Two Weeks Versus One Week of Maximal Patient-Intensivist Continuity for Adult Medical Intensive Care Patients: A Two-Center Target Trial Emulation.

OBJECTIVES: To compare outcomes for 2 weeks vs. 1 week of maximal patient-intensivist continuity in the ICU. DESIGN: Retrospective cohort study. SETTING: Two U.S. urban, teaching, medical ICUs where intensivists were scheduled for 2-week service blocks: site A was in the Midwest and site B was in the Northeast. PATIENTS: Patients 18 years old or older admitted to a study ICU between March 1, 2017, and February 28, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We applied target trial emulation to compare admission during an intensivist's first week (as a proxy for 2 wk of maximal continuity) vs. admission during their second week (as a proxy for 1 wk of maximal continuity). Outcomes included hospital mortality, ICU length of stay, and, for mechanically ventilated patients, duration of ventilation. Exploratory outcomes included imaging, echocardiogram, and consultation orders. We used inverse probability weighting to adjust for baseline differences and random-effects meta-analysis to calculate overall effect estimates. Among 2571 patients, 1254 were admitted during an intensivist's first week and 1317 were admitted during a second week. At sites A and B, hospital mortality rates were 25.8% and 24.2%, median ICU length of stay were 4 and 2 days, and median mechanical ventilation durations were 3 and 3 days, respectively. There were no differences in adjusted mortality (odds ratio [OR], 1.01 [95% CI, 0.96-1.06]) or ICU length of stay (-0.25 d [-0.82 d to +0.32 d]) for 2 weeks vs. 1 week of maximal continuity. Among mechanically ventilated patients, there were no differences in adjusted mortality (OR, 1.00 [0.87-1.16]), ICU length of stay (+0.06 d [-0.78 d to +0.91 d]), or duration of mechanical ventilation (+0.37 d [-0.46 d to +1.21 d]) for 2 weeks vs. 1 week of maximal continuity. CONCLUSIONS: Two weeks of maximal patient-intensivist continuity was not associated with differences in clinical outcomes compared with 1 week in two medical ICUs.

Rural-Urban Differences in Mortality among Mechanically Ventilated Patients in Intensive and Intermediate Care.

Rationale: Intermediate care (also termed "step-down" or "moderate care") has been proposed as a lower cost alternative to care for patients who may not clearly benefit from intensive care unit admission. Intermediate care units may be appealing to hospitals in financial crisis, including those in rural areas. Outcomes of patients receiving intermediate care are not widely described. Objectives: To examine relationships among rurality, location of care, and mortality for mechanically ventilated patients. Methods: Medicare beneficiaries aged 65 years and older who received invasive mechanical ventilation between 2010 and 2019 were included. Multivariable logistic regression was used to estimate the association between admission to a rural or an urban hospital and 30-day mortality, with separate analyses for patients in general, intermediate, and intensive care. Models were adjusted for age, sex, area deprivation index, primary diagnosis, severity of illness, year, comorbidities, and hospital volume. Results: There were 2,752,492 hospitalizations for patients receiving mechanical ventilation from 2010 to 2019, and 193,745 patients (7.0%) were in rural hospitals. The proportion of patients in rural intermediate care increased from 4.1% in 2010 to 6.3% in 2019. Patient admissions to urban hospitals remained relatively stable. Patients in rural and urban intensive care units had similar adjusted 30-day mortality, at 46.7% (adjusted absolute risk difference -0.1% [95% confidence interval, -0.7% to 0.6%]; P = 0.88). However, adjusted 30-day mortality for patients in rural intermediate care was significantly higher (36.9%) than for patients in urban intermediate care (31.3%) (adjusted absolute risk difference 5.6% [95% confidence interval, 3.7% to 7.6%]; P < 0.001). Conclusions: Hospitalization in rural intermediate care was associated with increased mortality. There is a need to better understand how intermediate care is used across hospitals and to carefully evaluate the types of patients admitted to intermediate care units.

Hospital factors that influence ICU admission decision-making: a qualitative study of eight hospitals.

