMID: 35413280 PMCID: PMC9529611 DOI: 10.1016/j.chest.2022.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/28/2021] [Revised: 02/04/2022] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background The Veterans Health Administration issued policy for lung cancer screening resources at eight Veterans Affairs Medical Centers (VAMCs) in a demonstration project (DP) from 2013 through 2015. Research Question Do policies that provide resources increase lung cancer screening rates? Study Design and Methods Data from eight DP VAMCs (DP group) and 20 comparable VAMCs (comparison group) were divided into before DP (January 2011-June 2013), DP (July 2013-June 2015), and after DP (July 2015-December 2018) periods. Coprimary outcomes were unique veterans screened per 1,000 eligible per month and those with 1-year (9-15 months) follow-up screening. Eligible veterans were estimated using yearly counts and the percentage of those with eligible smoking histories. Controlled interrupted time series and difference-in-differences analyses were performed. Results Of 27,746 veterans screened, the median age was 66.5 years and most were White (77.7%), male (95.6%), and urban dwelling (67.3%). During the DP, the average rate of unique veterans screened at DP VAMCs was 17.7 per 1,000 eligible per month, compared with 0.3 at comparison VAMCs. Adjusted analyses found a higher rate increase at DP VAMCs by 0.93 screening per 1,000 eligible per month (95% CI, 0.25-1.61) during this time, with an average facility-level difference of 17.4 screenings per 1,000 eligible per month (95% CI, 12.6-22.3). Veterans with 1-year follow-up screening also increased more rapidly at DP VAMCs during the DP, by 0.39 screening per 1,000 eligible per month (95% CI, 0.18-0.60), for an average facility-level difference of 7.2 more screenings per 1,000 eligible per month (95% CI, 5.2-9.2). Gains were not maintained after the DP. Interpretation In this cohort, provision of resources for lung cancer screening implementation was associated with an increase in veterans screened and those with 1-year follow-up screening. Screening gains associated with the DP were not maintained.
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Affiliation(s)
- Jennifer A Lewis
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN; Veterans Health Administration - Tennessee Valley Healthcare System, Medicine Service, Nashville, TN; Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN.
| | - Lauren R Samuels
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Jason Denton
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Michael E Matheny
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Amelia Maiga
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Christopher G Slatore
- Veterans Health Administration-Portland Health Care System, Center to Improve Veteran Involvement in Care Pulmonary & Critical Care Medicine, Portland, OR
| | - Eric Grogan
- Veterans Health Administration - Tennessee Valley Healthcare System, Thoracic Surgery, Nashville, TN; Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jane Kim
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC
| | | | - Robert S Dittus
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Pierre P Massion
- Veterans Health Administration - Tennessee Valley Healthcare System, Medicine Service, Nashville, TN; Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Laura Keohane
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Christianne L Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System, Medicine Service, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Sayeh Nikpay
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
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Strayer TE, Spalluto LB, Burns A, Lindsell CJ, Henschke CI, Yankelevitz DF, Moghanaki D, Dittus RS, Vogus TJ, Audet C, Kripalani S, Roumie CL, Lewis JA. Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study lung cancer screening adaptations in the Veterans Health Administration. Res Sq 2022:rs.3.rs-1862731. [PMID: 35982653 PMCID: PMC9387539 DOI: 10.21203/rs.3.rs-1862731/v1] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Lung cancer screening includes identification of eligible individuals, shared decision-making inclusive of tobacco cessation, and management of screening results. Adaptations to the implemented processes for lung cancer screening in situ are understudied and underreported, with potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for systematic enumeration of adaptations to implementations of evidence-based practices. We used FRAME to study adaptations in lung cancer screening processes that were implemented as part of a Veterans Health Administration (VHA) Enterprise-Wide Initiative. Methods: We conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMC) between 2019-2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, recorded and mapped to FRAME categories. Results: A total of 14 program navigators across 10 VHA lung cancer screening programs participated in 20 interviews. In year 1 (2019-2020), seven programs were operational and of these, three reported adaptations to their screening process that were either planned and in response to COVID-19. In year 2 (2020-2021), all 10 programs were operational. Programs reported 14 adaptations in year 2. These adaptations were both planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 6 of 10 programs to improve the data collection and tracking of Veterans in the screening process. Conclusions: Using FRAME, we found that adaptations occurred throughout the lung cancer screening process but primarily in the areas of patient identification and communication of results. These findings highlight considerations for lung cancer screening implementation and potential areas for future intervention.
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Affiliation(s)
| | | | | | | | | | | | - Drew Moghanaki
- UCLA Health System: University of California Los Angeles Health System
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11
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Staub MB, Pellegrino R, Gettler E, Johnson MC, Roumie CL, Grijalva CG, Reasoner K, Dittus RS, Hulgan T. Association of antibiotics with veteran visit satisfaction and antibiotic expectations for upper respiratory tract infections. Antimicrob Steward Healthc Epidemiol 2022; 2:e100. [PMID: 36483414 PMCID: PMC9726549 DOI: 10.1017/ash.2022.233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Veterans' Affairs (VA) healthcare providers perceive that Veterans expect and base visit satisfaction on receiving antibiotics for upper respiratory tract infections (URIs). No studies have tested this hypothesis. We sought to determine whether receiving and/or expecting antibiotics were associated with Veteran satisfaction with URI visits. METHODS This cross-sectional study included Veterans evaluated for URI January 2018-December 2019 in an 18-clinic ambulatory VA primary-care system. We evaluated Veteran satisfaction via the Patient Satisfaction Questionnaire Short Form (RAND Corporation), an 18-item 5-point Likert scale survey. Additional items assessed Veteran antibiotic expectations. Antibiotic receipt was determined via medical record review. We used multivariable regression to evaluate whether antibiotic receipt and/or Veteran antibiotic expectations were associated with satisfaction. Subgroup analyses focused on Veterans who accurately remembered antibiotic prescribing during their URI visit. RESULTS Of 1,329 eligible Veterans, 432 (33%) participated. Antibiotic receipt was not associated with differences in mean total satisfaction (adjusted score difference, 0.6 points; 95% confidence interval [CI], -2.1 to 3.3). However, mean total satisfaction was lower for Veterans expecting an antibiotic (adjusted score difference -4.4 points; 95% CI -7.2 to -1.6). Among Veterans who accurately remembered the visit and did not receive an antibiotic, those who expected an antibiotic had lower mean satisfaction scores than those who did not (unadjusted score difference, -16.6 points; 95% CI, -24.6 to -8.6). CONCLUSIONS Veteran expectations for antibiotics, not antibiotic receipt, are associated with changes in satisfaction with outpatient URI visits. Future research should further explore patient expectations and development of patient-centered and provider-focused interventions to change patient antibiotic expectations.
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Affiliation(s)
- Milner B. Staub
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Health Administration, Tennessee Valley Healthcare System, Nashville, Tennessee
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachael Pellegrino
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin Gettler
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Morgan C. Johnson
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Health Administration, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Christianne L. Roumie
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Health Administration, Tennessee Valley Healthcare System, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos G. Grijalva
- Division of Pharmacoepidemiology, Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee (Present affiliation: Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina [E.G.])
| | - Kaitlyn Reasoner
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert S. Dittus
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Health Administration, Tennessee Valley Healthcare System, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd Hulgan
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Infectious Diseases Section, Medical Services, Tennessee Valley Healthcare System, Nashville, Tennessee
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12
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DesRoches C, Chang Y, Kim J, Mukunda S, Norman L, Dittus RS, Donelan K. Who wants to work in geriatrics: Findings from a national survey of physicians and nurse practitioners. Nurs Outlook 2022; 70:309-314. [DOI: 10.1016/j.outlook.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/22/2021] [Accepted: 10/23/2021] [Indexed: 11/15/2022]
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13
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Spalluto LB, Lewis JA, Samuels LR, Callaway-Lane C, Matheny ME, Denton J, Robles JA, Dittus RS, Yankelevitz DF, Henschke CI, Massion PP, Moghanaki D, Roumie CL. Association of Rurality With Annual Repeat Lung Cancer Screening in the Veterans Health Administration. J Am Coll Radiol 2022; 19:131-138. [PMID: 35033300 PMCID: PMC8830608 DOI: 10.1016/j.jacr.2021.08.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 06/29/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Lung cancer causes the largest number of cancer-related deaths in the United States. Lung cancer incidence rates, mortality rates, and rates of advanced stage disease are higher among those who live in rural areas. Known disparities in lung cancer outcomes between rural and nonrural populations may be in part because of barriers faced by rural populations. The authors tested the hypothesis that among Veterans who receive initial lung cancer screening, rural Veterans would be less likely to complete annual repeat screening than nonrural Veterans. METHODS A retrospective cohort study was conducted of 10 Veterans Affairs medical centers from 2015 to 2019. Rural and nonrural Veterans undergoing lung cancer screening were identified. Rural status was defined using the rural-urban commuting area codes. The primary outcome was annual repeat lung cancer screening in the 9- to 15-month window (primary analysis) and 31-day to 18-month window (sensitivity analysis) after the first documented lung cancer screening. To examine rurality as a predictor of annual repeat lung cancer screening, multivariable logistic regression models were used. RESULTS In the final analytic sample of 11,402 Veterans, annual repeat lung cancer screening occurred in 27.7% of rural Veterans (641 of 2,316) and 31.8% of nonrural Veterans (2,891 of 9,086) (adjusted odds ratio: 0.86; 95% confidence interval: 0.73-1.03). Similar results were seen in the sensitivity analysis, with 41.6% of rural Veterans (963 of 2,316) versus 45.2% of nonrural Veterans (4,110 of 9,086) (adjusted odds ratio: 0.88; 95% confidence interval: 0.73-1.04) having annual repeat screening in the expanded 31-day to 18-month window. CONCLUSIONS Among a national cohort of Veterans, rural residence was associated with numerically lower odds of annual repeat lung cancer screening than nonrural residence. Continued, intentional outreach efforts to increase annual repeat lung cancer screening among rural Veterans may offer an opportunity to decrease deaths from lung cancer.
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Affiliation(s)
- Lucy B. Spalluto
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Radiology, Vanderbilt University Medical Center, Nashville, TN,Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jennifer A. Lewis
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Vanderbilt-Ingram Cancer Center, Nashville, TN,Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Lauren R. Samuels
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Carol Callaway-Lane
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN
| | - Michael E. Matheny
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Jason Denton
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Jennifer A. Robles
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Veterans Health Administration – Tennessee Valley Healthcare System, Surgery Service, Nashville, TN,Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Robert S. Dittus
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | | | - Claudia I. Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY,Phoenix Veterans Health Care System, Phoenix, AZ
| | - Pierre P. Massion
- Vanderbilt-Ingram Cancer Center, Nashville, TN,Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN,Veterans Health Administration – Tennessee Valley Healthcare System, Medical Service, Nashville, TN
| | - Drew Moghanaki
- Radiation Oncology, Greater Los Angeles Veterans Affairs Medical Center, Los Angeles, CA,Department of Radiation Oncology, University of California at Los Angeles, Los Angeles, CA
| | - Christianne L. Roumie
- Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
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14
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Auerbach DI, Levy DE, Maramaldi P, Dittus RS, Spetz J, Buerhaus PI, Donelan K. Optimal Staffing Models To Care For Frail Older Adults In Primary Care And Geriatrics Practices In The US. Health Aff (Millwood) 2021; 40:1368-1376. [PMID: 34495726 DOI: 10.1377/hlthaff.2021.00401] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Different staffing configurations in primary and geriatric care practices could have implications for how best to deliver services that are essential for a growing population of older adults. Using data from a 2018 survey of physicians (MDs) and nurse practitioners (NPs) working in primary and geriatric care, we assessed whether different configurations were associated with better or worse performance on a number of standard process measures indicative of comprehensive, high-quality primary care. Practices with a large concentration of MDs had the highest estimated labor costs. Practices high in NPs and physician assistants (PAs) were most common in states that grant full scope of practice to NPs. The high-NP/PA configuration was associated with a 17-percentage-point greater probability of facilitating patient visits and a 26-percentage-point greater probability of providing the full bundle of primary care services compared with the high-MD model. Team-based configurations had a 27.7-percentage-point greater probability of providing the full bundle of primary care services. The complex needs of older adults may be best served by team-based practices with a broad provider mix that can provide a range of services in the office and the community.
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Affiliation(s)
- David I Auerbach
- David I. Auerbach is an external adjunct faculty member at the Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University, in Bozeman, Montana, and is senior director for research and cost trends at the Massachusetts Health Policy Commission, in Boston, Massachusetts
| | - Douglas E Levy
- Douglas E. Levy is an associate professor in the Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, in Boston
| | - Peter Maramaldi
- Peter Maramaldi is a professor in the School of Social Work, Simmons University, in Boston
| | - Robert S Dittus
- Robert S. Dittus is the Albert and Bernard Werthan Professor of Medicine at Vanderbilt University; chief innovation officer and senior vice president for the Vanderbilt Health Affiliated Network; and director of the Geriatric Research, Education, and Clinical Center at the Veterans Affairs Tennessee Valley Healthcare System, in Nashville, Tennessee
| | - Joanne Spetz
- Joanne Spetz is director and Brenda and Jeffrey L. Kang Presidential Chair in Healthcare Finance at the Philip R. Lee Institute for Health Policy Studies at the University of California San Francisco, in San Francisco, California
| | - Peter I Buerhaus
- Peter I. Buerhaus is a professor of nursing and director of the Center for Interdisciplinary Health Workforce Studies, both in the College of Nursing, Montana State University
| | - Karen Donelan
- Karen Donelan is the Stuart H. Altman Chair in U.S. Health Policy at the Heller School for Social Policy and Management, Brandeis University, in Waltham, Massachusetts. At the time this work was performed, she was a senior scientist at the Health Policy Research Center at the Mongan Institute, Massachusetts General Hospital, and an associate professor in the Department of Medicine at Harvard Medical School, in Boston
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Lindsell CJ, Gatto CL, Dear ML, Buie R, Rice TW, Pulley JM, Hartert TV, Kripalani S, Harrell FE, Byrne DW, Edgeworth MC, Steaban R, Dittus RS, Bernard GR. Learning From What We Do, and Doing What We Learn: A Learning Health Care System in Action. Acad Med 2021; 96:1291-1299. [PMID: 33635834 DOI: 10.1097/acm.0000000000004021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Different models of learning health systems are emerging. At Vanderbilt University Medical Center, the Learning Health Care System (LHS) Platform was established with the goal of creating generalizable knowledge. This differentiates the LHS Platform from other efforts that have adopted a quality improvement paradigm. By supporting pragmatic trials at the intersection of research, operations, and clinical care, the LHS Platform was designed to yield evidence for advancing content and processes of care through carefully designed, rigorous study. The LHS Platform provides the necessary infrastructure and governance to leverage translational, transdisciplinary team science to inform clinical and operational decision making across the health system. The process transforms a clinical or operational question into a research question amenable to a pragmatic trial. Scientific, technical, procedural, and human infrastructure is maintained for the design and execution of individual LHS projects. This includes experienced pragmatic trialists, project management, data science inclusive of biostatistics and clinical informatics, and regulatory support. Careful attention is paid to stakeholder engagement, including health care providers and the community. Capturing lessons from each new study, the LHS Platform continues to mature with plans to integrate implementation science and to complement clinical and process outcomes with cost and value considerations. The Vanderbilt University Medical Center LHS Platform is now a pillar of the health care system and leads the evolving culture of learning from what we do and doing what we learn.
