Clinical

SAN ANTONIO – Patients with pulmonary embolism who were obese paradoxically had a lower mortality risk, compared with those who are not obese, according to results of a retrospective analysis covering 13 years and nearly 2 million PE discharges.

Andrew D. Bowser/MDedge News

The obese patients in the analysis had a lower mortality risk, despite receiving more thrombolytics and mechanical intubation, said investigator Zubair Khan, MD, an internal medicine resident at the University of Toledo (Ohio) Medical Center.

“Surprisingly, the mortality of PE was significantly less in obese patients,” Dr. Khan said in a podium presentation at the annual meeting of the American College of Chest Physicians. “When we initiated the study, we did not expect this result.”

The association between obesity and lower mortality, sometimes called the “obesity paradox,” has been observed in studies of other chronic health conditions including stable heart failure, coronary artery disease, unstable angina, MI, and also in some PE studies, Dr. Khan said.

The study by Dr. Khan and his colleagues, based on the National Inpatient Sample (NIS) database, included adults with a primary discharge diagnosis of PE between 2002 and 2014. They included 1,959,018 PE discharges, of which 312,770 (16%) had an underlying obesity diagnosis.

Obese PE patients had more risk factors and more severe disease but had an overall mortality of 2.2%, compared with 3.7% in PE patients without obesity (P less than .001), Dr. Khan reported.

Hypertension was significantly more prevalent in the obese PE patients (65% vs. 50.5%; P less than .001), as was chronic lung disease and chronic liver disease, he noted in his presentation.

Obese patients more often received thrombolytics (3.6% vs. 1.9%; P less than .001) and mechanical ventilation (5.8% vs. 4%; P less than .001), and more frequently had cardiogenic shock (0.65% vs. 0.45%; P less than .001), he said.

The obese PE patients were more often female, black, and younger than 65 years of age, it was reported.

Notably, the prevalence of obesity in PE patients more than doubled over the course of the study period, from 10.2% in 2002 to 22.6% in 2014, Dr. Khan added.

The paradoxically lower mortality in obese patients might be explained by increased levels of endocannabinoids, which have shown protective effects in rat and mouse studies, Dr. Khan told attendees at the meeting.

“I think it’s a rich area for more and further research, especially in basic science,” Dr. Khan said.

Dr. Khan and his coauthors disclosed that they had no relationships relevant to the study.
 

SOURCE: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.

SAN ANTONIO – Patients with pulmonary embolism who were obese paradoxically had a lower mortality risk, compared with those who are not obese, according to results of a retrospective analysis covering 13 years and nearly 2 million PE discharges.

Andrew D. Bowser/MDedge News

The obese patients in the analysis had a lower mortality risk, despite receiving more thrombolytics and mechanical intubation, said investigator Zubair Khan, MD, an internal medicine resident at the University of Toledo (Ohio) Medical Center.

“Surprisingly, the mortality of PE was significantly less in obese patients,” Dr. Khan said in a podium presentation at the annual meeting of the American College of Chest Physicians. “When we initiated the study, we did not expect this result.”

The association between obesity and lower mortality, sometimes called the “obesity paradox,” has been observed in studies of other chronic health conditions including stable heart failure, coronary artery disease, unstable angina, MI, and also in some PE studies, Dr. Khan said.

The study by Dr. Khan and his colleagues, based on the National Inpatient Sample (NIS) database, included adults with a primary discharge diagnosis of PE between 2002 and 2014. They included 1,959,018 PE discharges, of which 312,770 (16%) had an underlying obesity diagnosis.

Obese PE patients had more risk factors and more severe disease but had an overall mortality of 2.2%, compared with 3.7% in PE patients without obesity (P less than .001), Dr. Khan reported.

Hypertension was significantly more prevalent in the obese PE patients (65% vs. 50.5%; P less than .001), as was chronic lung disease and chronic liver disease, he noted in his presentation.

Obese patients more often received thrombolytics (3.6% vs. 1.9%; P less than .001) and mechanical ventilation (5.8% vs. 4%; P less than .001), and more frequently had cardiogenic shock (0.65% vs. 0.45%; P less than .001), he said.

The obese PE patients were more often female, black, and younger than 65 years of age, it was reported.

Notably, the prevalence of obesity in PE patients more than doubled over the course of the study period, from 10.2% in 2002 to 22.6% in 2014, Dr. Khan added.

The paradoxically lower mortality in obese patients might be explained by increased levels of endocannabinoids, which have shown protective effects in rat and mouse studies, Dr. Khan told attendees at the meeting.

“I think it’s a rich area for more and further research, especially in basic science,” Dr. Khan said.

Dr. Khan and his coauthors disclosed that they had no relationships relevant to the study.
 

SOURCE: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.

SAN ANTONIO – Patients with pulmonary embolism who were obese paradoxically had a lower mortality risk, compared with those who are not obese, according to results of a retrospective analysis covering 13 years and nearly 2 million PE discharges.

Andrew D. Bowser/MDedge News

The obese patients in the analysis had a lower mortality risk, despite receiving more thrombolytics and mechanical intubation, said investigator Zubair Khan, MD, an internal medicine resident at the University of Toledo (Ohio) Medical Center.

“Surprisingly, the mortality of PE was significantly less in obese patients,” Dr. Khan said in a podium presentation at the annual meeting of the American College of Chest Physicians. “When we initiated the study, we did not expect this result.”

The association between obesity and lower mortality, sometimes called the “obesity paradox,” has been observed in studies of other chronic health conditions including stable heart failure, coronary artery disease, unstable angina, MI, and also in some PE studies, Dr. Khan said.

The study by Dr. Khan and his colleagues, based on the National Inpatient Sample (NIS) database, included adults with a primary discharge diagnosis of PE between 2002 and 2014. They included 1,959,018 PE discharges, of which 312,770 (16%) had an underlying obesity diagnosis.

Obese PE patients had more risk factors and more severe disease but had an overall mortality of 2.2%, compared with 3.7% in PE patients without obesity (P less than .001), Dr. Khan reported.

Hypertension was significantly more prevalent in the obese PE patients (65% vs. 50.5%; P less than .001), as was chronic lung disease and chronic liver disease, he noted in his presentation.

Obese patients more often received thrombolytics (3.6% vs. 1.9%; P less than .001) and mechanical ventilation (5.8% vs. 4%; P less than .001), and more frequently had cardiogenic shock (0.65% vs. 0.45%; P less than .001), he said.

The obese PE patients were more often female, black, and younger than 65 years of age, it was reported.

Notably, the prevalence of obesity in PE patients more than doubled over the course of the study period, from 10.2% in 2002 to 22.6% in 2014, Dr. Khan added.

The paradoxically lower mortality in obese patients might be explained by increased levels of endocannabinoids, which have shown protective effects in rat and mouse studies, Dr. Khan told attendees at the meeting.

“I think it’s a rich area for more and further research, especially in basic science,” Dr. Khan said.

Dr. Khan and his coauthors disclosed that they had no relationships relevant to the study.
 

SOURCE: Khan Z et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.919.

SAN FRANCISCO – A heightened loading dose of vancomycin may lead to faster recovery and greater efficacy in Clostridium difficile infections, according to the results of a quasi-experimental study presented at an annual scientific meeting on infectious diseases.

The study looked at a loading dose of 500 mg of vancomycin delivered four times per day for the first 48 hours, followed by a step down to 125 mg every 6 hours. It came on the heels of an attempted randomized, clinical trial that was inconclusive because of insufficient recruitment. Still, the results were promising enough to convince the Yale New Haven Hospital to make it standard practice in C. difficile patients.

