Patient Characteristics and Treatment Patterns for Speech-Language Pathology Services in Skilled Nursing Facilities.

PURPOSE: Skilled nursing facility (SNF) care has historically been influenced by systemic issues that could impact speech-language pathology (SLP) service provision. However, there has been little study specifically on factors associated with SLP service provision in SNFs. Large administrative data sets are rarely analyzed in SLP research but can be used to understand real-world SLP services. This study investigated associations between patient and facility characteristics and SLP services. METHOD: Mixed-effects logistic regression models were used to evaluate factors associated with SLP service provision in 2018 Medicare administrative data representing 833,653 beneficiaries. RESULTS: Beneficiaries had higher odds of receiving SLP services when they had neurologic diagnosis (odds ratio [OR] = 3.32), had SLP-related functional impairments (ORs = 1.19-3.41), and received other rehabilitative services (ORs = 3.11-3.78). Beneficiaries had lower odds of receiving SLP services when they received care from SNFs located in hospitals versus freestanding (OR = 0.45), with need for interpreter services (OR = 0.76) and with thresholding (OR = 0.68), a financially motivated practice. Direction of association varied across racial and ethnic groups and measures of location. Odds of being provided SLP services decreased with increasing communication impairment severity. CONCLUSIONS: The results suggest that clinicians are identifying patients with diagnoses most likely to warrant SLP services. However, association disparities and weakening association of service provision with increasing impairment severity have concerning clinical implications. Health services research methods can be used to further explore SLP practices in SNFs to support equitable service provision.

Associations between baseline cognitive status and motor outcomes after treadmill training in people with Parkinson's disease: a pilot study.

PURPOSE: To determine the effect of baseline cognition on gait outcomes after a treadmill training program for people with Parkinson's disease (PD). METHODS: This pilot clinical trial involved people with PD who were classified as having no cognitive impairment (PD-NCI) or mild cognitive impairment (PD-MCI). Baseline executive function and memory were assessed. The intervention was a 10-week gait training program (twice-weekly treadmill sessions), with structured speed and distance progression and verbal cues for gait quality. Response to intervention was assessed by gait speed measured after week 2 (short-term) and week 10 (long-term). RESULTS: Participants (n = 19; 12 PD-NCI, 7 PD-MCI) had a mean (standard deviation) age of 66.5 (6.3) years, disease duration of 8.8 (6.3) years, and MDS-UPDRS III score of 21.3 (10.7). Gait speed increased at short-term and long-term assessments. The response did not differ between PD-NCI and PD-MCI groups; however, better baseline memory performance and milder PD motor severity were independently associated with greater improvements in gait speed in unadjusted and adjusted models. CONCLUSIONS: These findings suggest that memory impairments and more severe motor involvement can influence the response to gait rehabilitation in PD and highlight the need for treatments optimized for people with greater cognitive and motor impairment.IMPLICATIONS FOR REHABILITATIONCognitive deficits in Parkinson's disease (PD) could impact motor learning and gait rehabilitation, yet little is known about the effects of cognitive impairments on the response to rehabilitation in people with PD.This study demonstrates that the response to gait rehabilitation did not differ between people with PD who had no cognitive impairment and those with mild cognitive impairment.Across all participants, better baseline memory was associated with greater improvements in gait speed.Rehabilitation professionals should be mindful of PD severity, as those with more substantial memory and motor impairments may require additional dosing or support to maximize gait training benefits.

Skilled Nursing Facility Changes in Ownership and Short-Stay Medicare Patient Outcomes.

