Andrew J. Admon

Hospital-Level Variation in ICU Admission and Critical Care Procedures for Patients Hospitalized for Pulmonary Embolism

BACKGROUND Variation in the use of ICUs for low-risk conditions contributes to health system inefficiency. We sought to examine the relationship between ICU use for patients with pulmonary embolism (PE) and cost, mortality, readmission, and procedure use. METHODS We performed a retrospective cohort study including 61,249 adults with PE discharged from 263 hospitals in three states between 2007 and 2010. We generated hospital-specific ICU admission rate quartiles and used a series of multilevel models to evaluate relationships between admission rates and risk-adjusted in-hospital mortality, readmission, and costs and between ICU admission rates and several critical care procedures. RESULTS Hospital quartiles varied in unadjusted ICU admission rates for PE (range, ≤ 15% to > 31%). Among all patients, there was a small trend toward increased use of arterial catheterization (0.6%-1.1%, P < .01) in hospital quartiles with higher levels of ICU admission. However, use of invasive mechanical ventilation (14.4%-7.9%, P < .01), noninvasive ventilation (6.6%-3.0%, P < .01), central venous catheterization (14.6%-11.3%, P < .02), and thrombolytics (11.0%-4.7%, P < .01) in patients in the ICU declined across hospital quartiles. There was no relationship between ICU admission rate and risk-adjusted hospital mortality, costs, or readmission. CONCLUSIONS Hospitals vary widely in ICU admission rates for acute PE without a detectable impact on mortality, cost, or readmission. Patients admitted to ICUs in higher-using hospitals received many critical care procedures less often, suggesting that these patients may have had weaker indications for ICU admission. Hospitals with greater ICU admission may be appropriate targets for improving efficiency in ICU admissions.

Long term follow-up of drug resistant and drug susceptible tuberculosis contacts in a Low incidence setting

BackgroundStudies examining the transmission of multidrug-resistant tuberculosis (MDR-TB) strains have yielded conflicting results.MethodsWe examined transmission of MDR-TB strains using contact tracing data from a low incidence setting. Contacts of MDR-TB cases diagnosed in British Columbia, Canada, from 1990-2008 were identified through a provincial tuberculosis (TB) registry. Tuberculin skin test (TST) results and TB disease incident rates were determined for contacts. For comparison, TB disease incident rates and TST results were measured in close contacts of isoniazid mono-resistant (HMR-TB) and drug susceptible TB (DS-TB) cases.ResultsOf 89 identified close contacts of MDR-TB patients, 5 patients (6%) developed TB disease and 42 (47%) were TST positive. The incidence rate of TB disease (3%, p = 0.31) and TST positivity (49%, p = 0.82) were similar in contacts of HMR-TB cases. Compared with MDR-TB contacts, DS-TB contacts had lower incidence rate of TB disease (2%, p = 0.04) and TST positivity (32%, p < 0.01). All MDR-TB contacts with culture positive TB diagnosed in follow-up were drug-susceptible; three of six HMR-TB contacts with culture positive TB were HMR-TB. Multivariate analysis demonstrated that contact with MDR-TB (adjusted OR 1.72; 95%CI 1.05-2.81) and HMR-TB (adjusted OR 1.99; 95%CI 1.48-2.67) was associated with TST positivity. In addition, adult age, male gender, BCG positivity, source case sputum smear positivity, foreign birth and fewer contacts per source case were significantly associated with TST positivity in the multivariate model.ConclusionContacts of MDR-TB and HMR-TB patients in a low incidence setting show high rates of TST positivity and TB disease but low rates of drug resistance.

Truth survival: on de-adoption of practices in critical care

166 www.thelancet.com/respiratory Vol 5 March 2017 Another unsolved problem is the absence of defi nitive evaluations regarding the safety of adjuvants to improve the immune response. As has been repeatedly shown, the immunogenicity of IIVs is poor in elderly people, young children, and immunocompromised people. Moreover, IIVs are not capable of evoking high antibody titres against heterovariant viruses in cases of mismatch between the circulating strain and the strains included in the vaccines. Finally, high amounts of haemagglutinin of each virus included in the vaccine are required to achieve adequate antibody production, with substantial limitations in the total number of doses that can be produced—a problem of particular relevance when mass vaccination is recommended, as in case of a pandemic. Adjuvants have been studied for many years. Among them, aluminium salts were considered ineff ective, and virosomes were abandoned because use of preparations containing these adjuvants in children was associated with an unexpected increase in development of high fever. However, use of oil-in-water emulsions deserves attention at least for MF-59 because its addition to IIV has led to vaccines (seasonal and pandemic) capable of inducing increased antibody production with protection against heterovariant viruses without any increase in severe adverse events, independent of age. Only a slight increase in solicited adverse events without clinical relevance was reported in some studies. Therefore, it is surprising that its use has been licensed only for elderly people and that children remain excluded despite their poor response to the traditional IIV, particularly among the youngest. By contrast, the addition of the adjuvant ASO3 to IIV has been shown to cause adverse events in children including high fever, increased incidence of anaphylaxis, and the development of narcolepsy. These results indicate the need for further studies before this adjuvant can be used in children. However, an accurate evaluation of adverse events is highlighted in the European Medical Agency’s guidelines. In conclusion, infl uenza vaccines remain essential to reduce the total burden of infl uenza. However, available preparations have several limitations, and any eff ort to improve their immunogenicity and effi cacy should be made. In the future, vaccines based on conserved proteins will certainly be able to overcome some of these limitations; however, several problems concerning the evaluation of immunogenicity, effi cacy, safety, and tolerability will remain. Health authorities are aware of the problem, and the latest guidelines by the European Medical Agency suggest some solutions. Pharmaceutical companies should follow these suggestions to produce more eff ective and safe infl uenza vaccines.