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Affiliation(s)
- Christopher J Lindsell
- C.J. Lindsell is professor of biostatistics, associate director, Center for Clinical Quality and Implementation Research, director, Vanderbilt Institute for Clinical and Translational Research Methods Program, and co-director, Center for Health Data Science, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cheryl L Gatto
- C.L. Gatto is research assistant professor of biostatistics and associate director, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Lynn Dear
- M.L. Dear is project manager, Learning Health Care System Platform, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reagan Buie
- R. Buie is health policy service analyst, Learning Health Care System Platform, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W Rice
- T.W. Rice is associate professor of medicine, Department of Allergy, Pulmonary and Critical Care Medicine, vice president for clinical trial innovation and operations, Vanderbilt Institute for Clinical and Translational Research, and medical director, Vanderbilt Human Research Protection Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill M Pulley
- J.M. Pulley is research associate professor of medicine, Department of Allergy, Pulmonary and Critical Care Medicine, and executive director, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tina V Hartert
- T.V. Hartert is professor of medicine, Department of Allergy, Pulmonary and Critical Care Medicine, director, Center for Asthma Research, assistant vice president for translational science, and Lulu H. Owen Chair in Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- S. Kripalani is professor of medicine, Department of General Internal Medicine and Public Health, director, Center for Clinical Quality and Implementation Research, and co-director, Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frank E Harrell
- F.E. Harrell is professor and founding chair, Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel W Byrne
- D.W. Byrne is senior associate in biostatistics and director, Quality Improvement and Program Evaluation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mitchell C Edgeworth
- M.C. Edgeworth was chief executive officer, Vanderbilt University Hospital, Vanderbilt University Medical Center, Nashville, Tennessee, at the time this manuscript was written
| | - Robin Steaban
- R. Steaban is chief nursing officer, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert S Dittus
- R.S. Dittus is the Albert and Bernard Werthan Professor of Medicine, Division of General Internal Medicine and Public Health, senior vice president and chief innovation officer, Vanderbilt Health Affiliated Network, executive vice president for public health and health care, and senior associate dean for population health sciences, Vanderbilt University Medical Center and VA Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center, Nashville, Tennessee
| | - Gordon R Bernard
- G.R. Bernard is the Melinda Owen Bass Professor of Medicine, Department of Allergy, Pulmonary and Critical Care Medicine, executive vice president for research, senior associate dean for clinical sciences, and director, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
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Edwards GC, Martin RL, Samuels LR, Wyman K, Bailey CE, Kiernan CM, Snyder RA, Dittus RS, Roumie CL. Association of Adherence to Quality Metrics with Recurrence or Mortality among Veterans with Colorectal Cancer. J Gastrointest Surg 2021; 25:2055-2064. [PMID: 33169321 DOI: 10.1007/s11605-020-04804-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 05/27/2020] [Accepted: 09/15/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The National Comprehensive Cancer Network has defined metrics for colorectal cancer; however, the association of metric adherence with patient clinical outcomes remains underexplored. The study aim was to evaluate the association of National Comprehensive Cancer Network metric adherence with recurrence and mortality in Veterans with nonmetastatic colorectal cancer. METHODS Veterans with stage I-III colorectal cancer who underwent non-emergent resection from 2001 to 2015 at a single Veterans Affairs Medical Center were included. The primary predictor was completion of eligible National Comprehensive Cancer Network metrics. The primary outcome was a composite of recurrence or all-cause death in three phases of care: surgical (up to 6 months after resection), treatment (6-18 months after resection), and surveillance (18 months-3 years after resection). Hazard ratios were estimated via Cox proportional hazards regression in a propensity score-weighted cohort. RESULTS A total of 1107 electronic medical records of patients undergoing colorectal surgery were reviewed, and 379 patients were included (301 colon and 78 rectal cancer). In the surgical phase, the weighted analysis yielded a hazard ratio of 0.37 (95% confidence interval 0.12-1.13) for metric-adherent patients compared with non-adherent patients. In the treatment and surveillance phases, the hazard ratios for metric-adherent care were 0.68 (95% confidence interval 0.25-1.85) and 0.91 (95% confidence interval 0.31-2.68), respectively. CONCLUSIONS The National Comprehensive Cancer Network guideline metric adherence was associated with a lower rate of recurrence and death in the surgical phase of care among stage I-III patients with resected colorectal cancer.
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Affiliation(s)
- Gretchen C Edwards
- Department of General Surgery, Vanderbilt University Medical Center & Tennessee Valley Healthcare System - Veterans Health Administration, Medical Center North, Suite CCC-4312, 1161 21st Avenue South, Nashville, TN, 37232-2730, USA. .,Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA.
| | - Richard L Martin
- Department of Medicine, Division of Medical Oncology, Vanderbilt University Medical Center & Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA
| | - Lauren R Samuels
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kenneth Wyman
- Department of Medicine, Division of Medical Oncology, Vanderbilt University Medical Center & Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA
| | - Christina E Bailey
- Department of General Surgery, Division of Surgical Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen M Kiernan
- Department of General Surgery, Vanderbilt University Medical Center & Tennessee Valley Healthcare System - Veterans Health Administration, Medical Center North, Suite CCC-4312, 1161 21st Avenue South, Nashville, TN, 37232-2730, USA.,Department of General Surgery, Division of Surgical Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rebecca A Snyder
- Departments of Surgery and Public Health, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Robert S Dittus
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA.,Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christianne L Roumie
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System - Veterans Health Administration, Nashville, TN, USA.,Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
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Lewis JA, Spalluto LB, Henschke CI, Yankelevitz DF, Aguayo SM, Morales P, Avila R, Audet CM, Prusaczyk B, Lindsell CJ, Callaway-Lane C, Dittus RS, Vogus TJ, Massion PP, Limper HM, Kripalani S, Moghanaki D, Roumie CL. Protocol to evaluate an enterprise-wide initiative to increase access to lung cancer screening in the Veterans Health Administration. Clin Imaging 2021; 73:151-161. [PMID: 33422974 PMCID: PMC8479827 DOI: 10.1016/j.clinimag.2020.11.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 10/27/2020] [Revised: 11/21/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The Veterans Affairs Partnership to increase Access to Lung Screening (VA-PALS) is an enterprise-wide initiative to implement lung cancer screening programs at VA medical centers (VAMCs). VA-PALS will be using implementation strategies that include program navigators to coordinate screening activities, trainings for navigators and radiologists, an open-source software management system, tools to standardize low-dose computed tomography image quality, and access to a support network. VAMCs can utilize strategies according to their local needs. In this protocol, we describe the planned program evaluation for the initial 10 VAMCs participating in VA-PALS. MATERIALS AND METHODS The implementation of programs will be evaluated using the Consolidated Framework for Implementation Research to ensure broad contextual guidance. Program evaluation measures have been developed using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Adaptations of screening processes will be assessed using the Framework for Reporting Adaptations and Modifications to Evidence Based Interventions. Measures collected will reflect the inner settings, estimate and describe the population reached, adoption by providers, implementation of the programs, report clinical outcomes and maintenance of programs. Analyses will include descriptive statistics and regression to evaluate predictors and assess implementation over time. DISCUSSION This theory-based protocol will evaluate the implementation of lung cancer screening programs across the Veterans Health Administration using scientific frameworks. The findings will inform plans to expand the VA-PALS initiative beyond the original sites and can guide implementation of lung cancer screening programs more broadly.
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Affiliation(s)
- Jennifer A Lewis
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Vanderbilt Ingram Cancer Center, Nashville, TN, United States of America.
| | - Lucy B Spalluto
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; Vanderbilt Ingram Cancer Center, Nashville, TN, United States of America; Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Claudia I Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America; Phoenix VA Health Care System, Phoenix, AZ, United States of America
| | - David F Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, NY, New York, United States of America; Phoenix VA Health Care System, Phoenix, AZ, United States of America
| | - Samuel M Aguayo
- Phoenix VA Health Care System, Phoenix, AZ, United States of America
| | | | - Rick Avila
- Paraxial LLC, Halfmoon, NY, United States of America
| | - Carolyn M Audet
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Beth Prusaczyk
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Carol Callaway-Lane
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; VA Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States of America
| | - Robert S Dittus
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, TN, United States of America
| | - Pierre P Massion
- Vanderbilt Ingram Cancer Center, Nashville, TN, United States of America; VA Tennessee Valley Healthcare System, Medicine Service, Nashville, TN, United States of America; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Heather M Limper
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Drew Moghanaki
- Radiation Oncology, Atlanta VA Medical Center, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Christianne L Roumie
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Hughes CG, Mailloux PT, Devlin JW, Swan JT, Sanders RD, Anzueto A, Jackson JC, Hoskins AS, Pun BT, Orun OM, Raman R, Stollings JL, Kiehl AL, Duprey MS, Bui LN, O'Neal HR, Snyder A, Gropper MA, Guntupalli KK, Stashenko GJ, Patel MB, Brummel NE, Girard TD, Dittus RS, Bernard GR, Ely EW, Pandharipande PP. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med 2021; 384:1424-1436. [PMID: 33528922 PMCID: PMC8162695 DOI: 10.1056/nejmoa2024922] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [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: 12/13/2022]
Abstract
BACKGROUND Guidelines currently recommend targeting light sedation with dexmedetomidine or propofol for adults receiving mechanical ventilation. Differences exist between these sedatives in arousability, immunity, and inflammation. Whether they affect outcomes differentially in mechanically ventilated adults with sepsis undergoing light sedation is unknown. METHODS In a multicenter, double-blind trial, we randomly assigned mechanically ventilated adults with sepsis to receive dexmedetomidine (0.2 to 1.5 μg per kilogram of body weight per hour) or propofol (5 to 50 μg per kilogram per minute), with doses adjusted by bedside nurses to achieve target sedation goals set by clinicians according to the Richmond Agitation-Sedation Scale (RASS, on which scores range from -5 [unresponsive] to +4 [combative]). The primary end point was days alive without delirium or coma during the 14-day intervention period. Secondary end points were ventilator-free days at 28 days, death at 90 days, and age-adjusted total score on the Telephone Interview for Cognitive Status questionnaire (TICS-T; scores range from 0 to 100, with a mean of 50±10 and lower scores indicating worse cognition) at 6 months. RESULTS Of 432 patients who underwent randomization, 422 were assigned to receive a trial drug and were included in the analyses - 214 patients received dexmedetomidine at a median dose of 0.27 μg per kilogram per hour, and 208 received propofol at a median dose of 10.21 μg per kilogram per minute. The median duration of receipt of the trial drugs was 3.0 days (interquartile range, 2.0 to 6.0), and the median RASS score was -2.0 (interquartile range, -3.0 to -1.0). We found no difference between dexmedetomidine and propofol in the number of days alive without delirium or coma (adjusted median, 10.7 vs. 10.8 days; odds ratio, 0.96; 95% confidence interval [CI], 0.74 to 1.26), ventilator-free days (adjusted median, 23.7 vs. 24.0 days; odds ratio, 0.98; 95% CI, 0.63 to 1.51), death at 90 days (38% vs. 39%; hazard ratio, 1.06; 95% CI, 0.74 to 1.52), or TICS-T score at 6 months (adjusted median score, 40.9 vs. 41.4; odds ratio, 0.94; 95% CI, 0.66 to 1.33). Safety end points were similar in the two groups. CONCLUSIONS Among mechanically ventilated adults with sepsis who were being treated with recommended light-sedation approaches, outcomes in patients who received dexmedetomidine did not differ from outcomes in those who received propofol. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01739933.).
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Affiliation(s)
- Christopher G Hughes
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Patrick T Mailloux
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - John W Devlin
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Joshua T Swan
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Robert D Sanders
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Antonio Anzueto
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - James C Jackson
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Aimee S Hoskins
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Brenda T Pun
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Onur M Orun
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Rameela Raman
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Joanna L Stollings
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Amy L Kiehl
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Matthew S Duprey
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Lan N Bui
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Hollis R O'Neal
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Allison Snyder
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Michael A Gropper
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Kalpalatha K Guntupalli
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Gregg J Stashenko
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Mayur B Patel
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Nathan E Brummel
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Timothy D Girard
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Robert S Dittus
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Gordon R Bernard
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - E Wesley Ely
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Pratik P Pandharipande
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
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Lewis JA, Senft N, Chen H, Weaver KE, Spalluto LB, Sandler KL, Horn L, Massion PP, Dittus RS, Roumie CL, Tindle HA. Evidence-based smoking cessation treatment: a comparison by healthcare system. BMC Health Serv Res 2021; 21:33. [PMID: 33413353 PMCID: PMC7792006 DOI: 10.1186/s12913-020-06016-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 05/20/2020] [Accepted: 12/13/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND A systems-level approach to smoking cessation treatment may optimize healthcare provider adherence to guidelines. Institutions such as the Veterans Health Administration (VHA) are unique in their systematic approach, but comparisons of provider behavior in different healthcare systems are limited. METHODS We surveyed general medicine providers and specialists in a large academic health center (AHC) and its affiliated VHA in the Mid-South in 2017 to determine the cross-sectional association of healthcare system in which the provider practiced (exposure: AHC versus VHA) with self-reported provision of evidence-based smoking cessation treatment (delivery of counseling plus smoking cessation medication or referral) at least once in the past 12 months (composite outcome). Multivariable logistic regression with adjustment for specialty was performed in 2017-2019. RESULTS Of 625 healthcare providers surveyed, 407 (65%) responded, and 366 (59%) were analyzed. Most respondents practiced at the AHC (273[75%] vs VHA 93[25%]) and were general internists (215[59%]); pulmonologists (39[11%]); hematologists/oncologists (69[19%]); and gynecologists (43[12%]). Most respondents (328[90%]) reported the primary outcome. The adjusted odds of evidence-based smoking cessation treatment were higher among VHA vs. AHC healthcare providers (aOR = 4.3; 95% CI 1.3-14.4; p = .02). Health systems differed by provision of individual treatment components, including smoking cessation medication use (98% VHA vs. 90% AHC, p = 0.02) and referral to smoking cessation services (91% VHA vs. 65% AHC p = 0.001). CONCLUSIONS VHA healthcare providers were significantly more likely to provide evidence-based smoking cessation treatment compared to AHC healthcare providers. Healthcare systems' prioritization of and investment in smoking cessation treatment is critical to improving providers' adherence to guidelines.