Importance: Skilled nursing facility (SNF) changes in ownership are receiving attention in the national conversation regarding health care quality and oversight. SNF ownership changes have been cited as possible ways for SNFs to obscure financial arrangements and shift funds away from patient care; however, it is unclear whether ownership changes are associated with quality outcomes, especially for short-stay patients. Objective: To determine which SNF characteristics are associated with changes in ownership and whether ownership changes were associated with differences in short-stay patient outcomes. Design, Setting, and Participants: This cohort study was a secondary analysis of 2016 to 2019 Medicare administrative data including SNFs in the United States with complete data. Data were analyzed from January 2016 through December 2019. Exposure: SNF change in ownership. Main Outcomes and Measures: Outcomes of interest were facility-level risk-adjusted rates of hospital readmissions, emergency department visits, and community discharge for short-stay patients after admission to an SNF. Analyses were conducted using multivariable logistic regression and controlled interrupted time series. Results: Of 11 004 SNFs, 1459 (13.26%) changed ownership between 2016 and 2019. Compared with for-profit SNFs, nonprofit and government SNFs had lower odds of changing ownership (nonprofit: odds ratio [OR], 0.40; 95% CI, 0.32-0.49; government: OR, 0.26; 95% CI, 0.17-0.41). Chain SNFs had higher odds of changing ownership than nonchain SNFs (OR, 1.38; 95% CI, 1.21-1.59). Urban SNFs with lower occupancy rates (OR per 10-percentage-point decrease, 1.19; 95% CI, 1.14-1.25), larger Medicaid populations (OR per 10-percentage-point increase, 1.17; 95% CI, 1.13-1.22), and lower staffing ratings (OR per 1-star increase on staffing rating, 1.18; 95% CI, 1.14-1.25) had higher odds of changing ownership. Descriptively, all 3 quality outcomes were worse throughout the study in SNFs undergoing ownership change compared with controls that did not change ownership. However, results of interrupted time series models found no associations between an ownership change and hospital readmissions or community discharge rates. Ownership change was associated with a short-term increase of 0.32 (95% CI, 0.03 to 0.62) percentage points in emergency department visits. Conclusions and Relevance: In this cohort study of 11 004 SNFs in the US between 2016 and 2019, SNF characteristics historically associated with lower quality were more likely to change ownership; however, ownership changes were only associated with short-term increases in ED visits. These results suggest that SNF ownership changes may be a symptom, not a cause, of lower quality.

Analyzing the value of IONM as a complex intervention: The gap between published evidence and clinical practice.

OBJECTIVE: Intraoperative neurophysiological monitoring (IONM) was investigated as a complex intervention (CI) as defined by the United Kingdom Medical Research Council (MRC) in published studies to identify challenges and solutions in estimating IONM's effects on postoperative outcomes. METHODS: A scoping review to April 2022 of the influence of setting on what was implemented as IONM and how it influenced postoperative outcomes was performed for studies that compared IONM to no IONM cohorts. IONM complexity was assessed with the iCAT_SR tool. Causal graphs were used to represent this complexity. RESULTS: IONM implementation depended on the surgical procedure, institution and/or surgeon. "How" IONM influenced neurologic outcomes was attributed to surgeon or institutional experience with the surgical procedure, surgeon or institutional experience with IONM, co-interventions in addition to IONM, models of IONM service delivery and individual characteristics of the IONM provider. Indirect effects of IONM mediated by extent of tumor resection, surgical approach, changes in operative procedure, shorter operative time, and duration of aneurysm clipping were also described. There were no quantitative estimates of the relative contribution of these indirect effects to total IONM effects on outcomes. CONCLUSIONS: IONM is a complex intervention whose evaluation is more challenging than that of a simple intervention. Its implementation and largely indirect effects depend on specific settings that are usefully represented in causal graphs. SIGNIFICANCE: IONM evaluation as a complex intervention aided by causal graphs and multivariable analysis could provide a valuable framework for future study design and assessments of IONM effectiveness in different settings.

PROMIS-25 Reliability and Validity Among Children Living with Burn Injury: A Burn Model System National Database Study.