Samad Tirmizi, PharmD, an infectious disease pharmacist at Stony Brook University (N.Y.), shares the results of a comparison of outcomes before and after the initiation of this treatment protocol in a video interview.

The approach grew out of concerns that vancomycin may not achieve sufficient concentrations in the colon early in treatment. A pharmacokinetics study published in 2010 suggested that a high initial loading led to higher fecal vancomycin levels, even in patients with increased stool frequency (BMC Infect Dis. 2010 Dec 30;10:363).

SOURCE: Tirmizi S et al. IDWeek 2018, Abstract 1980.

SAN FRANCISCO – A heightened loading dose of vancomycin may lead to faster recovery and greater efficacy in Clostridium difficile infections, according to the results of a quasi-experimental study presented at an annual scientific meeting on infectious diseases.

The study looked at a loading dose of 500 mg of vancomycin delivered four times per day for the first 48 hours, followed by a step down to 125 mg every 6 hours. It came on the heels of an attempted randomized, clinical trial that was inconclusive because of insufficient recruitment. Still, the results were promising enough to convince the Yale New Haven Hospital to make it standard practice in C. difficile patients.

Samad Tirmizi, PharmD, an infectious disease pharmacist at Stony Brook University (N.Y.), shares the results of a comparison of outcomes before and after the initiation of this treatment protocol in a video interview.

The approach grew out of concerns that vancomycin may not achieve sufficient concentrations in the colon early in treatment. A pharmacokinetics study published in 2010 suggested that a high initial loading led to higher fecal vancomycin levels, even in patients with increased stool frequency (BMC Infect Dis. 2010 Dec 30;10:363).

SOURCE: Tirmizi S et al. IDWeek 2018, Abstract 1980.

SAN FRANCISCO – A heightened loading dose of vancomycin may lead to faster recovery and greater efficacy in Clostridium difficile infections, according to the results of a quasi-experimental study presented at an annual scientific meeting on infectious diseases.

The study looked at a loading dose of 500 mg of vancomycin delivered four times per day for the first 48 hours, followed by a step down to 125 mg every 6 hours. It came on the heels of an attempted randomized, clinical trial that was inconclusive because of insufficient recruitment. Still, the results were promising enough to convince the Yale New Haven Hospital to make it standard practice in C. difficile patients.

Samad Tirmizi, PharmD, an infectious disease pharmacist at Stony Brook University (N.Y.), shares the results of a comparison of outcomes before and after the initiation of this treatment protocol in a video interview.

The approach grew out of concerns that vancomycin may not achieve sufficient concentrations in the colon early in treatment. A pharmacokinetics study published in 2010 suggested that a high initial loading led to higher fecal vancomycin levels, even in patients with increased stool frequency (BMC Infect Dis. 2010 Dec 30;10:363).

SOURCE: Tirmizi S et al. IDWeek 2018, Abstract 1980.

Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.

Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.

The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.

Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.

Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.

Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.

The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.

Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.

Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Early hospice referral among Medicare patients is associated with lower rates of hospital admission, intensive care unit admission, and in-hospital death. However, it is not known whether there is association between early hospice referral and health care costs among patients with maintenance hemodialysis.

Among 154,186 (20%) patients receiving hospice service at the time of death, 41.5% enrolled in hospice within 3 days of death. Because more patients were referred to hospice very close to the time of death, the Medicare cost for hospice patients was similar to those patients not referred to hospice ($10,756 vs. $10,871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with lower rates of health care utilization and costs. Late hospice referral was also associated with inadequate pain control and emotional needs.

The study was not able to capture patients who had end-stage renal disease but were on hemodialysis. Patients with private insurance or those covered by Veterans Affairs were not included.

Bottom line: Half of hospice referrals among patients with maintenance hemodialysis occur within the last 3 day of life, which has no significant effect on end-of-life costs and health care utilization.

Citation: Wachterman MW et al. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. Jama Intern Med. 2018;178(6):792-9.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

SAN ANTONIO – Unplanned readmissions declined among tracheostomy/ventilator-dependent children whose discharge process involved a pulmonary nurse practitioner to coordinate continuity of care, a study of more than 70 patients has found.

Tara Haelle/MDedge News

Despite an increase over time in the rate of discharges, readmissions fell, Sarah Barry, CRNP, of Children’s Hospital of Philadelphia (CHOP), said at the annual meeting of the American College of Chest Physicians.

“The technology-dependent pediatric population who is going home with tracheostomy and ventilator dependence is at risk for hospital readmission, and having an advanced practice provider in a continuity role promotes adherence to our standards of practice and improves transition to home,” Ms. Barry said in an interview.

She noted previous research showing that 40% of 109 home mechanical ventilation patients discharged between 2003 and 2009 had unplanned readmissions, 28% of which occurred within the first month after discharge.

Nearly two thirds (64%) of those readmissions were related to a pulmonary and/or tracheostomy problem. That study also found that changes in condition management 1 week before discharge, such as medications, ventilator settings, or feeding regimens, was associated with unplanned readmission.

That research “makes us ask ourselves if our readmissions are avoidable and what can we do to get these kids home safe and to keep them home,” Ms. Barry told attendees, adding that CHOP was unhappy with their readmission rates.

“Kids were often not making it to their first pulmonary appointment, and it was a burden for these families,” she said. “We questioned whether or not having a nurse practitioner in a role to promote adherence to our standards would have a positive impact on our unplanned route.”

They evaluated the effect of such an NP on unplanned readmissions among tracheostomy/ventilator-supported children. The NP’s role was to track patients, mostly from the progressive care unit, who required a tracheostomy and ventilator and were expected to be discharged home or to a long-term care facility. The NP provided continuity for medical management and coordinated care at discharge.

“We also do not make changes for 2 weeks before discharge so that we can focus on all the other coordination that goes into getting these kids home,” Ms. Barry said.

She reviewed the patients’ electronic charts to record time to scheduled follow-up visit, days until hospital readmission, admitting diagnosis at readmission, and length of stay after readmission. With consideration for the time needed for transition into this new process, the population studied was assessed within three cohorts.

The first cohort comprised the 22 children discharged between April 2016 and March 2017, the full year before a pulmonary NP began coordinating the discharge process. These patients averaged 1.8 discharges per month with an initial follow-up of 2-12 weeks.

Just over a quarter (27%) of the first cohort were readmitted before their scheduled follow-up, ranging from 2 to 25 days after discharge. Five percent were readmitted within a week of discharge, and 27% were readmitted within a month; their average length of stay was 13 days after readmission. Most (83%) of these discharges were respiratory related while the other 17% were gastrointestinal related.

The second cohort involved the 11 patients discharged between April 2017 and August 2017, the first 5 months after a pulmonary NP began overseeing the discharge readiness process.

“We chose 5 months because it took about 5months for me to develop my own protocols and standards of practice,” Ms. Barry explained.

An average 2.2 discharges occurred monthly with 2-8 weeks of initial postdischarge follow-up. Though nearly half these children (45%) were readmitted before their scheduled follow-up, their length of stay was shorter, an average of 11 days.

Readmission within a week after discharge occurred among 27% of the children, and 45% of them were readmitted within a month of discharge. Sixty percent of these patients were readmitted for respiratory issues, compared with 40% with GI issues.