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Affiliation(s)
- Jennifer A Lewis
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1200, Nashville, TN, 37203, USA.
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA.
| | - Nicole Senft
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Heidi Chen
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kathryn E Weaver
- Departments of Social Sciences and Health Policy and Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lucy B Spalluto
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kim L Sandler
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leora Horn
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1200, Nashville, TN, 37203, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Pierre P Massion
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Medicine Service, Veterans Health Administration-Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Robert S Dittus
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Christianne L Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Hilary A Tindle
- Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, USA
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Connell J, Kim A, Brummel NE, Patel MB, Vandekar SN, Pandharipande P, Dittus RS, Heckers S, Ely EW, Wilson JE. Advanced Age Is Associated With Catatonia in Critical Illness: Results From the Delirium and Catatonia Prospective Cohort Investigation. Front Psychiatry 2021; 12:673166. [PMID: 34867501 PMCID: PMC8639534 DOI: 10.3389/fpsyt.2021.673166] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 10/18/2021] [Indexed: 01/03/2023] Open
Abstract
Introduction: Catatonia, characterized by motor, behavioral and affective abnormalities, frequently co-occurs with delirium during critical illness. Advanced age is a known risk factor for development of delirium. However, the association between age and catatonia has not been described. We aim to describe the occurrence of catatonia, delirium, and coma by age group in a critically ill, adult population. Design: Convenience cohort, nested within two clinical trials and two observational cohort studies. Setting: Intensive care units in an academic medical center in Nashville, TN. Patients: 378 critically ill adult patients on mechanical ventilation and/or vasopressors. Measurements and Main Results: Patients were assessed for catatonia, delirium, and coma by independent and blinded personnel, the Bush Francis Catatonia Rating Scale, the Confusion Assessment Method for the Intensive Care Unit (ICU) and the Richmond Agitation and Sedation Scale. Of 378 patients, 23% met diagnostic criteria for catatonia, 66% experienced delirium, and 52% experienced coma during the period of observation. There was no relationship found between age and catatonia severity or age and presence of specific catatonia items. The prevalence of catatonia was strongly associated with age in the setting of critical illness (p < 0.05). Delirium and comas' association with age was limited to the setting of catatonia. Conclusion: Given the significant relationship between age and catatonia independent of coma and delirium status, these data demonstrate catatonia's association with advanced age in the setting of critical illness. Future studies can explore the causative factors for this association and further elucidate the risk factors for acute brain dysfunction across the age spectrum.
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Affiliation(s)
- Jennifer Connell
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States.,Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Ahra Kim
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States.,Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States.,Division of Trauma and Surgical Critical Care, Departments of Surgery, Neurosurgery, and Hearing and Speech Sciences, Section of Surgical Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN, United States.,Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States
| | - Simon N Vandekar
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Pratik Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States.,Division of Anesthesiology Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Robert S Dittus
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States.,Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States
| | - Stephan Heckers
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States.,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - E Wes Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States.,Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States.,Division of Allergy, Pulmonary and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship Center, Center for Health Services Research, Nashville, TN, United States.,Geriatric Research, Education, and Clinical Center Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN, United States.,Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
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Lewis JA, Chen H, Weaver KE, Spalluto LB, Sandler KL, Horn L, Dittus RS, Massion PP, Roumie CL, Tindle HA. Low Provider Knowledge Is Associated With Less Evidence-Based Lung Cancer Screening. J Natl Compr Canc Netw 2020; 17:339-346. [PMID: 30959463 DOI: 10.6004/jnccn.2018.7101] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/22/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite widespread recommendation and supportive policies, screening with low-dose CT (LDCT) is incompletely implemented in the US healthcare system. Low provider knowledge of the lung cancer screening (LCS) guidelines represents a potential barrier to implementation. Therefore, we tested the hypothesis that low provider knowledge of guidelines is associated with less provider-reported screening with LDCT. PATIENTS AND METHODS A cross-sectional survey was performed in a large academic medical center and affiliated Veterans Health Administration in the Mid-South United States that comprises hospital and community-based practices. Participants included general medicine providers and specialists who treat patients aged >50 years. The primary exposure was LCS guideline knowledge (US Preventive Services Task Force/Centers for Medicare & Medicaid Services). High knowledge was defined as identifying 3 major screening eligibility criteria (55 years as initial age of screening eligibility, smoking status as current or former smoker, and smoking history of ≥30 pack-years), and low knowledge was defined as not identifying these 3 criteria. The primary outcome was self-reported LDCT order/referral within the past year, and the secondary outcome was screening chest radiograph. Multivariable logistic regression evaluated the adjusted odds ratio (aOR) of screening by knowledge. RESULTS Of 625 providers recruited, 407 (65%) responded, and 378 (60.5%) were analyzed. Overall, 233 providers (62%) demonstrated low LCS knowledge, and 224 (59%) reported ordering/referring for LDCT. The aOR of ordering/referring LDCT was less among providers with low knowledge (0.41; 95% CI, 0.24-0.71) than among those with high knowledge. More providers with low knowledge reported ordering screening chest radiographs (aOR, 2.7; 95% CI, 1.4-5.0) within the past year. CONCLUSIONS Referring provider knowledge of LCS guidelines is low and directly proportional to the ordering rate for LDCT in an at-risk US population. Strategies to advance evidence-based LCS should incorporate provider education and system-level interventions to address gaps in provider knowledge.
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Affiliation(s)
- Jennifer A Lewis
- aGeriatric Research, Education and Clinical Center, Veterans Health Administration - Tennessee Valley Healthcare System, Nashville, Tennessee.,bDivision of Hematology/Oncology, Department of Medicine, and
| | - Heidi Chen
- cDepartment of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathryn E Weaver
- dDepartment of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lucy B Spalluto
- aGeriatric Research, Education and Clinical Center, Veterans Health Administration - Tennessee Valley Healthcare System, Nashville, Tennessee.,eDepartment of Radiology
| | | | - Leora Horn
- bDivision of Hematology/Oncology, Department of Medicine, and
| | - Robert S Dittus
- aGeriatric Research, Education and Clinical Center, Veterans Health Administration - Tennessee Valley Healthcare System, Nashville, Tennessee.,fDivision of General Internal Medicine and Public Health, Department of Medicine, and
| | - Pierre P Massion
- gDivision of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; and.,hDepartment of Medicine, Veterans Health Administration - Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Christianne L Roumie
- aGeriatric Research, Education and Clinical Center, Veterans Health Administration - Tennessee Valley Healthcare System, Nashville, Tennessee.,fDivision of General Internal Medicine and Public Health, Department of Medicine, and
| | - Hilary A Tindle
- aGeriatric Research, Education and Clinical Center, Veterans Health Administration - Tennessee Valley Healthcare System, Nashville, Tennessee.,fDivision of General Internal Medicine and Public Health, Department of Medicine, and
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22
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Lewis JA, Samuels LR, Denton J, Edwards GC, Matheny ME, Maiga A, Slatore CG, Grogan E, Kim J, Sherrier RH, Dittus RS, Massion PP, Keohane L, Nikpay S, Roumie CL. National Lung Cancer Screening Utilization Trends in the Veterans Health Administration. JNCI Cancer Spectr 2020; 4:pkaa053. [PMID: 33490864 DOI: 10.1093/jncics/pkaa053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/20/2020] [Accepted: 06/08/2020] [Indexed: 12/17/2022] Open
Abstract
Background Many Veterans are high risk for lung cancer. Low-dose computed tomography (LDCT) is an effective strategy for lung cancer early detection in a high-risk population. Our objective was to describe and compare annual and geographic utilization trends for LDCT screening in the Veteran's Health Administration (VHA). Methods A national retrospective cohort of screened Veterans from January 1, 2011 to May 31, 2018 was used to calculate annual and regional rates of initial LDCT utilization per 1000 eligible Veterans. We identified Veterans with a first LDCT exam using common procedure terminology codes G0297 or 71250 and described as "lung cancer screening," "screening," or "LCS." The number of screen-eligible Veterans per year was calculated as unique Veterans aged 55 to 80 years seen at a Veterans Affairs medical center (VAMC) in that year, multiplied by 32% (estimated proportion with eligible smoking history). We present 95% confidence intervals (CI) for rates. Results Screened Veterans had a mean age of 66.1 years (standard deviation [SD] = 5.6); 95.5% male; 77.4% Caucasian. There were 119 300 LDCT exams, of which 80 819 (67.7%) were initial. Nationally, initial screens increased from 0 (95% CI = 0.00 to 0.00) in 2011 to 29.6 (95% CI = 29.26 to 29.88) scans per 1000 eligible Veterans in 2018 (Ptrend < .001). Initial screens increased over time within all geographic regions, most prominently in northeastern and Florida VAMCs. Conclusion VHA LDCT utilization increased from 2011 to 2018. However, overall utilization remained low. Future interventions are needed to increase lung cancer screening utilization among eligible Veterans.
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Affiliation(s)
- Jennifer A Lewis
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Ingram Cancer Center, Nashville, TN, USA
| | - Lauren R Samuels
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jason Denton
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gretchen C Edwards
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael E Matheny
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amelia Maiga
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G Slatore
- Veterans Affairs Portland Health Care System, Center to Improve Veteran Involvement in Care, Pulmonary & Critical Care Medicine, Portland, Oregon
| | - Eric Grogan
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jane Kim
- Veterans Health Administration, National Center for Health Promotion and Disease Prevention, Durham, NC, USA
| | | | - Robert S Dittus
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pierre P Massion
- Vanderbilt Ingram Cancer Center, Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Medicine, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Laura Keohane
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sayeh Nikpay
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christianne L Roumie
- Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
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23
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Edwards GC, Broman KK, Martin RL, Smalley WE, Smith L, Snyder RA, Solórzano CC, Dittus RS, Roumie CL. Virtual Colorectal Cancer Surveillance: Bringing Scope Rate to Target. J Am Coll Surg 2020; 231:257-266. [PMID: 32454089 DOI: 10.1016/j.jamcollsurg.2020.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although endoscopy is recommended at 1 year after colorectal cancer (CRC) resection to detect locally recurrent CRC, earlier work at our Veterans Affairs (VA) facility demonstrated that 35% of patients achieve this metric. STUDY DESIGN The interdisciplinary team used quality improvement methods to standardize processes and implement a gastroenterology-managed virtual surveillance clinic. The intervention clinic was implemented in August 2014. Veterans who underwent resection for stage I to III CRC at a single VA facility from January 2010 to December 2017 were included, with those undergoing resection between January 2010 and July 2014 considered pre-intervention and those undergoing resection between August 2014 and December 2017 considered post-intervention. The primary endpoint was the proportion of eligible patients for whom endoscopy was completed within 1 year of resection. Secondary outcomes were the proportion of patients who completed endoscopy within 18 months of resection or at any time post-resection and time to surveillance endoscopy. RESULTS A total of 186 patients underwent resection for stage I to III CRC from 2010 to 2017; of these, 160 (86%) were eligible for endoscopy at 1-year post-resection (98 pre-intervention and 62 post-intervention). In the pre-intervention period, 30 of 98 patients (30.6%) underwent surveillance endoscopy within 1 year vs 31 of 62 (50.0%) post-intervention (p = 0.031). When evaluated at 18 months after resection, 56 of 98 patients (57.1%) in the pre-intervention group vs 52 of 62 (83.9%) in the post-intervention group underwent surveillance endoscopy (p = 0.001). Median time from resection to endoscopy decreased during the study period, from 1.19 years pre-intervention (interquartile range 0.93 to 1.74 years) to 1.0 years post-intervention (interquartile range 0.93 to 1.09 years) (p = 0.006). CONCLUSIONS Implementation of a virtual surveillance clinic with standardized processes was associated with increased guideline-concordant endoscopic surveillance after CRC resection.
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Affiliation(s)
- Gretchen C Edwards
- Departments of Surgery, Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, TN; Geriatric Research and Education Clinical Center, Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, TN; Departments of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Kristy K Broman
- Department of Surgery, Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Walter E Smalley
- Departments of Surgery, Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, TN; Medicine, Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, TN; Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - LeaAnne Smith
- Medicine, Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, TN
| | - Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Carmen C Solórzano
- Departments of Surgery, Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, TN; Departments of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Robert S Dittus
- Geriatric Research and Education Clinical Center, Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, TN; Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Christianne L Roumie
- Geriatric Research and Education Clinical Center, Tennessee Valley Healthcare System, Veterans Health Administration, Nashville, TN; Medicine, Vanderbilt University Medical Center, Nashville, TN
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24
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Donelan K, DesRoches CM, Guzikowski S, Dittus RS, Buerhaus P. Physician and nurse practitioner roles in emergency, trauma, critical, and intensive care. Nurs Outlook 2020; 68:591-600. [PMID: 32622648 PMCID: PMC7241342 DOI: 10.1016/j.outlook.2020.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/16/2020] [Accepted: 04/25/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The delivery of emergency, trauma, critical, and intensive care services requires coordination among all members of the care team. Perceived teamwork and role clarity may vary among physicians (MDs) and nurse practitioners (NPs). PURPOSE To examine differences in perceived roles and responsibilities of NPs and MDs practicing in emergency, trauma, critical, and intensive care. METHODS Secondary Analysis of the National Survey of Emergency, Intensive, and Critical Care Nurse Practitioners and Physicians, a cross-sectional national survey of clinicians. Mail survey of randomly selected stratified cross-sectional samples of MDs and NPs drawn from national lists of clinicians in eligible specialties working in emergency, trauma, intensive, and critical care units in the United States. 814 clinicians (351 NPs and 463 MDs) were recruited from national by postal mail survey. Our initial sample included n = 2,063 clinicians, n = 1,031 NPs and n = 1,032 MDs in eligible specialties. Of these, 63.5% of NPs and 70.1% of MDs completed and returned the survey excluding those who were ineligible due to lack of current practice in a relevant specialty. FINDINGS NPs in ICU/CCU are more likely to be female and report working fewer hours than do MDs and provide direct care to more patients. 55% of NPs and 82% of MDs agree that their individual role in their unit is clear (p < .001); 34% of MDs and 42% of NPs agree that their unit is an example of excellent team work among professionals (p = 0.021); 41% of MD and 37% of NP clinicians (p = 0.061) agree that their teams are "prepared to provide outstanding care in a crisis or disaster." Perceived role clarity was significantly associated with increased perceptions of excellent teamwork and disaster preparedness. DISCUSSION At the time of this survey, and majority of NPs and MDs working in emergency, critical and intensive care did not agree that their teams were prepared for a crisis or disaster. Leaders of health organizations should encourage teamwork and professional role clarity to assist units to perform effectively in emergency and disaster preparedness.
