Carbonyl Yields in Cigars under Three Smoking Regimens Using a Linear Smoking Machine.

This study used standard linear smoking machines and puffing protocols to generate data on carbonyl yields in mainstream smoke from 11 unfiltered sheet-wrapped cigars (SWC), seven leaf-wrapped cigars (LWC), and two Kentucky reference cigarettes (3R4F, 1R6F). Carbonyl yields in cigar and cigarette products were determined using three different smoking regimens: International Organization for Standardization (ISO), Canadian Intense (CI), and Cooperation Centre for Scientific Research Relative to Tobacco (CORESTA) Recommended Method (CRM) No. 64 (CRM64, Routine Analytical Cigar-Smoking Machine─Specifications, Definitions and Standard Conditions). Mainstream tobacco smoke was collected using a smoking machine fitted with an impinger containing 2,4-dinitrophenylhydrazine (DNPH) and carbonyl compounds quantified using liquid chromatography with an ultraviolet detector. Commercial SWC and LWC generated comparable formaldehyde yields (SWC, 9.4-28 µg/cigar [ISO], 8.2-43 µg/cigar [CI], 8.6-13 µg/cigar [CRM64]; LWC, 11-13 µg/cigar [ISO], 11-22 µg/cigar [CI], 16-21 µg/cigar [CRM64]) and acrolein yields; however, LWC generated higher acetaldehyde yields compared to SWC, using CI and CRM64 regimens. Reference cigarettes using standard puffing regimens generated carbonyl yields within reported ranges and 5-10% RSDs, whereas the CRM64 regimen generated lower carbonyl yields and 12-14% RSDs. Reference cigarettes generated higher formaldehyde yields using cigarette smoking regimens (21-28 µg/cigarette under ISO, 76-96 µg/cigarette under CI) but comparable formaldehyde yields under CRM64 (12-14 µg/cigarette). In addition, this study evaluated physical parameters (e.g., tobacco weight, length, diameter, circumference, tobacco rod density) that show the correlation between tobacco weight, tobacco rod density, and acetaldehyde yields under the three smoking regimens. Carbonyl yields in the mainstream smoke of cigar products using the three smoking regimens were highly variable; however, the CI smoking regimen may provide meaningful analytical information regarding cigar smoke constituents, with lower likelihood of self-extinguishment due to the short puffing intervals.

Cost Savings of Mother's Own Milk for Very Low Birth Weight Infants in the Neonatal Intensive Care Unit.

OBJECTIVE: The study aim was to determine the relationship between hospitalization costs and mother's own milk (MOM) dose for very low birth weight (VLBW; < 1500 g) infants during the initial neonatal intensive care unit (NICU) stay. Additionally, because MOM intake during the NICU hospitalization is associated with a reduction in the risk of late-onset sepsis, necrotizing enterocolitis (NEC), and bronchopulmonary dysplasia (BPD), we aimed to quantify the incremental cost of these potentially preventable complications of prematurity. METHODS: The study included 430 VLBW infants enrolled in the Longitudinal Outcomes of Very Low Birthweight Infants Exposed to Mothers' Own Milk prospective cohort study between 2008 and 2012 at Rush University Medical Center in Chicago, IL, USA. NICU hospitalization costs included hospital, feeding, and physician costs. The average marginal effect of MOM dose and prematurity-related complications known to be reduced by MOM intake on NICU hospitalization costs were estimated using generalized linear regression. RESULTS: The mean NICU hospitalization cost was $190,586 (standard deviation $119,235). The marginal cost of sepsis was $27,890 (95% confidence interval [CI] $2934-$52,646), of NEC was $46,103 (95% CI $16,829-$75,377), and of BPD was $41,976 (95% CI $24,660-59,292). The cumulative proportion of MOM during the NICU hospitalization was not significantly associated with cost. CONCLUSIONS: A reduction in the incidence of complications that are potentially preventable with MOM intake has significant cost implications. Hospitals should prioritize investments in initiatives to support MOM feedings in the NICU.

Racial and ethnic disparity in palliative care and hospice use.

