Christine Franey

Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database.

Objective:Retrospective analyses of several trials suggest etomidate may be unsafe for intubation in patients with sepsis. We evaluated the association of etomidate and mortality in a large cohort of septic patients to determine if single-dose etomidate was associated with increased in-hospital mortality. Design and Setting:Retrospective cohort study at the Philips eICU Research Institute ICU clinical database. Interventions:None. Patients:Among 741,036 patients monitored from 2008 through 2010, we identified 2,014 adults intubated in the ICU 4–96 hrs after admission, having clinical criteria consistent with sepsis, severe sepsis, or septic shock. In all, 1,102 patients received etomidate and 912 received other induction agents for intubation. Measurements and Main Results:The primary endpoint was in-hospital mortality, but we also evaluated demographic and clinical factors, severity of illness, ICU mortality, ICU length of stay, hospital length of stay, ventilator days, and vasopressor days. Competing risk Cox proportional hazard regression models were used for primary outcomes. Demographics and illness severity were similar between the groups. Hospital mortality was similar between the groups (37.2% vs. 37.8%, p = 0.77), as were ICU mortality (30.1% vs. 30.2%, p = 0.99), ICU length of stay (8.7 days vs. 8.9 days, p = 0.66), and hospital length of stay (15.2 vs. 14.6 days, p = 0.31). More patients in the etomidate group received steroids before and after intubation (52.9% vs. 44.5%, p < 0.001), but vasopressor use and duration of mechanical ventilation were similar. No regression model showed an independent association of etomidate with mortality, shock, duration of mechanical ventilation, ICU or hospital length of stay, or vasopressor use. A hospital mortality model limited to only patients with septic shock (n = 650) also showed no association of etomidate and hospital mortality. Conclusion:In a mixed-diagnosis group of critically ill patients with sepsis, severe sepsis, and septic shock, single-dose etomidate administration for intubation in the ICU was not associated with higher mortality or other adverse clinical outcomes.

Intensive care unit-acquired hypernatremia is an independent predictor of increased mortality and length of stay.

PURPOSE The purpose of this study is to examine the impact of hypernatremia acquired after intensive care unit (ICU) admission on mortality and length of stay (LOS). MATERIALS AND METHODS Data for this observational study were collected from patients admitted between January 1, 2008, and September 30, 2010 to 344 ICUs in the eICU Research Institute. RESULTS Of the 207702 eligible patients, 8896 (4.3%) developed hypernatremia (serum Na >149 mEq/L). Hospital mortality was 32% for patients with hypernatremia and 11% for patients without hypernatremia (P < .0001). Intensive care unit LOS was 13.7 ± 9.7 days for patients with hypernatremia and 5.1 ± 4.6 for patients without hypernatremia (P < .0001). Multivariate analysis showed that hypernatremia was an independent risk factor for hospital mortality with a relative risk (RR) of 1.40 (95% confidence interval, 1.34-1.45) and ICU LOS with a rate ratio (RtR) of 1.28 (1.26-1.30). The RR for mortality and RtR for ICU LOS increased with increasing severity strata of hypernatremia, but the duration of hypernatremia was not associated with mortality. CONCLUSIONS Hypernatremia developed following ICU admission in 4.3% of patients. Hypernatremia was independently associated with a 40% increase in risk for hospital mortality and a 28% increase in ICU LOS. Severity, but not duration of ICU-acquired hypernatremia was associated with hospital mortality.

Effect of Medications on Physical Function and Cognition in Nursing Home Residents with Dementia

To assess the effectiveness of medications used in the management of Alzheimers disease and related dementias (ADRD) on cognition and activity of daily living (ADL) trajectories and to determine whether sex modifies these effects.

