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The COVID-19 pandemic has negatively affected women more than men and may influence the publication of non-COVID research.Evaluate whether the COVID-19 pandemic is associated with changes in manuscript acceptance rates among pulmonary/critical care journals, and gender-based disparities in these rates.We analyzed first, senior, and corresponding-author gender (female vs. male, identified by matching first names in a validated Genderize database) of manuscripts submitted to four pulmonary/critical care journals between 1/1/18-12/31/20. 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 gender with acceptance of original research manuscripts.Among 8,332 original research submissions, women comprised 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-era. Non-COVID-19 manuscripts submitted during the COVID-era had reduced odds of acceptance, regardless of author gender (first-author: adjustedOR [aOR]0.46 [95%CI0.36-0.59]; senior-author: aOR0.46 [95%CI0.37-0.57]). Female senior-authorship was associated with decreased acceptance of non-COVID research manuscripts (crude rates: 14.4% [male] vs 13.2% [female]; aOR0.84, 95%CI0.71-0.99).Although female author submissions were not disproportionately influenced by COVID-19, we found evidence suggesting gender 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 manuscripts, into promotion decisions.

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.

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 ...

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).

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 dat

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.

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., SCOPUS: ar.j, info:eu-repo/semantics/published

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.

Despite the growing enthusiasm surrounding the Choosing Wisely® campaign, little is known regarding the evidence underlying these recommendations. We extracted references for all 320 recommendations published through August, 2014, including the 10 adult and pediatric recommendations published by the Society for Hospital Medicine. We then categorized each item by evidence strength, and then assessed a sample of referenced clinical practice guidelines (CPGs) using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Among all recommendations, 70.3% cited CPGs, whereas 22.2% cited primary research as their highest level of evidence. Moreover, 7.8% cited case series, review articles, editorials, or lower quality data as their highest level of evidence. Hospital medicine recommendations were more likely to cite CPGs (90%) as their highest level of evidence. Among the sampled CPGs, the median overall score obtained using AGREE II was 54.2% (IQR 33.3%–70.8%), whereas among hospital medicine-referenced CPGs, the median overall score was 58.3% (IQR 50.0%–83.3%). These findings suggest that Choosing Wisely® recommendations vary in terms of evidence strength.

Background Failure to reliably diagnose ARDS may be a major driver of negative clinical trials and underrecognition and treatment in clinical practice. We sought to examine the interobserver reliability of the Berlin ARDS definition and examine strategies for improving the reliability of ARDS diagnosis. Methods Two hundred five patients with hypoxic respiratory failure from four ICUs were reviewed independently by three clinicians, who evaluated whether patients had ARDS, the diagnostic confidence of the reviewers, whether patients met individual ARDS criteria, and the time when criteria were met. Results Interobserver reliability of an ARDS diagnosis was "moderate" (kappa = 0.50; 95% CI, 0.40-0.59). Sixty-seven percent of diagnostic disagreements between clinicians reviewing the same patient was explained by differences in how chest imaging studies were interpreted, with other ARDS criteria contributing less (identification of ARDS risk factor, 15%; cardiac edema/volume overload exclusion, 7%). Combining the independent reviews of three clinicians can increase reliability to "substantial" (kappa = 0.75; 95% CI, 0.68-0.80). When a clinician diagnosed ARDS with "high confidence," all other clinicians agreed with the diagnosis in 72% of reviews. There was close agreement between clinicians about the time when a patient met all ARDS criteria if ARDS developed within the first 48 hours of hospitalization (median difference, 5 hours). Conclusions The reliability of the Berlin ARDS definition is moderate, driven primarily by differences in chest imaging interpretation. Combining independent reviews by multiple clinicians or improving methods to identify bilateral infiltrates on chest imaging are important strategies for improving the reliability of ARDS diagnosis.

Objective Despite increasing use, evidence is mixed as to the appropriate use of noninvasive ventilation in patients with pneumonia. We aimed to determine the relationship between receipt of noninvasive ventilation and outcomes for patients with pneumonia in a real-world setting. Design, setting, patients We performed a retrospective cohort study of Medicare beneficiaries (aged > 64 yr) admitted to 2,757 acute-care hospitals in the United States with pneumonia, who received mechanical ventilation from 2010 to 2011. Exposures Noninvasive ventilation versus invasive mechanical ventilation. Measurement and main results The primary outcome was 30-day mortality with Medicare reimbursement as a secondary outcome. To account for unmeasured confounding associated with noninvasive ventilation use, an instrumental variable was used-the differential distance to a high noninvasive ventilation use hospital. All models were adjusted for patient and hospital characteristics to account for measured differences between groups. Among 65,747 Medicare beneficiaries with pneumonia who required mechanical ventilation, 12,480 (19%) received noninvasive ventilation. Patients receiving noninvasive ventilation were more likely to be older, male, white, rural-dwelling, have fewer comorbidities, and were less likely to be acutely ill as measured by organ failures. Results of the instrumental variable analysis suggested that, among marginal patients, receipt of noninvasive ventilation was not significantly associated with differences in 30-day mortality when compared with invasive mechanical ventilation (54% vs 55%; p = 0.92; 95% CI of absolute difference, -13.8 to 12.4) but was associated with significantly lower Medicare spending ($18,433 vs $27,051; p = 0.02). Conclusions Among Medicare beneficiaries hospitalized with pneumonia who received mechanical ventilation, noninvasive ventilation use was not associated with a real-world mortality benefit. Given the wide CIs, however, substantial harm associated with noninvasive ventilation could not be excluded. The use of noninvasive ventilation for patients with pneumonia should be cautioned, but targeted enrollment of marginal patients with pneumonia could enrich future randomized trials.