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Affiliation(s)
- Karen Donelan
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Catherine M DesRoches
- Open Notes, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Sophia Guzikowski
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Robert S Dittus
- Department of Medicine, Institute for Medicine and Public Health, Vanderbilt University, Nashville, TN
| | - Peter Buerhaus
- Center for Interdisciplinary Health Workforce Studies, Montana State University, Bozeman, MT
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25
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Presley CA, Wooldridge KT, Byerly SH, Aylor AR, Kaboli PJ, Roumie CL, Schnipper JL, Dittus RS, Mixon AS. The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS). Am J Health Syst Pharm 2020; 77:128-137. [PMID: 31912884 DOI: 10.1093/ajhp/zxz275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE High-quality medication reconciliation reduces medication discrepancies, but smaller hospitals serving rural patients may have difficulty implementing this because of limited resources. We sought to adapt and implement an evidence-based toolkit of best practices for medication reconciliation in smaller hospitals, evaluate the effect on unintentional medication discrepancies, and assess facilitators and barriers to implementation. METHODS We conducted a 2-year mentored-implementation quality improvement feasibility study in 3 Veterans Affairs (VA) hospitals serving rural patients. The primary outcome was unintentional medication discrepancies per medication per patient, determined by comparing the "gold standard" preadmission medication history to the documented preadmission medication list and admission and discharge orders. RESULTS In total, 797 patients were included; their average age was 68.7 years, 94.4% were male, and they were prescribed an average of 9.6 medications. Sites 2 and 3 implemented toolkit interventions, including clarifying roles among clinical personnel, educating providers on taking a best possible medication history, and hiring pharmacy professionals to obtain a best possible medication history and perform discharge medication reconciliation. Site 1 did not implement an intervention. Discrepancies improved in intervention patients compared with controls at Site 3 (adjusted incidence rate ratio [IRR], 0.55; 95% confidence interval [CI], 0.45-0.67) but increased in intervention patients compared with controls at Site 2 (adjusted IRR, 1.22; 95% CI, 1.08-1.36). CONCLUSIONS An evidence-based toolkit for medication reconciliation adapted to the VA setting was adopted in 2 of 3 small, rural, resource-limited hospitals, resulting in both reduced and increased unintentional medication discrepancies. We highlight facilitators and barriers to implementing evidence-based medication reconciliation in smaller hospitals.
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Affiliation(s)
- Caroline A Presley
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Kathleene T Wooldridge
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Susan H Byerly
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amy R Aylor
- Center for Applied Systems Engineering, VISN11-Veterans Engineering Resource Center, Indianapolis, IN
| | - Peter J Kaboli
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA, and Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Christianne L Roumie
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, and Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN
| | - Jeffrey L Schnipper
- BWH Hospitalist Service, Division of General Medicine, Brigham and Women's Hospital, Boston, MA, and Harvard Medical School, Boston, MA
| | - Robert S Dittus
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, and Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN
| | - Amanda S Mixon
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, and Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN
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26
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Spalluto LB, Thomas D, Beard KR, Campbell T, Audet CM, McBride Murry V, Shrubsole MJ, Barajas CP, Joosten YA, Dittus RS, Wilkins CH. A Community-Academic Partnership to Reduce Health Care Disparities in Diagnostic Imaging. J Am Coll Radiol 2019; 16:649-656. [PMID: 30947902 DOI: 10.1016/j.jacr.2018.12.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Lucy B Spalluto
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center, Nashville, Tennessee and the Department of Radiological Sciences, Vanderbillt University Medical Center, Nashville, Tennessee.
| | - Debbie Thomas
- MidSouth Division of the American Cancer Society, Nashville, Tennessee
| | - Katina R Beard
- Matthew Walker Comprehensive Health Center, Nashville, Tennessee
| | - Thoris Campbell
- Metro Public Health Department, Tennessee Breast and Cervical Screening Program, Nashville, Tennessee
| | - Carolyn M Audet
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Velma McBride Murry
- Department of Human and Organizational Development, Vanderbilt University, Nashville, Tennessee
| | - Martha J Shrubsole
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia P Barajas
- Office of Patient and Community Education, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Yvonne A Joosten
- Office for Community Engagement, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert S Dittus
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center, Nashville, Tennessee and the Department of Radiological Sciences, Vanderbillt University Medical Center, Nashville, Tennessee; Veterans Health Administration - Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center, Nashville, Tennessee and the Department of Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee and Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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27
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Maiga AW, Deppen SA, Massion PP, Callaway-Lane C, Pinkerman R, Dittus RS, Lambright ES, Nesbitt JC, Grogan EL. Communication About the Probability of Cancer in Indeterminate Pulmonary Nodules. JAMA Surg 2019; 153:353-357. [PMID: 29261826 DOI: 10.1001/jamasurg.2017.4878] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Clinical guidelines recommend that clinicians estimate the probability of malignancy for patients with indeterminate pulmonary nodules (IPNs) larger than 8 mm. Adherence to these guidelines is unknown. Objectives To determine whether clinicians document the probability of malignancy in high-risk IPNs and to compare these quantitative or qualitative predictions with the validated Mayo Clinic Model. Design, Setting, and Participants Single-institution, retrospective cohort study of patients from a tertiary care Department of Veterans Affairs hospital from January 1, 2003, through December 31, 2015. Cohort 1 included 291 veterans undergoing surgical resection of known or suspected lung cancer from January 1, 2003, through December 31, 2015. Cohort 2 included a random sample of 239 veterans undergoing inpatient or outpatient pulmonary evaluation of IPNs at the hospital from January 1, 2003, through December 31, 2012. Exposures Clinician documentation of the quantitative or qualitative probability of malignancy. Main Outcomes and Measures Documentation from pulmonary and/or thoracic surgery clinicians as well as information from multidisciplinary tumor board presentations was reviewed. Any documented quantitative or qualitative predictions of malignancy were extracted and summarized using descriptive statistics. Clinicians' predictions were compared with risk estimates from the Mayo Clinic Model. Results Of 291 patients in cohort 1, 282 (96.9%) were men; mean (SD) age was 64.6 (9.0) years. Of 239 patients in cohort 2, 233 (97.5%) were men; mean (SD) age was 65.5 (10.8) years. Cancer prevalence was 258 of 291 cases (88.7%) in cohort 1 and 110 of 225 patients with a definitive diagnosis (48.9%) in cohort 2. Only 13 patients (4.5%) in cohort 1 and 3 (1.3%) in cohort 2 had a documented quantitative prediction of malignancy prior to tissue diagnosis. Of the remaining patients, 217 of 278 (78.1%) in cohort 1 and 149 of 236 (63.1%) in cohort 2 had qualitative statements of cancer risk. In cohort 2, 23 of 79 patients (29.1%) without any documented malignancy risk statements had a final diagnosis of cancer. Qualitative risk statements were distributed among 32 broad categories. The most frequently used statements aligned well with Mayo Clinic Model predictions for cohort 1 compared with cohort 2. The median Mayo Clinic Model-predicted probability of cancer was 68.7% (range, 2.4%-100.0%). Qualitative risk statements roughly aligned with Mayo predictions. Conclusions and Relevance Clinicians rarely provide quantitative documentation of cancer probability for high-risk IPNs, even among patients drawn from a broad range of cancer probabilities. Qualitative statements of cancer risk in current practice are imprecise and highly variable. A standard scale that correlates with predicted cancer risk for IPNs should be used to communicate with patients and other clinicians.
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Affiliation(s)
- Amelia W Maiga
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville.,Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen A Deppen
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville.,Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pierre P Massion
- Department of Medicine, Tennessee Valley Healthcare System, Nashville.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Rhonda Pinkerman
- Department of Surgery, Tennessee Valley Healthcare System, Nashville
| | - Robert S Dittus
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville
| | - Eric S Lambright
- Department of Surgery, Tennessee Valley Healthcare System, Nashville.,Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan C Nesbitt
- Department of Surgery, Tennessee Valley Healthcare System, Nashville.,Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric L Grogan
- Department of Surgery, Tennessee Valley Healthcare System, Nashville.,Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Lewis JA, Denton J, Matheny ME, Slatore CG, Maiga AW, Grogan E, Massion PP, Sherrier RH, Dittus RS, Keohane L, Roumie CL, Nikpay S. National lung cancer screening utilization trends in the Veterans Health Administration. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6547] [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] [Indexed: 11/20/2022] Open
Abstract
6547 Background: Low-dose CT (LDCT) is an effective means for early lung cancer detection, but is often underutilized. An estimated 900,000 Veterans are eligible for lung cancer screening. We are the first to describe national lung cancer screening utilization trends in the Veterans Health Administration (VHA). Methods: We assembled a retrospective cohort of patients within the VHA’s Observational Medical Outcomes Partnership (OMOP) Common Data Model who underwent lung cancer screening. LDCT scans with Common Procedure Terminology (CPT) codes G0297 or 71250 from January 1, 2011 to May 31, 2018 were eligible for inclusion. We further selected exams described as “lung cancer screening,” “screening,” or “LCS.” We used descriptive statistics with frequencies and medians to calculate the total exams per Veteran and evaluate utilization trends over time and by region. Results: At initial screening, Veterans had a median age of 66 (IQR 61, 70), 95% were male, 76% Caucasian. From January 1, 2011 to May 31, 2018, 75 VHA facilities performed 129,363 LDCT exams for lung cancer screening; 87,950 (68%) initial and 41,413 (32%) subsequent exams. Screening has increased over time (226 in 2011-2012; 7848 in 2013-2014; 41,225 in 2015-2016; 80,064 in 2017 until May 31, 2018) in all regions. Providers in primary care/internal medicine (56%), family medicine (16%), pulmonology (6%), oncology (0.3%), other specialties (21%) ordered screening exams. Conclusions: Lung cancer screening with low-dose CT within the VHA increased over time within all geographic regions. Future strategies aimed at the Veteran, provider, and healthcare system levels are needed to increase lung cancer screening utilization among eligible Veterans. [Table: see text]
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Affiliation(s)
- Jennifer A. Lewis
- Veterans Health Administration, Tennessee Valley Healthcare System Geriatric Research Education Clinical Center, Nashville, TN
| | - Jason Denton
- Vanderbilt University Medical Center, Nashville, TN
| | | | - Christopher G. Slatore
- Portland VAMC Health Services Research and Development and Oregon Health & Sciences University, Portland, OR
| | | | - Eric Grogan
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Robert S. Dittus
- Veterans Health Administration, Tennessee Valley Healthcare System Geriatric Research Education Clinical Center, Nashville, TN
| | - Laura Keohane
- Vanderbilt University School of Medicine, Nashville, TN
| | - Christianne L. Roumie
- Veterans Health Administration, Tennessee Valley Healthcare System Geriatric Research Education Clinical Center, Nashville, TN
| | - Sayeh Nikpay
- Vanderbilt University School of Medicine, Nashville, TN
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Abstract
Maps of Histoplasma capsulatum infection prevalence were created 50 years ago; since then, the environment, climate, and anthropogenic land use have changed drastically. Recent outbreaks of acute disease in Montana and Nebraska, USA, suggest shifts in geographic distribution, necessitating updated prevalence maps. To create a weighted overlay geographic suitability model for Histoplasma, we used a geographic information system to combine satellite imagery integrating land cover use (70%), distance to water (20%), and soil pH (10%). We used logistic regression modeling to compare our map with state-level histoplasmosis incidence data from a 5% sample from the Centers for Medicare and Medicaid Services. When compared with the state-based Centers data, the predictive accuracy of the suitability score–predicted states with high and mid-to-high histoplasmosis incidence was moderate. Preferred soil environments for Histoplasma have migrated into the upper Missouri River basin. Suitability score mapping may be applicable to other geographically specific infectious vectors.
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Kripalani S, Chen G, Ciampa P, Theobald C, Cao A, McBride M, Dittus RS, Speroff T. A transition care coordinator model reduces hospital readmissions and costs. Contemp Clin Trials 2019; 81:55-61. [PMID: 31029692 DOI: 10.1016/j.cct.2019.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 11/28/2018] [Revised: 04/01/2019] [Accepted: 04/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal structure and intensity of interventions to reduce hospital readmission remains uncertain, due in part to lack of head-to-head comparison. To address this gap, we evaluated two forms of an evidence-based, multi-component transitional care intervention. METHODS A quasi-experimental evaluation design compared outcomes of Transition Care Coordinator (TCC) Care to Usual Care, while controlling for sociodemographic characteristics, comorbidities, readmission risk, and administrative factors. The study was conducted between January 1, 2013 and April 30, 2015 as a quality improvement initiative. Eligible adults (N = 7038) hospitalized with pneumonia, congestive heart failure, or chronic obstructive pulmonary disease were identified for program evaluation via an electronic health record algorithm. Nurse TCCs provided either a full intervention (delivered in-hospital and by post-discharge phone call) or a partial intervention (phone call only). RESULTS A total of 762 hospitalizations with TCC Care (460 full intervention and 302 partial intervention) and 6276 with Usual Care was examined. In multivariable models, hospitalizations with TCC Care had significantly lower odds of readmission at 30 days (OR = 0.512, 95% CI 0.392 to 0.668) and 90 days (OR = 0.591, 95% CI 0.483 to 0.723). Adjusted costs were significantly lower at 30 days (difference = $3969, 95% CI $5099 to $2691) and 90 days (difference = $5684, 95% CI $7602 to $3627). The effect was similar whether patients received the full or partial intervention. CONCLUSION An evidence-based multi-component intervention delivered by nurse TCCs reduced 30- and 90-day readmissions and associated health care costs. Lower intensity interventions delivered by telephone after discharge may have similar effectiveness to in-hospital programs.
