Chiedozie Udeh

Validation and Extension of the Prolonged Mechanical Ventilation Prognostic Model (ProVent) Score for Predicting 1-Year Mortality after Prolonged Mechanical Ventilation.

RATIONALE Prognostic models can inform management decisions for patients requiring prolonged mechanical ventilation. The Prolonged Mechanical Ventilation Prognostic model (ProVent) score was developed to predict 1-year mortality in these patients. External evaluation of such models is needed before they are adopted for routine use. OBJECTIVES The goal was to perform an independent external validation of the modified ProVent score and assess for spectrum extension at 14 days of mechanical ventilation. METHODS This was a retrospective cohort analysis of patients who received prolonged mechanical ventilation at the University of Iowa Hospitals. Patients who received 14 or more days of mechanical ventilation were identified from a database. Manual review of their medical records was performed to abstract relevant data including the four model variables at Days 14 and 21 of mechanical ventilation. Vital status at 1 year was checked in the medical records or the social security death index. Logistic regressions examined the associations between the different variables and mortality. Model performance at 14 to 20 days and 21+ days was assessed for discrimination by calculating the area under the receiver operating characteristic curve, and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. MEASUREMENTS AND MAIN RESULTS A total of 180 patients (21+ d) and 218 patients (14-20 d) were included. Overall, 75% were surgical patients. One-year mortality was 51% for 21+ days and 32% for 14 to 20 days of mechanical ventilation. Age greater than 65 years was the strongest predictor of mortality at 1 year in all cohorts. There was no significant difference between predicted and observed mortality rates for patients stratified by ProVent score. There was near-perfect specificity for mortality in the groups with higher ProVent scores. Areas under the curve were 0.69 and 0.75 for the 21+ days and the 14 to 20 days cohorts respectively. P values for the Hosmer-Lemeshow statistics were 0.24 for 21+ days and 0.22 for 14 to 20 days. CONCLUSIONS The modified ProVent model was accurate in our cohort. This supports its geographic and temporal generalizability. It can also accurately identify patients at risk of 1-year mortality at Day 14 of mechanical ventilation, but additional confirmation is required. Further studies should explore the implications of adopting the model into routine use.

The cost-effectiveness of epidural, patient-controlled intravenous opioid analgesia, or transversus abdominis plane infiltration with liposomal bupivacaine for postoperative pain management

STUDY OBJECTIVE Intravenous patient-controlled opioid analgesia (IVPCA), epidural analgesia and transversus abdominis plane (TAP) infiltrations are frequently used postoperative pain management modalities. The aim of this study was to conduct a cost-effectiveness analysis comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively in patients undergoing major lower abdominal surgery. DESIGN Retrospective cost effectiveness analysis. SETTING Operating room. PATIENTS We obtained data on major lower-abdominal surgeries performed under general anesthesia on adult patients between January 2012 and July 2014. INTERVENTIONS A cost-effectiveness analysis was comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively. MEASUREMENTS A decision analytic model was used to estimate the health outcomes for patients undergoing major lower abdominal surgery. The primary outcome was time-weighted pain from 0 to 72 h after surgery, as measured by numerical rating scale pain scores. The analysis was conducted from the perspective of the hospital as the party responsible for most costs related to surgery. MAIN RESULTS From the base case analysis, IVPCA was the optimal strategy regarding cost and effect. TAP with LB, however, was only narrowly dominated, while epidural was clearly dominated. From the sensitivity analysis at willingness-to-pay (WTP) of

107: IMPACT OF NOCTURNAL ICU TELEMEDICINE ON INTERHOSPITAL TRANSFER VOLUME

150, IV PCA and TAP infiltration were each the optimal strategy for approximately 50% of the iterations. At WTP of

577: IMPACT OF INTRAVENOUS ACETAMINOPHEN IN CARDIOTHORACIC SURGERY PATIENTS

10,000, epidural was only the optimal strategy in 10% of the iterations. CONCLUSIONS This is the first study in the literature to compare the cost-effectiveness of epidural, IVPCA, and TAP infiltrations with LB. Within reasonable WTP values, there is little differentiation in cost-effectiveness between IVPCA and TAP infiltration with LB. Epidural does not become a cost-effective strategy even at much higher WTP values.

The apples and oranges of cost-effectiveness: a rejoinder.