PURPOSE: Some hospitals in the United States (US) use intensive care 20 times more than others. Since intensive care is lifesaving for some but potentially harmful for others, there is a need to understand factors that influence how intensive care unit (ICU) admission decisions are made. METHODS: A qualitative analysis of eight US hospitals was conducted with semi-structured, one-on-one interviews supplemented by site visits and clinical observations. RESULTS: A total of 87 participants (24 nurses, 52 physicians, and 11 other staff) were interviewed, and 40 h were spent observing ICU operations across the eight hospitals. Four hospital-level factors were identified that influenced ICU admission decision-making. First, availability of intermediate care led to reallocation of patients who might otherwise be sent to an ICU. Second, participants stressed the importance of ICU nurse availability as a key modifier of ICU capacity. Patients cared for by experienced general care physicians and nurses were less likely to receive ICU care. Third, smaller or rural hospitals opted for longer emergency department patient-stays over ICU admission to expedite interhospital transfer of critically ill patients. Fourth, lack of clarity in ICU admission policies led clinicians to feel pressured to use ICU care for patients who might otherwise not have received it. CONCLUSION: Health care systems should evaluate their use of ICU care and establish institutional patterns that ensure ICU admission decisions are patient-centered but also account for resources and constraints particular to each hospital.

Influence of the COVID-19 Pandemic on Author Sex and Manuscript Acceptance Rates among Pulmonary and Critical Care Journals.

Rationale: The coronavirus disease (COVID-19) pandemic has negatively affected women more than men and may influence the publication of non-COVID-19 research. Objectives: To evaluate whether the COVID-19 pandemic is associated with changes in manuscript acceptance rates among pulmonary/critical care journals and sex-based disparities in these rates. Methods: We analyzed first, senior, and corresponding author sex (female vs. male, identified by matching first names in a validated Genderize database) of manuscripts submitted to four pulmonary/critical care journals between January 1, 2018 and December 31, 2020. We constructed interrupted time series regression models to evaluate whether the proportion of female first and senior authors of non-COVID-19 original research manuscripts changed with the pandemic. Next, we performed multivariable logistic regressions to evaluate the association of author sex with acceptance of original research manuscripts. Results: Among 8,332 original research submissions, women represented 39.9% and 28.3% of first and senior authors, respectively. We found no change in the proportion of female first or senior authors of non-COVID-19 or COVID-19 submitted research manuscripts during the COVID-19 era. Non-COVID-19 manuscripts submitted during the COVID-19 era had reduced odds of acceptance, regardless of author sex (first author adjusted OR [aOR], 0.46 [95% confidence interval (CI), 0.36-0.59]; senior author aOR, 0.46 [95% CI, 0.37-0.57]). Female senior authorship was associated with decreased acceptance of non-COVID-19 research manuscripts (crude rates, 14.4% [male] vs. 13.2% [female]; aOR, 0.84 [95% CI, 0.71-0.99]). Conclusions: Although female author submissions were not disproportionately influenced by COVID-19, we found evidence suggesting sex disparities in manuscript acceptance rates. Journals may need to consider strategies to reduce this disparity, and academic institutions may need to factor our findings, including lower acceptance rates for non-COVID-19 manuscripts, into promotion decisions.

Development and Retention of Early-Career Clinician-Scientists through a Novel Peer Mentorship Program: Multidisciplinary Intensive Care Research Workgroup.

Background: Early-career clinician-scientists often leave academic medicine, but strong mentorship can help facilitate retention. Beyond the traditional dyadic mentor-mentee relationship, formal peer mentoring provides a rich means to augment career development and foster independence. Objective: To describe a model for early-career peer mentorship and the retention of participating early-career clinician-scientists in academic medicine. Methods: In 2015, a multidisciplinary and interprofessional group of early-career clinician-scientists focused on critical care developed a peer mentoring group at the University of Michigan called the MICReW (Multidisciplinary Intensive Care Research Workgroup). We describe the establishment, sustainability, guiding principles, challenges, and successes of MICReW. Results: MICReW was established to be a formal, peer-only mentoring group without the direct participation of senior mentors. The purpose of MICReW was to support and promote the research and career development of early-career clinician-scientists by creating an environment that fostered diverse opinions, constructive feedback, and camaraderie. As a group, we wrote a mission statement and defined our guiding principles. Our sustainability, growth, and adaptability (seamlessly transitioning to all virtual meetings) were possible by the continued investment of our peer members. To date, MICReW has had 30 members, of whom 15 are current members and approximately half are women. Nearly all members (n = 29/30) remain in academic positions, and half (n = 15) have been awarded career development awards. Most members also report significant benefits from being a member of MICReW. Conclusion: The MICReW peer mentorship model is a sustainable and adaptable peer mentoring model whose members continue to be engaged in academic medicine.