Studies of nighttime intensivist staffing have yielded mixed results.To review the association of nighttime intensivist staffing with outcomes of intensive care unit (ICU) patients.We searched five databases (2000-2016) for studies comparing in-hospital nighttime intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models.Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographically diverse. Meta-analysis (one randomized controlled trial; three nonrandomized studies with exposure limited to nighttime intensivist staffing with adjusted estimates of effect) demonstrated no association with mortality (odds ratio, 0.99; 95% confidence interval, 0.75-1.29). Secondary analyses including studies without risk adjustment, with a composite exposure of organizational factors, stratified by intensity of daytime staffing and by ICU type, yielded similar results. Minimal or no differences were observed in ICU and hospital length of stay and several other secondary outcomes.Notwithstanding limitations of the predominantly observational evidence, our systematic review and meta-analysis suggests nighttime intensivist staffing is not associated with reduced ICU patient mortality. Other outcomes and alternative staffing models should be evaluated to further guide staffing decisions.

Objective To determine between-hospital variation in interventions provided to patients with do not resuscitate (DNR) orders. Data Sources/Setting United States Agency of Healthcare Research and Quality, Healthcare Cost and Utilization Project, California State Inpatient Database. Study Design Retrospective cohort study including hospitalized patients aged 40 and older with potential indications for invasive treatments: in-hospital cardiac arrest (indication for CPR), acute respiratory failure (mechanical ventilation), acute renal failure (hemodialysis), septic shock (central venous catheterization), and palliative care. Hierarchical logistic regression to determine associations of hospital “early” DNR rates (DNR order placed within 24 hours of admission) with utilization of invasive interventions. Data Collection/Extraction Methods California State Inpatient Database, year 2011. Principal Findings Patients with DNR orders at high-DNR-rate hospitals were less likely to receive invasive mechanical ventilation for acute respiratory failure or hemodialysis for acute renal failure, but more likely to receive palliative care than DNR patients at low-DNR-rate hospitals. Patients without DNR orders experienced similar rates of invasive interventions regardless of hospital DNR rates. Conclusions Hospitals vary widely in the scope of invasive or organ-supporting treatments provided to patients with DNR orders.

Objective:To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU.Methods:We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We a

OBJECTIVE Hospitals vary widely in ICU admission rates across numerous medical diagnoses. The extent to which variability in ICU use is specific to individual diagnoses or is a function of the hospital, regardless of disease, is unknown. DESIGN Retrospective cohort study. SETTING A total of 1,120 acute care hospitals with ICU capabilities. PATIENTS Medicare beneficiaries 65 years old or older admitted for five medical diagnoses (acute myocardial infarction, congestive heart failure, stroke, pneumonia, and chronic obstructive pulmonary disease) and a surgical diagnosis (hip fracture treated with arthroplasty) in 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used multilevel models to calculate risk- and reliability-adjusted ICU admission rates, examined the correlation in ICU admission rates across diagnosis and calculated intraclass correlation coefficients and median odds ratios to quantify the variability in ICU admission rate that was attributable to hospitals. We also examined the ability of a high ICU-use hospital for one condition to predict high ICU use for other conditions. We identified 348,462 patients with one of the eligible conditions. ICU admission rates were positively correlated within hospitals for included medical diagnoses (r range, 0.38-0.59; p < 0.01). The top hospital quartile of ICU use for congestive heart failure had a sensitivity of 50-60% and specificity of 79-81% for detecting top quartile hospitals for each other conditions. After adjustment for patient and hospital characteristics, hospitals accounted for 17.6% (95% CI, 16.2-19.1%) of variability in ICU admission, corresponding to a median odds ratio of 2.3, compared to 25.8% (95% CI, 24.5-27.1%) and median odds ratio 2.8 for diagnosis. This suggests a patient with median baseline risk of ICU admission would more than double his/her odds of ICU admission if moving to a higher utilizing hospital. CONCLUSIONS Hospitals account for a significant proportion of variation independent of measured patient and hospital characteristics, suggesting the need for further work to evaluate the causes of variation at the hospital level and potential consequences of variation across hospitals.