Learning Objectives: Approximately 5% of all patients admitted to American ICUs are transferred to hospitals which offer a higher intensity of care. The transfer of critically ill patients is associated with significant cost and is not without risk. A recent study conducted by Mayo Clinic found that implementation of an ICU telemedicine program was associated with an increase in transfers from less resourced ICUs to a quaternary care center. The aim of this retrospective study was to explore a nocturnal ICU telemedicine program’s impact on the rate of inter-hospital transfers originating from 7 community hospitals within the Cleveland Clinic Health System. Transfers to the Cleveland Clinic main downtown campus and inter hospital transfers among the community hospitals were reviewed. Methods: ICU to ICU transfer rates for one year pre-implementation (2013) and two years post full implementation (2015 and 2016) of a nocturnal ICU telemedicine program were analyzed. The year of implementation was considered a transitional year and excluded in the analysis. Implementation of ICU telemedicine coverage was staggered from 2014-2016. Therefore, two hospitals met criteria for full data analysis. Both have daytime in house intensivist coverage. Hospital A houses a 12 bed ICU. Hospital B is a Level II Trauma Center with a 38 bed ICU and services including interventional cardiology, cardiothoracic surgery and neurosurgery. Baseline transfer rates to the main campus were 1.4% and 0.84%, respectively. Overnight, Hospital A is primarily supported by the ICU telemedicine program while Hospital B has in-house residents supported by the ICU telemedicine program. Results: From 2013-2016 there was a 42% increase in ICU census at Hospital A. Hospital B experienced a 52% increase in ICU census. There was no statistically significant change in transfer rate to the main campus (-2.24%, p = 0.101; -0.23%, p = 0.402). However, nocturnal transfers between the two study hospitals significantly increased from the lower acuity hospital to the high acuity hospital (1.4% to 3.1%; p = 0.0102). Conclusions: The results of this study demonstrate the ability of ICU telemedicine programs to enhance patient flows and system logistics by facilitating transfers among supported facilities. ICU telemedicine presence also supports the ability of individual lower acuity hospitals to support more patients in the ICUs during periods of increasing hospital census.

473: COST-EFFECTIVENESS OF 6 TREATMENTS FOR PRIMARY CLOSTRIDIUM DIFFICILE INFECTION IN AN ICU POPULATION

Learning Objectives: Compared to other analgesic agents, several potential advantages of intravenous (IV) acetaminophen (APAP) exist due to differences in side effect profiles. Although a reduction in opioid requirements with use of IV APAP has been suggested in prior studies, data supporting improvement in patient outcomes is lacking. Methods: Single-center, retrospective cohort study with a matched historical control. Data were extracted from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery database and electronic medical record. Study group included adult patients who received at least one dose of IV APAP postoperatively in the cardiovascular ICU (CVICU) from October 2011 to October 2014. The study group was matched to control patients admitted to CVICU postoperatively, between October 2008 and September 2011 (prior to the availability of IV APAP at the study institution), in a 1:2 ratio using propensity scores (based on age, sex, ASA Physical Status Score, and type of surgery) stratified by operative urgency. The primary endpoint was time to ICU discharge. Additional endpoints included time to extubation and the incidence of opioid-related ADEs based on administration of anti-emetics or naloxone. Results: After matching, 2,138 patients were included in the IV APAP arm and 4,276 in the control arm. Baseline characteristics between groups were similar. An unadjusted Cox proportional hazards model was fit for time to ICU discharge, and the associated hazards ratio (HR) was 0.90 (95% CI,0.86–0.94,p < 0.0001), indicating a decreased risk of discharge from the ICU with IV APAP. A Cox proportional hazards model was fit for the secondary endpoint of time to extubation, and the associated HR was 0.97 (95% CI,0.87–1.07,p = 0.48. Opioid-related ADEs occurred in 55.3% of patients receiving IV APAP and 40.7% of patients in the control group (p<0.001). Conclusions: Cardiothoracic surgery patients who received IV APAP had longer ICU length of stay and no difference in time to extubation compared to a matched-historical control. IV APAP was not associated with a reduction in opioid-related ADEs.

1955: IMPLEMENTATION OF AN ON-DEMAND ICU-TELEMEDICINE CONSULT IN TWO LONG-TERM ACUTE CARE HOSPITALS.

A recent CCJM commentary used straw men to indict cost-effectiveness research.