Development and Reporting of Prediction Models: Guidance for Authors From Editors of Respiratory, Sleep, and Critical Care Journals.

Prediction models aim to use available data to predict a health state or outcome that has not yet been observed. Prediction is primarily relevant to clinical practice, but is also used in research, and administration. While prediction modeling involves estimating the relationship between patient factors and outcomes, it is distinct from casual inference. Prediction modeling thus requires unique considerations for development, validation, and updating. This document represents an effort from editors at 31 respiratory, sleep, and critical care medicine journals to consolidate contemporary best practices and recommendations related to prediction study design, conduct, and reporting. Herein, we address issues commonly encountered in submissions to our various journals. Key topics include considerations for selecting predictor variables, operationalizing variables, dealing with missing data, the importance of appropriate validation, model performance measures and their interpretation, and good reporting practices. Supplemental discussion covers emerging topics such as model fairness, competing risks, pitfalls of "modifiable risk factors", measurement error, and risk for bias. This guidance is not meant to be overly prescriptive; we acknowledge that every study is different, and no set of rules will fit all cases. Additional best practices can be found in the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) guidelines, to which we refer readers for further details.

Utilization of Intensive Care Unit Nutrition Consultation Is Associated With Reduced Mortality.

BACKGROUND: The aim of this project was to investigate the prevalence of nutrition consultation (NC) in U.S. intensive care units (ICUs) and to examine its association with patient outcomes. METHODS: Data from the Healthcare Cost and Utilization Project's state inpatient databases was utilized from 2010 - 2014. A multilevel logistic regression model was used to evaluate the relationship between NC and clinical outcomes. RESULTS: Institutional ICU NC rates varied significantly (mean: 14%, range: 0.1%-73%). Significant variation among underlying disease processes was identified, with burn patients having the highest consult rate (P < 0.001, mean: 6%, range: 2%-25%). ICU patients who received NC had significantly lower in-hospital mortality (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.48-0.74, P < 0.001), as did the subset with malnutrition (OR 0.72, 95% CI 0.53-0.99, P = 0.047) and the subset with concomitant physical therapy consultation (OR 0.53, 95% CI 0.38-0.74, P < 0.001). NC was associated with significantly lower rates of intubation, pulmonary failure, pneumonia, and gastrointestinal bleeding (P < 0.05). Furthermore, patients who received NC were more likely to receive enteral or parenteral nutrition (ENPN) (OR 1.8, 95% CI 1.4-2.3, P < 0.001). Patients who received follow-up NC were even more likely to receive ENPN (OR 3.0, 95% CI 2.1-4.2, P < 0.001). CONCLUSIONS: Rates of NC were low in critically ill patients. This study suggests that increased utilization of NC in critically ill patients may be associated with improved clinical outcomes.

Changes in coding of pneumonia and impact on the Hospital Readmission Reduction Program.

