Elizabeth Geelhoed

Determinants of long-term survival after intensive care

Objective:To identify prognostic determinants of long-term survival for patients treated in intensive care units (ICUs) who survived to hospital discharge. Design:An ICU clinical cohort linked to state-wide hospital records and death registers. Setting and Patients:Adult patients admitted to a 22-bed ICU at a major teaching hospital in Perth, Western Australia, between 1987 and 2002 who survived to hospital discharge (n = 19,921) were followed-up until December 31, 2003. Measurements:The main outcome measures are crude and adjusted survival. Main Results:The risk of death in the first year after hospital discharge was high for patients who survived the ICU compared with the general population (standardized mortality rate [SMR] at 1 yr = 2.90, 95% confidence interval [CI] 2.73–3.08) and remained higher than the general population for every year during 15 yrs of follow up (SMR at 15 yrs = 2.01, 95% CI 1.64–2.46). Factors that were independently associated with survival during the first year were older age (hazard ratio [HR] = 4.09; 95% CI 3.20–5.23), severe comorbidity (HR = 5.23; 95% CI 4.25–6.43), ICU diagnostic group (HR range 2.20 to 8.95), new malignancy (HR = 4.60; 95% CI 3.68–5.76), high acute physiology score on admission (HR = 1.55; 95% CI 1.23–1.96), and peak number of organ failures (HR = 1.51; 95% CI 1.11–2.04). All of these factors were independently associated with subsequent survival for those patients who were alive 1 yr after discharge from the hospital with the addition of male gender (HR = 1.17; 95% CI 1.10–1.25) and prolonged length of stay in ICU (HR = 1.42; 95% CI 1.29–1.55). Conclusions:Patients who survived an admission to the ICU have worse survival than the general population for at least 15 yrs. The factors that determine long-term survival include age, comorbidity, and primary diagnosis. Severity of illness was also associated with long-term survival and this suggests that an episode of critical illness, or its treatment, may shorten life-expectancy.

Familial hypercholesterolaemia: A model of care for Australasia

Familial hypercholesterolaemia (FH) is a dominantly inherited disorder present from birth that causes marked elevation in plasma cholesterol and premature coronary heart disease. There are at least 45,000 people with FH in Australia and New Zealand, but the vast majority remains undetected and those diagnosed with the condition are inadequately treated. To bridge this major gap in coronary prevention the FH Australasia Network (Australian Atherosclerosis Society) has developed a consensus model of care (MoC) for FH. The MoC is based on clinical experience, expert opinion, published evidence and consultations with a wide spectrum of stakeholders, and has been developed for use primarily by specialist centres intending starting a clinical service for FH. This MoC aims to provide a standardised, high-quality and cost-effective system of care that is likely to have the highest impact on patient outcomes. The MoC for FH is presented as a series of recommendations and algorithms focusing on the standards required for the detection, diagnosis, assessment and management of FH in adults and children. The process involved in cascade screening and risk notification, the backbone for detecting new cases of FH, is detailed. Guidance on treatment is based on risk stratifying patients, management of non-cholesterol risk factors, safe and effective use of statins, and a rational approach to follow-up of patients. Clinical and laboratory recommendations are given for genetic testing. An integrative system for providing best clinical care is described. This MoC for FH is not prescriptive and needs to be complemented by good clinical judgment and adjusted for local needs and resources. After initial implementation, the MoC will require critical evaluation, development and appropriate modification.

Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion

BACKGROUND Patients with malignant pleural effusion (MPE) have limited prognoses. They require long-lasting symptom relief with minimal hospitalization. Indwelling pleural catheters (IPCs) and talc pleurodesis are approved treatments for MPE. Establishing the implications of IPC and talc pleurodesis on subsequent hospital stay will influence patient choice of treatment. Therefore, our objective was to compare patients with MPE treated with IPC vs pleurodesis in terms of hospital bed days (from procedure to death or end of follow-up) and safety. METHODS In this prospective, 12-month, multicenter study, patients with MPE were treated with IPC or talc pleurodesis, based on patient choice. Key end points were hospital bed days from procedure to death (total and effusion-related). Complications, including infection and protein depletion, were monitored longitudinally. RESULTS One hundred sixty patients with MPE were recruited, and 65 required definitive fluid control; 34 chose IPCs and 31 pleurodesis. Total hospital bed days (from any causes) were significantly fewer in patients with IPCs (median, 6.5 days; interquartile range [IQR] = 3.75-13.0 vs pleurodesis, mean, 18.0; IQR, 8.0-26.0; P = .002). Effusion-related hospital bed days were significantly fewer with IPCs (median, 3.0 days; IQR, 1.8-8.3 vs pleurodesis, median, 10.0 days; IQR, 6.0-18.0; P < .001). Patients with IPCs spent significantly fewer of their remaining days of life in hospital (8.0% vs 11.2%, P < .001, χ(2) = 28.25). Fewer patients with IPCs required further pleural procedures (13.5% vs 32.3% in pleurodesis group). There was no difference in rates of pleural infection (P = .68) and protein (P = .65) or albumin loss (P = .22). More patients treated with IPC reported immediate (within 7 days) improvements in quality of life and dyspnea. CONCLUSIONS Patients treated with IPCs required significantly fewer days in hospital and fewer additional pleural procedures than those who received pleurodesis. Safety profiles and symptom control were comparable.

