The implications of long-term acute care hospital transfer practices for measures of in-hospital mortality and length of stay.

RATIONALE: The National Quality Forum recently endorsed in-hospital mortality and intensive care unit length of stay (LOS) as quality indicators for patients in the intensive care unit. These measures may be affected by transferring patients to long-term acute care hospitals (LTACs). OBJECTIVES: To quantify the implications of LTAC transfer practices on variation in mortality index and LOS index for patients in academic medical centers. METHODS: We used a cross-sectional study design using data reported to the University HealthSystem Consortium from 2008-2009. Data were from patients who were mechanically ventilated for more than 96 hours. MEASUREMENTS AND MAIN RESULTS: Using linear regression, we measured the association between mortality index and LTAC transfer rate, with the hospital as the unit of analysis. Similar analyses were conducted for LOS index and cost index. A total of 137 hospitals were analyzed, averaging 534 transfers to LTAC per hospital during the study period. Mean±SD in-hospital mortality was 24±6.4%, and observed LOS was 30.4±8.2 days. The mean LTAC transfer rate was 15.7±13.7%. Linear regression demonstrated a significant correlation between transfer rate and mortality index (R2=0.14; P<0.0001) and LOS index (R2=0.43; P<0.0001). CONCLUSIONS: LTAC hospital transfer rate has a significant impact on reported mortality and LOS indices for patients requiring prolonged acute mechanical ventilation. This is an example of factors unrelated to quality of medical care or illness severity that must be considered when interpreting mortality and LOS as quality indicators.

Vitamin d deficiency in cystic fibrosis.

Cystic Fibrosis is the most common inherited genetic respiratory disorder in the Western World. Hypovitaminosis D is almost universal in CF patients, likely due to a combination of inadequate absorption, impaired metabolism, and lack of sun exposure. Inadequate levels are associated with the high prevalence of bone disease or osteoporosis in CF patients, which is associated with increased morbidity including fractures, kyphosis, and worsening pulmonary status. Treatment goals include regular monitoring 25 hydroxyvitamin D (25OHD) levels with aggressive treatment for those with levels <75 nmol/L (<30 ng/mL). More research is needed to determine optimal supplementation goals and strategies.

The prevalence of clinically relevant incidental findings on chest computed tomographic angiograms ordered to diagnose pulmonary embolism.

BACKGROUND: Chest computed tomographic angiograms (CTAs) are frequently ordered for evaluation of suspected pulmonary embolism (PE) in the emergency department, but non-PE findings are often noted. Our objective was to determine the prevalence and management implications of incidental findings on chest CTAs ordered to assess for PE. METHODS: In a cross-sectional study, we reviewed 589 pulmonary CTAs that were ordered in the emergency department of a tertiary care hospital. We measured the prevalence of PE and placed other findings into the following 3 categories: (1) findings that provided potential alternative explanations for acute symptoms, (2) incidental findings that required clinical or radiologic follow-up, and (3) other findings that required less urgent or no follow-up. We reviewed all newly diagnosed pulmonary nodules and significant thoracic adenopathy and determined standard recommended clinical follow-up. RESULTS: Pulmonary embolism was found in 55 of 589 CTAs (9%). A total of 195 CTAs (33%) had findings that supported alternative diagnoses. A total of 141 patients (24%) had a new incidental finding that required diagnostic follow-up, including 73 patients (13%) with a new pulmonary nodule and 51 patients (9%) with new adenopathy. Using current clinical guidelines, follow-up computed tomography or another procedure would be recommended for 96% of patients with new incidental pulmonary nodules. CONCLUSIONS: The CTAs that are ordered in the emergency department are more than twice as likely to find an incidental pulmonary nodule or adenopathy than a PE. Systematic approaches should be developed to help primary care physicians contend with a growing number of clinically relevant incidental radiologic findings.

Endobronchial clear cell adenocarcinoma occurring in a patient 15 years after treatment for DES-associated vaginal clear cell adenocarcinoma.

BACKGROUND: Clear cell adenocarcinoma (CCA) of the vagina and cervix in young women is associated with prenatal exposure to diethylstilbestrol (DES). Parenchymal pulmonary metastases are known to occur following treatment of the primary tumor. Most recurrences present within 2 to 3 years of the initial diagnosis. CASE: This is a case report of a solitary endobronchial clear cell adenocarcinoma occurring 15.3 years after the initial diagnosis of DES-induced CCA. CONCLUSIONS: This case suggests that management of clear cell cancer survivors should involve long-term follow-up because of the potential for the appearance of a new focus of clear cell adenocarcinoma.