Many advances in health care fail to reach patients. Implementation science is the study of novel approaches to mitigate this evidence-to-practice gap.The American Thoracic Society (ATS) created a multidisciplinary ad hoc committee to develop a research statement on implementation science in pulmonary, critical care, and sleep medicine. The committee used an iterative consensus process to define implementation science and review the use of conceptual frameworks to guide implementation science for the pulmonary, critical care, and sleep community and to explore how professional medical societies such as the ATS can promote implementation science.The committee defined implementation science as the study of the mechanisms by which effective health care interventions are either adopted or not adopted in clinical and community settings. The committee also distinguished implementation science from the act of implementation. Ideally, implementation science should include early and continuous stakeholder involvement and the use of conceptual frameworks (i.e., models to systematize the conduct of studies and standardize the communication of findings). Multiple conceptual frameworks are available, and we suggest the selection of one or more frameworks on the basis of the specific research question and setting. Professional medical societies such as the ATS can have an important role in promoting implementation science. Recommendations for professional societies to consider include: unifying implementation science activities through a single organizational structure, linking front-line clinicians with implementation scientists, seeking collaborations to prioritize and conduct implementation science studies, supporting implementation science projects through funding opportunities, working with research funding bodies to set the research agenda in the field, collaborating with external bodies responsible for health care delivery, disseminating results of implementation science through scientific journals and conferences, and teaching the next generation about implementation science through courses and other media.Implementation science plays an increasingly important role in health care. Through support of implementation science, the ATS and other professional medical societies can work with other stakeholders to lead this effort.

Objective:Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern

Changes in population demographics and comorbid illness prevalence, improvements in medical care, and shifts in care delivery may be driving changes in the composition of patients admitted to the ICU. We sought to describe the changing demographics, diagnoses, and outcomes of patients admitted to critical care units in the U.S. hospitals. Retrospective cohort study. U.S. hospitals. There were 27.8 million elderly (age, > 64 yr) fee-for-service Medicare beneficiaries hospitalized with an intensive care or coronary care room and board charge from 1996 to 2010. None. We aggregated primary International Classification of Diseases, 9th Revision, Clinical Modification discharge diagnosis codes into diagnoses and disease categories. We examined trends in demographics, primary diagnosis, and outcomes among patients with critical care stays. Between 1996 and 2010, we found significant declines in patients with a primary diagnosis of cardiovascular disease, including coronary artery disease (26.6 to 12.6% of admissions) and congestive heart failure (8.5 to 5.4% of admissions). Patients with infectious diseases increased from 8.8% to 17.2% of admissions, and explicitly labeled sepsis moved from the 11th-ranked diagnosis in 1996 to the top-ranked primary discharge diagnosis in 2010. Crude in-hospital mortality rose (11.3 to 12.0%), whereas discharge destinations among survivors shifted, with an increase in discharges to hospice and postacute care facilities. Primary diagnoses of patients admitted to critical care units have substantially changed over 15 years. Funding agencies, physician accreditation groups, and quality improvement initiatives should ensure that their efforts account for the shifting epidemiology of critical illness.

Coexistence of multiple chronic conditions (i.e., multimorbidity) is the most common chronic health problem in adults. However, clinical practice guidelines have primarily focused on patients with a single disease, resulting in uncertainty about the care of patients with multimorbidity. The American Thoracic Society convened a workshop with the goal of establishing a strategy to address multimorbidity within clinical practice guidelines. In this Workshop Report, we describe a framework that addresses multimorbidity in each of the key steps of guideline development: topic selection, panel composition, identifying clinical questions, searching for and synthesizing evidence, rating the quality of that evidence, summarizing benefits and harms, formulating recommendations, and rating the strength of the recommendations. For the consideration of multimorbidity in guidelines to be successful and sustainable, the process must be both feasible and pragmatic. It is likely that this will be achieved best by the step-wise addition and refinement of the various components of the framework.

