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1.
Can J Anaesth ; 2020 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-32157588

RESUMO

PURPOSE: The purpose of the Canadian Anesthesia Research Priority Setting Partnership (CAR PSP) was to identify a top ten list of shared priorities for research in anesthesia and perioperative care in Canada. METHODS: We used the methods of the James Lind Alliance to involve patients, caregivers, healthcare professionals, and researchers in determining the research priorities in Canada. In a first survey, participants submitted questions that they want research to answer about anesthesia and perioperative care. We summarized those responses into a longlist of questions. We reviewed the literature to see if any of those questions were already answered. In a second survey, participants chose up to ten questions from the longlist that they thought were most important to be answered with research. From that list, the highest ranking questions were discussed and assigned a final rank at an in-person workshop. RESULTS: A total of 254 participants submitted 574 research suggestions that were then summarized into 49 questions. Those questions were checked against the literature to be sure they were not already adequately addressed, and in a second survey of those 49 questions, participants chose up to 10 that they thought were most important. A total of 233 participants submitted their priorities, which were then used to choose 24 questions for discussion at the final workshop. At the final workshop, 22 participants agreed on a top ten list of priorities. CONCLUSION: The CAR PSP top ten priorities reflect a wide variety of priorities captured by a broad spectrum of Canadians who receive and provide anesthesia care. The priorities are a tool to initiate and guide patient-oriented research in anesthesia and perioperative care.

2.
Crit Care Med ; 48(4): 515-524, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32205598

RESUMO

OBJECTIVES: Patients with major bleeding are commonly admitted to the ICU. A growing number are on either oral or parenteral anticoagulation, but the impact of anticoagulation on patient outcomes is unknown. We sought to examine this association between anticoagulation therapy and mortality, as well as the independent effects of warfarin compared to direct oral anticoagulants. DESIGN: Analysis of a prospectively collected registry (2011-2017) of consecutive ICU patients admitted with major bleeding (as defined by International Society on Thrombosis and Haemostasis clinical criteria). SETTING: Two hospitals within a single tertiary care level hospital system. PATIENTS: We analyzed 1,598 patients identified with major bleeding, of which 245 (15.3%) had been using anticoagulation at the time of ICU admission. Of patients on anticoagulation, 149 were using warfarin, and 60 were using a direct oral anticoagulant. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model. Patients with anticoagulation-associated major bleeding had higher in-hospital mortality (adjusted odds ratio, 1.49; 95% CI, 1.16-1.92). Among survivors, anticoagulation use was associated with longer median hospital length of stay, and higher mean costs. No differences in hospital mortality were seen between warfarin- and direct oral anticoagulant-associated major bleeding. Patients with warfarin-associated major bleeding had longer median length of stay (11 vs 6 d; p = 0.02), and higher total costs than patients with direct oral anticoagulant-associated major bleeding. CONCLUSIONS: Among ICU patients admitted with major bleeding, pre-admission anticoagulation use was associated with increased hospital mortality, prolonged length of stay, and higher costs among survivors. As compared to direct oral anticoagulants, patients with warfarin-associated major bleeding had increased length of stay and costs. These findings have important implications in the care of ICU patients with major bleeding.

3.
BMC Health Serv Res ; 20(1): 161, 2020 Mar 04.
Artigo em Inglês | MEDLINE | ID: mdl-32131817

RESUMO

BACKGROUND: Some patients admitted to acute care hospital require supportive services after discharge. The objective of our review was to identify models and variables that predict the need for supportive services after discharge from acute care hospital. METHODS: We performed a systematic review searching the MEDLINE, CINAHL, EMBASE, and COCHRANE databases from inception to May 1st 2017. We selected studies that derived and validated a prediction model for the need for supportive services after hospital discharge for patients admitted non-electively to a medical ward. We extracted cohort characteristics, model characteristics and variables screened and included in final predictive models. Risk of bias was assessed using the Quality in Prognostic Studies tool. RESULTS: Our search identified 3362 unique references. Full text review identified 6 models. Models had good discrimination in derivation (c-statistics > 0.75) and validation (c-statistics > 0.70) cohorts. There was high quality evidence that age, impaired physical function, disabilities in performing activities of daily living, absence of an informal care giver and frailty predict the need for supportive services after discharge. Stroke was the only unique diagnosis with at least moderate evidence of an independent effect on the outcome. No models were externally validated, and all were at moderate or higher risk of bias. CONCLUSIONS: Deficits in physical function and activities of daily living, age, absence of an informal care giver and frailty have the strongest evidence as determinants of the need for support services after hospital discharge. TRIAL REGISTRATION: This review was registered with PROSPERO #CRD42016037144.

