Relationship between pulmonary artery acceleration time and pulmonary artery pressures in infants.

BACKGROUND: Pulmonary artery acceleration time measured by echocardiography inversely correlates with pulmonary artery pressures in adults and children older than 1 year of age. There is a paucity of data investigating this relationship in young children, particularly among preterm infants. OBJECTIVE: To characterize the relationship between pulmonary artery acceleration time (PAAT) and pulmonary artery pressures in infants. DESIGN/METHODS: Patients ≤ 1 year of age at Children's Hospital of Philadelphia between 2011 and 2017 were reviewed. Infants with congenital heart disease were excluded, except those with a patent ductus arteriosus (PDA), atrial septal defect (ASD), or ventricular septal defect (VSD). Linear regression analysis was used to assess the correlation between PAAT measured by echocardiography and systolic pulmonary artery pressure, mean pulmonary artery pressure, and indexed pulmonary vascular resistance from cardiac catheterization. RESULTS: Fifty-seven infants were included, of which 61% were preterm and 49% had a diagnosis of bronchopulmonary dysplasia. The median postmenstrual age and weight at catheterization were 51.1 weeks (IQR 35.8-67.9 weeks) and 4400 g (IQR 3100-6500 g), respectively. Forty-four infants (77%) had a patent ductus arteriosus (PDA). There was a weak inverse correlation between PAAT with mPAP (r = -0.35, P = 0.01), sPAP (r = -0.29, P = 0.03), and PVRi (r = -0.29, P = 0.03). CONCLUSION: There is a weak inverse relationship between PAAT and pulmonary artery pressures. This relationship is less robust in our population of infants with a high incidence of PDAs compared to previous studies in older children. Thus, PAAT may be less clinically meaningful for diagnosing pulmonary arterial hypertension in infants, particularly those with PDAs.

Goals-of-Care Consultations Are Associated with Lower Costs and Less Acute Care Use among Propensity-Matched Cohorts of African Americans and Whites with Serious Illness.

Background: African Americans receive more aggressive end-of-life care than Whites. Little is known about how palliative care consultation to discuss goals-of-care ("PCC") is associated with acute care utilization and costs by race. Objective: To compare future acute care costs and utilization between propensity-matched cohorts of African Americans with and without PCC, and Whites with and without PCC. Design: Secondary analysis of a retrospective cohort study. Setting/Subjects: Thirty-five thousand one hundred and fifty-four African Americans and Whites age 18+ admitted for conditions other than childbirth or rehabilitation, who were not hospitalized at the end of the study, and did not die during index hospitalization (hospitalization during which the first PCC occurred). Measurements: Accumulated mean acute care costs and utilization (30-day readmissions, future hospital days, future intensive care unit [ICU] admission, future number of ICU days) after discharge from index hospitalization. Results: No significant difference between African Americans with or without PCC in mean future acute care costs ($11,651 vs. $15,050, p = 0.09), 30-day readmissions (p = 0.58), future hospital days (p = 0.34), future ICU admission (p = 0.25), or future ICU days (p = 0.30). There were significant differences between Whites with PCC and those without PCC in mean future acute care costs ($8,095 vs. $16,799, p < 0.001), 30-day readmissions (10.2% vs. 16.7%, p < 0.0001), and future days hospitalized (3.7 vs. 6.3 days, p < 0.0001). Conclusions: PCC decreases future acute care costs and utilization in Whites and, directionally but not significantly, in African Americans. Research is needed to explain why utilization and cost disparities persist among African Americans despite PCC.

Goals-of-Care Consultation Associated With Increased Hospice Enrollment Among Propensity-Matched Cohorts of Seriously Ill African American and White Patients.

CONTEXT: African Americans are less likely to receive hospice care and more likely to receive aggressive end-of-life care than whites. Little is known about how palliative care consultation (PCC) to discuss goals of care is associated with hospice enrollment by race. OBJECTIVES: To compare enrollment in hospice at discharge between propensity-matched cohorts of African Americans with and without PCC and whites with and without PCC. METHODS: Secondary analysis of a retrospective cohort study at a high-acuity hospital; using stratified propensity-score matching for 35,154 African Americans and whites aged 18+ admitted for conditions other than childbirth or rehabilitation, who were not hospitalized at end of study, and did not die during index hospitalization (hospitalization during which first PCC occurred). RESULTS: Compared with African Americans without PCC, African Americans with PCC were 15 times more likely to be discharged to hospice from index hospitalization (2.4% vs. 36.5%; P < 0.0001). Compared with white patients without PCC, white patients with PCC were 14 times more likely to be discharged to hospice from index hospitalization (3.0% vs. 42.7%; P < 0.0001). CONCLUSION: In propensity-matched cohorts of seriously ill patients, PCC to discuss goals of care was associated with significant increases in hospice enrollment at discharge among both African Americans and whites. Research is needed to understand how PCC influences decision making by race, how PCC is associated with postdischarge hospice outcomes such as disenrollment and hospice lengths of stay, and if PCC is associated with improving racial disparities in end-of-life care.

Palliative Care Consultation for Goals of Care and Future Acute Care Costs: A Propensity-Matched Study.

BACKGROUND: Hospitals are under increasing pressure to manage costs across multiple episodes of care. Most studies of the financial impact of palliative care have focused on costs during a single hospitalization. OBJECTIVE: To compare future acute health-care costs and utilization between patients who received inpatient palliative care consultation for goals of care (Palliative Care Service [PCS]) and a propensity-matched cohort of patients who did not receive palliative care consultation (non-PCS) in a single academic medical center. METHODS: Data were extracted from the hospital's electronic records for admissions and discharges between July 2014 and October 2016. A stratified propensity score matching was used to account for nonrandom assignment and potential inherent differences between PCS and non-PCS groups using variables of theoretical interest: age, gender, race, diagnosis, risk of mortality, and prior acute care costs. RESULTS: The analytical sample for this study included 41 363 patients (PCS = 1853; non-PCS = 39 510). Future acute care costs were significantly higher in the non-PCS group after propensity score matching (highest tier = US$15 654 vs US$8831; second highest tier = US$12 200 vs US$5496; P = .0001). The non-PCS group also had significantly higher future acute care utilization across all propensity tiers and outcomes including 30-day readmission ( P = .0001), number of future hospital days ( P = .0001), and number of future intensive care unit days ( P = .0001). CONCLUSION: Palliative care consultations for goals of care may decrease future health-care utilization with cost savings that persist into future hospitalizations.