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Purpose To provide population-level estimates of the association of frailty with one-year outcomes after critical illness. Materials and methods Retrospective cohort study of patients who survived an ICU admission between April 2002 and March 2015. Pre-existing frailty was classified using the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable Cox regression and Fine and Gray models were used to examine the association between frailty and mortality and hospital readmission. Results Of 534,991 patients, 19.3% had pre-existing frailty. Compared to non-frail survivors, at one-year frail patients had higher mortality (18.3% vs 9.5%, adjusted HR 1.17 95% CI: 1.15–1.19) and hospital readmission (44.4% vs 36.6%, adjusted HR 1.10 95% CI: 1.08–1.11) and a CAN$19,628 (95% CI: $19,279–$19,997) greater increase in healthcare costs compared to the year prior to hospitalization. The association between frailty and mortality was stronger among older individuals, but the risk of readmission among frail patients decreased with age. Conclusion Patients with pre-existing frailty who develop critical illness have higher rates of hospital readmission and death than patients without frailty, and age modifies these associations. These data highlight the importance of considering both frailty and age when seeking to identify at-risk patients who might benefit from closer follow-up after discharge.

Unplanned rehospitalization at a hospital other than the initial hospital may contribute to poor outcomes. We examined the location of rehospitalizations and assessed outcomes following critical illness in a single-payer healthcare system.Population-based retrospective cohort study using linked datasets (2012-2017) from Ontario, Canada including adults (≥18 years) with an unplanned rehospitalization within 30-days after an index hospitalization that included an ICU stay with mechanical ventilation. Outcomes were the percentage of 30-day rehospitalizations at non-index hospitals, mortality and costs. We employed logistic regression and generalized linear models to assess associations.There were 14,997 (16.4%) 30-day rehospitalizations. Of these 2765 (18.4%) occurred in a non-index hospital. Distance of home residence from the index hospital was the strongest predictor of a non-index rehospitalization (adjusted odds ratio (aOR) 8.40, 95%CI 7.05-10.01, highest vs. lowest distance quintile). Within 30-days of rehospitalization, deaths (aOR 0.91, 95%CI (0.80-1.04)) and total healthcare costs (adjusted relative risk 1.03 (1.00-1.06)), were similar for patients readmitted to the index or a non-index hospital.Non-index rehospitalization within 30-days of initial discharge is common following critical illness. These rehospitalizations were not significantly associated with an increased risk of harm or higher costs in a single-payer healthcare system.

To assess temporal trends in pre-existing opioid exposure prior to hospitalization among elderly intensive care unit (ICU) patients and its association with adverse outcomes.We performed a population-based retrospective cohort study using health administrative data from the province of Ontario, Canada. We included all older adult (65 years) admissions to an ICU between April 2002 and March 2015. The exposure was opioid use before admission categorized as chronic use, intermittent use, and non-use.The cohort included 711,312 elderly patient admissions to an ICU. Of these, 6.8% (n = 48,363) were chronic opioid users, 28.1% (n = 200,149) intermittent users, and 65.0% (n = 462,800) non-users. Compared with non-users, chronic opioid users and intermittent users had higher in-hospital mortality (adjusted odds ratio: 1.12, 95% CI, 1.09-1.15, p 0.0001 for chronic users; adjusted odds ratio: 1.09, 95% CI, 1.07-1.11, p 0.0001 for intermittent users), and a lower subdistribution hazard of time to hospital discharge, translating to a longer hospital length of stay (adjusted hazard ratio: 0.87, 95% CI, 0.85-0.88, p 0.0001 for chronic users; adjusted hazard ratio: 0.93, 95% CI, 0.92-0.94, p 0.0001 for intermittent users).Among elderly ICU patients, opioid exposure prior to admission is prevalent and use is associated with higher in-hospital mortality.

Purpose We examined the association between access to intensive care services and mortality in a cohort of critically ill patients. Materials and Methods We conducted an observational study involving 6298 consecutive admissions to the intensive care units (ICUs) of a tertiary care hospital. Data including demographics, admission source, and outcomes were collected on all patients. Admission source was classified as “transfer” for patients admitted to the ICU from other hospitals, “ER” for patients admitted from the emergency room, and “ward” for patients admitted from non-ICU inpatient wards. Results Transfer patients had higher crude ICU and hospital mortality rates compared with emergency room admissions (crude odds ratio [OR], 1.51; 95% confidence interval [CI], 1.32-1.75). After adjusting for age, sex, diagnosis, comorbidities, and acute physiology scores, the difference in ICU mortality remained significant (OR, 1.30; 95% CI, 1.09-1.56); however, hospital mortality did not (OR, 1.19; 95% CI, 1.00-1.41). Compared with ward patients, transfer from other hospitals was associated with lower hospital mortality after adjusting for severity of illness and other case-mix variables (OR, 0.81; 95% CI, 0.68-0.95). Conclusions We found some evidence to suggest that differential access to intensive care services impacts mortality within this case mix of patients. These findings may have implications for current efforts to centralize and regionalize critical care services.

Purpose: Increasingly, hospitals are engaging in continuous quality improvement (CQI) endeavors, aimed at optimizing patient care. Physician involvement is critical to the success of such initiatives. Little is known about any mediating factors that affect physician participation in these projects, though such knowledge may be potentially important for targeting approaches to maximize physician involvement. The purpose of this study was to develop a reliable and valid instrument to assess physicians' knowledge of and attitudes toward CQI. Materials and Methods: Items for the questionnaire were generated by using interviews and literature re-view and covered areas of knowledge, attitude, and facilitators and barriers to involvement in CQI projects. Five physicians participated in the interviews, 64 participated in the survey, and 9 participated in the assessment of test-retest reliability. Main outcomes were reliability and validity. Results: The CQI questionnaire (CQIQ) had acceptable internal consistency and Cronbach's α correlation coefficient exceeded .70 for all scales. Item-total correlation ranged from .30 to .63 for all scales except for 1 item. Pearson's correlation coefficient for test-retest reliability was 0.85 ( P = .02). A 76% response rate was achieved. Conclusions: Conclusions: There appears to be complex interactions among psychologic and environmental mediators that influence physician participation in hospital quality initiatives. The CQIQ shows reasonable measurement properties and our findings should be generalizable to physicians in other academic institutions. The CQIQ provides additional information on the implementation of programs and processes that should be validated in other institutional settings to enhance the interpretability of the instrument. Copyright © 2002 by W.B. Saunders Company