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Affiliation(s)
- Sunil Kripalani
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, USA; Center for Health Services Research, Vanderbilt University Medical Center, USA.
| | - Guanhua Chen
- Department of Biostatistics & Medical Informatics, University of Wisconsin - Madison, Madison, WI, USA
| | - Philip Ciampa
- Atrius Health, Center for Healthcare Innovation, Newton, MA, USA
| | - Cecelia Theobald
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, USA
| | - Aize Cao
- Department of Biomedical Informatics, Vanderbilt University Medical Center, USA
| | - Megan McBride
- Office of Population Health, Vanderbilt University Medical Center, USA
| | - Robert S Dittus
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, USA; Center for Health Services Research, Vanderbilt University Medical Center, USA; Department of Veterans Affairs, Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), TN, USA
| | - Theodore Speroff
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, USA; Center for Health Services Research, Vanderbilt University Medical Center, USA; Department of Biostatistics & Medical Informatics, University of Wisconsin - Madison, Madison, WI, USA; Department of Veterans Affairs, Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), TN, USA
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Girard TD, Exline MC, Carson SS, Hough CL, Rock P, Gong MN, Douglas IS, Malhotra A, Owens RL, Feinstein DJ, Khan B, Pisani MA, Hyzy RC, Schmidt GA, Schweickert WD, Hite RD, Bowton DL, Masica AL, Thompson JL, Chandrasekhar R, Pun BT, Strength C, Boehm LM, Jackson JC, Pandharipande PP, Brummel NE, Hughes CG, Patel MB, Stollings JL, Bernard GR, Dittus RS, Ely EW. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med 2018; 379:2506-2516. [PMID: 30346242 PMCID: PMC6364999 DOI: 10.1056/nejmoa1808217] [Citation(s) in RCA: 309] [Impact Index Per Article: 51.5] [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: 12/11/2022]
Abstract
BACKGROUND There are conflicting data on the effects of antipsychotic medications on delirium in patients in the intensive care unit (ICU). METHODS In a randomized, double-blind, placebo-controlled trial, we assigned patients with acute respiratory failure or shock and hypoactive or hyperactive delirium to receive intravenous boluses of haloperidol (maximum dose, 20 mg daily), ziprasidone (maximum dose, 40 mg daily), or placebo. The volume and dose of a trial drug or placebo was halved or doubled at 12-hour intervals on the basis of the presence or absence of delirium, as detected with the use of the Confusion Assessment Method for the ICU, and of side effects of the intervention. The primary end point was the number of days alive without delirium or coma during the 14-day intervention period. Secondary end points included 30-day and 90-day survival, time to freedom from mechanical ventilation, and time to ICU and hospital discharge. Safety end points included extrapyramidal symptoms and excessive sedation. RESULTS Written informed consent was obtained from 1183 patients or their authorized representatives. Delirium developed in 566 patients (48%), of whom 89% had hypoactive delirium and 11% had hyperactive delirium. Of the 566 patients, 184 were randomly assigned to receive placebo, 192 to receive haloperidol, and 190 to receive ziprasidone. The median duration of exposure to a trial drug or placebo was 4 days (interquartile range, 3 to 7). The median number of days alive without delirium or coma was 8.5 (95% confidence interval [CI], 5.6 to 9.9) in the placebo group, 7.9 (95% CI, 4.4 to 9.6) in the haloperidol group, and 8.7 (95% CI, 5.9 to 10.0) in the ziprasidone group (P=0.26 for overall effect across trial groups). The use of haloperidol or ziprasidone, as compared with placebo, had no significant effect on the primary end point (odds ratios, 0.88 [95% CI, 0.64 to 1.21] and 1.04 [95% CI, 0.73 to 1.48], respectively). There were no significant between-group differences with respect to the secondary end points or the frequency of extrapyramidal symptoms. CONCLUSIONS The use of haloperidol or ziprasidone, as compared with placebo, in patients with acute respiratory failure or shock and hypoactive or hyperactive delirium in the ICU did not significantly alter the duration of delirium. (Funded by the National Institutes of Health and the VA Geriatric Research Education and Clinical Center; MIND-USA ClinicalTrials.gov number, NCT01211522 .).
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Affiliation(s)
- Timothy D Girard
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Matthew C Exline
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Shannon S Carson
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Catherine L Hough
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Peter Rock
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Michelle N Gong
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Ivor S Douglas
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Atul Malhotra
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Robert L Owens
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Daniel J Feinstein
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Babar Khan
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Margaret A Pisani
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Robert C Hyzy
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Gregory A Schmidt
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - William D Schweickert
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - R Duncan Hite
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - David L Bowton
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Andrew L Masica
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Jennifer L Thompson
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Rameela Chandrasekhar
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Brenda T Pun
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Cayce Strength
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Leanne M Boehm
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - James C Jackson
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Pratik P Pandharipande
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Nathan E Brummel
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Christopher G Hughes
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Mayur B Patel
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Joanna L Stollings
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Gordon R Bernard
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Robert S Dittus
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - E Wesley Ely
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
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Girard TD, Thompson JL, Pandharipande PP, Brummel NE, Jackson JC, Patel MB, Hughes CG, Chandrasekhar R, Pun BT, Boehm LM, Elstad MR, Goodman RB, Bernard GR, Dittus RS, Ely EW. Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: a prospective cohort study. Lancet Respir Med 2018; 6:213-222. [PMID: 29508705 DOI: 10.1016/s2213-2600(18)30062-6] [Citation(s) in RCA: 230] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 01/17/2018] [Accepted: 01/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Delirium during critical illness results from numerous insults, which might be interconnected and yet individually contribute to long-term cognitive impairment. We sought to describe the prevalence and duration of clinical phenotypes of delirium (ie, phenotypes defined by clinical risk factors) and to understand associations between these clinical phenotypes and severity of subsequent long-term cognitive impairment. METHODS In this multicentre, prospective cohort study, we included adult (≥18 years) medical or surgical ICU patients with respiratory failure, shock, or both as part of two parallel studies: the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors (BRAIN-ICU) study, and the Delirium and Dementia in Veterans Surviving ICU Care (MIND-ICU) study. We assessed patients at least once a day for delirium using the Confusion Assessment Method-ICU and identified a priori-defined, non-mutually exclusive phenotypes of delirium per the presence of hypoxia, sepsis, sedative exposure, or metabolic (eg, renal or hepatic) dysfunction. We considered delirium in the absence of hypoxia, sepsis, sedation, and metabolic dysfunction to be unclassified. 3 and 12 months after discharge, we assessed cognition with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). We used multiple linear regression to separately analyse associations between the duration of each phenotype of delirium and RBANS global cognition scores at 3-month and 12-month follow-up, adjusting for potential confounders. FINDINGS Between March 14, 2007, and May 27, 2010, 1048 participants were enrolled, eight of whom could not be analysed. Of 1040 participants, 708 survived to 3 months of follow-up and 628 to 12 months. Delirium was common, affecting 740 (71%) of 1040 participants at some point during the study and occurring on 4187 (31%) of all 13 434 participant-days. A single delirium phenotype was present on only 1355 (32%) of all 4187 participant-delirium days, whereas two or more phenotypes were present during 2832 (68%) delirium days. Sedative-associated delirium was most common (present during 2634 [63%] delirium days), and a longer duration of sedative-associated delirium predicted a worse RBANS global cognition score 12 months later, after adjusting for covariates (difference in score comparing 3 days vs 0 days: -4·03, 95% CI -7·80 to -0·26). Similarly, longer durations of hypoxic delirium (-3·76, 95% CI -7·16 to -0·37), septic delirium (-3·67, -7·13 to -0·22), and unclassified delirium (-4·70, -7·16 to -2·25) also predicted worse cognitive function at 12 months, whereas duration of metabolic delirium did not (1·14, -0·12 to 3·01). INTERPRETATION Our findings suggest that clinicians should consider sedative-associated, hypoxic, and septic delirium, which often co-occur, as distinct indicators of acute brain injury and seek to identify all potential risk factors that may impact on long-term cognitive impairment, especially those that are iatrogenic and potentially modifiable such as sedation. FUNDING National Institutes of Health and the Department of Veterans Affairs.
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Affiliation(s)
- Timothy D Girard
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Jennifer L Thompson
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Pratik P Pandharipande
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Nathan E Brummel
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - James C Jackson
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA; Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Mayur B Patel
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of Trauma and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, TN, USA; Vanderbilt Brain Institute, Vanderbilt University School of Medicine, Nashville, TN, USA; Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Christopher G Hughes
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Rameela Chandrasekhar
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Brenda T Pun
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Leanne M Boehm
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Vanderbilt University School of Nursing, Nashville, TN, USA
| | - Mark R Elstad
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine in the Department of Internal Medicine at the University of Utah School of Medicine, Salt Lake City, UT, USA; George E Wahlen Department of Veterans Affairs Medical Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Richard B Goodman
- Division of Pulmonary, Critical Care, and Sleep Medicine in the Department of Internal Medicine at the University of Washington School of Medicine, Seattle, WA, USA; Department of Veterans Affairs Medical Center, Seattle Division, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Gordon R Bernard
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Robert S Dittus
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of General Internal Medicine and Public Health in the Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E W Ely
- ICU Delirium and Cognitive Impairment Study Group at the Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA; Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Wilson JE, Duggan MC, Chandrasekhar R, Brummel NE, Dittus RS, Ely EW, Patel MB, Jackson JC. Deficits in Self-Reported Initiation Are AssociatedWith Subsequent Disability in ICU Survivors. Psychosomatics 2018; 60:376-384. [PMID: 30352696 DOI: 10.1016/j.psym.2018.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 09/21/2018] [Accepted: 09/24/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine whether deficits in a key aspect of executive functioning, namely, initiation, were associated with current and future functional disabilities in intensive care unit survivors. METHODS A nested substudy within a 2-center prospective observational cohort. We used 3 tests of initiation at 3 and 12 months: the Ruff Total Unique Design, Controlled Oral Word Association, and Behavior Rating Inventory of Executive Function initiation. Disability in instrumental activities of daily living (IADL) was measured with the Functional Activities Questionnaire. We used a proportional odds logistic regression model to evaluate the association between initiation and disability. Covariates in the model included age, education, baseline Functional Activities Questionnaire, pre-existing cognitive impairment, comorbidities, admission severity of illness, episodes of hypoxia, and days of severe sepsis. RESULTS In 195 patients, after adjusting for covariates, only the Behavior Rating Inventory of Executive Function initiation was associated with disability at any time point. Comparing the 25th vs the 75th percentile scores (95% confidence interval) of the Behavior Rating Inventory of Executive Function initiation at 3 months, patients with worse initiation scores had 5.062 times the odds (95% confidence interval: 2.539, 10.092) of disability according to the Functional Activities Questionnaire at 3 months, with similar odds at 12 months (odds ratio: 3.476, 95% confidence interval: 1.943, 6.216). Worse Behavior Rating Inventory of Executive Function initiation scores at 3 months were associated with future disability at 12 months odds ratio (95% confidence interval) 5.079 (2.579, 10.000). CONCLUSIONS Executive function deficits acquired after a critical illness in the domain of initiation are common in intensive care unit survivors, and when they are identified via self-report tools, they are associated with current and future disability in instrumental activities of daily living.
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Affiliation(s)
- Jo Ellen Wilson
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN.
| | - Maria C Duggan
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
| | | | - Nathan E Brummel
- Department of Medicine, Division of Pulmonary and Critical Care, Center for Health Services Research and Quality Aging, Vanderbilt University Medical Center, Nashville, TN
| | - Robert S Dittus
- Veterans Affairs Tennessee Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN; Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
| | - Eugene Wesley Ely
- Veterans Affairs Tennessee Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN; Department of Medicine, Division of Pulmonary and Critical Care, Center for Health Services Research and Quality Aging, Vanderbilt University Medical Center, Nashville, TN
| | - Mayur B Patel
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery, Neurosurgery, and Hearing and Speech Sciences, Section of Surgical Sciences, Vanderbilt Brain Institute, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Surgical Service, General Surgery Section, US Department of Veterans Affairs, Nashville VA Medical Center, Tennessee Valley Healthcare System, Nashville, TN
| | - James C Jackson
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN
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Marra A, Jackson JC, Ely EW, Graves AJ, Schnelle JF, Dittus RS, Wilson A, Han JH. Focusing on Inattention: The Diagnostic Accuracy of Brief Measures of Inattention for Detecting Delirium. J Hosp Med 2018; 13:551-557. [PMID: 29578552 PMCID: PMC6502509 DOI: 10.12788/jhm.2943] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 12/25/2022]
Abstract
BACKGROUND Delirium is frequently missed in most clinical settings. Brief delirium assessments are needed. OBJECTIVE To determine the diagnostic accuracy of reciting the months of year backwards (MOTYB) from December to July (MOTYB-6) and December to January (MOTYB-12) for delirium as diagnosed by a psychiatrist and to explore the diagnostic accuracies of the following other brief attention tasks: (1) spell the word "LUNCH" backwards, (2) recite the days of the week backwards, (3) 10-letter vigilance "A" task, and (4) 5 picture recognition task. DESIGN Preplanned secondary analysis of a prospective observational study. SETTING Emergency department located within an academic, tertiary care hospital. PARTICIPANTS 234 acutely ill patients who were =65 years old. MEASUREMENTS The inattention tasks were administered by a physician. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivities and specificities were calculated. RESULTS Making any error on the MOTYB-6 task had a sensitivity of 80.0% (95% confidence interval [CI], 60.9%-91.1%) and specificity of 57.1% (95% CI, 50.4%- 63.7%). Making any error on the MOTYB-12 task had a sensitivity of 84.0% (95% CI, 65.4%-93.6%) and specificity of 51.9% (95% CI, 45.2%-58.5%). The best combination of sensitivity and specificity was reciting the days of the week backwards task; if the patient made any error, this was 84.0% (95% CI, 65.4%-93.6%) sensitive and 81.9% (95% CI, 76.1%-86.5%) specific. CONCLUSIONS MOTYB-6 and MOTYB-12 had very good sensitivities but had modest specificities for delirium, limiting their use as a standalone assessment. Reciting the days of the week backwards appeared to have the best combination of sensitivity and specificity for delirium.