This study examined the reliability and validity of the Patient Reported Outcomes Measurement System (PROMIS)-25, a profile instrument consisting of four-item fixed short forms for six health domains, in children living with burn injury. Data were provided by children participating in a multi-center longitudinal study of outcomes after burn injury. Floor and ceiling effects, unidimensionality, internal consistency, reliability, and differential item functioning (DIF) of the PROMIS-25 Profile v.2.0 were examined. Correlations with other established measures were calculated to assess concurrent validity. Children (n = 256) between the ages of 8-18 years with moderate to severe injury provided responses on PROMIS-25 domains. All PROMIS-25 domains showed high internal consistency. Substantial portions of the sample reported no symptoms (anxiety [58.2%], depressive symptoms [54.6%], fatigue [50.8%], pain [60.1%]). There was a large ceiling effect on peer relationships (46.8%) and physical function mobility (57.5%). One-factor confirmatory factor analyses supported unidimensionality for all domains. Reliability was sufficient for group mean comparisons (>0.8) across at least some trait levels for most domains except fatigue and anxiety. No DIF with respect to burn status was detected when comparing the burn sample to the PROMIS pediatric general U.S. population testing sample. These results provide evidence of reliability and validity of PROMIS-25 scores among children living with burn injury. Reliability of domains was low to moderate and would likely be improved, and ceiling effects reduced for some domains, by administering the PROMIS-37, which includes six items per domain.

Intersectionality of Systemic Disadvantage on Mortality and Care Following TBI.

BACKGROUND: People of color (POC), especially those who also hold social identities associated with disadvantage (non-English-speaking, female, older, lower socioeconomic level), continue to be underserved in the health system, which can result in poorer care and worsened health outcomes. Most disparity research in traumatic brain injury (TBI) focuses on the impact of single factors, which misses the compounding effect of belonging to multiple historically marginalized groups. OBJECTIVE: To examine the intersectional impact of multiple social identities vulnerable to systemic disadvantage following TBI on mortality, opioid usage during acute hospitalization, and discharge location. METHODS: Retrospective observational design utilizing electronic health records merged with local trauma registry data. Patient groups were defined by race and ethnicity (POC or non-Hispanic White), age, sex, type of insurance, and primary language (English-speaking vs non-English-speaking). Latent class analysis (LCA) was performed to identify clusters of systemic disadvantage. Outcome measures were then assessed across latent classes and tested for differences. RESULTS: Over an 8-year period, 10 809 admissions with TBI occurred (37% POC). LCA identified a 4-class model. Groups with more systemic disadvantage had higher rates of mortality. Classes with older populations had lower rates of opioid administration and were less likely to discharge to inpatient rehabilitation following acute care. Sensitivity analyses examining additional indicators of TBI severity demonstrated that the younger group with more systemic disadvantage had more severe TBI. Controlling for more indicators of TBI severity changed statistical significance in mortality for younger groups. CONCLUSION: Results demonstrate significant health inequities in the mortality and access to inpatient rehabilitation following TBI along with higher rates of severe injury in younger patients with more social disadvantages. While many inequities may be related to systemic racism, our findings suggested an additive, deleterious effect for patients who belonged to multiple historically disadvantaged groups. Further research is needed to understand the role of systemic disadvantage for individuals with TBI within the healthcare system.

Transmission of Bias in the Medical Record Among Physical Medicine and Rehabilitation Trainees.

ABSTRACT: Stigmatizing language can negatively influence providers' attitudes and care toward patients, but this has not been studied among physiatrists. An online survey was created to assess whether stigmatizing language can impact physical medicine and rehabilitation trainees' attitudes toward patients. We hypothesized stigmatizing language would negatively impact trainees' attitudes. Participants were randomized to a stigmatizing or neutral language vignette describing the same hypothetical spinal cord injury patient. Questions were asked about attitudes and assumptions toward the patient, pain management based on the vignette, and general views regarding individuals with disabilities. Between August 2021 and January 2022, 75 US physical medicine and rehabilitation residency trainees participated. Thirty-seven (49.3%) identified as women; 52 (69.3%) were White, and half (50.6%) received the stigmatized vignette. Participants exposed to stigmatizing language scored 4.8 points lower ( P < 0.01) on the provider attitude toward patient scale compared with those exposed to neutral language. There were no significant differences in the disability attitude scores between the two groups ( P = 0.81). These findings may indicate that stigmatizing language in the medical record may negatively affect physical medicine and rehabilitation trainees' attitudes toward patients. Further exploration is needed to identify the best way to educate trainees and reduce the propagation of bias in the medical record.

Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities.

BACKGROUND: Implementation of new skilled nursing facility (SNF) Medicare payment policy, the Patient Driven Payment Model (PDPM), resulted in immediate declines in physical and occupational therapy staffing. This study characterizes continuing impacts of PDPM in conjunction with COVID-19 on SNF therapy staffing and examines variability in staffing changes based on SNF organizational characteristics. METHODS: We analyzed Medicare administrative data from a national cohort of SNFs between January 2019 and March 2022. Interrupted time series mixed effects regression examined changes in level and trend of total therapy staffing minutes/patient-day during PDPM and COVID-19 and by type of staff (therapists, assistants, contractors, and in-house staff). Secondary analyses examined the variability in staffing by organizational characteristics. RESULTS: PDPM resulted in a -6.54% level change in total therapy staffing, with larger declines for assistants and contractors. Per-patient staffing fluctuated during COVID-19 as the census changed. PDPM-related staffing declines were larger in SNFs that were: Rural, for-profit, chain-affiliated, provided more intensive therapy, employed more therapy assistants, and admitted more Medicare patients before PDPM. COVID-19 resulted in larger staffing declines in rural SNFs but smaller early declines in SNFs that were hospital-based, for-profit, or received more relief funding. CONCLUSIONS: SNFs that historically engaged in profit-maximizing behaviors (e.g., providing more therapy via lower-paid assistants) had larger staffing declines during PDPM compared to other SNFs. Therapy staffing fluctuated during COVID-19, but PDPM-related reductions persisted 2 years into the pandemic, especially in rural SNFs. Results suggest specific organizational characteristics that should be targeted for staffing and quality improvement initiatives.

Long-term effects of transcranial direct current stimulation in the treatment of autism spectrum disorder: A randomized controlled trial.

AIM: To compare the efficacy of 0, 5, and 20 sessions of transcranial direct current stimulation (tDCS) for reducing symptoms of autism spectrum disorder (ASD). METHOD: Thirty-six male children with ASD (mean age 2 years 3 months, SD 4 months, age range 1 years 6 months-2 years 11 months) were balanced and stratified by age, sex, and baseline severity of ASD, to: (1) a control group that received 20 sessions of sham tDCS; (2) a 5-session tDCS group (5-tDCS) that received 5 sessions of active tDCS followed by 15 sessions of sham tDCS; and (3) a 20-session tDCS group (20-tDCS) that received 20 sessions of active tDCS. All groups participated in the special school activity of Khon Kaen Special Education Center, Thailand. The primary outcome was autism severity as measured by the Childhood Autism Severity Scale. RESULTS: The 5-tDCS and 20-tDCS groups evidenced greater reductions in autism severity than the control group at days 5 and 14, and months 6 and 12. There were no significant differences in the outcome between the 5- and 20-tDCS groups at any time point. Within-group analysis showed clinically meaningful improvements starting at month 6 for the participants in the control group, and clinically meaningful improvements starting on day 5 in both active tDCS groups, all of which were maintained to month 12. INTERPRETATION: The 5- and 20-session tDCS seems to reduce autism severity faster than sham tDCS. These effects maintained at least for 1 year. WHAT THIS PAPER ADDS: Twenty sessions of transcranial direct current stimulation (tDCS) were not superior to five sessions. Sham tDCS with a special school activity can reduce autism severity starting at 6 months after treatment. The benefits observed for 5 and 20 sessions of tDCS last for at least 12 months.

Associations Between Physical Activity Vital Sign in Patients and Health Care Utilization in a Health Care System, 2018-2020.

