Barret Rush

The use of mechanical ventilation in patients with idiopathic pulmonary fibrosis in the United States: A nationwide retrospective cohort analysis

OBJECTIVE To investigate the mortality of patients with Idiopathic Pulmonary Fibrosis (IPF) who undergo mechanical ventilation (MV) and non-invasive mechanical ventilation (NIMV) in the United States. METHODS We performed a retrospective cohort study using data from the Nationwide Inpatient Sample, isolating patients with a diagnosis of IPF who underwent MV and NIMV between 2006 and 2012. RESULTS We analyzed 55,208,382 hospitalizations and identified 17,770 patients with IPF, of whom 1703 received MV and 778 received NIMV. Those receiving MV had higher mortality (51.6 vs. 30.9%, p < 0.0001), were younger (66.3 years, SD 12.8 vs. 70.2 years, SD 12.9) and had longer hospital stays (13.3 days, IQR 16 vs. 6.5 days, IQR 7, p < 0.0001), compared to those receiving NIMV. The mortality of IPF patients treated with MV decreased from 58.4% in 2006 to 49.3% in 2012 (p = 0.03). There were 149 (8.7%) patients in the mechanical ventilation group who were also receiving home oxygen therapy. They experienced an overall mortality of 48.1%, which was not significantly different than patients who did not rely on home oxygen (p = 0.35). CONCLUSIONS In a large national cohort, the in-hospital mortality of patients with IPF who are mechanically ventilated is approximately 50%.

Use of Palliative Care in Patients With End-Stage COPD and Receiving Home Oxygen : National Trends and Barriers to Care in the United States

Background To investigate the use of palliative care (PC) in patients with end‐stage COPD receiving home oxygen hospitalized for an exacerbation. Methods A retrospective nationwide cohort analysis was performed, using the Nationwide Inpatient Sample. All patients ≥ 18 years of age with a diagnosis of COPD, receiving home oxygen, and admitted for an exacerbation were included. Results A total of 55,208,382 hospitalizations from the 2006‐2012 Nationwide Inpatient Sample were examined. There were 181,689 patients with COPD, receiving home oxygen, and admitted for an exacerbation; 3,145 patients (1.7%) also had a PC contact. There was a 4.5‐fold relative increase in PC referral from 2006 (0.45%) to 2012 (2.56%) (P < .01). Patients receiving PC consultations compared with those who did not were older (75.0 years [SD 10.9] vs 70.6 years [SD 9.7]; P < .01), had longer hospitalizations (4.9 days [interquartile range, 2.6‐8.2] vs 3.5 days [interquartile range, 2.1‐5.6]), and more likely to die in hospital (32.1% vs 1.5%; P < .01). Race was significantly associated with referral to palliative care, with white patients referred more often than minorities (P < .01). Factors associated with PC referral included age (OR, 1.03; 95% CI, 1.02‐1.04; P < .01), metastatic cancer (OR, 2.40; 95% CI, 2.02‐2.87; P < .01), nonmetastatic cancer (OR, 2.75; 95% CI, 2.43‐3.11; P < .01), invasive mechanical ventilation (OR, 4.89; 95% CI, 4.31‐5.55; P < .01), noninvasive mechanical ventilation (OR, 2.84; 95% CI, 2.58‐3.12; P < .01), and Do Not Resuscitate status (OR, 7.95; 95% CI, 7.29‐8.67; P < .01). Conclusions The use of PC increased dramatically during the study period; however, PC contact occurs only in a minority of patients with end‐stage COPD admitted with an exacerbation.

Utilization of palliative care in patients with end-stage chronic obstructive pulmonary disease on home oxygen: national trends and barriers to care in the United States.