Intermediate care (i.e., step-down or progressive care) is an alternative to the intensive care unit (ICU) for patients with moderate severity of illness. The adoption and current use of intermediate care is unknown.To characterize trends in intermediate care use among U.S. hospitals.We examined 135 million acute care hospitalizations among elderly individuals (≥65 yr) enrolled in fee-for-service Medicare (U.S. federal health insurance program) from 1996 to 2010. We identified patients receiving intermediate care as those with intensive care or coronary care room and board charges labeled intermediate ICU.In 1996, a total of 960 of the 3,425 hospitals providing critical care billed for intermediate care (28%), and this increased to 1,643 of 2,783 hospitals (59%) in 2010 (P 0.01). Only 8.2% of Medicare hospitalizations in 1996 were billed for intermediate care, but billing steadily increased to 22.8% by 2010 (P 0.01), whereas the percentage billed for ICU care and ward-only care declined. Patients billed for intermediate care had more acute organ failures diagnoses codes compared with general ward patients (22.4% vs. 15.8%). When compared with patients billed for ICU care, those billed for intermediate care had fewer organ failures (22.4% vs. 43.4%), less mechanical ventilation (0.9% vs. 16.7%), lower mean Medicare spending ($8,514 vs. $18,150), and lower 30-day mortality (5.6% vs. 16.5%) (P 0.01 for all comparisons).Intermediate care billing increased markedly between 1996 and 2010. These findings highlight the need to better define the value, specific practices, and effective use of intermediate care for patients and hospitals.

OBJECTIVES Acute renal replacement therapy in patients with sepsis has increased dramatically with substantial costs. However, the extent of variability in use across hospitals-and whether greater use is associated with better outcomes-is unknown. DESIGN Retrospective cohort study. SETTING Nationwide Inpatient Sample in 2011. PATIENTS Eighteen years old and older with sepsis and acute kidney injury admitted to hospitals sampled by the Nationwide Inpatient Sample in 2011. INTERVENTIONS We estimated the risk- and reliability-adjusted rate of acute renal replacement therapy use for patients with sepsis and acute kidney injury at each hospital. We examined the association between hospital-specific renal replacement therapy rate and in-hospital mortality and hospital costs after adjusting for patient and hospital characteristics. MEASUREMENTS AND MAIN RESULTS We identified 293,899 hospitalizations with sepsis and acute kidney injury at 440 hospitals, of which 6.4% (n = 18,885) received renal replacement therapy. After risk and reliability adjustment, the median hospital renal replacement therapy rate for patients with sepsis and acute kidney injury was 3.6% (interquartile range, 2.9-4.5%). However, hospitals in the top quintile of renal replacement therapy use had rates ranging from 4.8% to 13.4%. There was no significant association between hospital-specific renal replacement therapy rate and in-hospital mortality (odds ratio per 1% increase in renal replacement therapy rate: 1.03; 95% CI, 0.99-1.07; p = 0.10). Hospital costs were significantly higher with increasing renal replacement therapy rates (absolute cost increase per 1% increase in renal replacement therapy rate: $1,316; 95% CI, $157-$2,475; p = 0.03). CONCLUSIONS Use of renal replacement therapy in sepsis varied widely among nationally sampled hospitals without associated differences in mortality. Improving renal replacement standards for the initiation of therapy for sepsis may reduce healthcare costs without increasing mortality.

National trends in tracheostomy for mechanical ventilation (MV) patients are not well characterized.To investigate trends in tracheostomy use, timing, and outcomes in the United States.We calculated estimates of tracheostomy use and outcomes from the National Inpatient Sample from 1993 to 2012. We used hierarchical models to determine factors associated with tracheostomy use among MV patients.We identified 1,352,432 adults who received tracheostomy from 1993 to 2012 (9.1% of MV patients). Tracheostomy was more common in surgical patients, men, and racial/ethnic minorities. Age-adjusted incidence of tracheostomy increased by 106%, rising disproportionately to MV use. Among MV patients, tracheostomy rose from 6.9% in 1993 to 9.8% in 2008, and then it declined to 8.7% in 2012 (P 0.0001). Increases in tracheostomy use were driven by surgical patients (9.5% in 1993; 15.0% in 2012; P 0.0001), with little change among nonsurgical patients (5.8% in 1993; 5.9% in 2012; P 0.0001). Over time, tracheostomies were performed earlier (median, 11 d in 1998; 10 d in 2012; P 0.0001), whereas hospital length of stay declined (median, 39 d in 1993; 26 d in 2012; P 0.0001), discharges to long-term facilities increased (40.1% vs. 71.9%; P 0.0001), and hospital mortality declined (38.1% vs. 14.7%; P 0.0001).Over the past two decades, tracheostomy use rose substantially in the United States until 2008, when use began to decline. The observed dramatic increase in discharge of tracheostomy patients to long-term care facilities may have significant implications for clinical care, healthcare costs, policy, and research. Future studies should include long-term facilities when analyzing outcomes of tracheostomy.