BACKGROUND: Physical inactivity is a risk factor for many chronic conditions. This retrospective cohort study examined associations between physical activity (PA) with health care utilization (HU). METHODS: A PA vital sign was recorded in clinics from January 2018 to December 2020. Patients were categorized as inactive, insufficiently active, or sufficiently active by US PA aerobic guidelines. Associations between PA vital sign and visits (inpatient admissions, emergency department, urgent care, and primary care) were estimated using population average regression by visit type. RESULTS: 23,721 patients had at least one PA vital sign recorded, with a mean age of 47.3 years and mean body mass index (BMI) of 28; 52% were female and 63% were White. Sufficiently active patients were younger, male, White, and had lower BMI than insufficiently active patients. Achieving 150 minutes per week of moderate to vigorous PA per 1000 patient years was associated with 34 fewer emergency department visits (P < .001), 19 fewer inpatient admissions (P < .001), and 38 fewer primary care visits (P < .001) compared with inactive patients. Stronger associations between lower PA and higher HU were present among those who were older or had a higher comorbidity. BMI, sex, ethnicity, and race did not modify the association between PA and HU. CONCLUSIONS: Meeting aerobic guidelines was associated with reduced HU for inpatient, primary care, and emergency department visits.

Oral adverse outcomes associated with the buccal mucosa graft for urethroplasty.

OBJECTIVE: The buccal mucosa graft (BMG) is the standard graft for reconstructive urology, but management of the donor site remains under debate. The authors compared postoperative oral adverse outcomes between management methods (closure, nonclosure, or xenograft-assisted closure). STUDY DESIGN: A retrospective cohort study was conducted, enrolling patients treated at Harborview Medical Center, Seattle, Washington. The patients had a history of urethroplasty using a unilateral BMG, and the primary outcome variables were postoperative oral adverse outcomes, defined as subjective changes in mouth opening, smile, chewing, speech, intraoral bleeding, paresthesia, trismus, and infection. Multivariate and regression analyses were performed. RESULTS: The sample was composed of 137 patients (95% male; mean age, 48 years). The mean surface areas of the BMG for closure, nonclosure, and xenograft were 1059, 1178, and 1228 mm2, respectively. Thirty-four patients completed the survey (7 closure, 17 nonclosure, and 10 xenograft). Multiple linear regression showed a significant difference between the 3 groups with respect to patient-reported chewing ability and trismus favoring xenograft at larger graft sizes (P < .01). CONCLUSIONS: Xenograft-assisted closure may reduce long-term oral adverse outcomes associated with trismus and subjective changes in chewing, mouth opening, speaking, and smiling with larger grafts. In addition, limited postoperative patient education for oral rehabilitation exercises was noted.

Effects of prosthetic feet on metabolic energy expenditure in people with transtibial amputation: A systematic review and meta-analysis.

OBJECTIVE: To assess the effects of different prosthetic feet on energy costs associated with walking and running in people with transtibial amputation. LITERATURE SURVEY: The Pubmed, CINAHL, and Web-of-Science bibliographic databases were searched for original research published through June 30, 2018. References from identified articles were also reviewed. METHODOLOGY: Two reviewers screened titles, abstracts, and articles for pertinent studies. Details were extracted with a standardized template. Risk of bias was assessed using domain-based methods. Prosthetic feet were grouped into categories and compared according to energy costs associated with walking or running over various terrain conditions. Meta-analyses were conducted when data quantity and homogeneity permitted. Evidence statements were formed when results were consistent or undisputed. SYNTHESIS: Fifteen studies were included. Participants (n = 141) were predominantly male (87.9%), had unilateral amputation (95.7%) from non-dysvascular causes (87.9%), and were classified as unlimited community ambulators or active adults (56.0%). Participants were often young but varied in age (mean age 24.8-66.6 years). Available evidence indicates that feet with powered dorsiflexion reduce energy costs relative to dynamic response feet in unlimited community ambulators or active adults when walking on level or declined surfaces. Dynamic response feet do not significantly reduce energy costs compared to energy storing, flexible keel, or solid ankle feet when walking on level terrain. Running feet do not reduce energy costs relative to dynamic response in active adults when running. Select feet may reduce energy costs under specific conditions, but additional research is needed to confirm preliminary results. CONCLUSIONS: The overall body of evidence is based on small samples, comprised mostly of participants who may not well represent the population of prosthesis users and test conditions that may not well reflect how prostheses are used in daily life. However, evidence suggests energy costs are affected by prosthetic foot type only under select conditions.