OBJECTIVES: Prior research has demonstrated differences across race and ethnicity, as well as across geographic location, in palliative care and hospice use for patients near the end of life. However, there remains inconsistent evidence regarding whether these disparities are explained by hospital-level practice variation. The goals of this study were to evaluate whether inpatient palliative care consultation use and discharge to hospice differed by race/ethnicity and whether hospital-level variations explained these differences. STUDY DESIGN: Retrospective, cross-sectional study. METHODS: This study evaluated 5613 patients who were discharged to hospice or died during their hospital stay between 2012 and 2014 in 4 urban hospitals with an inpatient palliative care service. The main outcomes were receipt of an inpatient palliative care consultation and discharge to hospice. RESULTS: The sample was 43% white, 44% African American, and 13% Hispanic. After adjusting for patient characteristics and hospital site, race/ethnicity was not significantly associated with receipt of inpatient palliative care consultation. Hispanic race/ethnicity was associated with a higher likelihood of discharge to hospice (odds ratio, 1.22; P = .036), and inpatient palliative care consultation was associated with 4 times higher likelihood of discharge to hospice (P <.001). Hospital site was also associated with both receipt of inpatient palliative care consultation and discharge to hospice. CONCLUSIONS: Our results illustrate significant variation across hospitals in palliative care consultation use and discharge to hospice. No significant racial/ethnic disparities in the use of either palliative care or hospice at the end of life were found within hospitals.

Multi-year Study of PAHs in Mainstream Cigarette Smoke.

OBJECTIVES: Correlations are made between mainstream cigarette smoke deliveries of individual PAHs over multiple years. Average overall PAH deliveries in mainstream cigarette smoke by study year, mentholation, ring size, and manufacturer are compared. METHODS: Mainstream smoke deliveries were determined by GC/MS for 14 polycyclic aromatic hydrocarbons (PAHs) from selected cigarettes on the US market in 2002, 2004, 2007, and 2011. The mainstream smoke PAH emissions were measured under international standardization organization (ISO) smoking conditions. Pearson product-moment correlation was used to examine the linear relationship among the PAHs over multiple years. RESULTS: A number of the PAH analytes were statistically highly correlated with each other. The overall average for mainstream smoke deliveries of PAHs did not change significantly between study years. Similar levels in average PAH deliveries were seen for mentholated and non-mentholated cigarettes. CONCLUSIONS: The strong correlations between PAH compounds over multiple years show that a limited set of PAHs can predict deliveries of others with confidence over multiple years. A more limited panel of analytes may be considered when designing studies involving PAH measurements in mainstream smoke.

Palliative Workforce Development and a Regional Training Program.

AIMS: Our primary aims were to assess growth in the local hospital based workforce, changes in the composition of the workforce and use of an interdisciplinary team, and sources of support for palliative medicine teams in hospitals participating in a regional palliative training program in Chicago. METHODS: PC program directors and administrators at 16 sites were sent an electronic survey on institutional and PC program characteristics such as: hospital type, number of beds, PC staffing composition, PC programs offered, start-up years, PC service utilization and sources of financial support for fiscal years 2012 and 2014. RESULTS: The median number of consultations reported for existing programs in 2012 was 345 (IQR 109 - 2168) compared with 840 (IQR 320 - 4268) in 2014. At the same time there were small increases in the overall team size from a median of 3.2 full time equivalent positions (FTE) in 2012 to 3.3 FTE in 2013, with a median increase of 0.4 (IQR 0-1.0). Discharge to hospice was more common than deaths in the acute care setting in hospitals with palliative medicine teams that included both social workers and advanced practice nurses ( p < .0001). CONCLUSIONS: Given the shortage of palliative medicine specialist providers more emphasis should be placed on training other clinicians to provide primary level palliative care while addressing the need to hire sufficient workforce to care for seriously ill patients.

Development of a Cigarette Tobacco Filler Standard Reference Material.

A new tobacco filler Standard Reference Material (SRM) has been issued by the National Institute of Standards and Technology (NIST) in September 2016 with certified and reference mass fraction values for nicotine, N-nitrosonornicotine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone, and volatiles. The constituents have been determined by multiple analytical methods with measurements at NIST and at the Centers for Disease Control and Prevention, and with confirmatory measurements by commercial laboratories. This effort highlights the development of the first SRM for reduced nicotine and reduced tobacco-specific nitrosamines with certified values for composition.

Integration of Palliative Care Advanced Practice Nurses Into Intensive Care Unit Teams.