A validation study: how effective is the Hospital Morbidity Data as a surveillance tool for heart failure in Western Australia?

Objective: To determine the accuracy of the hospital discharge coding of heart failure (HF) in the Western Australian (WA) Hospital Morbidity Data (HMD).

Reduction in Hospitalisation Following Pulmonary Rehabilitation in Patients with COPD

OBJECTIVES Pulmonary rehabilitation (PR) improves exercise capacity and health-related quality of life (HRQoL), and reduces health care utilisation. This study quantified outcomes of a PR program over a 6-year period and determined the effects of PR on hospitalisation. METHODS Patients with chronic obstructive pulmonary disesae (COPD) who entered an 8-week outpatient PR program from 1998 to 2003 were included. Functional exercise capacity (6-minute walk distance [6MWD]) and HRQoL (Chronic Respiratory Disease Questionnaire) were measured before and following PR. The number of hospital admissions and total bed-days due to a COPD exacerbation in the 12 months before and following PR were recorded. SETTING Physiotherapy Department, Sir Charles Gairdner Hospital, Western Australia. RESULTS 187 (73%) of the 256 patients who entered PR completed the program. Improvements in 6MWD (404.2 +/- 114.6 m to 439.6 +/- 115.0m, P < 0.001) and HRQoL (4.1 +/- 0.9 points per item to 4.9 +/- 0.9 points per item, P < 0.001) occurred following PR. There was a 46% reduction in the number of patients admitted to hospital (71 to 38) with a COPD exacerbation and a 62% reduction in total bed-days (1131 to 432) following PR. CONCLUSION Pulmonary rehabilitation provided in an Australian teaching hospital was associated with a reduction in COPD hospitalisation, and the resultant savings outweighed the costs of providing the program.

A new method of prenatal alcohol classification accounting for dose, pattern and timing of exposure: improving our ability to examine fetal effects from low to moderate alcohol

Background When examining the association between prenatal alcohol exposure and fetal effects, the timing and intensity of exposure have been ignored in epidemiological studies. The effect of using dose, pattern and timing of consumption (“composite” method) was investigated in this study, to examine the association between prenatal alcohol exposure and fetal effects. Methods The composite method resulted in six categories of exposure (abstinent, low, moderate, binge <weekly, binge 1–2×/week and heavy). The odds of language delay and child behaviour problems were calculated for the composite method and then compared with an analysis using averaged estimates of <1 and 1+ drinks per day and with stratification by quantity ignoring dose per occasion. Data used for the analyses were from a 10% random sample of non-Indigenous women delivering a live infant in Western Australia (1995–1997). Participants from the 1995-1996 cohort were invited to participate in an 8-year longitudinal survey (78% response rate n=2224; 85% were followed-up at 2 years, 73% at 5 years and 61% at 8 years). Results The effect of moderate and binge levels of exposure was only evident with the composite method; anxiety/depression following first-trimester moderate exposure (OR 2.24, 95% CI 1.16 to 4.34), and following late pregnancy moderate (aggressive behaviour OR 1.93, 95% CI 0.91 to 4.09) and binge (language delay OR 3.00, 95% CI 0.90 to 9.93) exposures. Results for heavy levels of exposure were similar with each method. The estimates for late pregnancy were imprecise due to small numbers. Conclusion The composite method of classification more closely reflects real-life drinking patterns and better discriminates maternal drinking than the other methods, particularly low, moderate and binge levels.

Measuring the Assessment and Counseling Provided with the Supply of Nonprescription Asthma Reliever Medication: A Simulated Patient Study

Background: Over one quarter of asthma reliever medications are provided without prescription by community pharmacies in Australia. Evidence that community pharmacies provide these medications with sufficient patient assessment and medication counseling to ensure compliance with the governments Quality Use of Medicines principles is currently tacking. Objective: To assess current practice when asthma reliever medication is provided in the community pharmacy setting and to identify factors that correlate with assessment of asthma control. Methods: Researchers posing as patients visited a sample of Perth metropolitan community pharmacies in May 2007. During the visit, the simulated patient enacted a standardized scenario of someone with moderately controlled asthma who wished to purchase a salbutamol (albuterol) inhaler without prescription. Results of the encounter were recorded immediately after the visit. Regression analysis was performed, with medication use frequency (a marker of asthma control) as the dependent variable. Results: One hundred sixty community pharmacies in the Perth metropolitan area were visited in May 2007. Pharmacists and/or pharmacy assistants provided some form of assessment in 84% of the visits. Counseling was provided to the simulated patients in 24% of the visits. Only 4 pharmacy staff members asked whether the simulated patient knew how to use the inhaler. Significant correlation was found between assessment and/or counseling of reliever use frequency and 3 independent variables: visit length (p < 0.001), number of assessment questions asked (p < 0.001), and the simulated patient who conducted the visit (p < 0.02). Conclusions: Both patient assessment and medication counseling were suboptimal compared with recommended practice when nonprescription asthma reliever medication was supplied in the community pharmacy setting. Pharmacy and pharmacist demographic variables do not appear to affect assessment of asthma control. This research indicates the need for substantial improvements in practice in order to provide reliever medication in line with Quality Use of Medication principles of ensuring safe and effective use of medication.