Thrombosis Prophylaxis and Mortality Risk Among Critically Ill Adults

BACKGROUND The optimal approach for managing increased risk of VTE among critically ill adults is unknown. METHODS An observational study of 294,896 episodes of critical illness among adults was conducted in 271 geographically dispersed US adult ICUs. The primary outcomes were all-cause ICU and in-hospital mortality after adjustment for acuity and other factors among groups of patients assigned, based on clinical judgment, to prophylactic anticoagulation, mechanical devices, both, or neither. Outcomes of those managed with prophylactic anticoagulation or mechanical devices were compared in a separate paired, propensity-matched cohort. RESULTS After adjustment for propensity to receive VTE prophylaxis, APACHE (Acute Physiology and Chronic Health Evaluation) IV scores, and management with mechanical ventilation, the group treated with prophylactic anticoagulation was the only one with significantly lower risk of dying than those not provided VTE prophylaxis (ICU, 0.81 [95% CI, 0.79-0.84]; hospital, 0.84 [95% CI, 0.82-0.86; P < .0001). The mortality risk of those receiving mechanical device prophylaxis was not lower than that of patients without VTE prophylaxis. A study of 87,107 pairs of patients matched for propensity to receive VTE prophylaxis found that those managed with prophylactic anticoagulation therapy had significantly lower risk of death (ICU subhazard ratio, 0.82 [95% CI, 0.78-0.85]; hospital subhazard ratio, 0.82 [95% CI, 0.79-0.85]; P < .001) than those receiving only mechanical device prophylaxis. CONCLUSIONS These findings support a recommendation for prophylactic anticoagulation therapy in preference to mechanical device prophylaxis for critically ill adult patients who do not have a contraindication to anticoagulation.

The effect of dementia on medication use and adherence among Medicare beneficiaries with chronic heart failure.

BACKGROUND Alzheimers disease and related disorders (ADRD) are prevalent in older adults, increase the costs of chronic heart failure (CHF) management, and may be associated with undertreatment of cardiovascular disease. OBJECTIVE The purpose of our study was to determine the relationship between comorbid ADRD and CHF medication use and adherence among Medicare beneficiaries with CHF. METHODS This 2-year (1/1/2006-12/31/2007) cross-sectional study used data from the Chronic Condition Data Warehouse of the Centers for Medicare and Medicaid Services. Medicare beneficiaries with evidence of CHF who had systolic dysfunction and Medicare Parts A, B, and D coverage during the entire study period were included. ADRD was identified based on diagnostic codes using the Chronic Condition Data Warehouse algorithm. CHF evidence-based medications (EBMs) were selected based on published guidelines: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, selected β-blockers, aldosterone antagonists, and selected vasodilators. Measures of EBMs included a binary indicator of EBM use and medication possession ratio among users. RESULTS Of 9827 beneficiaries with CHF and systolic dysfunction, 24.2% had a diagnosis of ADRD. Beneficiaries with ADRD were older (80.8 vs 73.6 years; P < 0.0001) and more likely to be female (69.3% vs 58.1%; P < 0.0001). Overall EBM use was lower in patients with CHF and ADRD compared with patients with CHF but no ADRD (85.3% vs 91.2%; P < 0.0001). Lower use among those with ADRD was consistent across all EBM classes except vasodilators. Among beneficiaries receiving EBM, those with ADRD had a slightly higher mean medication possession ratio for EBM compared with those without ADRD (0.86 vs 0.84; P = 0.0001). CONCLUSIONS EBM medication adherence was high in this population, regardless of ADRD status. However, patients with ADRD had lower EBM use compared with those without ADRD. Low use of specific EBM medications such as β-blockers was found in both groups. Therefore, interventions targeting increased treatment with specific EBMs for CHF, even among patients with ADRD, may be of benefit and could help reduce CHF-related hospitalizations.

Intensive Care Units With Low Versus High Volume of Myocardial Infarction: Clinical Outcomes, Resource Utilization, and Quality Metrics

Background The volume-outcome relationship associated with intensive care unit (ICU) experience with managing acute myocardial infarction (AMI) remains inadequately understood. Methods and Results Within a multicenter clinical ICU database, we identified patients with a primary ICU admission diagnosis of AMI between 2008 and 2010 to evaluate whether annual AMI volume of an individual ICU is associated with mortality, length-of-stay, or quality indicators. Patients were categorized into those treated in ICUs with low-annual-AMI volume (≤50th percentile, <2 AMI patients/month, n=569 patients) versus high-annual-AMI volume (≥90th percentile, ≥8 AMI patients/month, n=17 553 patients). Poisson regression and generalized estimating equation with negative binomial regression were used to calculate the relative risk (95% CI) for mortality and length-of-stay, respectively, associated with admission to a low-AMI-volume ICU. When compared with high-AMI-volume, patients admitted to low-AMI-volume ICUs had substantially more medical comorbidities, higher in-hospital mortality (11% versus 4%, P<0.001), longer hospitalizations (6.9±7.0 versus 5.0±5.0 days, P<0.001), and fewer evidence-based therapies for AMI (reperfusion therapy, antiplatelets, β-blockers, and statins). However, after adjustment for baseline patient characteristics, low-AMI-volume ICU was no longer an independent predictor of in-hospital mortality (relative risk 1.17 [0.87 to 1.56]) or hospital length-of-stay (relative risk 1.01 [0.94 to 1.08]). Similar findings were noted in secondary analyses of ICU mortality and ICU length-of-stay. Conclusions Admission to an ICU with lower annual AMI volume is associated with higher in-hospital mortality, longer hospitalization, and lower use of evidence-based therapies for AMI. However, the relationship between low-AMI-volume and outcomes is no longer present after accounting for the higher-risk medical comorbidities and clinical characteristics of patients admitted to these ICUs.