5.
J Vasc Surg ; 2020 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-31980246

RESUMO

OBJECTIVE: Inpatient treatment of peripheral artery disease (PAD) is more than six times as costly as that of the general inpatient population. Our objective was to describe factors associated with hospital cost for patients admitted for PAD, the characteristics of high-cost patients, and their outcomes including amputations and death. METHODS: We performed a retrospective cohort study of admitted patients receiving a procedure for PAD at The Ottawa Hospital between 2007 and 2016. Demographics, comorbidity, inpatient events, and hospital cost data during the index admission were collected. We defined high-cost patients as those whose total costs of index admission were in the tenth percentile and above. Features associated with high-cost status were examined using logistic regression with elastic net regularization. We used generalized linear models to examine overall drivers of cost. RESULTS: We identified 3084 eligible patients, incurring $72.2 million in hospital costs. The mean cost of the most expensive 10% of patients was $88,076 (standard deviation, $54,720), more than five times the mean cost of $16,217 (standard deviation, $10,322) for nonhigh-cost patients. High-cost patients were more likely to present urgently (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.16-2.25; P < .01). After adjustment for preadmission factors, high-cost patients were more likely to have experienced an adverse patient safety incident (OR, 13.49; 95% CI, 6.97-24.8; P < .01), amputation (OR, 2.79; 95% CI, 1.68-4.49; P <.01), intensive care unit admission (OR, 6.42; 95% CI, 3.62-10.2; P < .01), and disposition barriers requiring alternate level of care status (OR, 10.44; 95% CI, 6.42-15.2; P < .01). The high-cost group was more likely to have received hybrid revascularization (OR, 7.07; 95% CI, 3.34-13.6; P < .01). High-cost patients had higher than predicted in-hospital mortality (18% vs 9.2% predicted) compared with the low-cost group (3.0% vs 2.7%; P < .001), and fewer than half of high-cost patients were discharged home. CONCLUSIONS: Providing hospital care for the top 10% most expensive patients in our cohort was more than five times as costly per patient than providing care for the nonhigh-cost patients. Whereas pre-existing factors may predispose a patient to require expensive care, there are potentially modifiable factors during the admission that could reduce costs of these patients.

6.
BMJ Open ; 10(1): e034060, 2020 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-31915174

RESUMO

INTRODUCTION: People 65 years and older represent the fastest growing segment of the surgical population. Older age is associated with doubling of risk when undergoing emergency general surgery (EGS) procedures and often coexists with medical complexity and considerations of end-of-life care, creating prognostic and decisional uncertainty. Combined with the time-sensitive nature of EGS, it is challenging to gauge perioperative risk and ensure that clinical decisions are aligned with the patient values. Current preoperative risk prediction models for older EGS patients have major limitations regarding derivation and validation, and do not address the specific risk profile of older patients. Accurate and externally validated models specific to older patients are needed to inform care and decision making. METHODS AND ANALYSIS: We will derive, internally and externally validate a multivariable model to predict 30-day mortality in EGS patients >65 years old. Our derivation sample will be individuals enrolled in the National Surgical Quality Improvement Program (NSQIP) database between 2012 and 2016 having 1 of 7 core EGS procedures. Postulated predictor variables have been identified based on previous research, clinical and epidemiological knowledge. Our model will be derived using logistic regression penalised with elastic net regularisation and ensembled using bootstrap aggregation. The resulting model will be internally validated using k-fold cross-validation and bootstrap validation techniques and externally validated using population-based health administrative data. Discrimination and calibration will be reported at each step. ETHICS AND DISSEMINATION: Ethics for NSQIP data use was obtained from the Ottawa Hospital Research Ethics Board; external validation will use routinely collected anonymised data legally exempt from research ethics review. The final risk score will be published in a peer-reviewed journal. We plan to further disseminate the model as an online calculator or application for clinical use. Future research will be required to test the clinical application of the final model.