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Affiliation(s)
- Annachiara Marra
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples, Federico II, Naples, Italy
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy J Graves
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John F Schnelle
- Research Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert S Dittus
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amanda Wilson
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin H Han
- Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Theobald CN, Resnick MJ, Spain T, Dittus RS, Roumie CL. A multifaceted quality improvement strategy reduces the risk of catheter-associated urinary tract infection. Int J Qual Health Care 2018. [PMID: 28633453 DOI: 10.1093/intqhc/mzx073] [Citation(s) in RCA: 9] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective Catheter-associated urinary tract infections (CAUTIs) are common and preventable hospital-acquired infections, yet their rate continues to rise nationwide. We describe the implementation of a multifaceted program to reduce catheter use and CAUTI rates while simultaneously addressing barriers to long-term success. Design/Setting/Participants Pre-post study of medical inpatient veterans between December 2012 and February 2015. Intervention Five component intervention: (i) a bedside catheter reminder; (ii) multidisciplinary educational campaign; (iii) structured catheter order set with clinical decision support; (iv) automated catheter discontinuation orders; and (v) protocol for post-catheter removal care. Main Outcome Measure(s) Catheter utilization rates and CAUTI rates on the study ward were followed during the 14-week baseline period, the 27-week transition/intervention period and the 70-week period of full implementation/sustainability. Rates of patient falls per bed days and catheter reinsertions were collected during the same time periods as balancing measures. Results Catheter use declined by 35% from the baseline period to the full implementation/sustainability period. This improvement was not realized until deployment of the structured electronic orders with automated catheter discontinuation and protocolized post-catheter care. The average number of days between CAUTIs on the study ward increased from 101 days in the baseline period to over 400 days in the full implementation/sustainability period. There was no significant change in the rates of falls or catheter reinsertions during the study period. Conclusions A multicomponent intervention aimed specifically at targeting local barriers was successful in reducing catheter utilization as well as CAUTIs in a veteran population without compensatory increase in patient falls or catheter replacement.
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Affiliation(s)
- Cecelia N Theobald
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA
| | - Matthew J Resnick
- VA National Quality Scholars Program, Department of Veteran Affairs, Tennessee Valley Health Care System, 1310 24th Ave. S, Nashville, TN 37212, USA.,Department of Urology, Vanderbilt University Medical Center, 1301 Medical Center Dr, Nashville, TN 37232, USA.,Geriatric Research, Education, and Clinical Center, Department of Veteran Affairs, Tennessee Valley Health System, 1310 24th Ave. S, Nashville, TN 37212, USA.,Department of Health Policy, Vanderbilt University Medical Center, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA
| | - Thomas Spain
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA.,VA National Quality Scholars Program, Department of Veteran Affairs, Tennessee Valley Health Care System, 1310 24th Ave. S, Nashville, TN 37212, USA.,Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, Tenn. 37232, USA
| | - Robert S Dittus
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA.,VA National Quality Scholars Program, Department of Veteran Affairs, Tennessee Valley Health Care System, 1310 24th Ave. S, Nashville, TN 37212, USA.,Geriatric Research, Education, and Clinical Center, Department of Veteran Affairs, Tennessee Valley Health System, 1310 24th Ave. S, Nashville, TN 37212, USA
| | - Christianne L Roumie
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA.,VA National Quality Scholars Program, Department of Veteran Affairs, Tennessee Valley Health Care System, 1310 24th Ave. S, Nashville, TN 37212, USA.,Geriatric Research, Education, and Clinical Center, Department of Veteran Affairs, Tennessee Valley Health System, 1310 24th Ave. S, Nashville, TN 37212, USA.,Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, Nashville, Tenn. 37232, USA
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Yiadom MYAB, Mumma BE, Baugh CW, Patterson BW, Mills AM, Salazar G, Tanski M, Jenkins CA, Vogus TJ, Miller KF, Jackson BE, Lehmann CU, Dorner SC, West JL, Wang TJ, Collins SP, Dittus RS, Bernard GR, Storrow AB, Liu D. Measuring outcome differences associated with STEMI screening and diagnostic performance: a multicentred retrospective cohort study protocol. BMJ Open 2018; 8:e022453. [PMID: 29724744 PMCID: PMC5942471 DOI: 10.1136/bmjopen-2018-022453] [Citation(s) in RCA: 6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Advances in ST-segment elevation myocardial infarction (STEMI) management have involved improving the clinical processes connecting patients with timely emergency cardiovascular care. Screening upon emergency department (ED) arrival for an early ECG to diagnose STEMI, however, is not optimal for all patients. In addition, the degree to which timely screening and diagnosis are associated with improved time to intervention and postpercutaneous coronary intervention outcomes, under more contemporary practice conditions, is not known. METHODS We present the methods for a retrospective multicentre cohort study anticipated to include 1220 patients across seven EDs to (1) evaluate the relationship between timely screening and diagnosis with treatment and postintervention clinical outcomes; (2) introduce novel measures for cross-facility performance comparisons of screening and diagnostic care team performance including: door-to-screening, door-to-diagnosis and door-to-catheterisation laboratory arrival times and (3) describe the use of electronic health record data in tandem with an existing disease registry. ETHICS AND DISSEMINATION The completion of this study will provide critical feedback on the quality of screening and diagnostic performance within the contemporary STEMI care pathway that can be used to (1) improve emergency care delivery for patients with STEMI presenting to the ED, (2) present novel metrics for the comparison of screening and diagnostic care and (3) inform the development of screening and diagnostic support tools that could be translated to other care environments. We will disseminate our results via publication and quality performance data sharing with each site. Institutional ethics review approval was received prior to study initiation.
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Affiliation(s)
- Maame Yaa A B Yiadom
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California at Davis, Sacramento, California, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Brian W Patterson
- Department of Emergency Medicine, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University Medical Center, New York, USA
| | - Gilberto Salazar
- Department of Emergency Medicine, Parkland Hospital, University of Texas Southwestern, Dallas, Texas, USA
| | - Mary Tanski
- Department of Emergency Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Brittney E Jackson
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Christoph U Lehmann
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
| | - Stephen C Dorner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Jennifer L West
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Thomas J Wang
- Division of Cardiology, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Robert S Dittus
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Gordon R Bernard
- Division of Critical Care, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
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Yiadom MY, Baugh CW, Jenkins CA, Tanski M, Mumma BE, Vogus TJ, Miller KF, Jackson BE, Lehmann CU, Dorner SC, West JL, Olubowale OO, Wang TJ, Collins SP, Dittus RS, Bernard GR, Storrow AB, Liu D. Abstract 185: Outcome Differences Associated With STEMI Diagnostic Delay: Disparities on the Frontlines of STEMI Care. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.185] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
AHA/ACC/ESC practice guidelines advise an ECG within 10 minutes for all patients with symptoms suggestive of ST-segment elevation myocardial infarction (STEMI). This facilitates early diagnosis and timely treatment. Earlier treatment, particularly percutaneous coronary intervention (PCI), has been associated with better clinical outcomes. Our objective was to quantify the impact of delayed screening on timely treatment and determine if there may be race, sex or presenting complaint disparities.
Methods:
We examined the association between time-to-first ECG (door-to-screening, or D2S) and time-to-PCI in a 3-center 1-year retrospective cohort study including all emergency department (ED) patients with acute STEMI per hospital discharge diagnosis who underwent catheterization for PCI. The primary outcome was door-to-balloon time (D2B) and the ED-centric secondary outcome was door-to-cath-lab arrival time (D2CAR).
Results:
Of 161,920 patients seen in the 3 EDs, 137 (0.08%) were diagnosed with STEMI. Of the 137, 75 (55%) underwent emergent PCI, and 31 (41%) of the ED STEMI PCI patients did not receive an ECG within 10 minutes. These 31 patients were more commonly female (55% vs. 19%, p=0.001), non-white (87% vs. 65%, p =0.028), and reported chest pain or shortness of breath less frequently (55% vs. 94%, p<0.001). In patients with D2S greater than 10 minutes, median D2CAR was longer (159 vs. 50 minutes, p=0.004) as was median D2B time (207 vs. 93 minutes, p=0.048).
Conclusion:
A significant proportion of ED patients with STEMI did not receive an ECG within 10 minutes of arrival resulting in a 2.2 fold increase in D2B time. They were more likely to be female, non-white, and with atypical chief complaints. Normalizing screening criteria for presentation diversity could improve more equitable access to timely STEMI treatment
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Affiliation(s)
| | | | | | - Mary Tanski
- Oregon Health and Sciences Univ, Portland, OR
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Marra A, Pandharipande PP, Shotwell MS, Chandrasekhar R, Girard TD, Shintani AK, Peelen LM, Moons KGM, Dittus RS, Ely EW, Vasilevskis EE. Acute Brain Dysfunction: Development and Validation of a Daily Prediction Model. Chest 2018; 154:293-301. [PMID: 29580772 DOI: 10.1016/j.chest.2018.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 11/21/2017] [Revised: 02/08/2018] [Accepted: 03/01/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The goal of this study was to develop and validate a dynamic risk model to predict daily changes in acute brain dysfunction (ie, delirium and coma), discharge, and mortality in ICU patients. METHODS Using data from a multicenter prospective ICU cohort, a daily acute brain dysfunction-prediction model (ABD-pm) was developed by using multinomial logistic regression that estimated 15 transition probabilities (from one of three brain function states [normal, delirious, or comatose] to one of five possible outcomes [normal, delirious, comatose, ICU discharge, or died]) using baseline and daily risk factors. Model discrimination was assessed by using predictive characteristics such as negative predictive value (NPV). Calibration was assessed by plotting empirical vs model-estimated probabilities. Internal validation was performed by using a bootstrap procedure. RESULTS Data were analyzed from 810 patients (6,711 daily transitions). The ABD-pm included individual risk factors: mental status, age, preexisting cognitive impairment, baseline and daily severity of illness, and daily administration of sedatives. The model yielded very high NPVs for "next day" delirium (NPV: 0.823), coma (NPV: 0.892), normal cognitive state (NPV: 0.875), ICU discharge (NPV: 0.905), and mortality (NPV: 0.981). The model demonstrated outstanding calibration when predicting the total number of patients expected to be in any given state across predicted risk. CONCLUSIONS We developed and internally validated a dynamic risk model that predicts the daily risk for one of three cognitive states, ICU discharge, or mortality. The ABD-pm may be useful for predicting the proportion of patients for each outcome state across entire ICU populations to guide quality, safety, and care delivery activities.
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Affiliation(s)
- Annachiara Marra
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples, Federico II, Naples, Italy
| | - Pratik P Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ayumi K Shintani
- Osaka University Graduate School of Medicine, Clinical Epidemiology and Biostatistics
| | - Linda M Peelen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karl G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert S Dittus
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center (GRECC) of the VA Tennessee Valley Healthcare System, Nashville, TN
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center (GRECC) of the VA Tennessee Valley Healthcare System, Nashville, TN; Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN
| | - Eduard E Vasilevskis
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center (GRECC) of the VA Tennessee Valley Healthcare System, Nashville, TN; Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN.
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Han JH, Wilson A, Schnelle JF, Dittus RS, Ely EW. An evaluation of single question delirium screening tools in older emergency department patients. Am J Emerg Med 2018; 36:1249-1252. [PMID: 29699898 DOI: 10.1016/j.ajem.2018.03.060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 03/21/2018] [Accepted: 03/21/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To determine the diagnostic performances of several single question delirium screens. To the patient we asked: "Have you had any difficulty thinking clearly lately?" To the patient's surrogate, we asked: "Is the patient at his or her baseline mental status?" and "Have you noticed the patient's mental status fluctuate throughout the course of the day?" METHODS This was a prospective observational study that enrolled English speaking patients 65 years or older. A research assistant (RA) and emergency physician (EP) independently asked the patient and surrogate the single question delirium screens. The reference standard for delirium was a consultation-liaison psychiatrist's assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria. All assessments were performed within 3 h and were all blinded to each other. RESULTS Of the 406 patients enrolled, 50 (12%) were delirious. A patient who was unable to answer the question "Have you had any difficulty thinking clearly lately?" was 99.7% (95% CI: 98.0%-99.9%) specific, but only 24.0% (95% CI: 14.3%-37.4%) sensitive for delirium when asked by the RA. The baseline mental status surrogate question was 77.1% (95% CI: 61.0%-87.9%) sensitive and 87.5% (95% CI: 82.8%-91.1%) specific for delirium when asked by the RA. The fluctuating course surrogate question was 77.1% (95% CI: 61.0%-87.9%) sensitive and 80.2% (95% CI: 74.8%-84.7%) specific. When asked by the EP, the single question delirium screens' diagnostic performances were similar. CONCLUSIONS The patient and surrogate single question delirium assessments may be useful for delirium screening in the ED.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, United States; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States.
| | - Amanda Wilson
- Department of Psychiatry, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN, United States; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, United States
| | - Robert S Dittus
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, United States
| | - E W Ely
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, United States
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Yiadom MYAB, Baugh CW, Jenkins CA, Collins SP, Bhatia MC, Dittus RS, Storrow AB. Change in Care Transition Practice for Patients With Nonspecific Chest Pain After Emergency Department Evaluation 2006 to 2012. Acad Emerg Med 2017; 24:1527-1530. [PMID: 28833882 DOI: 10.1111/acem.13279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES From 2005 to 2010 health care financing shifts in the United States may have affected care transition practices for emergency department (ED) patients with nonspecific chest pain (CP) after ED evaluation. Despite being less acutely ill than those with myocardial infarction, these patients' management can be challenging. The risk of missing acute coronary syndrome is considerable enough to often warrant admission. Diagnostic advances and reimbursement limitations on the use of inpatient admission are encouraging the use of alternative ED care transition practices. In the setting of these health care changes, we hypothesized that there is a decline in inpatient admission rates for patients with nonspecific CP after ED evaluation. METHODS We retrospectively used the Nationwide ED Sample to quantify total and annual inpatient hospital admission rates from 2006 to 2012 for patients with a final ED diagnosis of nonspecific CP. We assessed the change in admission rates over time and stratified by facility characteristics including safety-net hospital status, U.S. geographic region, urban/teaching status, trauma-level designation, and hospital funding status. RESULTS The admission rate for all patients with a final ED diagnosis of nonspecific CP declined from 19.2% in 2006 to 11.3% in 2012. Variability across regions was observed, while metropolitan teaching hospitals and trauma centers reflected lower admission rates. CONCLUSION There was a 41.1% decline in inpatient hospital admission for patients with nonspecific CP after ED evaluation. This reduction is temporally associated with national policy changes affecting reimbursement for inpatient admissions.