The third cohort included all 38 patients discharged from September 2017 to August 2018, the year after a pulmonary NP had become fully established in the continuity role, with an average 3.2 discharges occurred per month. Readmission rates were considerably lower: Eighteen percent of patients were readmitted before their scheduled follow-up appointment, which ranged from 1 to 13 weeks after discharge.

Five percent were readmitted within a week of discharge, and 24% were readmitted within a month, ranging from 1 to 26 days post discharge. But length of stay was shorter still at an average of 9 days.

The reasons for readmission varied more in this cohort: While 56% were respiratory related, 22% were related to fever, and 11% were related to neurodevelopment concerns or social reasons, such as necessary involvement of social services.

Ms. Barry’s colleague, Howard B. Panitch, MD, also on the staff of CHOP, noted during the discussion that the NP’s role is invaluable in “keeping the inpatient teams honest.

“She reminds her colleagues in critical care that you can’t make that ventilator change when on your way out the door or very close to discharge.”

Ms. Barry had no disclosures. No external funding was noted.

SOURCE: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.

SAN ANTONIO – Unplanned readmissions declined among tracheostomy/ventilator-dependent children whose discharge process involved a pulmonary nurse practitioner to coordinate continuity of care, a study of more than 70 patients has found.

Tara Haelle/MDedge News

Despite an increase over time in the rate of discharges, readmissions fell, Sarah Barry, CRNP, of Children’s Hospital of Philadelphia (CHOP), said at the annual meeting of the American College of Chest Physicians.

“The technology-dependent pediatric population who is going home with tracheostomy and ventilator dependence is at risk for hospital readmission, and having an advanced practice provider in a continuity role promotes adherence to our standards of practice and improves transition to home,” Ms. Barry said in an interview.

She noted previous research showing that 40% of 109 home mechanical ventilation patients discharged between 2003 and 2009 had unplanned readmissions, 28% of which occurred within the first month after discharge.

Nearly two thirds (64%) of those readmissions were related to a pulmonary and/or tracheostomy problem. That study also found that changes in condition management 1 week before discharge, such as medications, ventilator settings, or feeding regimens, was associated with unplanned readmission.

That research “makes us ask ourselves if our readmissions are avoidable and what can we do to get these kids home safe and to keep them home,” Ms. Barry told attendees, adding that CHOP was unhappy with their readmission rates.

“Kids were often not making it to their first pulmonary appointment, and it was a burden for these families,” she said. “We questioned whether or not having a nurse practitioner in a role to promote adherence to our standards would have a positive impact on our unplanned route.”

They evaluated the effect of such an NP on unplanned readmissions among tracheostomy/ventilator-supported children. The NP’s role was to track patients, mostly from the progressive care unit, who required a tracheostomy and ventilator and were expected to be discharged home or to a long-term care facility. The NP provided continuity for medical management and coordinated care at discharge.

“We also do not make changes for 2 weeks before discharge so that we can focus on all the other coordination that goes into getting these kids home,” Ms. Barry said.

She reviewed the patients’ electronic charts to record time to scheduled follow-up visit, days until hospital readmission, admitting diagnosis at readmission, and length of stay after readmission. With consideration for the time needed for transition into this new process, the population studied was assessed within three cohorts.

The first cohort comprised the 22 children discharged between April 2016 and March 2017, the full year before a pulmonary NP began coordinating the discharge process. These patients averaged 1.8 discharges per month with an initial follow-up of 2-12 weeks.

Just over a quarter (27%) of the first cohort were readmitted before their scheduled follow-up, ranging from 2 to 25 days after discharge. Five percent were readmitted within a week of discharge, and 27% were readmitted within a month; their average length of stay was 13 days after readmission. Most (83%) of these discharges were respiratory related while the other 17% were gastrointestinal related.

The second cohort involved the 11 patients discharged between April 2017 and August 2017, the first 5 months after a pulmonary NP began overseeing the discharge readiness process.

“We chose 5 months because it took about 5months for me to develop my own protocols and standards of practice,” Ms. Barry explained.

An average 2.2 discharges occurred monthly with 2-8 weeks of initial postdischarge follow-up. Though nearly half these children (45%) were readmitted before their scheduled follow-up, their length of stay was shorter, an average of 11 days.

Readmission within a week after discharge occurred among 27% of the children, and 45% of them were readmitted within a month of discharge. Sixty percent of these patients were readmitted for respiratory issues, compared with 40% with GI issues.

The third cohort included all 38 patients discharged from September 2017 to August 2018, the year after a pulmonary NP had become fully established in the continuity role, with an average 3.2 discharges occurred per month. Readmission rates were considerably lower: Eighteen percent of patients were readmitted before their scheduled follow-up appointment, which ranged from 1 to 13 weeks after discharge.

Five percent were readmitted within a week of discharge, and 24% were readmitted within a month, ranging from 1 to 26 days post discharge. But length of stay was shorter still at an average of 9 days.

The reasons for readmission varied more in this cohort: While 56% were respiratory related, 22% were related to fever, and 11% were related to neurodevelopment concerns or social reasons, such as necessary involvement of social services.

Ms. Barry’s colleague, Howard B. Panitch, MD, also on the staff of CHOP, noted during the discussion that the NP’s role is invaluable in “keeping the inpatient teams honest.

“She reminds her colleagues in critical care that you can’t make that ventilator change when on your way out the door or very close to discharge.”

Ms. Barry had no disclosures. No external funding was noted.

SOURCE: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.

SAN ANTONIO – Unplanned readmissions declined among tracheostomy/ventilator-dependent children whose discharge process involved a pulmonary nurse practitioner to coordinate continuity of care, a study of more than 70 patients has found.

Tara Haelle/MDedge News

Despite an increase over time in the rate of discharges, readmissions fell, Sarah Barry, CRNP, of Children’s Hospital of Philadelphia (CHOP), said at the annual meeting of the American College of Chest Physicians.

“The technology-dependent pediatric population who is going home with tracheostomy and ventilator dependence is at risk for hospital readmission, and having an advanced practice provider in a continuity role promotes adherence to our standards of practice and improves transition to home,” Ms. Barry said in an interview.

She noted previous research showing that 40% of 109 home mechanical ventilation patients discharged between 2003 and 2009 had unplanned readmissions, 28% of which occurred within the first month after discharge.

Nearly two thirds (64%) of those readmissions were related to a pulmonary and/or tracheostomy problem. That study also found that changes in condition management 1 week before discharge, such as medications, ventilator settings, or feeding regimens, was associated with unplanned readmission.

That research “makes us ask ourselves if our readmissions are avoidable and what can we do to get these kids home safe and to keep them home,” Ms. Barry told attendees, adding that CHOP was unhappy with their readmission rates.

“Kids were often not making it to their first pulmonary appointment, and it was a burden for these families,” she said. “We questioned whether or not having a nurse practitioner in a role to promote adherence to our standards would have a positive impact on our unplanned route.”

They evaluated the effect of such an NP on unplanned readmissions among tracheostomy/ventilator-supported children. The NP’s role was to track patients, mostly from the progressive care unit, who required a tracheostomy and ventilator and were expected to be discharged home or to a long-term care facility. The NP provided continuity for medical management and coordinated care at discharge.

“We also do not make changes for 2 weeks before discharge so that we can focus on all the other coordination that goes into getting these kids home,” Ms. Barry said.

She reviewed the patients’ electronic charts to record time to scheduled follow-up visit, days until hospital readmission, admitting diagnosis at readmission, and length of stay after readmission. With consideration for the time needed for transition into this new process, the population studied was assessed within three cohorts.