OBJECTIVE Quality of care for patients admitted with pneumonia varies across hospitals, but causes of this variation are poorly understood. Whether hospitals with high ICU utilization for patients with pneumonia provide better quality care is unknown. We sought to investigate the relationship between a hospital's ICU admission rate for elderly patients with pneumonia and the quality of care it provided to patients with pneumonia. DESIGN Retrospective cohort study. SETTING Two thousand eight hundred twelve U.S. hospitals. PATIENTS Elderly (age≥65 years) fee-for-service Medicare beneficiaries with either a (1) principal diagnosis of pneumonia or (2) principal diagnosis of sepsis or respiratory failure and secondary diagnosis of pneumonia in 2008. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We grouped hospitals into quintiles based on ICU admission rates for pneumonia. We compared rates of failure to deliver pneumonia processes of care (calculated as 100-adherence rate), 30-day mortality, hospital readmissions, and Medicare spending across hospital quintile. After controlling for other hospital characteristics, hospitals in the highest quintile more often failed to deliver pneumonia process measures, including appropriate initial antibiotics (13.0% vs 10.7%; p

Risk-standardized 30-day mortality and hospital readmission rates for pneumonia are increasingly being tied to hospital reimbursement to incentivize the delivery of high-quality care. Such measures may be susceptible to gaming by recoding patients with pneumonia to a primary diagnosis of sepsis or respiratory failure. We sought to determine the degree to which hospitals can game mortality or readmission measures and change their rankings by recoding patients with pneumonia.Simulated experimental study of 2,906 U.S. acute care hospitals with at least 25 admissions for pneumonia using 2009 Medicare data.Elderly (age ≥ 65 yr) Medicare fee-for-service beneficiaries hospitalized with pneumonia. Patients eligible for recoding to sepsis or respiratory failure were those with a principal International Classification of Diseases, 9th Edition, Clinical Modification, discharge code for pneumonia and secondary codes for respiratory failure or acute organ dysfunction.None.We measured the number of hospitals that improved their pneumonia mortality or readmission rates after recoding eligible patients. When a sample of 100 hospitals with pneumonia mortality rates above the 50th percentile recoded all eligible patients to sepsis or respiratory failure, 90 hospitals (95% CI, 84-95) improved their mortality rate (mean improvement, 1.09%; 95% CI, 0.94-1.28%) and 41 hospitals dropped below the 50th percentile (95% CI, 33-52). When a sample of 100 hospitals with pneumonia readmission rates above the 50th percentile recoded all eligible patients, 66 hospitals (95% CI, 54-75) improved their readmission rate (mean improvement, 0.34%; 95% CI, 0.19-0.45%) and 15 hospitals (95% CI, 9-22) dropped below the 50th percentile.Hospitals can improve apparent pneumonia mortality and readmission rates by recoding pneumonia patients. Centers for Medicare and Medicaid Services should consider changes to their methods used to calculate hospital-level pneumonia outcome measures to make them less susceptible to gaming.

Background— A growing number of hospitals have begun to implement policies allowing for family presence during resuscitation (FPDR). However, the overall safety of these policies and their effect on resuscitation care is unknown. Methods and Results— We conducted an observational cohort study of 252 hospitals in the United States with 41 568 adults with cardiac arrest. Multivariable hierarchical regression models were used to evaluate patterns of care at hospitals with and without an FPDR policy. Primary outcomes included return of spontaneous circulation and survival to discharge. Secondary outcomes included resuscitation quality, interventions, and facility-reported potential resuscitation systems errors. There were no significant differences in facility characteristics between hospitals with and without an FPDR policy, nor were there significant differences in return of spontaneous circulation (adjusted risk ratio, 1.02; 95% confidence interval, 0.95–1.06) or survival to discharge (adjusted risk ratio, 1.05; 95% confidence interval, 0.95–1.15). There was a small, borderline significant decrease in the mean time to defibrillation at hospitals with an FPDR policy compared with hospitals without the policy (mean difference, 0.32 minutes; 95% confidence interval, −0.01 to 0.64). Resuscitation quality, interventions, and facility-reported potential resuscitation systems errors did not meaningfully differ between hospitals with and without an FPDR policy. Conclusions— Hospitals with an FPDR policy generally have no statistically significant differences in outcomes and processes of care as hospitals without this policy, suggesting such policies may not negatively affect resuscitation care. Further study is warranted about the direct effect of FPDR attempts on adult patients with an in-hospital cardiac arrest and their families.