COVID-19 vaccine hesitancy in adults with multiple sclerosis in the United States: A follow up survey during the initial vaccine rollout in 2021.

BACKGROUND: Multiple sclerosis (MS) organizations have recommended that adults with MS obtain the COVID-19 vaccination. Vaccine hesitancy is a barrier to full COVID-19 inoculation in the general population. Whether vaccine hesitancy is also a barrier towards optimizing vaccination rates in the MS community is unknown. To investigate vaccine hesitancy and inform efforts to increase vaccine uptake in the MS population, we conducted a follow up survey of a national sample of adults with MS living in the United States who completed an initial survey early in the COVID-19 pandemic. The current study aimed to answer questions vital to understanding vaccine hesitancy, specifically: (1) What is the prevalence of COVID-19 vaccine hesitancy in early 2021? (2) What are the reasons for and factors associated with current hesitancy? (3) How has vaccine willingness and hesitancy changed from April/May 2020 to January/February 2021? and (4) Who has changed in their vaccine willingness? METHODS: Adults with MS living in the United States (N = 359) completed two online surveys (the first between 10 April 2020 and 06 May 2020; the second between 11 January 2021 and 08 February 2021) about their willingness and intent to obtain a COVID-19 vaccine. Participants also completed measures to assess factors potentially related to vaccine hesitancy, including demographics, MS variables, influenza vaccine history, vaccine concerns, and contextual factors, including perceived risk for SARS-CoV-2 infection, trust in COVID-19 information source, anxiety, and loneliness. RESULTS: Of the participants who completed the second survey in early 2021, 20.3% were vaccine hesitant, that is, either reporting that they were undecided (13.9%) or not intending to get vaccinated (6.4%). Vaccine hesitancy decreased between the two surveys, with nearly three-fourths (73.8%) of the second sample reporting that they planned to obtain the COVID-19 vaccine. Vaccine hesitancy was associated with having a lower level of education, being non-White, not having a recent flu vaccination, holding a lower perception of one's risk of getting COVID-19, and having lower trust in the Centers for Disease Control and Prevention. Participants who were vaccine hesitant reported concerns about the long-term effects of the vaccine, the vaccine approval process, and the potential impact of the vaccine given their own health conditions/history. Notably, 90% of the undecided group wanted additional information about the vaccine before deciding. Vaccine willingness changed over time, with many of those who were somewhat willing more willing to get the COVID-19 vaccine at survey 2. Individuals who were unwilling at survey 1 were highly likely to remain unwilling at survey 2. CONCLUSION: Overall, COVID-19 vaccine hesitancy decreased during the pandemic, although one in five adults with MS were hesitant in early 2021. Of those who were undecided, most indicated that they wanted additional information about the vaccine before deciding whether to be vaccinated, suggesting additional educational efforts on the vaccine's safety, long-term effects, and potential health implications are still needed. Findings indicate that public health efforts may be best focused on those who are undecided, whose vaccine hesitancy may change over time and, possibly, with appropriate information or intervention.

Relationship Between Duration of Targeted Temperature Management, Ischemic Interval, and Good Functional Outcome From Out-of-Hospital Cardiac Arrest.