Temporal trends in the incidence and recurrence of hospitalised atherothrombotic disease in an Australian population, 2000–07: data linkage study

Objectives To examine temporal trends in the incidence and recurrence of hospitalised coronary heart disease (CHD), cerebrovascular disease (CeVD) and peripheral arterial disease (PAD) separately and combined, and by the history of all forms of atherothrombotic disease (ATD). Design Population-based longitudinal data linkage study. Setting Western Australia. Participants All patients aged 35–84 years hospitalised in Western Australia for CHD, CeVD or PAD from 2000 to 2007. Main Outcome Measures Age-standardised incidence and recurrence rates of CHD, CeVD and PAD stratified by ATD history, sex and age. Results 107 576 events (65.9% men) were identified; 70% of all admissions were for CHD. In patients without a history of any ATD, incidence rates declined significantly in all groups, although the reduction in incident CHD in women was marginal (−0.7%/year, 95% CI −1.5 to +0.1%). The largest annual reductions in incidence rates were for PAD (men, −6.4%/year, 95% CI −7.7 to −5.0%; women, −5.4%/year, 95% CI −7.2 to −3.6%) and CeVD in women (−4.0%/year, 95% CI −5.0 to −3.0%). Falls in overall recurrence rates were greatest for CeVD (men, −3.2%/year, 95% CI −4.7 to −1.6%; women −4.6%/year, 95% CI −6.4 to −2.7%). Trends across all categories of polyvascular ATD were generally downward, although not all changes were statistically significant. Conclusion The incidence and recurrence rates of hospitalised ATD have decreased over time, including in patients with disease involving multiple vascular territories. This implies that primary and secondary prevention strategies have been broadly effective. However, high absolute rates of recurrence and limited reduction in 35–54-year-old individuals highlight patient groups to target to reduce further the burden of ATD.

Trends in long-term cardiovascular mortality and morbidity in men and women with heart failure of ischemic versus non-ischemic aetiology in Western Australia between 1990 and 2005.

BACKGROUND It is uncertain if improvements in long-term cardiovascular (CV) mortality have occurred in both men and women with ischemic and non-ischemic forms of heart failure (HF). METHODS The Western Australia Hospital Morbidity Database was used to identify all index (first-ever) hospitalizations for HF between 1990 and 2005. Patients were followed until death attributed to cardiovascular causes or censored on December 31, 2006 to determine 5-year survival. Cox proportional hazards models were used to compare the adjusted mortality hazard ratio (HR) during the study follow-up (4-year periods). RESULTS A total of 21,507 patients (mean age 73.9 years, 49.1% women) were identified. Women were significantly older than men, and less likely to have ischemic HF (38.8% versus 46.1%). Over the period, age-standardized incidence of first HF hospitalization declined but with the least decline in women with non-ischemic HF (-13.3%) compared to other subgroups. Risk-adjusted 5-year CV mortality declined over the study period, with HR 0.64 (95% CI 0.60-0.68) for patients admitted in 1998-2001 compared to 1990-1993, with significant improvement in both forms of HF, and in both sexes and across age groups. However, overall total HF hospitalizations increased (+26.7%) over the period, particularly for non-ischemic HF (+43.7%), of which elderly women formed the predominant group. CONCLUSIONS Risk-adjusted long-term survival improved similarly in men and women, including the elderly, with ischemic and non-ischemic forms of HF during 1990-2005 in Western Australia. However, there was a growing burden of HF hospitalizations particularly for HF of non-ischemic aetiology.

A randomized controlled trial comparing autologous cranioplasty with custom-made titanium cranioplasty

OBJECTIVE Autologous bone is usually used to reconstruct skull defects following decompressive surgery. However, it is associated with a high failure rate due to infection and resorption. The aim of this study was to see whether it would be cost-effective to use titanium as a primary reconstructive material. METHODS Sixty-four patients were enrolled and randomized to receive either their own bone or a primary titanium cranioplasty. All surgical procedures were performed by the senior surgeon. Primary and secondary outcome measures were assessed at 1 year after cranioplasty. RESULTS There were no primary infections in either arm of the trial. There was one secondary infection of a titanium cranioplasty that had replaced a resorbed autologous cranioplasty. In the titanium group, no patient was considered to have partial or complete cranioplasty failure at 12 months of follow-up (p = 0.002) and none needed revision (p = 0.053). There were 2 deaths unrelated to the cranioplasty, one in each arm of the trial. Among the 31 patients who had an autologous cranioplasty, 7 patients (22%) had complete resorption of the autologous bone such that it was deemed a complete failure. Partial or complete autologous bone resorption appeared to be more common among young patients than older patients (32 vs 45 years old, p = 0.013). The total cumulative cost between the 2 groups was not significantly different (mean difference A