Admission to an intensive care unit (ICU) may be beneficial to patients with pneumonia with uncertain ICU needs; however, evidence regarding the association between ICU admission and mortality for other common conditions is largely unknown.To estimate the relationship between ICU admission and outcomes for hospitalized patients with exacerbation of chronic obstructive pulmonary disease (COPD), exacerbation of heart failure (HF), or acute myocardial infarction (AMI).We performed a retrospective cohort study of all acute care hospitalizations from 2010 to 2012 for U.S. fee-for-service Medicare beneficiaries aged 65 years and older admitted with COPD exacerbation, HF exacerbation, or AMI. We used multivariable adjustment and instrumental variable analysis to assess each condition separately. The instrumental variable analysis used differential distance to a high ICU use hospital (defined separately for each condition) as an instrument for ICU admission to examine marginal patients whose likelihood of ICU admission depended on the hospital to which they were admitted. The primary outcome was 30-day mortality. Secondary outcomes included hospital costs.Among 1,555,798 Medicare beneficiaries with COPD exacerbation, HF exacerbation, or AMI, 486,272 (31%) were admitted to an ICU. The instrumental variable analysis found that ICU admission was not associated with significant differences in 30-day mortality for any condition. ICU admission was associated with significantly greater hospital costs for HF ($11,793 vs. $9,185, P 0.001; absolute increase, $2,608 [95% confidence interval, $1,377-$3,840]) and AMI ($19,513 vs. $14,590, P 0.001; absolute increase, $4,922 [95% confidence interval, $2,665-$7,180]), but not for COPD.ICU admission did not confer a survival benefit for patients with uncertain ICU needs hospitalized with COPD exacerbation, HF exacerbation, or AMI. These findings suggest that the ICU may be overused for some patients with these conditions. Identifying patients most likely to benefit from ICU admission may improve health care efficiency while reducing costs.

Study objective We characterize hospital admissions among older adults for any cause in the 30 days after a significant natural disaster in the United States. The main outcome was all-cause hospital admissions in the 30 days after natural disaster. Separate analyses were conducted to examine all-cause hospital admissions excluding the 72 hours after the disaster, ICU admissions, all-cause inhospital mortality, and admissions by state. Methods A self-controlled case series analysis using the 2011 Medicare Provider and Analysis Review was conducted to examine exposure to natural disaster by elderly adults located in zip codes affected by tornadoes during the 2011 southeastern superstorm. Spatial data of tornado events were obtained from the National Oceanic and Atmospheric Administration's Severe Report database, and zip code data were obtained from the US Census Bureau. Results All-cause hospital admissions increased by 4% for older adults in the 30 days after the April 27, 2011, tornadoes (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). When the first 3 days after the disaster that may have been attributed to immediate injuries were excluded, hospitalizations for any cause also remained higher than when compared with the other 11 months of the year (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). There was no increase in ICU admissions or inhospital mortality associated with the natural disaster. When data were examined by individual states, Alabama, which had the highest number of persons affected, had a 9% increase in both hospitalizations and ICU admissions. Conclusion When all time-invariant characteristics were controlled for, this natural disaster was associated with a significant increase in all-cause hospitalizations. This analysis quantifies acute care use after disasters through examining all-cause hospitalizations and represents an important contribution to building models of resilience—the ability to recover from a disaster—and hospital surge capacity.

To determine national readmission rates among sepsis survivors, variations in rates between hospitals, and determine whether measures of quality correlate with performance on sepsis readmissions.Cross-sectional study of sepsis readmissions between 2008 and 2011 in the Medicare fee-for-service database.Acute care, Medicare participating hospitals from 2008 to 2011.Septic patients as identified by International Classification of Diseases, Ninth Revision codes using the Angus method.None.We generated hospital-level, risk-standardized, 30-day readmission rates among survivors of sepsis and compared rates across region, ownership, teaching status, sepsis volume, hospital size, and proportion of underserved patients. We examined the relationship between risk-standardized readmission rates and hospital-level composite measures of quality and mortality. From 633,407 hospitalizations among 3,315 hospitals from 2008 to 2011, median risk-standardized readmission rates was 28.7% (interquartile range, 26.1-31.9). There were differences in risk-standardized readmission rates by region (Northeast, 30.4%; South, 29.6%; Midwest, 28.8%; and West, 27.7%; p0.001), teaching versus nonteaching status (31.1% vs 29.0%; p0.001), and hospitals serving the highest proportion of underserved patients (30.6% vs 28.7%; p0.001). The best performing hospitals on a composite quality measure had highest risk-standardized readmission rates compared with the lowest (32.0% vs 27.5%; p0.001). Risk-standardized readmission rates was lower in the highest mortality hospitals compared with those in the lowest (28.7% vs 30.7%; p0.001).One third of sepsis survivors were readmitted and wide variation exists between hospitals. Several demographic and structural factors are associated with this variation. Measures of higher quality in-hospital care were correlated with higher readmission rates. Several potential explanations are possible including poor risk standardization, more research is needed.