OBJECTIVES: Tailoring hypothermia duration to ischemia duration may improve outcome from out-of-hospital cardiac arrest. We investigated the association between the hypothermia/ischemia ratio and functional outcome in a secondary analysis of data from the Resuscitation Outcomes Consortium Amiodarone, Lidocaine, or Placebo Study trial. DESIGN: Cohort study of out-of-hospital cardiac arrest patients screened for Resuscitation Outcomes Consortium-Amiodarone, Lidocaine, or Placebo Study. SETTING: Multicenter study across North America. PATIENTS: Adult, nontraumatic, out-of-hospital cardiac arrest patients screened for Resuscitation Outcomes Consortium-Amiodarone, Lidocaine, or Placebo Study who survived to hospital admission and received targeted temperature management between May 2012 and October 2015. INTERVENTIONS: Targeted temperature management in comatose survivors of out-of-hospital cardiac arrest. We defined hypothermia/ischemia ratio as total targeted temperature management time (initiation through rewarming) divided by calculated total ischemia time (approximate time of arrest [9-1-1 call or emergency medical services-witnessed] to return of spontaneous circulation). MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital survival with good functional status (modified Rankin Score, 0-3) at hospital discharge. We fitted logistic regression models to estimate the association between hypothermia/ischemia ratio and the primary outcome, adjusting for demographics, arrest characteristics, and Resuscitation Outcomes Consortium enrolling site. A total of 3,429 patients were eligible for inclusion, of whom 36.2% were discharged with good functional outcome. Patients had a mean age of 62.0 years (SD, 15.8), with 69.7% male, and 58.0% receiving lay-rescuer cardiopulmonary resuscitation. Median time to return of spontaneous circulation was 21.1 minutes (interquartile range, 16.1-26.9), and median duration of targeted temperature management was 32.9 hours (interquartile range, 23.7-37.8). A total of 2,579 had complete data and were included in adjusted regression analyses. After adjustment for patient characteristics and Resuscitation Outcomes Consortium site, a greater hypothermia/ischemia ratio was associated with increased survival with good functional outcome (odds ratio, 2.01; 95% CI, 1.82-2.23). This relationship, however, appears to be primarily driven by time to return of spontaneous circulation in this patient cohort. CONCLUSIONS: Although a larger hypothermia/ischemia ratio was associated with good functional outcome after out-of-hospital cardiac arrest in this cohort, this association is primarily driven by duration of time to return of spontaneous circulation. Tailoring duration of targeted temperature management based on duration of time to return of spontaneous circulation or patient characteristics requires prospective study.

Bayesian Analysis of the Pragmatic Airway Resuscitation Trial.

STUDY OBJECTIVE: Intubation and laryngeal tube insertion are common airway management strategies in out-of-hospital cardiac arrest. Bayesian analysis offers an alternate statistical approach to assess the results of a trial. We use Bayesian analysis to compare the effectiveness of initial laryngeal tube versus initial intubation strategies on outcomes after out-of-hospital cardiac arrest in the Pragmatic Airway Resuscitation Trial. METHODS: We performed a post hoc Bayesian analysis of the Pragmatic Airway Resuscitation Trial. We defined prior distributions representing neutral or skeptical estimates of laryngeal tube benefit. Using Bayesian log binomial models, we fit models for 72-hour survival, hospital survival, and hospital survival with favorable neurologic status. We estimated the posterior probability (the probability of observing an effect difference between treatment groups) of the benefit of laryngeal tube over intubation on out-of-hospital cardiac arrest outcomes. RESULTS: The parent trial enrolled 3,004 patients (1,505 laryngeal tube, 1,499 intubation). Under a neutral prior distribution (relative risk 1.0), laryngeal tube was better than intubation (72-hour survival risk difference 1.8% [95% credible interval {CrI} -0.9% to 4.5%], posterior probability 91%; hospital survival 1.4% [95% CrI -0.4% to 3.4%], posterior probability 93%; and hospital survival with favorable neurologic status 0.7% [95% CrI -0.5% to 2.1%], posterior probability 86%). Under a skeptical prior distribution (relative risk 0.83 to 0.92), laryngeal tube was also better than intubation (72-hour survival risk difference 1.7% [95% CrI -0.9% to 4.3%], posterior probability 89%; hospital survival 1.3% [95% CrI -0.5% to 3.3%], posterior probability 91%; and hospital survival with favorable neurologic status 0.6% [95% CrI -0.5% to 2.0%], posterior probability 82%). CONCLUSION: Under various prior assumptions, post hoc Bayesian analysis of the Pragmatic Airway Resuscitation Trial confirmed better out-of-hospital cardiac arrest outcomes with a strategy of initial laryngeal tube than initial intubation.