The first cohort comprised the 22 children discharged between April 2016 and March 2017, the full year before a pulmonary NP began coordinating the discharge process. These patients averaged 1.8 discharges per month with an initial follow-up of 2-12 weeks.

Just over a quarter (27%) of the first cohort were readmitted before their scheduled follow-up, ranging from 2 to 25 days after discharge. Five percent were readmitted within a week of discharge, and 27% were readmitted within a month; their average length of stay was 13 days after readmission. Most (83%) of these discharges were respiratory related while the other 17% were gastrointestinal related.

The second cohort involved the 11 patients discharged between April 2017 and August 2017, the first 5 months after a pulmonary NP began overseeing the discharge readiness process.

“We chose 5 months because it took about 5months for me to develop my own protocols and standards of practice,” Ms. Barry explained.

An average 2.2 discharges occurred monthly with 2-8 weeks of initial postdischarge follow-up. Though nearly half these children (45%) were readmitted before their scheduled follow-up, their length of stay was shorter, an average of 11 days.

Readmission within a week after discharge occurred among 27% of the children, and 45% of them were readmitted within a month of discharge. Sixty percent of these patients were readmitted for respiratory issues, compared with 40% with GI issues.

The third cohort included all 38 patients discharged from September 2017 to August 2018, the year after a pulmonary NP had become fully established in the continuity role, with an average 3.2 discharges occurred per month. Readmission rates were considerably lower: Eighteen percent of patients were readmitted before their scheduled follow-up appointment, which ranged from 1 to 13 weeks after discharge.

Five percent were readmitted within a week of discharge, and 24% were readmitted within a month, ranging from 1 to 26 days post discharge. But length of stay was shorter still at an average of 9 days.

The reasons for readmission varied more in this cohort: While 56% were respiratory related, 22% were related to fever, and 11% were related to neurodevelopment concerns or social reasons, such as necessary involvement of social services.

Ms. Barry’s colleague, Howard B. Panitch, MD, also on the staff of CHOP, noted during the discussion that the NP’s role is invaluable in “keeping the inpatient teams honest.

“She reminds her colleagues in critical care that you can’t make that ventilator change when on your way out the door or very close to discharge.”

Ms. Barry had no disclosures. No external funding was noted.

SOURCE: Barry S et al. CHEST 2018 Oct. doi: 10.1016/j.chest.2018.08.743.

Short-term prescription NSAIDs appeared safe in high-risk patients with musculoskeletal disease and chronic kidney disease (CKD), hypertension, or heart failure, in a retrospective, observational study.

The findings of the study challenge the Choosing Wisely campaign of the American Society of Nephrology, which recommends against NSAIDs for high-risk patients, according to lead author Zachary Bouck, MPH, of the department of medicine at Sunnybrook Health Sciences Centre in Toronto, and his coauthors.

“While these recommendations offer basic analgesics and nonpharmacological treatments as preferable alternatives, it is both possible and disconcerting that some physicians might instead prescribe opioids, which typically pose elevated risk of adverse events and dependence vs. NSAIDs,” the investigators wrote. The report is in JAMA Internal Medicine.

They sought to estimate the frequency and characteristics of NSAID prescriptions while also looking for associations with acute renal and cardiovascular complications. The retrospective, observational study involved 814,049 adults with musculoskeletal disease and 7,365 primary care physicians in Ontario, Canada. All patients were aged 65 years and older, and had been diagnosed with hypertension, chronic kidney disease, or heart failure in the past year. Instances in which a patient was prescribed an NSAID within 7 days of presentation were included.

To assess for associations between prescription NSAIDs and negative outcomes, the investigators searched for renal or cardiovascular complications within 37 days of presentation. Over-the-counter NSAID usage was not evaluated.

There were 224,825 visits. An NSAID was prescribed after 9.3% of these visits.

Renal and cardiovascular outcomes were similar between high-risk patients who received a prescription NSAID and those who did not (absolute risk reduction, .0003; P = .74).

“The similarity in risk between users and nonusers, each group primarily consisting of patients with hypertension, suggests that the short-term association of NSAIDs in high-risk patients with musculoskeletal pain may not be as dangerous as initially thought,” the authors concluded.

The investigators found that prescribing rates varied widely, ranging from 6.7% to 14.4% of different health regions, and from 0.9% to 60.3% among 688 primary care practices, with “substantial variation in use” among primary care physicians.

The authors acknowledged limitations, including the use of administrative data, but noted that their study, showing substantial variations in NSAID prescribing, “along with the identification of patient and physician characteristics associated with NSAID use, presents an opportunity for quality improvement, with some potential targets for any resulting interventions,” they wrote.

The Institute for Clinical Evaluative Sciences funded the study. The authors reported compensation from the Canadian Institute of Health Research, the department of family and community medicine at the University of Toronto, the Heart and Stroke Foundation of Canada, and Women’s College Hospital.

SOURCE: Bouck et al. JAMA Intern Med. 2018 Oct 8. doi: 10.1001/jamainternmed.2018.4273.

Short-term prescription NSAIDs appeared safe in high-risk patients with musculoskeletal disease and chronic kidney disease (CKD), hypertension, or heart failure, in a retrospective, observational study.

The findings of the study challenge the Choosing Wisely campaign of the American Society of Nephrology, which recommends against NSAIDs for high-risk patients, according to lead author Zachary Bouck, MPH, of the department of medicine at Sunnybrook Health Sciences Centre in Toronto, and his coauthors.

“While these recommendations offer basic analgesics and nonpharmacological treatments as preferable alternatives, it is both possible and disconcerting that some physicians might instead prescribe opioids, which typically pose elevated risk of adverse events and dependence vs. NSAIDs,” the investigators wrote. The report is in JAMA Internal Medicine.

They sought to estimate the frequency and characteristics of NSAID prescriptions while also looking for associations with acute renal and cardiovascular complications. The retrospective, observational study involved 814,049 adults with musculoskeletal disease and 7,365 primary care physicians in Ontario, Canada. All patients were aged 65 years and older, and had been diagnosed with hypertension, chronic kidney disease, or heart failure in the past year. Instances in which a patient was prescribed an NSAID within 7 days of presentation were included.

To assess for associations between prescription NSAIDs and negative outcomes, the investigators searched for renal or cardiovascular complications within 37 days of presentation. Over-the-counter NSAID usage was not evaluated.

There were 224,825 visits. An NSAID was prescribed after 9.3% of these visits.

Renal and cardiovascular outcomes were similar between high-risk patients who received a prescription NSAID and those who did not (absolute risk reduction, .0003; P = .74).

“The similarity in risk between users and nonusers, each group primarily consisting of patients with hypertension, suggests that the short-term association of NSAIDs in high-risk patients with musculoskeletal pain may not be as dangerous as initially thought,” the authors concluded.

The investigators found that prescribing rates varied widely, ranging from 6.7% to 14.4% of different health regions, and from 0.9% to 60.3% among 688 primary care practices, with “substantial variation in use” among primary care physicians.

The authors acknowledged limitations, including the use of administrative data, but noted that their study, showing substantial variations in NSAID prescribing, “along with the identification of patient and physician characteristics associated with NSAID use, presents an opportunity for quality improvement, with some potential targets for any resulting interventions,” they wrote.

The Institute for Clinical Evaluative Sciences funded the study. The authors reported compensation from the Canadian Institute of Health Research, the department of family and community medicine at the University of Toronto, the Heart and Stroke Foundation of Canada, and Women’s College Hospital.