BACKGROUND: Referrals to palliative care for patients at the end of life in the intensive care unit (ICU) often happen late in the ICU stay, if at all. The integration of a palliative medicine advanced practice nurse (APN) is one potential strategy for proactively identifying patients who could benefit from this service. OBJECTIVE: To evaluate the association between the integration of palliative medicine APNs into the routine operations of ICUs and hospital costs at 2 different institutions, Montefiore Medical Center (MMC) and Rush University Medical Center. METHODS: The association between collaborative palliative care consultation service programs and hospital costs per patient was evaluated for the 2 institutions. Hospital costs were compared for patients with and without a referral to palliative care using Mann-Whitney U tests. RESULTS: Hospital nonroom and board costs at the Weiler campus of MMC were significantly lower for patients with palliative care compared with those who did not receive palliative care (Median = US$6643 vs US$12 399, P < .001). Cost differences for ICU patients with and without palliative care at Rush University Medical Center were not significantly different. CONCLUSION: Our evaluation suggests that the integration of APNs into a palliative care team for case finding may be a promising strategy, but more work is needed to determine whether reductions in cost are significant.

Influence of own mother's milk on bronchopulmonary dysplasia and costs.

BACKGROUND: Human milk from the infant's mother (own mother's milk; OMM) feedings reduces the risk of several morbidities in very low birthweight (VLBW) infants, but limited data exist regarding its impact on bronchopulmonary dysplasia (BPD). OBJECTIVE: To prospectively study the impact of OMM received in the neonatal intensive care unit (NICU) on the risk of BPD and associated costs. DESIGN/METHODS: A 5-year prospective cohort study of the impact of OMM dose on growth, morbidity and NICU costs in VLBW infants. OMM dose was the proportion of enteral intake that consisted of OMM from birth to 36 weeks postmenstrual age (PMA) or discharge, whichever occurred first. BPD was defined as the receipt of oxygen and/or positive pressure ventilation at 36 weeks PMA. NICU costs included hospital and physician costs. RESULTS: The cohort consisted of 254 VLBW infants with mean birth weight 1027±257 g and gestational age 27.8±2.5 weeks. Multivariable logistic regression demonstrated a 9.5% reduction in the odds of BPD for every 10% increase in OMM dose (OR 0.905 (0.824 to 0.995)). After controlling for demographic and clinical factors, BPD was associated with an increase of US$41 929 in NICU costs. CONCLUSIONS: Increased dose of OMM feedings from birth to 36 weeks PMA was associated with a reduction in the odds of BPD in VLBW infants. Thus, high-dose OMM feeding may be an inexpensive, effective strategy to help reduce the risk of this costly multifactorial morbidity.

Patient safety intervention to reduce unnecessary red blood cell utilization.

OBJECTIVES: To measure the impact of a local patient safety intervention and a national guideline to reduce unnecessary red blood cell (RBC) transfusions in the Department of Medicine of an academic medical center. STUDY DESIGN: This was a retrospective, pre-post study. METHODS: In May 2013, a clinical practice guideline, modeled after the 2012 AABB recommendations for RBC use, was implemented with the goal of decreasing unnecessary RBC transfusions. This was done using a previously developed model for change management in the Department of Medicine that included academic safety conferences, e-mail safety alerts, and feedback to providers on global blood product utilization. Data regarding the utilization of RBC products were obtained for the time before the AABB guideline, after the AABB guideline but before the local intervention, and after the local intervention (January 2011 through March 2014). RESULTS: Blood product use started to decline after the AABB guideline, but dropped much further after the focused, local interventions were implemented. The proportion of patients receiving a transfusion decreased from 12.6% prior to the AABB guideline to 8.8% after the intervention (P < .001). The percent of total blood use with a hemoglobin level above 8 g/dL decreased from 20.2% to 12.4%; the total units of RBCs transfused per 100 discharges also decreased from 33.4 to 21.7. The direct RBC costs per discharge dropped from $61.60 to $39.70. CONCLUSIONS: Passive adoption of restrictive transfusion guidelines was shown to reduce blood product use on general medicine floors of an academic medical center, but the effect was greatly improved after a local, targeted intervention to improve patient safety was implemented.

Management Options and Outcomes for Neonatal Hypoplastic Left Heart Syndrome in the Early Twenty-First Century.

