Extracorporeal Membrane Oxygenation for Refractory Asthma Exacerbations With Respiratory Failure.

BACKGROUND: Asthma exacerbations with respiratory failure (AERF) are associated with hospital mortality of 7% to 15%. Extracorporeal membrane oxygenation (ECMO) has been used as a salvage therapy for refractory AERF, but controlled studies showing its association with mortality have not been performed. RESEARCH QUESTION: Is treatment with ECMO associated with lower mortality in refractory AERF compared with standard care? STUDY DESIGN AND METHODS: This is a retrospective, epidemiologic, observational cohort study using a national, administrative data set from 2010 to 2020 that includes 25% of US hospitalizations. People were included if they were admitted to an ECMO-capable hospital with an asthma exacerbation, and were treated with short-acting bronchodilators, systemic corticosteroids, and invasive ventilation. People were excluded for age < 18 years, no ICU stay, nonasthma chronic lung disease, COVID-19, or multiple admissions. The main exposure was ECMO vs No ECMO. The primary outcome was hospital mortality. Key secondary outcomes were ICU length of stay (LOS), hospital LOS, time receiving invasive ventilation, and total hospital costs. RESULTS: The study analyzed 13,714 patients with AERF, including 127 with ECMO and 13,587 with No ECMO. ECMO was associated with reduced mortality in the covariate-adjusted (OR, 0.33; 95% CI, 0.17-0.64; P = .001), propensity score-adjusted (OR, 0.36; 95% CI, 0.16-0.81; P = .01), and propensity score-matched models (OR, 0.48; 95% CI, 0.24-0.98; P = .04) vs No ECMO. Sensitivity analyses showed that mortality reduction related to ECMO ranged from OR 0.34 to 0.61. ECMO was also associated with increased hospital costs in all three models (P < .0001 for all) vs No ECMO, but not with decreased ICU LOS, hospital LOS, or time receiving invasive ventilation. INTERPRETATION: ECMO was associated with lower mortality and higher hospital costs, suggesting that it may be an important salvage therapy for refractory AERF following confirmatory clinical trials.

Half-Dose Versus Full-Dose Alteplase for Treatment of Pulmonary Embolism.

OBJECTIVES: Recent evidence suggests that half-dose thrombolysis for pulmonary embolism may provide similar efficacy with reduced bleeding risk compared with full-dose therapy, but comparative studies are lacking. We aimed to evaluate the effectiveness and safety of half-dose versus full-dose alteplase for treatment of pulmonary embolism. DESIGN: A retrospective cohort study comparing outcomes in patients receiving half-dose (50 mg) versus full-dose (100 mg) alteplase for pulmonary embolism. We used propensity score matching and sensitivity analyses to address confounding and hospital-level clustering. SETTING: Data from 420 hospitals obtained from the Premier Healthcare Database between January 2010 and December 2014. SUBJECTS: Adult critically ill patients with acute pulmonary embolism treated with IV alteplase therapy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: This study included 3,768 patients: 699 (18.6%) in the half-dose and 3,069 (81.4%) in the full-dose group. At baseline, patients receiving half-dose alteplase required vasopressor therapy (23.3% vs 39.4%; p < 0.01) and invasive ventilation (14.3% vs 28.5%; p < 0.01) less often, compared with full dose. After propensity matching (n = 548 per group), half-dose alteplase was associated with increased treatment escalation (53.8% vs 41.4%; p < 0.01), driven mostly by secondary thrombolysis (25.9% vs 7.3%; p < 0.01) and catheter thrombus fragmentation (14.2% vs 3.8%; p < 0.01). Hospital mortality was similar (13% vs 15%; p = 0.3). There was no difference in cerebral hemorrhage (0.5% vs 0.4%; p = 0.67), gastrointestinal bleeding (1.6% vs 1.6%; p = 0.99), acute blood loss anemia (6.9% vs 4.6%; p = 0.11), use of blood products (p > 0.05 for all), or documented fibrinolytic adverse events (2.6% vs 2.8%; p = 0.82). CONCLUSIONS: Compared with full-dose alteplase, half-dose was associated with similar mortality and rates of major bleeding. Treatment escalation occurred more often in half-dose-treated patients. These results question whether half-dose alteplase provides similar efficacy with improved safety, and highlights the need for further study before use of half-dose alteplase therapy can be routinely recommended in patients with pulmonary embolism.