Background— Early reports suggest the number of cardiac intensive care unit (CICU) patients with primary noncardiac diagnoses is rising in the United States, but no national data currently exist. We examined changes in primary noncardiac diagnoses among elderly patients admitted to a CICU during the past decade. Methods and Results— Using 2003 to 2013 Medicare data, we grouped elderly patients admitted to CICUs into 2 categories based on principal diagnosis at discharge: (1) primary noncardiac diagnoses and (2) primary cardiac diagnoses. We examined changes in patient demographics, comorbidities, procedure use, and risk-adjusted in-hospital mortality. Among 3.4 million admissions with a CICU stay, primary noncardiac diagnoses rose in prevalence from 38.0% to 51.7% between 2003 and 2013. The fastest rising primary noncardiac diagnoses were infectious diseases (7.8%–15.1%) and respiratory diseases (6.0%–7.6%; P P P P P Conclusions— More than half of all elderly patients with a CICU stay across the United States now have primary noncardiac diagnoses at discharge. These patients receive different types of care and have worse outcomes than patients with primary cardiac diagnoses. Our work has important implications for the development of appropriate training and staffing models for the future critical care workforce.

In the United States, approximately 20% of patients hospitalized with pneumonia are readmitted to a hospital within 30 days. Given the significant costs and healthcare system use resulting from unplanned readmissions, pneumonia readmission rates are a target of national quality measures. Patient do-not-resuscitate (DNR) status strongly influences hospital pneumonia mortality measures; however, associations between DNR status and 30-day readmissions after pneumonia are unclear.Determine the effect of accounting for patient DNR status on hospital readmission measures for pneumonia.After excluding patients with missing data, those who died during the index hospitalization, those who were discharged against medical advice, those who did not reside in California, and those admitted to low pneumonia case-volume hospitals, we identified 30-day unplanned readmissions after an index pneumonia hospitalization from the 2011 California State Inpatient Database. We used hierarchical logistic regression to determine the association between early DNR status (within 24 hours of admission) and 30-day readmission and hospital risk-adjusted readmission rates.We identified 68,691 hospitalizations for pneumonia across 321 hospitals. Patients with early DNR orders were less likely to be readmitted within 30 days (20.0% vs. 22.5%, adjusted odds ratio [aOR], 0.93; 95% confidence interval [CI], 0.88-0.99). Patients with pneumonia admitted to high-versus-low DNR rate hospitals were at lower risk for readmission (DNR rate quartile 4 vs. quartile 1, aOR, 0.62; 95% CI, 0.55-0.70), regardless of individual DNR status. Higher hospital risk-adjusted DNR rates were strongly associated with lower risk-adjusted readmission rates (r = -0.44; P 0.0001). Inclusion of early DNR status in risk-adjusted readmission models changed ranking categories for 7/321 (2.2%) hospitals, with 2 hospitals no longer labeled as "under-performing outliers."Patients with an early DNR order have a lower risk for readmission after a pneumonia hospitalization. Unmeasured DNR status weakly confounds hospital readmission measures; accounting for patient DNR status would alter readmission ratings for a small number of hospitals.

BACKGROUND:Variation in the use of ICUs for low-risk conditions contributes to health system inefficiency. We sought to examine the relationship between ICU use for patients with pulmonary embolism (PE) and cost, mortality, readmission, and procedure use. METHODS:We performed a retrospective cohort study including 61,249 adults with PE discharged from 263 hospitals in three states between 2007 and 2010. We generated hospital-specific ICU admission rate quartiles and used a series of multilevel models to evaluate relationships between admission rates and risk-adjusted in-hospital mortality, readmission, and costs and between ICU admission rates and several critical care procedures. RESULTS:Hospital quartiles varied in unadjusted ICU admission rates for PE (range, ≤ 15% to > 31%). Among all patients, there was a small trend toward increased use of arterial catheterization (0.6%-1.1%,P< .01) in hospital quartiles with higher levels of ICU admission. However, use of invasive mechanical ventilation (14.4%-7.9%,P< .01), noninvasive ventilation (6.6%-3.0%,P< .01), central venous catheterization (14.6%-11.3%,P< .02), and thrombolytics (11.0%-4.7%,P< .01) in patients in the ICU declined across hospital quartiles. There was no relationship between ICU admission rate and risk-adjusted hospital mortality, costs, or readmission. CONCLUSIONS:Hospitals vary widely in ICU admission rates for acute PE without a detectable impact on mortality, cost, or readmission. Patients admitted to ICUs in higher-using hospitals received many critical care procedures less often, suggesting that these patients may have had weaker indications for ICU admission. Hospitals with greater ICU admission may be appropriate targets for improving efficiency in ICU admissions.

In 2009, a group of experts convened by the Institute of Medicine estimated that 30% of health care costs amounted to waste, including a substantial share from nonbeneficial and often harmful services. Professional organizations and medical ethicists subsequently called on specialty groups to generate "top five" lists of expensive tests or treatments without known benefits. Responding to this call, the American Board of Internal Medicine launched its Choosing Wisely campaign, with the top-five Choosing Wisely lists for pulmonary medicine and critical care released in 2014. In order for the critical care list to have an impact on costs and quality, two things must occur: providers whose practice is discordant with the list must adhere to the list when making decisions, and those decisions must lead to improvements in the quality of care at lower costs. Although the campaign addresses some limitations of past efforts to improve quality and reduce waste, we believe it will do little to change provider behavior. Even if the top-five list for critical care were to change the behavior of providers, its ultimate impact on costs and quality will be lower than anticipated. Here we suggest several strategies for stakeholders to increase the impact of the critical care top-five list, and further discuss that despite limitations of the campaign it is still imperative for advancing best practice in critical care.