Without surgical treatment, neonatal hypoplastic left heart syndrome (HLHS) mortality in the first year of life exceeds 90 % and, in spite of improved surgical outcomes, many families still opt for non-surgical management. The purpose of this study was to investigate trends in neonatal HLHS management and to identify characteristics of patients who did not undergo surgical palliation. Neonates with HLHS were identified from a serial cross-sectional analysis using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 2000 to 2012. The primary analysis compared children undergoing surgical palliation to those discharged alive without surgery using a binary logistic regression model. Multivariate logistic regression was conducted to determine factors associated with treatment choice. A total of 1750 patients underwent analysis. Overall hospital mortality decreased from 35.3 % in 2000 to 22.9 % in 2012. The percentage of patients undergoing comfort care discharge without surgery also decreased from 21.2 to 14.8 %. After controlling for demographics and comorbidities, older patients at presentation were less likely to undergo surgery (OR 0.93, 0.91-0.96), and patients in 2012 were more likely to undergo surgery compared to those in prior years (OR 1.5, 1.1-2.1). Discharge without surgical intervention is decreasing with a 30 % reduction between 2000 and 2012. Given the improvement in surgical outcomes, further dialogue about ethical justification of non-operative comfort or palliative care is warranted. In the meantime, clinicians should present families with surgical outcome data and recommend intervention, while supporting their option to refuse.

Case Volume and Outcomes of Congenital Diaphragmatic Hernia Surgery in Academic Medical Centers.

OBJECTIVE: The outcome of patients with congenital diaphragmatic hernia (CDH) has not improved in the last decade and surgical repair remains the mainstay of treatment. The purpose of the present study was to assess whether a volume-outcome relationship exists in the U.S. academic medical centers performing surgical repair of neonatal CDH. STUDY DESIGN: A retrospective cross-sectional analysis of discharge data for neonates undergoing CDH repair in academic medical center members of the University Health-System Consortium was employed. Unadjusted mortality was compared between lower and higher surgical volume centers. A binary logistic regression model was fit to test the relationship of surgical volume with mortality. RESULTS: A total of 3,738 patients underwent surgical repair in 122 unique academic medical centers in the United States. The overall rate of survival was 75.2%. There was no difference in unadjusted mortality between lower and higher volume centers. After controlling for patient and hospital variables, there was no difference in the odds of mortality between lower and higher volume centers (odds ratio 1.03 [95% confidence interval, 0.86-1.23, p = 0.730]). CONCLUSIONS: Neonates born with congenital diaphragmatic hernia can undergo surgical repair in the U.S. academic medical centers independent of center procedure volume and expect good surgical outcomes.

Economic benefits and costs of human milk feedings: a strategy to reduce the risk of prematurity-related morbidities in very-low-birth-weight infants.

Infants born at very low birth weight (VLBW; birth weight <1500 g) are at high risk of mortality and are some of the most expensive patients in the hospital. Additionally, VLBW infants are susceptible to prematurity-related morbidities, including late-onset sepsis, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis, and retinopathy of prematurity, which have short- and long-term economic consequences. The incremental cost of these morbidities during the neonatal intensive care unit (NICU) hospitalization is high, ranging from $10,055 (in 2009 US$) for late-onset sepsis to $31,565 for BPD. Human milk has been shown to reduce both the incidence and severity of some of these morbidities and, therefore, has an indirect impact on the cost of the NICU hospitalization. Furthermore, human milk may also directly reduce NICU hospitalization costs, independent of the indirect impact on the incidence and/or severity of these morbidities. Although there is an economic cost to both the mother and institution for providing human milk during the NICU hospitalization, these costs are relatively low. This review describes the total cost of the initial NICU hospitalization, the incremental cost associated with these prematurity-related morbidities, and the incremental benefits and costs of human milk feedings during critical periods of the NICU hospitalization as a strategy to reduce the incidence and severity of these morbidities.

An exploratory analysis of the correlation of pain scores, patient satisfaction with relief from pain, and a new measure of pain control on the total dose of opioids in pain care.

OBJECTIVE: We explored the associations between opioid dose and multiple measures of pain. STUDY DESIGN AND MEASURES: Thirty-two consecutive patients admitted solely for an acute exacerbation of cancer-related pain or for surgery were followed for their entire hospital stay (115 days of pain). For each hospital day, we collected pain scores, the number of pain scores, trends in pain scores, the percentage of time patients had 100% acceptable relief from pain, and the number of times patients were asked about acceptable pain relief. Finally, we asked those who had 100% relief of pain whether they could have used more pain medicine. Linear regression models were fit to estimate the amount of variation explained (R) in dose of medication, by each pain measurement variable. RESULTS: Nineteen patients with cancer (74 days of pain) and 13 patients undergoing surgery (41 days of pain) were evaluated. Pain scores, the number of pain scores, trends in pain scores, and 100% acceptable relief scores poorly correlated with the use of medication in the linear regression models (R for all models ≤0.2). A question about needing more pain medicine explained the greatest amount of variation in opioid dose. CONCLUSIONS: Pain and acceptable relief scores do not adequately reflect the use of medication. A prospective study is needed to further assess the value of additional measures of the adequacy of pain care.