Outcomes of ICU Patients With a Discharge Diagnosis of Critical Illness Polyneuromyopathy: A Propensity-Matched Analysis.

OBJECTIVES: To assess the impact of a discharge diagnosis of critical illness polyneuromyopathy on health-related outcomes in a large cohort of patients requiring ICU admission. DESIGN: Retrospective cohort with propensity score-matched analysis. SETTING: Analysis of a large multihospital database. PATIENTS: Adult ICU patients without preexisting neuromuscular abnormalities and a discharge diagnosis of critical illness polyneuropathy and/or myopathy along with adult ICU propensity-matched control patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 3,567 ICU patients with a discharge diagnosis of critical illness polyneuropathy and/or myopathy, we matched 3,436 of these patients to 3,436 ICU patients who did not have a discharge diagnosis of critical illness polyneuropathy and/or myopathy. After propensity matching and adjusting for unbalanced covariates, we used conditional logistic regression and a repeated measures model to compare patient outcomes. Compared to patients without a discharge diagnosis of critical illness polyneuropathy and/or myopathy, patients with a discharge diagnosis of critical illness polyneuropathy and/or myopathy had fewer 28-day hospital-free days (6 [0.1] vs 7.4 [0.1] d; p < 0.0001), had fewer 28-day ventilator-free days (15.7 [0.2] vs 17.5 [0.2] d; p < 0.0001), had higher hospitalization charges (313,508 [4,853] vs 256,288 [4,470] dollars; p < 0.0001), and were less likely to be discharged home (15.3% vs 32.8%; p < 0.0001) but had lower in-hospital mortality (13.7% vs 18.3%; p < 0.0001). CONCLUSIONS: In a propensity-matched analysis of a large national database, a discharge diagnosis of critical illness polyneuropathy and/or myopathy is strongly associated with deleterious outcomes including fewer hospital-free days, fewer ventilator-free days, higher hospital charges, and reduced discharge home but also an unexpectedly lower in-hospital mortality. This study demonstrates the clinical importance of a discharge diagnosis of critical illness polyneuropathy and/or myopathy and the need for effective preventive interventions.

Maintaining goal blood pressures after switching from olmesartan to other angiotensin receptor blockers.

This study assessed blood pressure (BP) goal maintenance in patients controlled with olmesartan monotherapy after switching to another angiotensin type II receptor blocker (ARB). Hypertensive patients prescribed olmesartan monotherapy were identified from GE Healthcare's Centricity electronic medical record between 2007 and 2011. After documentation of BP goal (<140/90 mm Hg) attainment, patients were placed into the continuation cohort if olmesartan monotherapy was maintained or into the switch cohort if they were changed to irbesartan, losartan, or valsartan. Follow-up assessments were the first BP measurement 28 to 390 days after attaining BP goal (continuation cohort) or after prescribing an alternative ARB (switch cohort). Of 3412 patients included (3027 continuation cohort, 385 switch cohort), 52% were women and mean age was 58.0 years. In the switch cohort, 310 (80.5%) were switched to losartan (n=236), irbesartan (n=58), or valsartan (n=16) monotherapy and 75 (19.5%) were switched to combination antihypertensive therapy. Mean baseline and follow-up BP were 122.5/75.8 mm Hg and 126.6/77.6 mm Hg, respectively, in the continuation cohort (P<.001) and 123.5/75.4 mm Hg and 129.6/78.5 mm Hg, respectively, in the switch cohort (P<.001). BP goal maintenance was 78.7% and 72.2% in the continuation and switch cohort, respectively (odds ratio, 0.707; 95% confidence interval, 0.555-0.899). Patients who continued on olmesartan monotherapy after attaining BP goal had a higher percentage of BP goal maintenance than patients who switched therapy.

Costs and outcomes associated with clopidogrel discontinuation in Medicare beneficiaries with acute coronary syndrome in the coverage gap.