7.
BMJ Qual Saf ; 29(3): 209-216, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31439760

RESUMO

OBJECTIVE: Administrative data systems are used to identify hospital-based patient safety events; few studies evaluate their accuracy. We assessed the accuracy of a new set of patient safety indicators (PSIs; designed to identify in hospital complications). STUDY DESIGN: Prospectively defined analysis of registry data (1 April 2010-29 February 2016) in a Canadian hospital network. Assignment of complications was by two methods independently. The National Surgical Quality Improvement Programme (NSQIP) database was the clinical reference standard (primary outcome=any in-hospital NSQIP complication); PSI clusters were assigned using International Classification of Disease (ICD-10) codes in the discharge abstract. Our primary analysis assessed the accuracy of any PSI condition compared with any complication in the NSQIP; secondary analysis evaluated accuracy of complication-specific PSIs. PATIENTS: All inpatient surgical cases captured in NSQIP data. ANALYSIS: We assessed the accuracy of PSIs (with NSQIP as reference standard) using positive and negative predictive values (PPV/NPV), as well as positive and negative likelihood ratios (±LR). RESULTS: We identified 12 898 linked episodes of care. Complications were identified by PSIs and NSQIP in 2415 (18.7%) and 2885 (22.4%) episodes, respectively. The presence of any PSI code had a PPV of 0.55 (95% CI 0.53 to 0.57) and NPV of 0.93 (95% CI 0.92 to 0.93); +LR 6.41 (95% CI 6.01 to 6.84) and -LR 0.40 (95% CI 0.37 to 0.42). Subgroup analyses (by surgery type and urgency) showed similar performance. Complication-specific PSIs had high NPVs (95% CI 0.92 to 0.99), but low to moderate PPVs (0.13-0.61). CONCLUSION: Validation of the ICD-10 PSI system suggests applicability as a first screening step, integrated with data from other sources, to produce an adverse event detection pathway that informs learning healthcare systems. However, accuracy was insufficient to directly identify or rule out individual-level complications.

8.
Resuscitation ; 146: 138-144, 2020 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-31785373

RESUMO

BACKGROUND: In-hospital cardiac arrest (IHCA) is common and associated with high mortality. Frailty is increasingly recognized as a predictor of worse prognosis among critically ill patients, but its association with outcomes and resource utilization following IHCA is unknown. METHODS: We performed a retrospective analysis (2013-2016) of a prospectively collected registry from two hospitals of consecutive hospitalized adult patients with IHCA occurring on the hospital wards. We defined frailty using the Clinical Frailty Scale (CFS) score ≥5. CFS scores were based on validated medical review criteria. The primary outcome is hospital mortality. Secondary outcomes include return of spontaneous circulation (ROSC), discharge to long-term care, and hospital costs. We used multivariable logistic regression to adjust for known confounders. RESULTS: We included 477 patients, and 124 (26.0%) had frailty. Frailty was associated with increased odds of hospital death (adjusted odds ratio [aOR]: 2.91 [95% confidence interval [CI]: 2.37-3.48) and discharge to long-term care (aOR 1.94 [95% CI: 1.57-2.32]). Compared with patients without frailty, patients with frailty had decreased odds of ROSC following IHCA (aOR 0.63 [95% CI: 0.41-0.93]). No difference in mean total costs was demonstrated between patients with and without frailty ($50,799 vs. $45,849). Frail patients did have higher cost-per-survivor ($947,546 vs. $161,550). CONCLUSIONS: Frail individuals who experience an IHCA are more likely to die in hospital or be discharged to long-term care, and less likely to achieve ROSC in comparison with individuals who are not frail. The hospital costs per-survivor of IHCA are increased when frailty is present.

9.
Ann Surg ; 271(2): 283-289, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30048320

RESUMO

OBJECTIVE: To compare the accuracy of the modified Fried Index (mFI) and the Clinical Frailty Scale (CFS) to predict death or patient-reported new disability 90 days after major elective surgery. BACKGROUND: The association of frailty with patient-reported outcomes, and comparisons between preoperative frailty instruments are poorly described. METHODS: This was a prospective multicenter cohort study. We determined frailty status in individuals ≥65 years having elective noncardiac surgery using the mFI and CFS. Outcomes included death or patient-reported new disability (primary); safety incidents, length of stay (LOS), and institutional discharge (secondary); ease of use, usefulness, benefit, clinical importance, and feasibility (tertiary). We measured the adjusted association of frailty with outcomes using regression analysis and compared true positive and false positive rates (TPR/FPR). RESULTS: Of 702 participants, 645 had complete follow up. The CFS identified 297 (42.3%) with frailty, the mFI 257 (36.6%); 72 (11.1%) died or experienced a new disability. Frailty was significantly associated with the primary outcome (CFS adjusted odds ratio, OR, 2.51, 95% confidence interval, CI, 1.50-4.21; mFI adjusted-OR 2.60, 95% CI 1.57-4.31). TPR and FPR were not significantly different between instruments. Frailty was the only significant predictor of death or new disability in a multivariable analysis. Need for institutional discharge, costs and LOS were significantly increased in individuals with frailty. The CFS was easier to use, required less time and had less missing data. CONCLUSIONS: Older people with frailty are significantly more likely to die or experience a new patient-reported disability after surgery. Clinicians performing frailty assessments before surgery should consider the CFS over the mFI as accuracy was similar, but ease of use and feasibility were higher.