SOURCE: Bouck et al. JAMA Intern Med. 2018 Oct 8. doi: 10.1001/jamainternmed.2018.4273.

Short-term prescription NSAIDs appeared safe in high-risk patients with musculoskeletal disease and chronic kidney disease (CKD), hypertension, or heart failure, in a retrospective, observational study.

The findings of the study challenge the Choosing Wisely campaign of the American Society of Nephrology, which recommends against NSAIDs for high-risk patients, according to lead author Zachary Bouck, MPH, of the department of medicine at Sunnybrook Health Sciences Centre in Toronto, and his coauthors.

“While these recommendations offer basic analgesics and nonpharmacological treatments as preferable alternatives, it is both possible and disconcerting that some physicians might instead prescribe opioids, which typically pose elevated risk of adverse events and dependence vs. NSAIDs,” the investigators wrote. The report is in JAMA Internal Medicine.

They sought to estimate the frequency and characteristics of NSAID prescriptions while also looking for associations with acute renal and cardiovascular complications. The retrospective, observational study involved 814,049 adults with musculoskeletal disease and 7,365 primary care physicians in Ontario, Canada. All patients were aged 65 years and older, and had been diagnosed with hypertension, chronic kidney disease, or heart failure in the past year. Instances in which a patient was prescribed an NSAID within 7 days of presentation were included.

To assess for associations between prescription NSAIDs and negative outcomes, the investigators searched for renal or cardiovascular complications within 37 days of presentation. Over-the-counter NSAID usage was not evaluated.

There were 224,825 visits. An NSAID was prescribed after 9.3% of these visits.

Renal and cardiovascular outcomes were similar between high-risk patients who received a prescription NSAID and those who did not (absolute risk reduction, .0003; P = .74).

“The similarity in risk between users and nonusers, each group primarily consisting of patients with hypertension, suggests that the short-term association of NSAIDs in high-risk patients with musculoskeletal pain may not be as dangerous as initially thought,” the authors concluded.

The investigators found that prescribing rates varied widely, ranging from 6.7% to 14.4% of different health regions, and from 0.9% to 60.3% among 688 primary care practices, with “substantial variation in use” among primary care physicians.

The authors acknowledged limitations, including the use of administrative data, but noted that their study, showing substantial variations in NSAID prescribing, “along with the identification of patient and physician characteristics associated with NSAID use, presents an opportunity for quality improvement, with some potential targets for any resulting interventions,” they wrote.

The Institute for Clinical Evaluative Sciences funded the study. The authors reported compensation from the Canadian Institute of Health Research, the department of family and community medicine at the University of Toronto, the Heart and Stroke Foundation of Canada, and Women’s College Hospital.

SOURCE: Bouck et al. JAMA Intern Med. 2018 Oct 8. doi: 10.1001/jamainternmed.2018.4273.

SAN ANTONIO – While septic shock mortality has decreased since the Surviving Sepsis Campaign guidelines were introduced, discharge trends for survivors have not changed significantly over time, a recent analysis suggests.

invisioner/Thinkstock

The percentage of survivors discharged to subacute rehab or long-term facilities did not change appreciably over time, according to the 10-year retrospective analysis, presented at the annual meeting of the American College of Chest Physicians.

However, average length of stay did significantly trend downward over the decade analyzed, while total charge per septic shock admission significantly increased, according to investigator Di Pan, DO, Icahn School of Medicine at Mount Sinai, New York, and his colleagues.

This is one of few studies looking at outcomes in survivors of septic shock, as most analyses have primarily focused on mortality outcomes, the investigators said.

Their analysis was based on the 2004 to 2014 National (Nationwide) Inpatient Sample databases and included patients with a primary diagnosis of septic shock at discharge.

Out of nearly 1.8 million patients with septic shock in that cohort, about 1 million survived, according to data Dr. Pan and colleagues provided in an abstract of the presentation.

In-hospital mortality decreased from 51.7% in 2004 to 39.3% in 2014 (P less than .001), the investigators reported.

The proportion of survivors discharged to subacute rehab or long-term acute care facilities was 61.9% in 2004, and similarly, 62.4% in 2014 (P = .1), while the percentage discharged home was 17.1% in 2004 and 15.1% in 2014 (P = 0.55).

However, there was a small but statistically significant downtick in mean length of stay, from 12.6 days in 2004 to 11.05 days in 2014, the investigators said. Meanwhile, total hospitalization charges surged from $105,776 in 2004 to $134,394 over the same time period.

The first edition of the Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock was published in March 2004 in Critical Care Medicine.

Future studies and clinical trials should look beyond mortality outcomes to additionally evaluate morbidity outcomes in septic shock survivors, Dr. Pan and coauthors said in their report.

The researchers had no relationships to disclose relevant to the presented study.

SOURCE: Pan D et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.339.

SAN ANTONIO – While septic shock mortality has decreased since the Surviving Sepsis Campaign guidelines were introduced, discharge trends for survivors have not changed significantly over time, a recent analysis suggests.

invisioner/Thinkstock

The percentage of survivors discharged to subacute rehab or long-term facilities did not change appreciably over time, according to the 10-year retrospective analysis, presented at the annual meeting of the American College of Chest Physicians.

However, average length of stay did significantly trend downward over the decade analyzed, while total charge per septic shock admission significantly increased, according to investigator Di Pan, DO, Icahn School of Medicine at Mount Sinai, New York, and his colleagues.

This is one of few studies looking at outcomes in survivors of septic shock, as most analyses have primarily focused on mortality outcomes, the investigators said.

Their analysis was based on the 2004 to 2014 National (Nationwide) Inpatient Sample databases and included patients with a primary diagnosis of septic shock at discharge.

Out of nearly 1.8 million patients with septic shock in that cohort, about 1 million survived, according to data Dr. Pan and colleagues provided in an abstract of the presentation.

In-hospital mortality decreased from 51.7% in 2004 to 39.3% in 2014 (P less than .001), the investigators reported.

The proportion of survivors discharged to subacute rehab or long-term acute care facilities was 61.9% in 2004, and similarly, 62.4% in 2014 (P = .1), while the percentage discharged home was 17.1% in 2004 and 15.1% in 2014 (P = 0.55).

However, there was a small but statistically significant downtick in mean length of stay, from 12.6 days in 2004 to 11.05 days in 2014, the investigators said. Meanwhile, total hospitalization charges surged from $105,776 in 2004 to $134,394 over the same time period.

The first edition of the Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock was published in March 2004 in Critical Care Medicine.

Future studies and clinical trials should look beyond mortality outcomes to additionally evaluate morbidity outcomes in septic shock survivors, Dr. Pan and coauthors said in their report.

The researchers had no relationships to disclose relevant to the presented study.

SOURCE: Pan D et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.339.

SAN ANTONIO – While septic shock mortality has decreased since the Surviving Sepsis Campaign guidelines were introduced, discharge trends for survivors have not changed significantly over time, a recent analysis suggests.

invisioner/Thinkstock

The percentage of survivors discharged to subacute rehab or long-term facilities did not change appreciably over time, according to the 10-year retrospective analysis, presented at the annual meeting of the American College of Chest Physicians.

However, average length of stay did significantly trend downward over the decade analyzed, while total charge per septic shock admission significantly increased, according to investigator Di Pan, DO, Icahn School of Medicine at Mount Sinai, New York, and his colleagues.