A unifying framework of the demand for transnational medical travel.

Transnational medical travel has gained attention recently as a strategy for patients to obtain care that is higher quality, costs less, or offers improved access relative to care provided within their home countries. This article examines institutional environments in the European Union and United States that influence transnational medical travel, describes the conceptual model of demand for medical travel, and illustrates individual dimensions in the conceptual model of medical travel using a series of case studies. The conceptual model of medical travel is predicated on Andersen's behavioral model of health services. Transnational medical travel is a heterogeneous phenomenon that is influenced by a number of patient-related factors and by the institutional environment in which the patient resides. While cost, access, and quality are commonly cited factors that influence a patient's decision regarding where to seek care, multiple factors may simultaneously influence the decision about the destination for care, including culture, social factors, and the institutional environment. The conceptual framework addresses the patient-related factors that influence where a patient seeks care. This framework can help researchers and regulatory bodies to evaluate the opportunities and the risks of transnational medical travel and help providers and governments to develop international patient programs.

Using administrative data for mortality risk adjustment in pediatric congenital cardiac surgery.

OBJECTIVE: To evaluate the performance of risk-adjustment models from the University HealthSystem Consortium and the Agency for Healthcare Research Quality on an administrative dataset for children undergoing congenital cardiac surgery. DESIGN: Retrospective cross-sectional cohort analysis. SETTING: Multi-institutional database of administrative data provided by the University HealthSystem Consortium. PATIENTS: Children whose discharge diagnosis had an associated cardiac surgical procedure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The performance of two risk-adjustment modeling schemata was measured in terms of discrimination and calibration, and receiver operating characteristic curves were compared. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. A total of 19,436 patients were included in the analysis with 816 deaths and an unadjusted overall mortality rate of 4.2%. The University HealthSystem Consortium models applied to the entire population resulted in an area under the curve = 0.73, and by comparison, the Agency for Healthcare Research Quality risk-adjustment model revealed area under the curve = 0.86. The risk-adjustment model of the University HealthSystem Consortium subgroup of Circulatory System Major Diagnostic Category 5 showed better performance with area under the curve = 0.81. Calibration using the Hosmer-Lemeshow test failed to show good agreement between the predicted and actual outcomes across the University HealthSystem Consortium mortality risk groups with an overall standardized mortality ratio of 1.2 (95% CI, 1.1-1.3; p < 0.0001) and poor predictive ability for the highest risk group, with a nearly 1.5-fold overprediction of death. The Agency for Healthcare Research Quality model shared similar calibration results with an overall standardized mortality ratio of 1.6 (95% CI, 1.5-1.7; p < 0.0001) and a nearly two-fold underprediction of death in the highest risk group. CONCLUSIONS: Administrative data can be used to create risk-adjustment models in the congenital cardiac surgery population. Risk-adjustment models generated from administrative data may represent an attractive addition to clinically derived models in pediatric congenital cardiac surgery patients and should be considered for use either alone or in combination with clinical data in future analyses where mortality is a measure of performance and quality.

Cost of morbidities in very low birth weight infants.

OBJECTIVE: To determine the association between direct costs for the initial neonatal intensive care unit hospitalization and 4 potentially preventable morbidities in a retrospective cohort of very low birth weight (VLBW) infants (birth weight <1500 g). STUDY DESIGN: The sample included 425 VLBW infants born alive between July 2005 and June 2009 at Rush University Medical Center. Morbidities included brain injury, necrotizing enterocolitis, bronchopulmonary dysplasia, and late-onset sepsis. Clinical and economic data were retrieved from the institution's system-wide data and cost accounting system. A general linear regression model was fit to determine incremental direct costs associated with each morbidity. RESULTS: After controlling for birth weight, gestational age, and sociodemographic characteristics, the presence of brain injury was associated with a $12048 (P = .005) increase in direct costs; necrotizing enterocolitis, with a $15 440 (P = .005) increase; bronchopulmonary dysplasia, with a $31565 (P < .001) increase; and late-onset sepsis, with a $10055 (P < .001) increase. The absolute number of morbidities was also associated with significantly higher costs. CONCLUSION: This study provides collective estimates of the direct costs incurred during neonatal intensive care unit hospitalization for these 4 morbidities in VLBW infants. The incremental costs associated with these morbidities are high, and these data can inform future studies evaluating interventions aimed at preventing or reducing these costly morbidities.