10.
BMJ ; 367: l6373, 2019 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-31801749

RESUMO

OBJECTIVE: To determine associations between important pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, PubMed, Embase, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception to 4 February 2019. Primary, unpublished data from the United Kingdom National Cardiac Arrest Audit database. STUDY SELECTION CRITERIA: English language studies that investigated pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest. DATA EXTRACTION: PROGRESS (prognosis research strategy group) recommendations and the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist were followed. Risk of bias was assessed by using the QUIPS tool (quality in prognosis studies). The primary analysis pooled associations only if they were adjusted for relevant confounders. The GRADE approach (grading of recommendations assessment, development, and evaluation) was used to rate certainty in the evidence. RESULTS: The primary analysis included 23 cohort studies. Of the pre-arrest factors, male sex (odds ratio 0.84, 95% confidence interval 0.73 to 0.95, moderate certainty), age 60 or older (0.50, 0.40 to 0.62, low certainty), active malignancy (0.57, 0.45 to 0.71, high certainty), and history of chronic kidney disease (0.56, 0.40 to 0.78, high certainty) were associated with reduced odds of survival after in-hospital cardiac arrest. Of the intra-arrest factors, witnessed arrest (2.71, 2.17 to 3.38, high certainty), monitored arrest (2.23, 1.41 to 3.52, high certainty), arrest during daytime hours (1.41, 1.20 to 1.66, high certainty), and initial shockable rhythm (5.28, 3.78 to 7.39, high certainty) were associated with increased odds of survival. Intubation during arrest (0.54, 0.42 to 0.70, moderate certainty) and duration of resuscitation of at least 15 minutes (0.12, 0.07 to 0.19, high certainty) were associated with reduced odds of survival. CONCLUSION: Moderate to high certainty evidence was found for associations of pre-arrest and intra-arrest prognostic factors with survival after in-hospital cardiac arrest. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018104795.


Assuntos
Parada Cardíaca/mortalidade , Mortalidade Hospitalar , Adulto , Feminino , Parada Cardíaca/patologia , Humanos , Masculino , Razão de Chances , Prognóstico , Medição de Risco/métodos , Fatores de Risco , Fatores Sexuais , Reino Unido/epidemiologia
11.
Crit Care Med ; 2019 Dec 19.
Artigo em Inglês | MEDLINE | ID: mdl-31855999

RESUMO

OBJECTIVES: Patients with major bleeding are commonly admitted to the ICU. A growing number are on either oral or parenteral anticoagulation, but the impact of anticoagulation on patient outcomes is unknown. We sought to examine this association between anticoagulation therapy and mortality, as well as the independent effects of warfarin compared to direct oral anticoagulants. DESIGN: Analysis of a prospectively collected registry (2011-2017) of consecutive ICU patients admitted with major bleeding (as defined by International Society on Thrombosis and Haemostasis clinical criteria). SETTING: Two hospitals within a single tertiary care level hospital system. PATIENTS: We analyzed 1,598 patients identified with major bleeding, of which 245 (15.3%) had been using anticoagulation at the time of ICU admission. Of patients on anticoagulation, 149 were using warfarin, and 60 were using a direct oral anticoagulant. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model. Patients with anticoagulation-associated major bleeding had higher in-hospital mortality (adjusted odds ratio, 1.49; 95% CI, 1.16-1.92). Among survivors, anticoagulation use was associated with longer median hospital length of stay, and higher mean costs. No differences in hospital mortality were seen between warfarin- and direct oral anticoagulant-associated major bleeding. Patients with warfarin-associated major bleeding had longer median length of stay (11 vs 6 d; p = 0.02), and higher total costs than patients with direct oral anticoagulant-associated major bleeding. CONCLUSIONS: Among ICU patients admitted with major bleeding, pre-admission anticoagulation use was associated with increased hospital mortality, prolonged length of stay, and higher costs among survivors. As compared to direct oral anticoagulants, patients with warfarin-associated major bleeding had increased length of stay and costs. These findings have important implications in the care of ICU patients with major bleeding.