Background To investigate the use of palliative care (PC) in patients with end‐stage COPD receiving home oxygen hospitalized for an exacerbation. Methods A retrospective nationwide cohort analysis was performed, using the Nationwide Inpatient Sample. All patients ≥ 18 years of age with a diagnosis of COPD, receiving home oxygen, and admitted for an exacerbation were included. Results A total of 55,208,382 hospitalizations from the 2006‐2012 Nationwide Inpatient Sample were examined. There were 181,689 patients with COPD, receiving home oxygen, and admitted for an exacerbation; 3,145 patients (1.7%) also had a PC contact. There was a 4.5‐fold relative increase in PC referral from 2006 (0.45%) to 2012 (2.56%) (P < .01). Patients receiving PC consultations compared with those who did not were older (75.0 years [SD 10.9] vs 70.6 years [SD 9.7]; P < .01), had longer hospitalizations (4.9 days [interquartile range, 2.6‐8.2] vs 3.5 days [interquartile range, 2.1‐5.6]), and more likely to die in hospital (32.1% vs 1.5%; P < .01). Race was significantly associated with referral to palliative care, with white patients referred more often than minorities (P < .01). Factors associated with PC referral included age (OR, 1.03; 95% CI, 1.02‐1.04; P < .01), metastatic cancer (OR, 2.40; 95% CI, 2.02‐2.87; P < .01), nonmetastatic cancer (OR, 2.75; 95% CI, 2.43‐3.11; P < .01), invasive mechanical ventilation (OR, 4.89; 95% CI, 4.31‐5.55; P < .01), noninvasive mechanical ventilation (OR, 2.84; 95% CI, 2.58‐3.12; P < .01), and Do Not Resuscitate status (OR, 7.95; 95% CI, 7.29‐8.67; P < .01). Conclusions The use of PC increased dramatically during the study period; however, PC contact occurs only in a minority of patients with end‐stage COPD admitted with an exacerbation.

Inpatient palliative care referral and 9-month hospital readmission in patients with congestive heart failure: a linked nationwide analysis

End‐stage heart failure (HF) is characterized by high symptom burden and frequent hospitalization. Palliative care (PC) is recommended for advanced HF, and there is some evidence in other diseases that this may reduce readmission rates. We attempted examine the association of an inpatient PC visit on hospital readmission for patients admitted with HF.

Trends in Extracorporeal Membrane Oxygenation for the Treatment of Acute Respiratory Distress Syndrome in the United States.

Objectives: Our aim was to describe patient characteristics and trends in the use of extracorporeal membrane oxygenation (ECMO) for the treatment of acute respiratory distress syndrome (ARDS) in the United States from 2006 to 2011. Methods: We used the Nationwide Inpatient Sample to isolate all patients aged 18 years who had a discharge International Classification of Diseases, Ninth Revision diagnosis of ARDS, with and without procedure codes for ECMO, between 2006 and 2011. Results: We examined a total of 47 911 414 hospital discharges, representing 235 911 271 hospitalizations using national weights. Of the 1 479 022 patients meeting the definition of ARDS (representing 7 281 206 discharges), 775 underwent ECMO. There was a 409% relative increase in the use of ECMO for ARDS in the United States between 2006 and 2011, from 0.0178% to 0.090% (P = .0041). Patients treated with ECMO had higher in-hospital mortality (58.6% vs 25.1%, P < .0001) and longer hospital stays (15.8 days vs 6.9 days, P < .0001). They were also younger (47.9 vs 66.4 years, P < .0001) and more likely to be male (62.2% vs 49.6%, P < .0001). The median time to initiate ECMO from the time of admission was 0.5 days (interquartile range [IQR] 4.9 days). Conclusion: There has been a dramatic increase in ECMO use for the treatment of ARDS in the United States.

Palliative care access for hospitalized patients with end‐stage liver disease across the United States