This is one of few studies looking at outcomes in survivors of septic shock, as most analyses have primarily focused on mortality outcomes, the investigators said.

Their analysis was based on the 2004 to 2014 National (Nationwide) Inpatient Sample databases and included patients with a primary diagnosis of septic shock at discharge.

Out of nearly 1.8 million patients with septic shock in that cohort, about 1 million survived, according to data Dr. Pan and colleagues provided in an abstract of the presentation.

In-hospital mortality decreased from 51.7% in 2004 to 39.3% in 2014 (P less than .001), the investigators reported.

The proportion of survivors discharged to subacute rehab or long-term acute care facilities was 61.9% in 2004, and similarly, 62.4% in 2014 (P = .1), while the percentage discharged home was 17.1% in 2004 and 15.1% in 2014 (P = 0.55).

However, there was a small but statistically significant downtick in mean length of stay, from 12.6 days in 2004 to 11.05 days in 2014, the investigators said. Meanwhile, total hospitalization charges surged from $105,776 in 2004 to $134,394 over the same time period.

The first edition of the Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock was published in March 2004 in Critical Care Medicine.

Future studies and clinical trials should look beyond mortality outcomes to additionally evaluate morbidity outcomes in septic shock survivors, Dr. Pan and coauthors said in their report.

The researchers had no relationships to disclose relevant to the presented study.

SOURCE: Pan D et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.339.

Background: Previous studies have shown that perioperative gabapentin has no effect on remote pain cessation but have not linked it with effects on remote opioid cessation. Also, most trials were limited to immediate postoperative use during hospital admission; limited data were available with extensive postoperative longitudinal follow-up.

One caveat to the outcomes is that use of a gabapentin regimen may have increased after discharge date, which could have biased the outcome.

Bottom line: Perioperative gabapentin may promote opioid cessation and prevent the development of chronic opioid use after surgery.

Citation: Hah J et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surg. 2018;153(4):303-11.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Previous studies have shown that perioperative gabapentin has no effect on remote pain cessation but have not linked it with effects on remote opioid cessation. Also, most trials were limited to immediate postoperative use during hospital admission; limited data were available with extensive postoperative longitudinal follow-up.

One caveat to the outcomes is that use of a gabapentin regimen may have increased after discharge date, which could have biased the outcome.

Bottom line: Perioperative gabapentin may promote opioid cessation and prevent the development of chronic opioid use after surgery.

Citation: Hah J et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surg. 2018;153(4):303-11.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Background: Previous studies have shown that perioperative gabapentin has no effect on remote pain cessation but have not linked it with effects on remote opioid cessation. Also, most trials were limited to immediate postoperative use during hospital admission; limited data were available with extensive postoperative longitudinal follow-up.

One caveat to the outcomes is that use of a gabapentin regimen may have increased after discharge date, which could have biased the outcome.

Bottom line: Perioperative gabapentin may promote opioid cessation and prevent the development of chronic opioid use after surgery.

Citation: Hah J et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surg. 2018;153(4):303-11.

Dr. Katsouli is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

SAN ANTONIO – COPD patients with pulmonary circulation disorders were more than four times as likely to need invasive ventilation after noninvasive ventilation (NIV) failed for acute exacerbations, found a new study.

Tara Haelle/MDedge News

Patients with fluid and electrolyte abnormalities or alcohol abuse also had a greater risk of escalating beyond NIV for exacerbations, according to the findings.

“Patients with these underlying conditions should be monitored closely, especially individuals with existing pulmonary disorders as they are at highest risk,” Di Pan, DO, of Mount Sinai Hospital, New York, reported at annual meeting of the American College of Chest Physicians.

The researchers used the 2012-2014 Nationwide Inpatient Sample database to retrospectively analyze data from 73,480 patients, average age 67.8 years, who had a primary diagnosis of COPD exacerbation and who had received initial treatment with NIV in their first 24 hours after hospitalization. The report is in CHEST^® Journal(2018 Oct. doi: 10.1016/j.chest.2018.08.340).

The researchers examined associations between NIV failure and 29 Elixhauser comorbidity measures to identify what clinical characteristics might predict the need for invasive ventilation. They defined NIV failure as requiring intubation at any time within 30 days of admission.

Pulmonary circulation disorders emerged as the strongest predictor of the need for intubation, with a fourfold increase in relative risk (hazard ratio [HR]: 4.19, P less than .001). Alcohol abuse (HR: 1.85, P = .01) and fluid and electrolyte abnormalities (HR: 1.3, P less than .001) followed as additional factors associated with NIV failure. The latter included irregularities in potassium or sodium, acid-base disorders, hypervolemia and hypovolemia.

Among the 3,740 patients with alcohol abuse, additional statistically significant associations with intubation included a slightly higher mean age, female sex, and the mean Charlson comorbidity index. Mean age of those requiring intubation in this group was 62.28 years, compared 61.47 years among those in whom NIV was adequate (P = .03). Among those intubated, 30.2% of the patients were female, compared with 26.3% female patients in the nonintubated group.

Among the 26,150 patients with fluid, electrolyte and acid-base disturbances, younger patients were more likely to require intubation: The average age of those needing intubation was 67.23 years, compared with 69.3 years for those non-intubated (P less than .001). While a higher Charlson index (2.83 vs. 2.53) was again correlated with greater risk of needing intubation (P less than .001), males were now more likely to require intubation: 58.1% of those without intubation were female, compared with 53.9% of those needing intubation (P less than .001).

Within the 890 patients with pulmonary circulation disorders, mean age was 68.03 years for intubation and 70.77 years for nonintubation (P less than .001). In this group, 56.4% of the patients requiring intubation were female, compared to 47.9% of patients not intubated. The average Charlson index was lower (3.11) among those requiring intubation than among those not needing it (3.57, P less than .001).

The findings were limited by the lack of disease severity stratification and use of now-outdated ICD-9 coding. The researchers also lacked detailed clinical data, such as lab values, imaging results, and vital signs, and Dr. Pan acknowledged the broad variation within the diagnoses of the also-broad Elixhauser comorbidity index.

“For the next steps, we can do a stratified analysis” to identify which specific pulmonary circulation diseases primarily account for the association with intubation, Dr. Pan said.

No external funding was noted. The authors reported having no disclosures.

SOURCE: Pan D. et al. CHEST 2018. https://doi.org/10.1016/j.chest.2018.08.340.

SAN ANTONIO – COPD patients with pulmonary circulation disorders were more than four times as likely to need invasive ventilation after noninvasive ventilation (NIV) failed for acute exacerbations, found a new study.

Tara Haelle/MDedge News

Patients with fluid and electrolyte abnormalities or alcohol abuse also had a greater risk of escalating beyond NIV for exacerbations, according to the findings.

“Patients with these underlying conditions should be monitored closely, especially individuals with existing pulmonary disorders as they are at highest risk,” Di Pan, DO, of Mount Sinai Hospital, New York, reported at annual meeting of the American College of Chest Physicians.

The researchers used the 2012-2014 Nationwide Inpatient Sample database to retrospectively analyze data from 73,480 patients, average age 67.8 years, who had a primary diagnosis of COPD exacerbation and who had received initial treatment with NIV in their first 24 hours after hospitalization. The report is in CHEST^® Journal(2018 Oct. doi: 10.1016/j.chest.2018.08.340).

The researchers examined associations between NIV failure and 29 Elixhauser comorbidity measures to identify what clinical characteristics might predict the need for invasive ventilation. They defined NIV failure as requiring intubation at any time within 30 days of admission.