12.
Anesth Analg ; 129(6): 1699-1706, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31743191

RESUMO

BACKGROUND: Older people with frailty have decreased postoperative survival. Understanding how comorbidities modify the association between frailty and survival could improve risk stratification and guide development of interventions. Therefore, we evaluated whether the concurrent presence of common and high-risk comorbidities (dementia, chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], diabetes mellitus, heart failure [HF]) in conjunction with frailty might be associated with a larger decrease in postoperative survival after major elective surgery than would be expected based on the presence of the comorbidity and frailty on their own. METHODS: This cohort study used linked administrative data from Ontario, Canada to identify adults >65 years having elective noncardiac surgery from 2010 to 2015. Frailty was identified using a validated index; comorbidities were identified with validated codes. We evaluated the presence of effect modification (also called interaction) between frailty and each comorbidity on (1) the relative (or multiplicative) scale by assessing whether the risk of mortality when both frailty and the comorbidity were present was different than the product of the risks associated with each condition; and (2) the absolute risk difference (or additive) scale by assessing whether the risk of mortality when both frailty and the comorbidity were present was greater than the sum of the risks associated with each condition. RESULTS: 11,150 (9.7%) people with frailty died versus 7826 (2.8%) without frailty. After adjustment, frailty was associated with decreased survival (adjusted hazard ratio [HR] = 2.42; 95% confidence interval [CI], 2.31-2.54). On the relative (multiplicative) scale, only diabetes mellitus demonstrated significant effect modification (P value for interaction .03; reduced risk together). On the absolute risk difference (additive) scale, all comorbidities except for coronary disease demonstrated effect modification of the association of frailty with survival. Co-occurrence of dementia with frailty carried the greatest excess risk (Synergy Index [S; the excess risk from exposure to both risk factors compared to the sum of the risks from each factor in isolation] = 2.29; 95% CI, 1.32-10.80, the excess risk from exposure to both risk factors compared to the sum of the risks from each factor in isolation). CONCLUSIONS: Common comorbidities modify the association of frailty with postoperative survival; however, this effect was only apparent when analyses accounted for effect modification on the absolute risk difference, as opposed to relative scale. While the relative scale is more commonly used in biomedical research, smaller effects may be easier to detect on the risk difference scale. The concurrent presence of dementia, COPD, and HF with frailty were all associated with excess mortality on the absolute risk difference scale.

13.
Med Decis Making ; 39(8): 1010-1018, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31731879

RESUMO

Background. We aimed to validate the SURE test for use with parents in primary care. Methods. A secondary analysis of cluster randomized trial data was used to compare the SURE test (index, higher score = less conflict) to the Decisional Conflict Scale (DCS; reference, higher score = greater conflict). Our a priori hypothesis was that the scales would correlate negatively. We evaluated the association between scores and estimated the proportion of variance in the DCS explained by the SURE test. Then, we dichotomized each measure using established cutoffs to calculate diagnostic accuracy and internal consistency with confidence intervals adjusted for clustering. We evaluated the presence of effect modification by sex, followed by sex-specific calculation of validation statistics. Results. In total, 185 of 201 parents completed a DCS and SURE test. Total DCS (mean = 4.2/100, SD = 14.3) and SURE test (median 4/4; interquartile range, 4-4) scores were significantly correlated (ρ = -0.36, P < 0.0001). The SURE test explained 34% of the DCS score variance. Internal consistency (Kuder-Richardson 20) was 0.38 (P < 0.0001). SURE test sensitivity and specificity for identifying decisional conflict were 32% (95% confidence interval [CI], 20%-44%) and 96% (95% CI, 93%-100%), respectively. The SURE test's positive likelihood ratio was 8.4 (95% CI, 0.1-17) and its negative likelihood ratio was 0.7 (95% CI, 0.53-0.87). There were no significant differences between females and males in DCS (P = 0.5) or SURE test (P = 0.97) total scores; however, correlations between test total scores (-0.37 for females v. for -0.21 for males; P = 0.001 for the interaction) and sensitivity and specificity were higher for females than males. Conclusions. SURE test demonstrated acceptable psychometric properties for screening decisional conflict among parents making a health decision about their child in primary care. However, clinicians cannot be confident that a negative SURE test rules out the presence of decisional conflict.