Patients with end‐stage liver disease (ESLD) often have a high symptom burden. Historically, palliative care (PC) services have been underused in this population. We investigated the use of PC services in patients with ESLD hospitalized across the United States. We used the Nationwide Inpatient Sample to conduct a retrospective nationwide cohort analysis. All patients >18 years of age admitted with ESLD, defined as those with at least two liver decompensation events, were included in the analysis. A multivariate logistic regression model predicting referral to PC was created. We analyzed 55,208,382 hospitalizations from the 2006‐2012 Nationwide Inpatient Sample, with 39,349 (0.07%) patients meeting study inclusion. PC consultation was performed in 1,789 (4.5%) ESLD patients. The rate of PC referral in ESLD increased from 0.97% in 2006 to 7.1% in 2012 (P < 0.01). In multivariate analysis, factors associated with lower referral to PC were Hispanic race (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.66‐0.89; P < 0.01) and insurance coverage (OR, 0.74; 95% CI, 0.65‐0.84; P < 0.01). Factors associated with increased referral to PC were age (per 5‐year increase, OR, 1.05; 95% CI, 1.03‐1.08; P < 0.01), do‐not‐resuscitate status (OR, 16.24; 95% CI, 14.20‐18.56; P < 0.01), treatment in a teaching hospital (OR, 1.25; 95% CI, 1.12‐1.39; P < 0.01), presence of hepatocellular carcinoma (OR, 2.00; 95% CI, 1.71‐2.33; P < 0.01), and presence of metastatic cancer (OR, 2.39; 95% CI, 1.80‐3.18; P < 0.01). PC referral was most common in west coast hospitals (OR, 1.81; 95% CI, 1.53‐2.14; P < 0.01) as well as large‐sized hospitals (OR, 1.49; 95% CI, 1.22‐1.82; P < 0.01). Conclusion: From 2006 to 2012 the use of PC in ESLD patients increased substantially; socioeconomic, geographical, and ethnic barriers to accessing PC were observed. (Hepatology 2017;66:1585–1591).

The association between anemia and neurological outcome in hypoxic ischemic brain injury after cardiac arrest

AIM To examine the relationship between daily mean hemoglobin concentration and neurological outcome in hypoxic ischemic brain injury (HIBI) following cardiac arrest. METHODS We conducted a single center retrospective observational study using a database of HIBI patients between March 2009 and December 2014. We included all adults admitted to the intensive care unit following an in-hospital or out-of-hospital cardiac arrest. The primary outcome was neurological outcome measured by the Cerebral Performance Category (CPC) at hospital discharge. Multivariable logistic regression was used to analyze the association of mean hemoglobin concentration over 48h and 7 days after the onset of HIBI and discharge CPC. Favorable and unfavorable neurological outcome was dichotomized for a discharge CPC 1-2 vs 3-5, respectively. RESULTS 118 patients were included in the analysis. Patients with a favorable neurological outcome had higher mean 7-day hemoglobin (115g/L vs 107g/L; p=0.05) compared to those with unfavorable outcome. Multivariate logistic regression controlling for age, time to return of spontaneous circulation and blood transfusion demonstrated that lower mean 48-h hemoglobin concentration was associated with unfavorable outcome (OR 0.69 per 10 unit change in Hgb, 95% CI 0.54-0.88, p<0.01). A repeated analysis using mean Hgb for the first 7 days yielded similar results for unfavorable outcome (OR 0.75 per 10 unit change in Hgb, 95% CI 0.57-0.97, p=0.03). CONCLUSIONS Lower mean hemoglobin concentration in the first 48h and 7 days following HIBI is associated with a higher odds of unfavorable outcome at hospital discharge. Further study to examine this association is warranted.

Acute Respiratory Distress Syndrome in Pregnant Women

OBJECTIVE To estimate the rate of acute respiratory distress syndrome (ARDS) in pregnant patients as well as to investigate clinical conditions associated with mortality. METHODS We used the Nationwide Inpatient Sample from 2006 to 2012 to identify a cohort of pregnant patients who underwent mechanical ventilation for ARDS. A multivariate model predicting in-hospital mortality was created. RESULTS A total of 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Samples were analyzed. There were 2,808 pregnant patients with ARDS who underwent mechanical ventilation included in the cohort. The overall mortality rate for the cohort was 9%. The rate of ARDS requiring mechanical ventilation increased from 36.5 cases (95% confidence interval [CI] 33.1-39.8) per 100,000 live births in 2006 to 59.6 cases (95% CI 57.7-61.4) per 100,000 live births in 2012. Factors associated with a higher risk of death were prolonged mechanical ventilation (adjusted odds ratio [OR] 1.69, 95% CI 1.25-2.28), renal failure requiring hemodialysis (adjusted OR 3.40, 95% CI 2.11-5.47), liver failure (adjusted OR 1.71, 95% CI 1.09-2.68), amniotic fluid embolism (adjusted OR 2.31, 95% CI 1.16-4.59), influenza infection (OR 2.26, 95% CI 1.28-4.00), septic obstetric emboli (adjusted OR 2.15, 95% CI 1.17-3.96), and puerperal infection (adjusted OR 1.86, 95% CI 1.28-2.70). Factors associated with a lower risk of death were: insurance coverage (adjusted OR 0.56, 95% CI 0.37-0.85), tobacco use (adjusted OR 0.53, 95% CI 0.31-0.90), and pneumonia (adjusted OR 0.70, 95% CI 0.50-0.98). CONCLUSION In this nationwide study, the overall mortality rate for pregnant patients mechanically ventilated for ARDS was 9%. The rate of ARDS requiring mechanical ventilation increased from 36.5 cases (95% CI 33.5-41.8) per 100,000 live births in 2006 to 59.6 cases (95% CI 54.3-65.3) per 100,000 live births in 2012.