Pulmonary circulation disorders emerged as the strongest predictor of the need for intubation, with a fourfold increase in relative risk (hazard ratio [HR]: 4.19, P less than .001). Alcohol abuse (HR: 1.85, P = .01) and fluid and electrolyte abnormalities (HR: 1.3, P less than .001) followed as additional factors associated with NIV failure. The latter included irregularities in potassium or sodium, acid-base disorders, hypervolemia and hypovolemia.

Among the 3,740 patients with alcohol abuse, additional statistically significant associations with intubation included a slightly higher mean age, female sex, and the mean Charlson comorbidity index. Mean age of those requiring intubation in this group was 62.28 years, compared 61.47 years among those in whom NIV was adequate (P = .03). Among those intubated, 30.2% of the patients were female, compared with 26.3% female patients in the nonintubated group.

Among the 26,150 patients with fluid, electrolyte and acid-base disturbances, younger patients were more likely to require intubation: The average age of those needing intubation was 67.23 years, compared with 69.3 years for those non-intubated (P less than .001). While a higher Charlson index (2.83 vs. 2.53) was again correlated with greater risk of needing intubation (P less than .001), males were now more likely to require intubation: 58.1% of those without intubation were female, compared with 53.9% of those needing intubation (P less than .001).

Within the 890 patients with pulmonary circulation disorders, mean age was 68.03 years for intubation and 70.77 years for nonintubation (P less than .001). In this group, 56.4% of the patients requiring intubation were female, compared to 47.9% of patients not intubated. The average Charlson index was lower (3.11) among those requiring intubation than among those not needing it (3.57, P less than .001).

The findings were limited by the lack of disease severity stratification and use of now-outdated ICD-9 coding. The researchers also lacked detailed clinical data, such as lab values, imaging results, and vital signs, and Dr. Pan acknowledged the broad variation within the diagnoses of the also-broad Elixhauser comorbidity index.

“For the next steps, we can do a stratified analysis” to identify which specific pulmonary circulation diseases primarily account for the association with intubation, Dr. Pan said.

No external funding was noted. The authors reported having no disclosures.

SOURCE: Pan D. et al. CHEST 2018. https://doi.org/10.1016/j.chest.2018.08.340.

SAN ANTONIO – COPD patients with pulmonary circulation disorders were more than four times as likely to need invasive ventilation after noninvasive ventilation (NIV) failed for acute exacerbations, found a new study.

Tara Haelle/MDedge News

Patients with fluid and electrolyte abnormalities or alcohol abuse also had a greater risk of escalating beyond NIV for exacerbations, according to the findings.

“Patients with these underlying conditions should be monitored closely, especially individuals with existing pulmonary disorders as they are at highest risk,” Di Pan, DO, of Mount Sinai Hospital, New York, reported at annual meeting of the American College of Chest Physicians.

The researchers used the 2012-2014 Nationwide Inpatient Sample database to retrospectively analyze data from 73,480 patients, average age 67.8 years, who had a primary diagnosis of COPD exacerbation and who had received initial treatment with NIV in their first 24 hours after hospitalization. The report is in CHEST^® Journal(2018 Oct. doi: 10.1016/j.chest.2018.08.340).

The researchers examined associations between NIV failure and 29 Elixhauser comorbidity measures to identify what clinical characteristics might predict the need for invasive ventilation. They defined NIV failure as requiring intubation at any time within 30 days of admission.

Pulmonary circulation disorders emerged as the strongest predictor of the need for intubation, with a fourfold increase in relative risk (hazard ratio [HR]: 4.19, P less than .001). Alcohol abuse (HR: 1.85, P = .01) and fluid and electrolyte abnormalities (HR: 1.3, P less than .001) followed as additional factors associated with NIV failure. The latter included irregularities in potassium or sodium, acid-base disorders, hypervolemia and hypovolemia.

Among the 3,740 patients with alcohol abuse, additional statistically significant associations with intubation included a slightly higher mean age, female sex, and the mean Charlson comorbidity index. Mean age of those requiring intubation in this group was 62.28 years, compared 61.47 years among those in whom NIV was adequate (P = .03). Among those intubated, 30.2% of the patients were female, compared with 26.3% female patients in the nonintubated group.

Among the 26,150 patients with fluid, electrolyte and acid-base disturbances, younger patients were more likely to require intubation: The average age of those needing intubation was 67.23 years, compared with 69.3 years for those non-intubated (P less than .001). While a higher Charlson index (2.83 vs. 2.53) was again correlated with greater risk of needing intubation (P less than .001), males were now more likely to require intubation: 58.1% of those without intubation were female, compared with 53.9% of those needing intubation (P less than .001).

Within the 890 patients with pulmonary circulation disorders, mean age was 68.03 years for intubation and 70.77 years for nonintubation (P less than .001). In this group, 56.4% of the patients requiring intubation were female, compared to 47.9% of patients not intubated. The average Charlson index was lower (3.11) among those requiring intubation than among those not needing it (3.57, P less than .001).

The findings were limited by the lack of disease severity stratification and use of now-outdated ICD-9 coding. The researchers also lacked detailed clinical data, such as lab values, imaging results, and vital signs, and Dr. Pan acknowledged the broad variation within the diagnoses of the also-broad Elixhauser comorbidity index.

“For the next steps, we can do a stratified analysis” to identify which specific pulmonary circulation diseases primarily account for the association with intubation, Dr. Pan said.

No external funding was noted. The authors reported having no disclosures.

SOURCE: Pan D. et al. CHEST 2018. https://doi.org/10.1016/j.chest.2018.08.340.

SAN ANTONIO – Chronic liver disease increased mortality risk by up to about 80% in patients with pneumonia, according to an investigator who presented results of a large retrospective analysis.

Andrew Bowser/MDedge News

Liver disease increased the risk of intubation by 39% and increased length of stay by 1 day in the study, presented at the annual meeting of the American College of Chest Physicians.

These findings have implications for clinicians and the scoring systems they use to evaluate patients with pneumonia, according to investigator Zin Mar Htun, MD, internal medicine resident at Louis A. Weiss Memorial Hospital and Presence Saint Joseph Hospital, Chicago.

“We should recognize the importance of chronic liver disease as an independent risk factor for worse outcomes in pneumonia, regardless of the clinical findings or other coexisting comorbidities,” Dr. Htun said in a podium presentation.

Traditional scoring systems for evaluating pneumonia severity do not incorporate hepatic function status, she said.

“We need to come up with a better scoring system that recognizes comorbidities better than the Patient Safety Indicator scoring,” she told attendees at the meeting.

In their study, Dr. Htun and coinvestigator Muhammad Gul, MD, used the 2014 Nationwide Inpatient Sample database to look at pneumonia patients with or without a liver disease diagnosis.

Intubation was done in 14.2% of pneumonia patients with chronic liver disease present, compared with 10.6% of patients with no chronic liver disease (odds ratio [OR], 1.39; 95% confidence interval, 1.30-1.48) in one of their analyses, which included 17,528 pneumonia patients with a liver disease diagnosis and 17,528 pneumonia patients with no such diagnosis, propensity score-matched for age, gender, and Charlson comorbidities.

Length of stay was 8.76 and 7.83 days, respectively, for pneumonia patients with and without chronic liver disease (P less than .001), the propensity score-matched analysis further showed. In-hospital mortality was 10.5% and 6.9% for the liver disease and no liver disease groups in this analysis (OR, 1.57; 95% CI, 1.46-1.70).