Hospital Contributions to Variability in the Use of ICUs Among Elderly Medicare Recipients.

Objective: Hospitals vary widely in ICU admission rates across numerous medical diagnoses. The extent to which variability in ICU use is specific to individual diagnoses or is a function of the hospital, regardless of disease, is unknown. Design: Retrospective cohort study. Setting: A total of 1,120 acute care hospitals with ICU capabilities. Patients: Medicare beneficiaries 65 years old or older admitted for five medical diagnoses (acute myocardial infarction, congestive heart failure, stroke, pneumonia, and chronic obstructive pulmonary disease) and a surgical diagnosis (hip fracture treated with arthroplasty) in 2010. Interventions: None. Measurements and Main Results: We used multilevel models to calculate risk- and reliability-adjusted ICU admission rates, examined the correlation in ICU admission rates across diagnosis and calculated intraclass correlation coefficients and median odds ratios to quantify the variability in ICU admission rate that was attributable to hospitals. We also examined the ability of a high ICU–use hospital for one condition to predict high ICU use for other conditions. We identified 348,462 patients with one of the eligible conditions. ICU admission rates were positively correlated within hospitals for included medical diagnoses (r range, 0.38–0.59; p < 0.01). The top hospital quartile of ICU use for congestive heart failure had a sensitivity of 50–60% and specificity of 79–81% for detecting top quartile hospitals for each other conditions. After adjustment for patient and hospital characteristics, hospitals accounted for 17.6% (95% CI, 16.2–19.1%) of variability in ICU admission, corresponding to a median odds ratio of 2.3, compared to 25.8% (95% CI, 24.5–27.1%) and median odds ratio 2.8 for diagnosis. This suggests a patient with median baseline risk of ICU admission would more than double his/her odds of ICU admission if moving to a higher utilizing hospital. Conclusions: Hospitals account for a significant proportion of variation independent of measured patient and hospital characteristics, suggesting the need for further work to evaluate the causes of variation at the hospital level and potential consequences of variation across hospitals.

Appraising the Evidence Supporting Choosing Wisely® Recommendations

Despite the growing enthusiasm surrounding the Choosing Wisely® campaign, little is known regarding the evidence underlying these recommendations. We extracted references for all 320 recommendations published through August, 2014, including the 10 adult and pediatric recommendations published by the Society for Hospital Medicine. We then categorized each item by evidence strength, and then assessed a sample of referenced clinical practice guidelines (CPGs) using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Among all recommendations, 70.3% cited CPGs, whereas 22.2% cited primary research as their highest level of evidence. Moreover, 7.8% cited case series, review articles, editorials, or lower quality data as their highest level of evidence. Hospital medicine recommendations were more likely to cite CPGs (90%) as their highest level of evidence. Among the sampled CPGs, the median overall score obtained using AGREE II was 54.2% (interquartile range [IQR] 33.3%-70.8%), whereas among hospital medicine-referenced CPGs, the median overall score was 58.3% (IQR 50.0%-83.3%). These findings suggest that Choosing Wisely® recommendations vary in terms of evidence strength.

Late organ failures in patients with prolonged intensive care unit stays

Purpose: The purpose of this study was to characterize the organ failures that develop among patients with prolonged ICU stays, defined as those who spent a minimum of 14 days in an ICU. Methods: We retrospectively studied a cohort of consecutive patients from a university hospital who were in an ICU for a minimum of 14 days during 2014–2016. We calculated daily Sequential Organ Failure Assessment (SOFA) scores from admission to ICU day 14. The primary outcome was the number of new late organ failures, defined as occurring on ICU day 4 through 14. Results: In a retrospective cohort of 3777 consecutive patients in six ICUs, 50 patients had prolonged ICU stays. Of those 50, new cardiovascular failure occurred in 24 (62%) on day 4 or later; persistent mechanical ventilation was present in only 28 (56%). Conclusions: Strategies aiming to reduce the development of new late organ failures may be a novel target for preventing persistent critical illness. HIGHLIGHTSLower comorbidity was associated with persistent critical illness rather than death or earlier dischargeFour in five of long‐staying ICU patients developed at least one new late organ failure, which was cardiovascular in nature in most cases.Respiratory failure and the need for mechanical ventilation was present in only half (of all long‐staying ICU patientsOnly one in five patients in this cohort did not develop new late organ failures