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Affiliation(s)
| | | | | | | | | | - Robert S. Dittus
- Department of Internal Medicine; Nashville TN
- Geriatric Research, Education and Clinical Center; VA Tennessee Valley Healthcare System; Nashville TN
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Chotai S, Devin CJ, Archer KR, Bydon M, McGirt MJ, Nian H, Harrell FE, Dittus RS, Asher AL, McGirt MJ, Devin CJ, Foley KT, Sorenson JM, Knightly JJ, Glassman SD, Briggs TB, Kremer A, Griffitt WE, Stadlan NY, Grahm TW, Schmidt MH, Mummaneni P, Shaffrey ME. Effect of patients' functional status on satisfaction with outcomes 12 months after elective spine surgery for lumbar degenerative disease. Spine J 2017; 17:1783-1793. [PMID: 28970074 DOI: 10.1016/j.spinee.2017.05.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 08/11/2016] [Revised: 05/02/2017] [Accepted: 05/25/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Comprehensive assessment of quality of care includes patient-reported outcomes, safety of care delivered, and patient satisfaction. The impact of the patient-reported Oswestry Disability Index (ODI) scores at baseline and 12 months on satisfaction with outcomes following spine surgery is not well documented. PURPOSE This study aimed to determine the impact of patient disability (ODI) scores at baseline and 12 months on satisfaction with outcomes following surgery. STUDY DESIGN Analysis of prospectively collected longitudinal web-based multicenter data. PATIENT SAMPLE Patients undergoing elective surgery for degenerative lumbar disease were entered into a prospective multicenter registry. OUTCOME MEASURES Primary outcome measures were ODI, North American Spine Society satisfaction (NASS) questionnaire. METHODS Baseline and 12-month ODI scores were recorded. Satisfaction at 12 months after surgery was measured using NASS questionnaire. Multivariable proportional odds logistic regression analysis was conducted to determine the impact of baseline and 12-month ODI on satisfaction with outcomes. RESULTS Of the total 5,443 patients, 64% (n=3,460) were satisfied at a level where surgery met their expectations (NASS level 1) at 12 months after surgery. After adjusting for all baseline and surgery-specific variables, the 12-month ODI score had the highest impact (Wald χ2=1,555, 86% of the total χ2) on achieving satisfaction with outcomes compared with baseline ODI scores (Wald χ2=93, 5% of the total χ2). The level of satisfaction decreases with increasing 12-month ODI score. Greater change in ODI is required to achieve a better satisfaction level when the patient starts with a higher baseline ODI score. CONCLUSION Absolute 12-month ODI following surgery had a significant association on satisfaction with outcomes 12 months after surgery. Patients with higher baseline ODI required a larger change in ODI score to achieve satisfaction. No single measure can be used as a sole yardstick to measure quality of care after spine surgery. Satisfaction may be used in conjunction with baseline and 12-month ODI scores to provide an assessment of the quality of spine surgery provided in a patient centric fashion.
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Affiliation(s)
- Silky Chotai
- Department of Orthopaedic and Neurological Surgery, Vanderbilt Spine Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Clinton J Devin
- Department of Orthopaedic and Neurological Surgery, Vanderbilt Spine Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kristin R Archer
- Department Orthopaedic Surgery, Vanderbilt Spine Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, USA
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neurological Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Robert S Dittus
- Departments of Medicine, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA; VA Tennessee Valley Geriatric Research, Education and Clinical Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Anthony L Asher
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neurological Institute, Carolinas Healthcare System, Charlotte, NC, USA.
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Maiga AW, Deppen SA, Pinkerman R, Callaway-Lane C, Massion PP, Dittus RS, Lambright ES, Nesbitt JC, Baker D, Grogan EL. Timeliness of Care and Lung Cancer Tumor-Stage Progression: How Long Can We Wait? Ann Thorac Surg 2017; 104:1791-1797. [PMID: 29033012 PMCID: PMC5813822 DOI: 10.1016/j.athoracsur.2017.06.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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] [Received: 01/23/2017] [Revised: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Timely care of lung cancer is presumed critical, yet clear evidence of stage progression with delays in care is lacking. We investigated the reasons for delays in treatment and the impact these delays have on tumor-stage progression. METHODS We queried our retrospective database of 265 veterans who underwent cancer resection from 2005 to 2015. We extracted time intervals between nodule identification, diagnosis, and surgical resection; changes in nodule radiographic size over time; final pathologic staging; and reasons for delays in care. Pearson's correlation and Fisher's exact test were used to compare cancer growth and stage by time to treatment. RESULTS Median time from referral to surgical evaluation was 11 days (interquartile range, 8 to 17). Median time from identification to therapeutic resection was 98 days (interquartile range, 66 to 139), and from diagnosis to resection, 53 days (interquartile range, 35 to 77). Sixty-eight patients (26%) were diagnosed at resection; the remainder had preoperative tissue diagnoses. No significant correlation existed between tumor growth and time between nodule identification and resection, or between tumor growth and time between diagnosis and resection. Among 197 patients with preoperative diagnoses, 42% (83) had intervals longer than 60 days between diagnosis and resection. Most common reasons for delay were cardiac clearance, staging, and smoking cessation. Larger nodules had fewer days between identification and resection (p = 0.03). CONCLUSIONS Evaluation, staging, and smoking cessation drive resection delays. The lack of association between tumor growth and time to treatment suggests other clinical or biological factors, not time alone, underlie growth risk. Until these factors are identified, delays to diagnosis and treatment should be minimized.
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Affiliation(s)
- Amelia W Maiga
- Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen A Deppen
- Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Pierre P Massion
- Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert S Dittus
- Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric S Lambright
- Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan C Nesbitt
- Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Baker
- Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Eric L Grogan
- Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University Medical Center, Nashville, Tennessee.
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Boyle J, Speroff T, Worley K, Cao A, Goggins K, Dittus RS, Kripalani S. Low Health Literacy Is Associated with Increased Transitional Care Needs in Hospitalized Patients. J Hosp Med 2017; 12:918-924. [PMID: 29091980 DOI: 10.12788/jhm.2841] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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: 11/20/2022]
Abstract
OBJECTIVE To examine the association of health literacy with the number and type of transitional care needs (TCN) among patients being discharged to home. DESIGN, SETTING, PARTICIPANTS A cross-sectional analysis of patients admitted to an academic medical center. MEASUREMENTS Nurses administered the Brief Health Literacy Screen and documented TCNs along 10 domains: caregiver support, transportation, healthcare utilization, high-risk medical comorbidities, medication management, medical devices, functional status, mental health comorbidities, communication, and financial resources. RESULTS Among the 384 patients analyzed, 113 (29%) had inadequate health literacy. Patients with inadequate health literacy had needs in more TCN domains (mean = 5.29 vs 4.36; P < 0 .001). In unadjusted analysis, patients with inadequate health literacy were significantly more likely to have TCNs in 7 out of the 10 domains. In multivariate analyses, inadequate health literacy remained significantly associated with inadequate caregiver support (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.37-4.99) and transportation barriers (OR, 1.69; 95% CI, 1.04-2.76). CONCLUSIONS Among hospitalized patients, inadequate health literacy is prevalent and independently associated with other needs that place patients at a higher risk of adverse outcomes, such as hospital readmission. Screening for inadequate health literacy and associated needs may enable hospitals to address these barriers and improve postdischarge outcomes.
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Affiliation(s)
- Joseph Boyle
- School of Graduate Medical Education, University of Colorado, Aurora, Colorado, USA
| | - Theodore Speroff
- Department of Veterans Affairs, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katherine Worley
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aize Cao
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn Goggins
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert S Dittus
- Department of Veterans Affairs, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Brummel NE, Boehm LM, Girard TD, Pandharipande PP, Jackson JC, Hughes CG, Patel MB, Han JH, Vasilevskis EE, Thompson JL, Chandrasekhar R, Bernard GR, Dittus RS, Ely EW. Subsyndromal Delirium and Institutionalization Among Patients With Critical Illness. Am J Crit Care 2017; 26:447-455. [PMID: 29092867 PMCID: PMC5831547 DOI: 10.4037/ajcc2017263] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [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] [Indexed: 12/31/2022]
Abstract
BACKGROUND The prognostic importance of subsyndromal delirium is unknown. OBJECTIVE To test whether duration of subsyndromal delirium is independently associated with institutionalization. METHODS The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used twice daily to assess for subsyndromal delirium in patients with respiratory failure or shock. Delirium was considered present if the assessment was positive. Subsyndromal delirium was considered present if the assessment was negative but the patient exhibited any CAM-ICU features. Multivariable regression was used to determine the association between duration of subsyndromal delirium and institutionalization, adjusting for age, education, baseline cognition and disability, comorbidities, severity of illness, delirium, coma, sepsis, and doses of sedatives and opiates. RESULTS Subsyndromal delirium, lasting a median of 3 days, developed in 702 of 821 patients (86%). After adjusting for covariates, duration of subsyndromal delirium was an independent predictor of increased odds of institutionalization (P = .007). This association was greatest in patients with less delirium (P for interaction = .01). Specifically, of patients who were never delirious, those with 5 days of subsyndromal delirium (upper interquartile range [IQR]) were 4.2 times more likely to be institutionalized than those with 1.5 days of subsyndromal delirium (lower IQR). CONCLUSIONS Subsyndromal delirium occurred in most critically ill patients, and its duration was an independent predictor of institutionalization. Routine monitoring of all delirium symptoms may enable detection of full and subsyndromal forms of delirium.
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Affiliation(s)
- Nathan E Brummel
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center.
| | - Leanne M Boehm
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Timothy D Girard
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Pratik P Pandharipande
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - James C Jackson
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Christopher G Hughes
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Mayur B Patel
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Jin H Han
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Eduard E Vasilevskis
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Jennifer L Thompson
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Rameela Chandrasekhar
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Gordon R Bernard
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - Robert S Dittus
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
| | - E Wesley Ely
- Nathan E. Brummel is an assistant professor and E. Wesley Ely is a professor, Department of Medicine, Center for Quality Aging and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee. Dr Ely is also the associate director for research for the Geriatric Research, Education, and Clinical Center Service (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. Leanne M. Boehm is a postdoctoral fellow, Vanderbilt University School of Nursing, a quality scholar, GRECC, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and a research nurse, Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center. Timothy D. Girard is an associate professor, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Pratik P. Pandharipande is a professor and Christopher G. Hughes is an associate professor, Department of Anesthesiology, Vanderbilt University Medical Center. James C. Jackson is a research associate professor, Department of Medicine, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, and Mayur B. Patel is an assistant professor, Department of Surgery, Vanderbilt University Medical Center. Jin H. Han is an associate professor, Department of Emergency Medicine and Center for Quality Aging, Vanderbilt University Medical Center. Eduard E. Vasilevskis is a staff physician, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and an assistant professor, Department of Medicine and Center for Health Services Research, Vanderbilt University Medical Center. Jennifer L. Thompson is a biostatistician and Rameela Chandrasekhar is an assistant professor, Department of Biostatistics, Vanderbilt University School of Medicine. Gordon R. Bernard is associate vice-chancellor for research and a professor, Department of Medicine, Vanderbilt University Medical Center. Robert S. Dittus is director, GRECC, Department of Veterans Affairs Medical Center, VA Tennessee Valley Healthcare System, and a professor, Department of Medicine, Vanderbilt University Medical Center
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Maiga AW, Broman KK, Wright JP, Carter NH, Roumie CL, Dittus RS, Pierce RA. Postoperative Telephone Follow-Up Is a Safe and Sustainable Way to Increase Access to General Surgical Care. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Asher AL, Devin CJ, Archer KR, Chotai S, Parker SL, Bydon M, Nian H, Harrell FE, Speroff T, Dittus RS, Philips SE, Shaffrey CI, Foley KT, McGirt MJ. An analysis from the Quality Outcomes Database, Part 2. Predictive model for return to work after elective surgery for lumbar degenerative disease. J Neurosurg Spine 2017; 27:370-381. [DOI: 10.3171/2016.8.spine16527] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVECurrent costs associated with spine care are unsustainable. Productivity loss and time away from work for patients who were once gainfully employed contributes greatly to the financial burden experienced by individuals and, more broadly, society. Therefore, it is vital to identify the factors associated with return to work (RTW) after lumbar spine surgery. In this analysis, the authors used data from a national prospective outcomes registry to create a predictive model of patients’ ability to RTW after undergoing lumbar spine surgery for degenerative spine disease.METHODSData from 4694 patients who underwent elective spine surgery for degenerative lumbar disease, who had been employed preoperatively, and who had completed a 3-month follow-up evaluation, were entered into a prospective, multicenter registry. Patient-reported outcomes—Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain (BP) and leg pain (LP), and EQ-5D scores—were recorded at baseline and at 3 months postoperatively. The time to RTW was defined as the period between operation and date of returning to work. A multivariable Cox proportional hazards regression model, including an array of preoperative factors, was fitted for RTW. The model performance was measured using the concordance index (c-index).RESULTSEighty-two percent of patients (n = 3855) returned to work within 3 months postoperatively. The risk-adjusted predictors of a lower likelihood of RTW were being preoperatively employed but not working at the time of presentation, manual labor as an occupation, worker’s compensation, liability insurance for disability, higher preoperative ODI score, higher preoperative NRS-BP score, and demographic factors such as female sex, African American race, history of diabetes, and higher American Society of Anesthesiologists score. The likelihood of a RTW within 3 months was higher in patients with higher education level than in those with less than high school–level education. The c-index of the model’s performance was 0.71.CONCLUSIONSThis study presents a novel predictive model for the probability of returning to work after lumbar spine surgery. Spine care providers can use this model to educate patients and encourage them in shared decision-making regarding the RTW outcome. This evidence-based decision support will result in better communication between patients and clinicians and improve postoperative recovery expectations, which will ultimately increase the likelihood of a positive RTW trajectory.