OBJECTIVE: To evaluate whether changes in diagnosis assignment explain reductions in 30-day readmission for patients with pneumonia following the Hospital Readmission Reduction Program (HRRP). DATA SOURCES: 100 percent MedPAR, 2008-2015. STUDY DESIGN: Retrospective cohort study of Medicare discharges in HRRP-eligible hospitals. Outcomes were 30-day readmission rates for pneumonia under a "narrow" definition (used for the HRRP until October 2015; n = 2 288 644) and a "broad" definition that included certain diagnoses of sepsis and aspiration pneumonia (used since October 2015; n = 3 618 215). We estimated changes in 30-day readmissions in the pre-HRRP period (January 2008-March 2010), the HRRP implementation period (April 2010-September 2012), and the HRRP penalty period (October 2012-June 2015). PRINCIPAL FINDINGS: Under the narrow definition, adjusted annual readmission rates changed by +0.07 percentage points (pp) during the pre-HRRP period (95% CI: -0.03 pp, +0.18 pp), -1.07 pp during HRRP implementation (95% CI: -1.15 pp, -0.99 pp), and -0.09 pp during the penalty period (95% CI: -0.18 pp, -0.00 pp). Under the broad definition, 30-day readmissions changed by +0.21 pp during the pre-HRRP period (95% CI: +0.12 pp, +0.30 pp), -1.28 pp during HRRP implementation (95% CI: -1.35 pp, -1.21 pp), and -0.09 pp during the penalty period (95% CI: -0.16 pp, -0.02 pp). CONCLUSIONS: Changes in the coding of inpatient pneumonia admissions do not explain readmission reduction following the HRRP.

Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study.

OBJECTIVE: To evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI). DESIGN: Retrospective cohort study. SETTING: 1727 acute care hospitals in the United States. PARTICIPANTS: Medicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015. MAIN OUTCOME MEASURE: 30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI. RESULTS: The analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval -11.9 to -0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (-0.9 to 3.4) percentage points). CONCLUSIONS: ICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial.

Trends in Hospital Utilization After Medicaid Expansion.

BACKGROUND: Medicaid expansion was associated with an increase in hospitalizations funded by Medicaid. Whether this increase reflects an isolated payer shift or broader changes in case-mix among hospitalized adults remains uncertain. RESEEARCH DESIGN: Difference-in-differences analysis of discharge data from 4 states that expanded Medicaid in 2014 (Arizona, Iowa, New Jersey, and Washington) and 3 comparison states that did not (North Carolina, Nebraska, and Wisconsin). SUBJECTS: All nonobstetric hospitalizations among patients aged 19-64 years of age admitted between January 2012 and December 2015. MEASURES: Outcomes included state-level per-capita rates of insurance coverage, several markers of admission severity, and admission diagnosis. RESULTS: We identified 6,516,576 patients admitted during the study period. Per-capita admissions remained consistent in expansion and nonexpansion states, though Medicaid-covered admissions increased in expansion states (274.6-403.8 per 100,000 people vs. 268.9-262.8 per 100,000; P<0.001). There were no significant differences after Medicaid expansion in hospital utilization, based on per-capita rates of patients-designated emergent, admitted via the emergency department, admitted via clinic, discharged within 1 day, or with lengths of stay ≥7 days. Similarly, there were no differences in diagnosis category at admission, admission severity, comorbidity burden, or mortality associated with Medicaid expansion (P>0.05 for all comparisons). CONCLUSIONS: Medicaid expansion was associated with a shift in payers among nonelderly hospitalized adults without significant changes in case-mix or in several markers of acuity. These findings suggest that Medicaid expansion may reduce uncompensated care without shifting admissions practices or acuity among hospitalized adults.

Medicaid Expansion and Mechanical Ventilation in Asthma, Chronic Obstructive Pulmonary Disease, and Heart Failure.

Rationale: The Affordable Care Act's Medicaid expansion has led to increased access to chronic disease care among newly insured adults. Despite this, its effects on clinical outcomes, particularly for patients with asthma, chronic obstructive pulmonary disease, and heart failure, are uncertain. Objectives: To assess whether Medicaid expansion was associated with changes in mechanical ventilation rates among hospitalized patients with heart failure, asthma, and chronic obstructive pulmonary disease. Methods: Difference-in-differences analysis comparing discharge data from four states that expanded Medicaid in 2014 (Arizona, Iowa, New Jersey, and Washington) and three comparison states that did not (North Carolina, Nebraska, and Wisconsin) was performed. Models were adjusted for patient and hospital factors. Results: Mechanical ventilation rates at baseline were 7.2% in nonexpansion states and 8.8% in expansion states. Medicaid expansion was associated with a decline in mechanical ventilation rates at -0.2% per quarter (95% confidence interval [CI], -0.3% to 0.0%; P = 0.010). We did not observe a change in the rate of ICU admission (-0.4% per quarter; 95% CI, -0.8% to 0.1%; P = 0.10) or in-hospital mortality (0.1% per quarter; 95% CI, 0.0% to 0.1%; P = 0.30). In a negative control among adults aged 65 years or older, changes in mechanical ventilation rates were similar, though the CIs crossed zero (-0.1%; 95% CI, -0.2% to 0.0%; P = 0.08). Conclusions: Medicaid expansion may have been associated with a decline in mechanical ventilation rates among uninsured and Medicaid-covered patients admitted with heart failure, chronic obstructive pulmonary disease, and asthma.