14.
Anesthesiology ; 131(5): 1025-1035, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31634246

RESUMO

BACKGROUND: Adverse outcomes and resource use rates are high after hip fracture surgery. Peripheral nerve blocks could improve outcomes through enhanced analgesia and decreased opioid related adverse events. We hypothesized that these benefits would translate into decreased resource use (length of stay [primary outcome] and costs), and better clinical outcomes (pneumonia and mortality). METHODS: The authors conducted a retrospective cohort study of hip fracture surgery patients in Ontario, Canada (2011 to 2015) using linked health administrative data. Multilevel regression, instrumental variable, and propensity scores were used to determine the association of nerve blocks with resource use and outcomes. RESULTS: The authors identified 65,271 hip fracture surgery patients; 10,030 (15.4%) received a block. With a block, the median hospital stay was 7 (interquartile range, 4 to 13) days versus 8 (interquartile range, 5 to 14) days without. Following adjustment, nerve blocks were associated with a 0.6-day decrease in length of stay (95% CI, 0.5 to 0.8). This small difference was consistent with instrumental variable (1.1 days; 95% CI, 0.9 to 1.2) and propensity score (0.2 days; 95% CI, 0.2 to 0.3) analyses. Costs were lower with a nerve block (adjusted difference, -$1,421; 95% CI, -$1,579 to -$1,289 [Canadian dollars]), but no difference in mortality (adjusted odds ratio, 0.99; 95% CI, 0.89 to 1.11) or pneumonia (adjusted odds ratio, 1.01; 95% CI, 0.88 to 1.16) was observed. CONCLUSIONS: Receipt of nerve blocks for hip fracture surgery is associated with decreased length of stay and health system costs, although small effect sizes may not reflect clinical significance for length of stay.

15.
Anesth Analg ; 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31569165

RESUMO

BACKGROUND: Guidelines recommend routine preoperative frailty assessment for older people. However, the degree to which frailty instruments improve predictive accuracy when added to traditional risk factors is poorly described. Our objective was to measure the accuracy gained in predicting outcomes important to older patients when adding the Clinical Frailty Scale (CFS), Fried Phenotype (FP), or Frailty Index (FI) to traditional risk factors. METHODS: This was an analysis of a multicenter prospective cohort of elective noncardiac surgery patients ≥65 years of age. Each frailty instrument was prospectively collected. The added predictive performance of each frailty instrument beyond the baseline model (age, sex, American Society of Anesthesiologists' score, procedural risk) was estimated using likelihood ratio test, discrimination, calibration, explained variance, and reclassification. Outcomes analyzed included death or new disability, prolonged length of stay (LoS, >75th percentile), and adverse discharge (death or non-home discharge). RESULTS: We included 645 participants (mean age, 74 [standard deviation, 6]); 72 (11.2%) participants died or experienced a new disability, 164 (25.4%) had prolonged LoS, and 60 (9.2%) had adverse discharge. Compared to the baseline model predicting death or new disability (area under the curve [AUC], 0.67; R, 0.08, good calibration), prolonged LoS (AUC, 0.73; R, 0.18, good calibration), and adverse discharge (AUC, 0.78; R, 0.16, poor calibration), the CFS improved fit per the likelihood ratio test (P < .02 for death or new disability, <.001 for LoS, <.001 for discharge), discrimination (AUC = 0.71 for death or new disability, 0.76 for LoS, 0.82 for discharge), calibration (good for death or new disability, LoS, and discharge), explained variance (R = 0.11 for death or new disability, 0.22 for LoS, 0.25 for discharge), and reclassification (appropriate directional reclassification) for all outcomes. The FP improved discrimination and R for all outcomes, but to a lesser degree than the CFS. The FI improved discrimination for death or new disability and R for all outcomes, but to a lesser degree than the CFS and the FP. These results were consistent in internal validation. CONCLUSIONS: Frailty instruments provide meaningful increases in accuracy when predicting postoperative outcomes for older people. Compared to the FP and FI, the CFS appears to improve all measures of predictive performance to the greatest extent and across outcomes. Combined with previous research demonstrating that the CFS is easy to use and requires less time than the FP, clinicians should consider its use in preoperative practice.

16.
Intensive Care Med ; 45(12): 1742-1752, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31595352

RESUMO

PURPOSE: Invasive mechanical ventilation is a common form of life support provided to critically ill patients. Frailty is an emerging prognostic factor for poor outcome in the Intensive Care Unit (ICU); however, its association with adverse outcomes following invasive mechanical ventilation is unknown. We sought to evaluate the association between frailty, defined by the Clinical Frailty Scale (CFS), and outcomes of ICU patients receiving invasive mechanical ventilation. METHODS: We performed a retrospective analysis (2011-2016) of a prospectively collected registry from two hospitals of consecutive ICU patients ≥ 18 years of age receiving invasive mechanical ventilation. CFS scores were based on recorded pre-admission function at the time of hospital admission. The primary outcome was hospital mortality. Secondary outcomes included discharge to long-term care, extubation failure at time of first liberation attempt, and tracheostomy. RESULTS: We included 8110 patients, and 2529 (31.2%) had frailty (CFS ≥ 5). Frailty was associated with increased odds of hospital death (adjusted odds ratio [aOR]: 1.24 [95% confidence interval [CI] 1.10-1.40) and discharge to long-term care (aOR 1.21 [95% CI 1.13-1.35]). As compared to patients without frailty, patients with frailty had increased odds of extubation failure (aOR 1.17 [95% CI 1.04-1.37]), hospital death following extubation failure (aOR 1.18 [95% CI 1.07-1.28]), tracheostomy (aOR 1.17 [95% CI 1.01-1.36]), and hospital death following tracheostomy (aOR 1.14 [95% CI 1.03-1.25]). CONCLUSIONS: The presence of frailty among patients receiving mechanical ventilation is associated with increased odds of hospital mortality, discharge to long-term care, extubation failure, and need for tracheostomy.

