Utility of 30-day mortality as a quality metric for palliative radiation treatment: A population-based analysis from Queensland, Australia.

INTRODUCTION: Palliative radiotherapy (PRT) is frequently used to treat symptoms of advanced cancer, however benefits are questionable when life expectancy is limited. The 30-day mortality rate after PRT is a potential quality indicator, and results from a recent meta-analysis suggest a benchmark of 16% as an upper limit. In this population-based study from Queensland, Australia, we examined 30-day mortality rates following PRT and factors associated with decreased life expectancy. METHODS: Retrospective population data from Queensland Oncology Repository was used. Study population data included 22,501 patients diagnosed with an invasive cancer who died from any cause between 2008 and 2017 and had received PRT. Thirty-day mortality rates were determined from the date of last PRT fraction to date of death. Cox proportional hazards models were used to identify factors independently associated with risk of death within 30 days of PRT. RESULTS: Overall 30-day mortality after PRT was 22.2% with decreasing trend in more recent years (P = 0.001). Male (HR = 1.20, 95% CI = 1.13-1.27); receiving 5 or less radiotherapy fractions (HR = 2.97, 95% CI = 2.74-3.22 and HR = 2.17, 95% CI = 2.03-2.32, respectively) and receiving PRT in a private compared to public facility (HR = 1.61, 95% CI = 1.51-1.71) was associated with decreased survival. CONCLUSION: The 30-day mortality rate in Queensland following PRT is higher than expected and there is scope to reduce unnecessarily protracted treatment schedules. We encourage other Australian and New Zealand centres to examine and report their own 30-day mortality rate following PRT and would support collaboration for 30-day mortality to become a national and international quality metric for radiation oncology centres.

Perspectives of Pediatric Providers on Patients With Complex Chronic Conditions: A Mixed-Methods Sequential Explanatory Study.

BACKGROUND: Children with complex chronic conditions present unique challenges to the pediatric intensive care unit, including prolonged length of stay, complex medical regimens, and complicated family dynamics. OBJECTIVES: To examine perspectives of pediatric intensive care unit health care providers regarding pediatric patients with complex chronic conditions, and to explore potential opportunities to improve these patients' care. METHODS: A prospective mixed-methods sequential explanatory study was conducted in a tertiary medical-surgical pediatric intensive care unit using surveys performed with REDCap (Research Electronic Data Capture) followed by semistructured interviews. RESULTS: The survey response rate was 70.6% (77 of 109). Perspectives of health care providers did not vary with duration of work experience. Ten semistructured interviews were conducted. Eight overarching themes emerged from the interviews: (1) the desire for increased formal education specific to pediatric complex chronic care patients; (2) designation of a primary intensivist; (3) modifying delivery of care to include a discrete location for care provision; (4) establishing daily, short-term, and long-term goals; (5) monitoring and documenting care milestones; (6) strengthening patient and family communications with the health care team; (7) optimizing discharge coordination and planning; and (8) integrating families into care responsibilities. CONCLUSIONS: Pediatric intensive care unit health care providers' perspectives of pediatric patients with complex chronic conditions indicated opportunities to refine the care provided by establishing daily goals, coordinating discharge planning, and creating occasions for close communication between patients, families, and providers.

Which pressure to believe? A comparison of direct arterial with indirect blood pressure measurement techniques in the pediatric intensive care unit.

OBJECTIVE: To determine the accuracy of arterial blood pressure monitoring using 1) direct arterial; 2) automated oscillometric; and 3) sphygmomanometer/Doppler ultrasound measurements in pediatric intensive care patients comparing methods 1) and 2) with 3), the gold standard used to define normal blood pressure. DESIGN: Prospective observational study. SETTING: Pediatric intensive care unit of a tertiary care pediatric teaching hospital. PATIENTS: Forty children (birth to 17 yrs) admitted to the pediatric intensive care unit with various clinical conditions requiring a radial arterial catheter for continuous arterial blood pressure monitoring. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Each subject had measurements taken every 6 hrs over a 24-hr period. Each set of measurements were: direct arterial blood pressure, indirect blood pressure using the Phillips automated oscillometric device, and indirect blood pressure using the sphygmomanometer and Doppler ultrasound. Analysis used the Bland-Altman plot followed by paired t testing to compare the three different methods. One hundred sixty triads of measurements were analyzed. There were no significant differences between the methods of blood pressure measurement when groups were analyzed based on age. When analyzed by age-specific normo-, hypo-, and hypertensive criteria, arterial blood pressure measurements agree closely with Doppler ultrasound readings, whereas systolic arterial blood pressure measurements were lower than indirect blood pressure using the Phillips automated oscillometric device readings in the hypotensive group (p < .001). In the hypertensive group, the systolic arterial blood pressure values were higher and indirect blood pressure using the Phillips automated oscillometric device readings lower (p < .001) than Doppler ultrasound (p = .03). There was no clinically significant difference between methods in the normotensive group. Diastolic blood pressure measurements were higher by arterial blood pressure in normotensive and hypertensive groups but no different in the hypotensive group. CONCLUSION: Outside the normotensive range, the automated readings were higher during hypotension and lower during hypertension compared with the arterial and Doppler ultrasound methods. The arterial blood pressure was closer to the gold standard Doppler ultrasound blood pressure in all three blood pressure groups.