Development and Assessment of Objective Surveillance Definitions for Nonventilator Hospital-Acquired Pneumonia.

Importance: Hospital-acquired pneumonia is the most common health care-associated infection in the United States. Most cases occur in nonventilated patients, but many hospitals track hospital-acquired pneumonia only in ventilated patients because of the complexity and subjectivity of conducting surveillance for large numbers of nonventilated patients. Objective: To propose and assess potentially objective, efficient, and reproducible surveillance definitions for nonventilator hospital-acquired pneumonia (NV-HAP) using routine clinical data stored in electronic health record systems. Design, Setting, and Participants: This cohort study was conducted in 2 tertiary referral and 2 community hospitals in Massachusetts between May 31, 2015, and July 1, 2018. All nonventilated patients aged 18 years or older who were admitted to these hospitals were included (N = 310 651). Exposures: Ten candidate definitions for NV-HAP based on clinically meaningful combinations of 6 potential surveillance criteria were proposed: worsening oxygenation, temperature higher than 38 °C (fever), abnormal white blood cell count of less than 4000/µL or more than 12 000/µL, performance of chest imaging, submission of respiratory specimen for culture, and 3 or more days of new antibiotics. Main Outcomes and Measures: Incidence rates, lengths of stay, hospital mortality rates, and odds ratios (ORs) for time to discharge and mortality compared with those of matched controls were calculated for each candidate definition. The ORs were adjusted for demographics, clinical service, comorbidities, and severity of illness. Results: The study analyzed 310 651 patients with 489 519 admissions, including 205 054 patients with 311 484 admissions of 3 or more days. Among the patients with 311 484 admissions, the mean (SD) patient age was 58.3 (19.3) years and 176 936 (56.8%) were of women. Incidence rates for candidate definitions per 100 admissions ranged from 3.4 events for worsening oxygenation alone to 0.9 event for worsening oxygenation and at least 3 days of new antibiotics to 0.6 event for worsening oxygenation, at least 3 days of new antibiotics, fever, abnormal white blood cell count, and performance of chest imaging. Crude mortality rates ranged from 16.1% (n = 2643) for patients with worsening oxygen alone to 27.7% (n = 868) for patients with worsening oxygenation, at least 3 days of antibiotics, fever or abnormal white blood cell count, and chest imaging. Patients who met NV-HAP candidate definitions remained in the hospital for twice as long as their matched controls (adjusted ORs ranged from 1.8 [95% CI, 1.7-1.8] to 2.1 [95% CI, 2.0-2.1]) and were 4 to 6 times as likely to die in the hospital (adjusted ORs ranged from 3.8 [95% CI, 3.5-4.0] to 6.5 [95% CI, 5.2-8.2]). Agreement between candidate definitions and clinical diagnoses was fair (κ = 0.33). Conclusions and Relevance: These findings suggest that objective surveillance for NV-HAP using electronically computable definitions that incorporate common clinical criteria is feasible and generates incidence, mortality, and adjusted ORs for hospital mortality similar to estimates from manual surveillance. These definitions have the potential to facilitate widespread, automated surveillance for NV-HAP and thus inform the development and evaluation of prevention programs.

The natural history of the benign thyroid nodule: what is the appropriate follow-up strategy?

BACKGROUND: Long-term monitoring of benign thyroid nodules is not addressed in the present American Thyroid Association guidelines. The objective of this study was to determine the appropriate nature and length of follow-up for patients with a benign thyroid nodule. STUDY DESIGN: A retrospective review was performed of all patients referred to single endocrine surgeon for evaluation of thyroid nodules between 2006 and 2012. The review included 263 patients who had benign fine needle aspiration (FNA) cytology and either underwent thyroidectomy or had at least a 1-year follow-up ultrasound. Main outcomes measures were repeat FNA and pathology results. RESULTS: There were 231 women and 32 men. Forty-eight patients underwent immediate thyroidectomy, with pathology showing 2 papillary thyroid cancers (PTC), and 215 patients were followed with annual ultrasounds. During follow-up, 89 (41.3%) nodules underwent repeat FNA after initial biopsy. The repeat FNA cytology showed 91% benign, 7% follicular neoplasm, and 2% PTC. During follow-up, 81 (37.6%) patients underwent thyroidectomy after 3.3±2.8 years. Reasons for surgery included development of symptoms in 58 (71.6%), a non-benign repeat FNA in 8 (9.8%), or patient preference in 15 (18.5%). Surgical pathology identified 70 (86.4%) benign, 7 (8.6%) PTC, 3 (4%) follicular thyroid cancers, and 1 (1.2%) lymphoma. Median time from initial FNA to thyroidectomy in patients who had malignancy was 4.3 years. The maximum initial nodule size and average increase in nodule size did not differ between benign and malignant nodules (p=0.54 and p=0.75, respectively). CONCLUSIONS: Significant numbers of benign thyroid nodules enlarge more than 5 mm over 3 years, triggering repeat FNA or thyroidectomy. Larger diameter nodules and more rapidly growing nodules were not predictive of malignancy. The practice of annually obtaining ultrasound for benign thyroid nodules should be discouraged.