Association between seizures and mortality in patients with aneurysmal subarachnoid hemorrhage: A nationwide retrospective cohort analysis

PURPOSE The impact of seizures on outcomes in patients with subarachnoid hemorrhage (SAH) is not well understood, with conflicting results published in the literature. METHOD For this retrospective cohort analysis, data from the Nationwide Inpatient Samples (NIS) for 2006-2011 were utilized. All patients aged ≥18 years with a primary admitting diagnosis of subarachnoid hemorrhage were included. Patients with a diagnosis of seizure were segregated from the initial cohort. Multivariable logistic regression modeled the risk of death while adjusting for severity of SAH as well as co-morbidities. The primary outcome of this analysis was in-hospital mortality. RESULTS 12,647 patients met inclusion criteria for the study, of which 1336 had a diagnosis of seizures. The unadjusted in-hospital mortality was higher for patients with seizures compared to those without (16.2% vs 11.6%, p<0.01). Compared to patients without seizures, patients with seizures were younger (52.4 years SD 13.9 vs 54.8 years, SD 13.6; p<0.01), more likely to be male (35.6% vs 31.0%, p<0.01) and had longer hospital stays (18.3 days, IQR 12.0-27.5 vs 14.8 days, IQR 10.0-21.9; p<0.01). After adjusting for the severity of SAH, seizures were found to be associated with increased mortality (OR 1.57, 95% CI 1.32-1.87, p<0.01). CONCLUSION In this large nationwide analysis, the presence of seizures in patients with SAH was associated with higher in-hospital mortality. This finding has potentially important implications for goals of care decision-making and prognostication, but further study in the area is needed.

Utilization of electroencephalogram post cardiac arrest in the United States: A nationwide retrospective cohort analysis.

OBJECTIVE The use of electroencephalogram (EEG) has been demonstrated to have diagnostic and prognostic value in cardiac arrest patients. The use of this modality across the United States in this population is unknown. METHODS The Nationwide Inpatient Sample (NIS) is a federal database capturing 20% of all US hospital admissions. A cohort of patients who suffered both in and out of hospital cardiac arrests from the 2006 to 2012 NIS datasets was created. RESULTS The records of 55,208,382 hospitalizations were analyzed, of which 207,703 patients suffered a cardiac arrest. There were 2952 (1.42%) patients who also had an EEG. Patients who had an EEG compared to those who did not were: younger (62.2 years SD 16.6 vs 66.9 years SD 16.2, p<0.01), were less likely to have insurance coverage (89.9% vs 91.6%, p=0.03) and had significantly longer length of stay (8.6days IQR 3.7-17.1 vs 4.1days IQR 1.0-10.5, p<0.01). Patients treated at urban teaching hospitals were more likely to receive an EEG than patients treated at urban non-teaching and rural hospitals (p<0.01). The rate of EEG in survivors of cardiac arrest increased from 1.03% in 2006 to 2.16% in 2012, a relative increase of 110% (p<0.02). The median time to performance of an EEG was 1.6days IQR 0.33-4.53 days. CONCLUSION EEG is performed on approximately 2% of patients who suffer cardiac arrest in the United States. The treatment hospital and patient characteristics of those who received an EEG different from those who did not.