Skeletal-related events (SREs) and survival among elderly patients with stage IV prostate cancer (PCa) in SEER Medicare data.

249 Background: Skeletal-related events occurring among PCa patients with bone metastasis include radiation to the bone (RttB), pathological fracture, spinal cord compression (SCC), and bone surgery (BS). There is no validated algorithm for identifying RttB using claims data. We investigated the prevalence and mortality impact of SREs across alternative claims-based algorithms for identifying RttB. METHODS We analyzed data for stage IV PCa cases identified between 2005 and 2009 in the Surveillance, Epidemiology, and End Results registry linked with Medicare claims. Fracture, SCC, and BS were identified from claims. Focusing on external beam radiation therapy, radiopharmaceutical therapy, intensity modulated radiotherapy and stereotactic radiosurgery, three approaches were created based on data visualization software: 1) radiation claim occurred after a claim with a bone metastasis (BM) code; 2) BM code directly coincided with the period of the radiation treatment episode; 3) either #2 or the duration of the radiation episode was less than or equal to 4 weeks. Regression models for all-cause mortality used these measures. RESULTS The study sample included 5,380 men with stage IV PCa. The median age of the sample was 77 years. All-cause mortality was 54% during median (mean) follow-up of 579 (656) days. The proportion who had any fracture, SCC, and BS was 23.2%, 6.3%, and 5.8%. Without taking BM code or duration of radiation into consideration, the proportion who received radiation therapy was 35%. Using approaches 1, 2 and 3 we have the following four results: 1) the proportion who received RttB was 22%, 18%, and 24%; 2) the prevalence of any SRE was 39%, 37%, and 41%; 3) among those with an SRE, the proportion receiving RttB was 57%, 50%, and 58%; 4) the adjusted hazard ratio (95% CI) associated with any SRE was 1.22 (1.13-1.33), 1.22 (1.12-1.33), and 1.25 (1.15-1.36). CONCLUSIONS Among older men diagnosed with stage IV prostate cancer, approximately one in five men received palliative radiation and the mortality impact of skeletal-related events was comparable across alternative approaches to identifying palliative radiation.

Benefits Improvement and Protection Act's impact on transplantation rates among elderly MEDICARE beneficiaries with end-stage renal disease.

Background The Benefits Improvement and Protection Act (BIPA) expanded Medicare coverage for posttransplantation immunosuppresants for elderly patients and others eligible for Medicare beyond their end-stage renal disease (ESRD) status yet retained the 3-year limit for patients eligible solely because of ESRD status. Our objective was to determine BIPA’s impact on renal transplantation among elderly patients (age ≥65 years) affected by BIPA. Methods Medicare claims and the U.S. Renal Data System Standard Analysis Files were used to analyze the likelihood of transplantation among elderly patients, all of whom were affected by BIPA, versus the nonelderly, many of whom were unaffected by BIPA. A difference-in-differences approach and generalized logistic regressions were used to estimate BIPA’s impact. Results Analysis of data for 632,904 ESRD Medicare beneficiaries who met inclusion/exclusion criteria suggests that BIPA made elderly patients more likely (relative likelihood, 1.36; 95% confidence interval, 1.32–1.41) to have a transplant. The likelihood for nonelderly patients decreased following BIPA (relative likelihood, 0.93; 95% confidence interval, 0.92–0.94). Conclusion Transplantation rates increased among those elderly patients, all of whom were affected by BIPA by extending immunosuppressant coverage under BIPA. These results suggest that removing financial barriers to posttransplantation care may positively impact transplantation rates yet raise questions regarding whether the law shifted transplants from younger to older patients.