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Affiliation(s)
- Anthony L. Asher
- 1Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, and Neurological Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Clinton J. Devin
- 2Department of Orthopedic Surgery and Neurological Surgery, Vanderbilt Spine Center,
| | - Kristin R. Archer
- 3Department of Orthopedic Surgery, Vanderbilt Spine Center, and
- 4Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Silky Chotai
- 2Department of Orthopedic Surgery and Neurological Surgery, Vanderbilt Spine Center,
| | - Scott L. Parker
- 2Department of Orthopedic Surgery and Neurological Surgery, Vanderbilt Spine Center,
| | - Mohamad Bydon
- 5Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hui Nian
- 6Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Frank E. Harrell
- 6Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Theodore Speroff
- 7Geriatric Research Education Clinical Center, Tennessee Valley Health System, Veterans Health Administration, Nashville, Tennessee
- 8Departments of Medicine and Biostatistics, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert S. Dittus
- 7Geriatric Research Education Clinical Center, Tennessee Valley Health System, Veterans Health Administration, Nashville, Tennessee
- 8Departments of Medicine and Biostatistics, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sharon E. Philips
- 6Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Christopher I. Shaffrey
- 9Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia; and
| | - Kevin T. Foley
- 10Department of Neurosurgery, University of Tennessee Health Sciences Center, Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
| | - Matthew J. McGirt
- 1Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, and Neurological Institute, Carolinas Healthcare System, Charlotte, North Carolina
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Brummel NE, Bell SP, Girard TD, Pandharipande PP, Jackson JC, Morandi A, Thompson JL, Chandrasekhar R, Bernard GR, Dittus RS, Gill TM, Ely EW. Frailty and Subsequent Disability and Mortality among Patients with Critical Illness. Am J Respir Crit Care Med 2017; 196:64-72. [PMID: 27922747 DOI: 10.1164/rccm.201605-0939oc] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
RATIONALE The prevalence of frailty (diminished physiologic reserve) and its effect on outcomes for those aged 18 years and older with critical illness is unclear. OBJECTIVES We hypothesized greater frailty would be associated with subsequent mortality, disability, and cognitive impairment, regardless of age. METHODS At enrollment, we measured frailty using the Clinical Frailty Scale (range, 1 [very fit] to 7 [severely frail]). At 3 and 12 months post-discharge, we assessed vital status, instrumental activities of daily living, basic activities of daily living, and cognition. We used multivariable regression to analyze associations between Clinical Frailty Scale scores and outcomes, adjusting for age, sex, education, comorbidities, baseline disability, baseline cognition, severity of illness, delirium, coma, sepsis, mechanical ventilation, and sedatives/opiates. MEASUREMENTS AND MAIN RESULTS We enrolled 1,040 patients who were a median (interquartile range) of 62 (53-72) years old and who had a median Clinical Frailty Scale score of 3 (3-5). Half of those with clinical frailty (i.e., Clinical Frailty Scale score ≥5) were younger than 65 years old. Greater Clinical Frailty Scale scores were independently associated with greater mortality (P = 0.01 at 3 mo and P < 0.001 at 12 mo) and with greater odds of disability in instrumental activities of daily living (P = 0.04 at 3 mo and P = 0.002 at 12 mo). Clinical Frailty Scale scores were not associated with disability in basic activities of daily living or with cognition. CONCLUSIONS Frailty is common in critically ill adults aged 18 years and older and is independently associated with increased mortality and greater disability. Future studies should explore routine screening for clinical frailty in critically ill patients of all ages. Interventions to reduce mortality and disability among patients with heightened vulnerability should be developed and tested. Clinical trial registered with www.clinicaltrials.gov (NCT 00392795 and NCT 00400062).
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Affiliation(s)
- Nathan E Brummel
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,2 Center for Health Services Research.,3 Center for Quality Aging
| | - Susan P Bell
- 3 Center for Quality Aging.,4 Division of Cardiovascular Medicine.,5 Vanderbilt Memory & Alzheimer's Center
| | - Timothy D Girard
- 6 Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - James C Jackson
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,2 Center for Health Services Research.,8 Department of Psychiatry and Behavioral Sciences, and.,9 Research Service and
| | - Alessandro Morandi
- 10 Geriatric Research Group, Brescia, Italy.,11 Department of Rehabilitation and Aged Care, Hospital Ancelle, Cremona, Italy; and
| | - Jennifer L Thompson
- 12 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Rameela Chandrasekhar
- 12 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gordon R Bernard
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Robert S Dittus
- 2 Center for Health Services Research.,13 Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Thomas M Gill
- 14 Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - E Wesley Ely
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,2 Center for Health Services Research.,3 Center for Quality Aging.,13 Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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Patel MB, Jackson JC, Morandi A, Girard TD, Hughes CG, Thompson JL, Kiehl AL, Elstad MR, Wasserstein ML, Goodman RB, Beckham JC, Chandrasekhar R, Dittus RS, Ely EW, Pandharipande PP. Incidence and Risk Factors for Intensive Care Unit-related Post-traumatic Stress Disorder in Veterans and Civilians. Am J Respir Crit Care Med 2017; 193:1373-81. [PMID: 26735627 DOI: 10.1164/rccm.201506-1158oc] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE The incidence and risk factors of post-traumatic stress disorder (PTSD) related to the intensive care unit (ICU) experience have not been reported in a mixed veteran and civilian cohort. OBJECTIVES To describe the incidence and risk factors for ICU-related PTSD in veterans and civilians. METHODS This is a prospective, observational, multicenter cohort enrolling adult survivors of critical illness after respiratory failure and/or shock from three Veterans Affairs and one civilian hospital. After classifying those with/without preexisting PTSD (i.e., PTSD before hospitalization), we then assessed all subjects for ICU-related PTSD at 3 and 12 months post hospitalization. MEASUREMENTS AND MAIN RESULTS Of 255 survivors, 181 and 160 subjects were assessed for ICU-related PTSD at 3- and 12-month follow-up, respectively. A high probability of ICU-related PTSD was found in up to 10% of patients at either follow-up time point, whether assessed by PTSD Checklist Event-Specific Version (score ≥ 50) or item mapping using the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). In the multivariable regression, preexisting PTSD was independently associated with ICU-related PTSD at both 3 and 12 months (P < 0.001), as was preexisting depression (P < 0.03), but veteran status was not a consistent independent risk factor for ICU-related PTSD (3-month P = 0.01, 12-month P = 0.48). CONCLUSIONS This study found around 1 in 10 ICU survivors experienced ICU-related PTSD (i.e., PTSD anchored to their critical illness) in the year after hospitalization. Preexisting PTSD and depression were strongly associated with ICU-related PTSD.
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Affiliation(s)
- Mayur B Patel
- 1 Surgical Services, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,2 Division of Trauma and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences, Vanderbilt Brain Institute, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C Jackson
- 3 Geriatric Research, Education, and Clinical Center, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,4 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee.,5 Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alessandro Morandi
- 6 Department of Rehabilitation and Aged Care Unit, Hospital Ancelle, Cremona, Italy.,7 Geriatric Research Group, Brescia, Italy
| | - Timothy D Girard
- 3 Geriatric Research, Education, and Clinical Center, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,4 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher G Hughes
- 8 Anesthesia Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,9 Division of Critical Care, Department of Anesthesiology, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer L Thompson
- 10 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amy L Kiehl
- 4 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark R Elstad
- 11 George E. Wahlen Department of Veterans Affairs Medical Center, VA Salt Lake City Health Care System, U.S. Department of Veterans Affairs, Salt Lake City, Utah.,12 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mitzi L Wasserstein
- 11 George E. Wahlen Department of Veterans Affairs Medical Center, VA Salt Lake City Health Care System, U.S. Department of Veterans Affairs, Salt Lake City, Utah
| | - Richard B Goodman
- 13 Seattle Division, VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington.,14 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jean C Beckham
- 15 Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, U.S. Department of Veterans Affairs Medical Center, Durham, North Carolina.,16 Behavioral Medicine Division, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; and
| | - Rameela Chandrasekhar
- 10 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert S Dittus
- 3 Geriatric Research, Education, and Clinical Center, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,17 Division of General Internal Medicine and Public Health and Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E Wesley Ely
- 3 Geriatric Research, Education, and Clinical Center, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,4 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pratik P Pandharipande
- 8 Anesthesia Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,9 Division of Critical Care, Department of Anesthesiology, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
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McGirt MJ, Bydon M, Archer KR, Devin CJ, Chotai S, Parker SL, Nian H, Harrell FE, Speroff T, Dittus RS, Philips SE, Shaffrey CI, Foley KT, Asher AL. An analysis from the Quality Outcomes Database, Part 1. Disability, quality of life, and pain outcomes following lumbar spine surgery: predicting likely individual patient outcomes for shared decision-making. J Neurosurg Spine 2017; 27:357-369. [PMID: 28498074 DOI: 10.3171/2016.11.spine16526] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Quality and outcomes registry platforms lie at the center of many emerging evidence-driven reform models. Specifically, clinical registry data are progressively informing health care decision-making. In this analysis, the authors used data from a national prospective outcomes registry (the Quality Outcomes Database) to develop a predictive model for 12-month postoperative pain, disability, and quality of life (QOL) in patients undergoing elective lumbar spine surgery. METHODS Included in this analysis were 7618 patients who had completed 12 months of follow-up. The authors prospectively assessed baseline and 12-month patient-reported outcomes (PROs) via telephone interviews. The PROs assessed were those ascertained using the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for back pain (BP) and leg pain (LP). Variables analyzed for the predictive model included age, gender, body mass index, race, education level, history of prior surgery, smoking status, comorbid conditions, American Society of Anesthesiologists (ASA) score, symptom duration, indication for surgery, number of levels surgically treated, history of fusion surgery, surgical approach, receipt of workers' compensation, liability insurance, insurance status, and ambulatory ability. To create a predictive model, each 12-month PRO was treated as an ordinal dependent variable and a separate proportional-odds ordinal logistic regression model was fitted for each PRO. RESULTS There was a significant improvement in all PROs (p < 0.0001) at 12 months following lumbar spine surgery. The most important predictors of overall disability, QOL, and pain outcomes following lumbar spine surgery were employment status, baseline NRS-BP scores, psychological distress, baseline ODI scores, level of education, workers' compensation status, symptom duration, race, baseline NRS-LP scores, ASA score, age, predominant symptom, smoking status, and insurance status. The prediction discrimination of the 4 separate novel predictive models was good, with a c-index of 0.69 for ODI, 0.69 for EQ-5D, 0.67 for NRS-BP, and 0.64 for NRS-LP (i.e., good concordance between predicted outcomes and observed outcomes). CONCLUSIONS This study found that preoperative patient-specific factors derived from a prospective national outcomes registry significantly influence PRO measures of treatment effectiveness at 12 months after lumbar surgery. Novel predictive models constructed with these data hold the potential to improve surgical effectiveness and the overall value of spine surgery by optimizing patient selection and identifying important modifiable factors before a surgery even takes place. Furthermore, these models can advance patient-focused care when used as shared decision-making tools during preoperative patient counseling.
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Affiliation(s)
- Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, and Neurological Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kristin R Archer
- Department of Orthopedic Surgery, Vanderbilt Spine Center.,Department of Physical Medicine and Rehabilitation, and
| | - Clinton J Devin
- Department of Orthopedic Surgery and Neurological Surgery, Vanderbilt Spine Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Silky Chotai
- Department of Orthopedic Surgery and Neurological Surgery, Vanderbilt Spine Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott L Parker
- Department of Orthopedic Surgery and Neurological Surgery, Vanderbilt Spine Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Theodore Speroff
- Geriatric Research Education Clinical Center, Tennessee Valley Health System, Veterans Health Administration, Nashville, Tennessee.,Departments of Medicine and Biostatistics, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert S Dittus
- Geriatric Research Education Clinical Center, Tennessee Valley Health System, Veterans Health Administration, Nashville, Tennessee.,Departments of Medicine and Biostatistics, Division of General Internal Medicine and Public Health, Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sharon E Philips
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Christopher I Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia; and
| | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
| | - Anthony L Asher
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, and Neurological Institute, Carolinas Healthcare System, Charlotte, North Carolina
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Han JH, Vasilevskis EE, Chandrasekhar R, Liu X, Schnelle JF, Dittus RS, Ely EW. Delirium in the Emergency Department and Its Extension into Hospitalization (DELINEATE) Study: Effect on 6-month Function and Cognition. J Am Geriatr Soc 2017; 65:1333-1338. [PMID: 28263444 DOI: 10.1111/jgs.14824] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [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: 10/04/2016] [Revised: 12/15/2016] [Accepted: 12/16/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The natural course and clinical significance of delirium in the emergency department (ED) is unclear. OBJECTIVES We sought to (1) describe the extent to which delirium in the ED persists into hospitalization (ED delirium duration) and (2) determine how ED delirium duration is associated with 6-month functional status and cognition. DESIGN Prospective cohort study. SETTING Tertiary care, academic medical center. PARTICIPANTS ED patients ≥65 years old who were admitted to the hospital. MEASUREMENTS The modified Brief Confusion Assessment Method was used to ascertain delirium in the ED and hospital. Premorbid and 6-month function were determined using the Older American Resources and Services Activities of Daily Living (OARS ADL) questionnaire which ranged from 0 (completely dependent) to 28 (completely dependent). Premorbid and 6-month cognition were determined using the short form Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) which ranged from 1 to 5 (severe dementia). Multiple linear regression was performed to determine if ED delirium duration was associated with 6-month function and cognition adjusted for baseline OARS ADL and IQCODE, and other confounders. RESULTS A total of 228 older ED patients were enrolled. Of the 105 patients who were delirious in the ED, 81 (77.1%) patients' delirium persisted into hospitalization. For every ED delirium duration day, the 6-month OARS ADL decreased by 0.63 points (95% CI: -1.01 to -0.24), indicating poorer function. For every ED delirium duration day, the 6-month IQCODE increased 0.06 points (95% CI: 0.01-0.10) indicating poorer cognition. CONCLUSIONS Delirium in the ED is not a transient event and frequently persists into hospitalization. Longer ED delirium duration is associated with an incremental worsening of 6-month functional and cognitive outcomes.
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Affiliation(s)
- Jin H Han
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Emergency Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, USA
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Xulei Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - John F Schnelle
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, USA
| | - Robert S Dittus
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, USA
| | - E Wesley Ely
- Center for Quality Aging, Vanderbilt University School of Medicine, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, TN, USA
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