Frequency of Operative Anesthesia Care After Traumatic Injury.

BACKGROUND: Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I-V), using data from a comprehensive, regional database-the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation. METHODS: We conducted a retrospective analysis measuring the frequency of operative anesthesia care among patients enrolled in the WSTR. Univariate comparisons were made between trauma patients who had surgery during their admission and those who did not (medical management only). In addition, clinical factors associated with surgical intervention were measured. We also measured the average times from hospital admission to surgery and compared these times across trauma centers, grouped level I, II, and III-V. RESULTS: From 2004 to 2014, there were approximately 176,000 encounters meeting WSTR inclusion criteria. Approximately 60% of these trauma encounters included exposure to operative anesthesia during the admission. Among all surgical procedures during the trauma admission, approximately 33% occurred within a level I trauma center, 23% occurred within a level II trauma center, and 44% occurred in a trauma center with a III, IV, or V designation. The predominant procedure category during a trauma admission was orthopedic. The presence of hypotension on admission (P < .01), increasing injury severity score (P < .01) and higher emergency department Glasgow Coma Score (P < .01) were all associated with surgical intervention during the trauma hospitalization, after adjustment for potential confounders. In level I trauma centers, for general surgical procedures, the median time to surgery was 2.5 hours; in level II trauma centers, the median time was 1.7 hours. CONCLUSIONS: This study highlights the frequent role anesthesiologists play in caring for patients who sustain traumatic injuries, in trauma centers levels I-V. In level II trauma centers, in-house anesthesiology coverage might have benefit for those patients requiring surgery within 1 hour, whereas the former American College of Surgeons requirement of 30-minute response time for out-of-hospital anesthesiology coverage is likely sufficient to provide satisfactory care to patients requiring surgery within 3 hours. Whether the increased cost of such in-house anesthesiology coverage at level II trauma centers is justified by its clinical benefit remains an unanswered question.

Hospital Variation in the Utilization and Implementation of Targeted Temperature Management in Out-of-Hospital Cardiac Arrest.

Background Targeted temperature management (TTM) for out-of-hospital cardiac arrest is associated with improved functional survival and is a class I recommendation in resuscitation guidelines. However, patterns of utilization of TTM and adherence to recommended TTM guidelines in contemporary practice are unknown. Methods and Results In a multicenter, prospective cohort of consecutive adults with non-traumatic out-of-hospital cardiac arrest in the Resuscitation Outcomes Consortium in 2012 to 2015, we identified all adults (≥18 years) who were potential candidates for TTM. Of 37 898 out-of-hospital cardiac arrest patients at 186 hospitals across 10 Resuscitation Outcomes Consortium sites, 8313 survived for ≥4 hours after hospital arrival, of which, 2878 (34.6%) received TTM. Mean age was 61.5 years and 36.3% were women. Median hospital rate of TTM use was 27% (interquartile range [IQR]: 14%, 45%), with an over 2-fold difference across sites after accounting for differences in presentation characteristics (median odds ratio, 2.10 [1.83-2.26]). Notably, TTM utilization decreased during the study period (57.5% [2012] to 26.5% [2015], P<0.001) including among shockable out-of-hospital cardiac arrest (73.4% to 46.3%, P<0.001). When administered, the median rate of deviation from one or more recommended practices was 60% (IQR: 40%, 78%). The median rate for delayed onset of TTM was 13% (IQR: 0%, 25%), varying by 70% for identical patients across 2 randomly chosen hospitals (median odds ratio 1.70 [1.39-1.97]). Similarly, the median rate for TTM <24 hours was 20% (IQR: 0%, 34%) and for achieved temperature <32°C was 18% (IQR: 0%, 39%), with marked variation across sites (median odds ratios of 1.44 [1.18-1.64] and 1.98 [1.62-2.31], respectively). Conclusions There has been a substantial decline in the utilization of TTM with significant variation in its real-world implementation. Further standardization of contemporary post-resuscitation practices, like TTM, is critical to ensure that their potential survival benefit is realized.