ObjectiveTo evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI).DesignRetrospective cohort study.Setting1727 acute care hospitals in the United States.ParticipantsMedicare 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 measure30 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.ResultsThe 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).ConclusionsICU 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.

Objectives Emergency medical services (EMS) personnel commonly use systolic blood pressure (sBP) to triage and treat acutely ill patients. The definition of prehospital hypotension and its associated outcomes are poorly defined. The authors sought to determine the discrimination of prehospital sBP thresholds for 30-day mortality and to compare patient classification by best-performing thresholds to traditional cutoffs. Methods In a community-based cohort of adult, nontrauma, noncardiac arrest patients transported by EMS between 2002 and 2006, entries to state hospital discharge data and death certificates were linked. Prehospital sBP thresholds between 40 and 140 mm Hg in derivation (n = 132,624) and validation (n = 22,020) cohorts and their discrimination for 30-day mortality, were examined. Cutoffs were evaluated using the 0/1 distance, Youden index, and adjusted Z-statistics from multivariable logistic regression models. Results In the derivation cohort, 1,594 (1.2%) died within 24 hours, 7,404 (6%) were critically ill during hospitalization, and 6,888 (5%) died within 30 days. The area under the receiver operating characteristic (ROC) curve for sBP was 0.60 (95% confidence interval [CI] = 0.59, 0.61) for 30-day mortality and 0.64 (95% CI = 0.62 0.66) for 24-hour mortality. The 0/1 distance, Youden index, and adjusted Z-statistics found best-performing sBP thresholds between 110 and 120 mm Hg. When compared to an sBP ≤ 90 mm Hg, a cutoff of 110 mm Hg would identify 17% (n = 137) more deaths at 30 days, while overtriaging four times as many survivors. Conclusions Prehospital sBP is a modest discriminator of clinical outcomes, yet no threshold avoids substantial misclassification of 30-day mortality among noninjured patients. Resumen Los Umbrales de la Presion Arterial Sistolica Prehospitalaria: Un Estudio de Base Comunitaria Acerca de la Evolucion de los Pacientes Objetivos El personal de los sistemas de emergencias medicas (SEM) usa frecuentemente la presion arterial sistolica (PAS) para clasificar y tratar a los pacientes agudos. Las definiciones de hipotension prehospitalaria y sus resultados asociados estan pobremente definidos. Se determino la discriminacion de los umbrales de PAS prehospitalaria para la mortalidad a los 30 dias, y se comparo la clasificacion del paciente por los mejores umbrales con los puntos de corte tradicionales. Metodologia Estudio de cohorte de base comunitaria de pacientes adultos no traumatologicos ni con paradas cardiorrespiratorias transportados por los SEM entre 2002 y 2006, cuyas historias estaban vinculadas con los datos de alta hospitalaria y los certificados de mortalidad. Se examinaron los umbrales de PAS prehospitalaria entre 40 mm Hg y 140 mm Hg en las cohortes de derivacion (n = 132.624), y validacion (n = 22,020), y su discriminacion para la mortalidad a los 30 dias. Los puntos de corte se evaluaron usando la distancia 0/1, el indice de Youden y los estadisticos Z ajustados de los modelos de regresion logistica multivariable. Resultados: En la cohorte de derivacion, 1.594 (1,2%) fallecieron en las primeras 24 horas, 7.404 (6%) estuvieron criticamente enfermos durante el ingreso y 6.888 (5%) fallecieron en los 30 primeros dias. El area bajo la curva de la ROC para PAS fue 0,60 (IC 95% = 0,59–0,61) para la mortalidad a los 30 dias y 0,64 (IC 95% = 0,62–0,66) para la mortalidad a las 24 horas. La distancia 0/1, el indice de Youden y las estadisticas Z ajustadas hallaronque los mejores umbrales de PAS estaban entre 110 y 120 mm Hg. Cuando se comparo con una PAS ≤ 90 mm Hg, un punto de corte de 110 mm Hg identificaria un 17% (n = 137) mas de muertes a los 30 dias, mientras que sobreclasificaria cuatro veces mas a los supervivientes. Conclusiones La presion arterial sistolica es un discriminador modesto de resultados clinicos. No obstante, ningun umbral evita una mala clasificacion de la mortalidad a los 30 dias entre los pacientes no traumatologicos.