Electronic "Sniffer" Systems to Identify the Acute Respiratory Distress Syndrome.

BACKGROUND: The acute respiratory distress syndrome (ARDS) results in substantial mortality but remains underdiagnosed in clinical practice. Automated ARDS "sniffer" systems, tools that can automatically analyze electronic medical record data, have been developed to improve recognition of ARDS in clinical practice. OBJECTIVES: To perform a systematic review examining the evidence underlying automated sniffer systems for ARDS detection. DATA SOURCES: MEDLINE and Scopus databases through November 2018 to identify studies of tools using routinely available clinical data to detect patients with ARDS. DATA EXTRACTION: Study design, tool description, and diagnostic performance were extracted by two reviewers. The Quality Assessment of Diagnostic Accuracy Studies-2 was used to evaluate each study for risk of bias in four domains: patient selection, index test, reference standard, and study flow and timing. SYNTHESIS: Among 480 studies identified, 9 met inclusion criteria, and they evaluated six unique ARDS sniffer tools. Eight studies had derivation and/or temporal validation designs, with one also evaluating the effects of implementing a tool in clinical practice. A single study performed an external validation of previously published ARDS sniffer tools. Studies reported a wide range of sensitivities (43-98%) and positive predictive values (26-90%) for detection of ARDS. Most studies had potential for high risk of bias identified in their study design, including patient selection (five of nine), reference standard (four of nine), and flow and timing (three of nine). In the single external validation without any perceived risks of biases, the performance of ARDS sniffer tools was worse. CONCLUSIONS: Sniffer systems developed to detect ARDS had moderate to high predictive value in their derivation cohorts, although most studies had the potential for high risks of bias in study design. Methodological issues may explain some of the variability in tool performance. There remains an ongoing need for robust evaluation of ARDS sniffer systems and their impact on clinical practice. Systematic review registered with PROSPERO (CRD42015026584).

Patient-centered Outcomes Research in Pulmonary, Critical Care, and Sleep Medicine. An Official American Thoracic Society Workshop Report.

Patient-centered outcomes research (PCOR) represents a paradigm shift in research methods aimed to create the body of evidence that supports clinical practice and informs health care decisions. PCOR integrates patients and other key stakeholders including family members, policy makers, clinicians, and patient advocates and advocacy groups as research partners throughout all stages of the research process. The importance of PCOR has received increased recognition, yet there is little evidence available to help guide researchers interested in the design and conduct of PCOR. In May 2014, we convened a workshop to identify key issues related to designing, conducting, and disseminating findings from PCOR studies. Workshop participants included a diverse group of patients, patient advocates, clinicians (physicians, nurses, psychologists, and advanced practice providers), researchers, administrators, and funders within and beyond the pulmonary, critical care, and sleep medicine communities. Participants identified important issues and considerations to address when undertaking PCOR. In this report, we summarize the results of this workshop to inform members of the pulmonary, sleep, and critical care community interested in participating in PCOR. Key findings include the following: 1) requirements for research to be considered PCOR; 2) the potential significant impact of PCOR on patients, clinicians, and researchers; 3) guiding principles and practical strategies to form successful patient-centered research partnerships, conduct PCOR, and disseminate study results to a broad audience of stakeholders; 4) benefits and challenges of PCOR for researchers; and 5) resources available within the American Thoracic Society to help with the conduct of PCOR.