17.
J Vasc Surg ; 2019 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-31495676

RESUMO

BACKGROUND: Abdominal aortic aneurysm (AAA) repair is associated with significant morbidity and mortality. As a result, many of these patients are monitored postoperatively in the intensive care unit (ICU). However, little is known about resource utilization and costs associated with ICU admission in this population. We sought to evaluate predictors of total costs among patients admitted to the ICU after repair of nonruptured or ruptured AAA. METHODS: We retrospectively analyzed prospectively collected data (2011-2016) of ICU patients admitted after AAA repair. The primary outcome was total hospital costs. We used elastic net regression to identify pre-ICU admission predictors of hospitalization costs separately for nonruptured and ruptured AAA patients. RESULTS: We included 552 patients in the analysis. Of these, 440 (79.7%) were admitted after repair of nonruptured AAA, and 112 (20.3%) were admitted after repair of ruptured AAA. The mean age of patients with nonruptured AAA was 74 (standard deviation, 9) years, and the mean age of patients with ruptured AAA was 70 (standard deviation, 8) years. Median total hospital cost (in Canadian dollars) was $21,555 (interquartile range, $17,798-$27,294) for patients with nonruptured AAA and $33,709 (interquartile range, $23,173-$53,913) for patients with ruptured AAA. Among both nonruptured and ruptured AAA patients, increasing age, illness severity, use of endovascular repair, history of chronic obstructive pulmonary disease, and excessive blood loss (≥4000 mL) were associated with increased costs, whereas having an anesthesiologist with vascular subspecialty training was associated with lower costs. CONCLUSIONS: Patient-, procedure-, and clinician-specific variables are associated with costs in patients admitted to the ICU after repair of AAA. These factors may be considered future targets in initiatives to improve cost-effectiveness in this population.

18.
Surgery ; 166(6): 1084-1091, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31377000

RESUMO

BACKGROUND: Thromboprophylaxis aims to reduce venous thromboembolism but has the potential to increase bleeding. We sought to evaluate the risk of venous thromboembolism and transfusion after major abdominopelvic procedures and to quantify the association of the procedure with venous thromboembolism. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program was queried for patients who received an abdominopelvic surgery between 2005 and 2016. Patient factors, operative factors, and outcomes were collected. Multivariable analyses were used to determine the association between individual procedures and venous thromboembolism. Area under the curve analyses were performed to assess whether addition of the procedure to Caprini score improved the association of the model with venous thromboembolism. The primary outcome was risk of venous thromboembolism within 30 days of surgery. Secondary outcomes were the risk of transfusion within 30 days and the association between operative time with venous thromboembolism. RESULTS: There were 896,441 patients who received an abdominopelvic procedure. The overall risk of venous thromboembolism was 1.9% (n = 16,665). Procedures with the highest risk of venous thromboembolism were esophagectomy (5.5%) and partial esophagectomy (5.3%). The overall risk of transfusion was 9.5% (n = 84,889). Procedures with the highest risk of transfusion were pelvic exenteration (53.6%) and radical cystectomy (37.7%). On multivariable analyses, individual procedures were independently associated with venous thromboembolism, despite adjusting for Caprini score. Area under the curve analyses indicated risk prediction of the baseline model (area under the curve 0.59) improved when procedures were added (area under the curve 0.68). CONCLUSION: Patients undergoing abdominopelvic surgery are at a high risk of venous thromboembolism and transfusion. Improved risk stratification may be possible by including more procedural information in scoring systems.