BACKGROUND: Current guidelines for acute coronary syndrome recommend clopidogrel for an optimal period of 12 months in order to reduce the risk of reinfarction and mortality. Premature clopidogrel discontinuation has been associated with higher rates of rehospitalization, coronary stent thrombosis, and mortality. No data exist regarding the effect of the Medicare Part D coverage gap on medical costs and outcomes in Medicare beneficiaries who discontinue their clopidogrel upon entering the coverage gap. METHODS: Beneficiaries with a Medicare Advantage plan in 2009 who had a diagnosis of acute coronary syndrome were taking clopidogrel 75 mg daily, and reached the gap in the same year representing the study sample. From this cohort, those who filled at least two prescriptions for clopidogrel (continued) versus those that did not (discontinued) while in the gap were compared with regard to outcomes related to acute coronary syndrome and expenditure 30 days after the last prescription was filled and during any time while in the gap. Descriptive and multivariate analyses were used to compare these differences. RESULTS: A total of 1365 beneficiaries with acute coronary syndrome met the inclusion criteria, of which 705 beneficiaries entered into the coverage gap, wherein 103 (14.6%) and 602 (85.4%) of beneficiaries discontinued and continued clopidogrel, respectively. Compared with those who continued clopidogrel during the gap, beneficiaries who discontinued clopidogrel showed a higher trend in the number of hospitalizations related to acute coronary syndrome and emergency room visits, albeit not statistically significant. Those who discontinued clopidogrel showed a higher mean adjusted cost per member per month in hospitalizations ($3604) related to acute coronary syndrome and outpatient visits ($1144) related to acute coronary syndrome and total medical costs ($5614), albeit not statistically significant. CONCLUSION: Medicare beneficiaries who face large out-of-pocket costs for clopidogrel while in the coverage gap and discontinue therapy may experience adverse events related to acute coronary syndrome.

Clinical characterization and blepharoptosis surgery outcomes in Hispanic New Mexicans with oculopharyngeal muscular dystrophy.

PURPOSE: To clinically characterize blepharoptosis in Hispanic New Mexicans with oculopharyngeal muscular dystrophy and examine eyelid surgery outcomes. METHODS: A retrospective noncomparative case series and retrospective, nonrandomized, comparative interventional case series was performed on medical records from 86 patients. Main outcome measures included preoperative correlations between margin reflex distance, palpebral fissure height, levator function, and age and postoperative change in palpebral fissure height and time to reoperation for recurrent blepharoptosis after blepharoplasty, levator advancement, or frontalis sling surgery. RESULTS: Preoperative measurements between the right and left eye were symmetrical with respect to margin reflex distance, palpebral fissure height, and levator function (all p < 0.001). There were correlations between age and margin reflex distance, palpebral fissure height, and levator function (all p < or = 0.02). There was no gender difference detected with respect to age, margin reflex distance, palpebral fissure height, and levator function (p > 0.39). Eighty-three patients underwent eyelid surgery. As initial surgery, 15 underwent blepharoplasty, 17 levator advancement, and 51 frontalis suspension. Overall, 93.3% of blepharoplasty patients, 47.1% levator advancement patients, and 7.84% undergoing frontalis suspension had additional surgery for recurrent ptosis (rates differed, p < 0.001). Postoperative change for palpebral fissure height was 0.33 +/- 1.83 mm OD and 1.1 +/- 0.86 mm OS for levator advancement and 2.63 +/- 1.34 mm OD and 2.68 +/-1.47 mm OS for frontalis suspension (p = 0.03, OD and p = 0.004, OS). CONCLUSIONS: Oculopharyngeal muscular dystrophy in Hispanic New Mexicans is a symmetrical, progressive disease that affects men and women similarly. Frontalis suspension is an effective primary surgery with respect to upper eyelid elevation, need for reoperation, and time to reoperation in this patient population.

Prescription copay reduction program for diabetic employees: impact on medication compliance and healthcare costs and utilization.

OBJECTIVE: To examine the impact of a value-based benefit design on utilization and expenditures. METHODS: This benefit design involved all diabetes-related drugs and testing supplies placed on the lowest copay tier for 1 employer group. The sample of diabetic members were enrolled from a 9-month preperiod and for 2 years after the benefit design was implemented. Measured outcomes included prescription drug utilization for diabetes and medical utilization. Generalized measures were used to estimate differences between years 1 and 2 and the preperiod adjusting for age, gender, and comorbidity risk. RESULTS: Diabetes prescription drug use increased by 9.5% in year 1 and by 5.5% in year 2, and mean adherence increased by 7% to 8% in year 1 and fell slightly in year 2 compared with the preperiod. Pharmacy expenditures increased by 47% and 53% and expenditures for diabetes services increased by 16% and 32% in years 1 and 2, respectively. CONCLUSION: Increases in adherence and use of diabetes medications were observed. There were no compensatory cost-savings for the employer through lower utilization of medical expenditures in the first 2 years. Adherent patients had fewer emergency department visits than nonadherent patients after the implementation of this benefit design.