Assuntos
Anticoagulantes/administração & dosagem , Transfusão de Sangue/estatística & dados numéricos , Hemorragia Pós-Operatória/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Tromboembolia Venosa/prevenção & controle , Abdome/cirurgia , Adulto , Idoso , Anticoagulantes/efeitos adversos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pelve/cirurgia , Hemorragia Pós-Operatória/induzido quimicamente , Hemorragia Pós-Operatória/terapia , Medição de Risco , Fatores de Risco , Tromboembolia Venosa/etiologia
19.
Anesth Analg ; 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31453872

RESUMO

BACKGROUND: Older people with frailty have decreased postoperative survival. Understanding how comorbidities modify the association between frailty and survival could improve risk stratification and guide development of interventions. Therefore, we evaluated whether the concurrent presence of common and high-risk comorbidities (dementia, chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], diabetes mellitus, heart failure [HF]) in conjunction with frailty might be associated with a larger decrease in postoperative survival after major elective surgery than would be expected based on the presence of the comorbidity and frailty on their own. METHODS: This cohort study used linked administrative data from Ontario, Canada to identify adults >65 years having elective noncardiac surgery from 2010 to 2015. Frailty was identified using a validated index; comorbidities were identified with validated codes. We evaluated the presence of effect modification (also called interaction) between frailty and each comorbidity on (1) the relative (or multiplicative) scale by assessing whether the risk of mortality when both frailty and the comorbidity were present was different than the product of the risks associated with each condition; and (2) the absolute risk difference (or additive) scale by assessing whether the risk of mortality when both frailty and the comorbidity were present was greater than the sum of the risks associated with each condition. RESULTS: 11,150 (9.7%) people with frailty died versus 7826 (2.8%) without frailty. After adjustment, frailty was associated with decreased survival (adjusted hazard ratio [HR] = 2.42; 95% confidence interval [CI], 2.31-2.54). On the relative (multiplicative) scale, only diabetes mellitus demonstrated significant effect modification (P value for interaction .03; reduced risk together). On the absolute risk difference (additive) scale, all comorbidities except for coronary disease demonstrated effect modification of the association of frailty with survival. Co-occurrence of dementia with frailty carried the greatest excess risk (Synergy Index [S; the excess risk from exposure to both risk factors compared to the sum of the risks from each factor in isolation] = 2.29; 95% CI, 1.32-10.80, the excess risk from exposure to both risk factors compared to the sum of the risks from each factor in isolation). CONCLUSIONS: Common comorbidities modify the association of frailty with postoperative survival; however, this effect was only apparent when analyses accounted for effect modification on the absolute risk difference, as opposed to relative scale. While the relative scale is more commonly used in biomedical research, smaller effects may be easier to detect on the risk difference scale. The concurrent presence of dementia, COPD, and HF with frailty were all associated with excess mortality on the absolute risk difference scale.

20.
Crit Care ; 23(1): 286, 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31455376

RESUMO

BACKGROUND: Patients with hematologic malignancies who are admitted to hospital are at increased risk of deterioration and death. Rapid response systems (RRSs) respond to hospitalized patients who clinically deteriorate. We sought to describe the characteristics and outcomes of hematologic oncology inpatients requiring rapid response system (RRS) activation, and to determine the prognostic accuracy of the SIRS and qSOFA criteria for in-hospital mortality of hematologic oncology patients with suspected infection. METHODS: We used registry data from two hospitals within The Ottawa Hospital network, between 2012 and 2016. Consecutive hematologic oncology inpatients who experienced activation of the RRS were included in the study. Data was gathered at the time of RRS activation and assessment. The primary outcome was in-hospital mortality. Logistical regression was used to evaluate for predictors of in-hospital mortality. RESULTS: We included 401 patients during the study period. In-hospital mortality for all included patients was 41.9% (168 patients), and 145 patients (45%) were admitted to ICU following RRS activation. Among patients with suspected infection at the time of RRS activation, Systemic Inflammatory Response Syndrome (SIRS) criteria had a sensitivity of 86.9% (95% CI 80.9-91.6) and a specificity of 38.2% (95% CI 31.9-44.8) for predicting in-hospital mortality, while Quick Sequential Organ Failure Assessment (qSOFA) criteria had a sensitivity of 61.9% (95% CI 54.1-69.3) and a specificity of 91.4% (95% CI 87.1-94.7). Factors associated with increased in-hospital mortality included transfer to ICU after RRS activation (adjusted odds ratio [OR] 3.56, 95% CI 2.12-5.97) and a higher number of RRS activations (OR 2.45, 95% CI 1.63-3.69). Factors associated with improved survival included active malignancy treatment at the time of RRS activation (OR 0.54, 95% CI 0.34-0.86) and longer hospital length of stay (OR 0.78, 95% CI 0.70-0.87). CONCLUSIONS: Hematologic oncology inpatients requiring RRS activation have high rates of subsequent ICU admission and mortality. ICU admission and higher number of RRS activations are associated with increased risk of death, while active cancer treatment and longer hospital stay are associated with lower risk of mortality. Clinicians should consider these factors in risk-stratifying these patients during RRS assessment.

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