In a regression analysis looking at 1.5 million pneumonia patients, of whom about 51,000 had chronic liver disease, the odds ratio for mortality was 1.82 (95% CI, 1.76-1.88; P less than .001), Dr. Htun further reported.

The pathogens causing pneumonia in patients with chronic liver disease were about the same as those in other hospitalized patients, she said in her presentation.

These are “compelling” results that suggest liver disease should considered as a factor in the development of future pneumonia scoring systems, according to Zachary Q. Morris, MD, of Henry Ford Hospital.

Creators of scoring systems may err on the side of making them “simplistic” so they are accessible and easy to analyze, Dr. Morris said in an interview.

“There comes a point in time that maybe you do need to have another layer of complexity to it,” added Dr. Morris, who moderated the original research session where Dr. Htun presented her results.

Both Dr. Htun and Dr. Gul reported that they had no relationships relevant to their study.

SOURCE: Htun ZM, et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.862.

SAN ANTONIO – Chronic liver disease increased mortality risk by up to about 80% in patients with pneumonia, according to an investigator who presented results of a large retrospective analysis.

Andrew Bowser/MDedge News

Liver disease increased the risk of intubation by 39% and increased length of stay by 1 day in the study, presented at the annual meeting of the American College of Chest Physicians.

These findings have implications for clinicians and the scoring systems they use to evaluate patients with pneumonia, according to investigator Zin Mar Htun, MD, internal medicine resident at Louis A. Weiss Memorial Hospital and Presence Saint Joseph Hospital, Chicago.

“We should recognize the importance of chronic liver disease as an independent risk factor for worse outcomes in pneumonia, regardless of the clinical findings or other coexisting comorbidities,” Dr. Htun said in a podium presentation.

Traditional scoring systems for evaluating pneumonia severity do not incorporate hepatic function status, she said.

“We need to come up with a better scoring system that recognizes comorbidities better than the Patient Safety Indicator scoring,” she told attendees at the meeting.

In their study, Dr. Htun and coinvestigator Muhammad Gul, MD, used the 2014 Nationwide Inpatient Sample database to look at pneumonia patients with or without a liver disease diagnosis.

Intubation was done in 14.2% of pneumonia patients with chronic liver disease present, compared with 10.6% of patients with no chronic liver disease (odds ratio [OR], 1.39; 95% confidence interval, 1.30-1.48) in one of their analyses, which included 17,528 pneumonia patients with a liver disease diagnosis and 17,528 pneumonia patients with no such diagnosis, propensity score-matched for age, gender, and Charlson comorbidities.

Length of stay was 8.76 and 7.83 days, respectively, for pneumonia patients with and without chronic liver disease (P less than .001), the propensity score-matched analysis further showed. In-hospital mortality was 10.5% and 6.9% for the liver disease and no liver disease groups in this analysis (OR, 1.57; 95% CI, 1.46-1.70).

In a regression analysis looking at 1.5 million pneumonia patients, of whom about 51,000 had chronic liver disease, the odds ratio for mortality was 1.82 (95% CI, 1.76-1.88; P less than .001), Dr. Htun further reported.

The pathogens causing pneumonia in patients with chronic liver disease were about the same as those in other hospitalized patients, she said in her presentation.

These are “compelling” results that suggest liver disease should considered as a factor in the development of future pneumonia scoring systems, according to Zachary Q. Morris, MD, of Henry Ford Hospital.

Creators of scoring systems may err on the side of making them “simplistic” so they are accessible and easy to analyze, Dr. Morris said in an interview.

“There comes a point in time that maybe you do need to have another layer of complexity to it,” added Dr. Morris, who moderated the original research session where Dr. Htun presented her results.

Both Dr. Htun and Dr. Gul reported that they had no relationships relevant to their study.

SOURCE: Htun ZM, et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.862.

SAN ANTONIO – Chronic liver disease increased mortality risk by up to about 80% in patients with pneumonia, according to an investigator who presented results of a large retrospective analysis.

Andrew Bowser/MDedge News

Liver disease increased the risk of intubation by 39% and increased length of stay by 1 day in the study, presented at the annual meeting of the American College of Chest Physicians.

These findings have implications for clinicians and the scoring systems they use to evaluate patients with pneumonia, according to investigator Zin Mar Htun, MD, internal medicine resident at Louis A. Weiss Memorial Hospital and Presence Saint Joseph Hospital, Chicago.

“We should recognize the importance of chronic liver disease as an independent risk factor for worse outcomes in pneumonia, regardless of the clinical findings or other coexisting comorbidities,” Dr. Htun said in a podium presentation.

Traditional scoring systems for evaluating pneumonia severity do not incorporate hepatic function status, she said.

“We need to come up with a better scoring system that recognizes comorbidities better than the Patient Safety Indicator scoring,” she told attendees at the meeting.

In their study, Dr. Htun and coinvestigator Muhammad Gul, MD, used the 2014 Nationwide Inpatient Sample database to look at pneumonia patients with or without a liver disease diagnosis.

Intubation was done in 14.2% of pneumonia patients with chronic liver disease present, compared with 10.6% of patients with no chronic liver disease (odds ratio [OR], 1.39; 95% confidence interval, 1.30-1.48) in one of their analyses, which included 17,528 pneumonia patients with a liver disease diagnosis and 17,528 pneumonia patients with no such diagnosis, propensity score-matched for age, gender, and Charlson comorbidities.

Length of stay was 8.76 and 7.83 days, respectively, for pneumonia patients with and without chronic liver disease (P less than .001), the propensity score-matched analysis further showed. In-hospital mortality was 10.5% and 6.9% for the liver disease and no liver disease groups in this analysis (OR, 1.57; 95% CI, 1.46-1.70).

In a regression analysis looking at 1.5 million pneumonia patients, of whom about 51,000 had chronic liver disease, the odds ratio for mortality was 1.82 (95% CI, 1.76-1.88; P less than .001), Dr. Htun further reported.

The pathogens causing pneumonia in patients with chronic liver disease were about the same as those in other hospitalized patients, she said in her presentation.

These are “compelling” results that suggest liver disease should considered as a factor in the development of future pneumonia scoring systems, according to Zachary Q. Morris, MD, of Henry Ford Hospital.

Creators of scoring systems may err on the side of making them “simplistic” so they are accessible and easy to analyze, Dr. Morris said in an interview.

“There comes a point in time that maybe you do need to have another layer of complexity to it,” added Dr. Morris, who moderated the original research session where Dr. Htun presented her results.

Both Dr. Htun and Dr. Gul reported that they had no relationships relevant to their study.

SOURCE: Htun ZM, et al. CHEST 2018. doi: 10.1016/j.chest.2018.08.862.

Clinical question: Can a procalcitonin (PCT)–guided strategy safely reduce antibiotic exposure in patients admitted to the ICU with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) with or without pneumonia?

Background: Studies have demonstrated PCT-based strategies can safely reduce antibiotic use in patients without severe lower respiratory tract infections, community-acquired pneumonia, or acute exacerbations of COPD. The data on safety of PCT-based strategies in critically ill patients is limited.

Study design: Prospective, multicenter, randomized, controlled trial.

Setting: ICUs of 11 hospitals in France, including 7 tertiary care hospitals.

Synopsis: In this study 302 patients admitted to the ICU with severe exacerbations of COPD with or without pneumonia were randomly assigned to groups with antibiotic therapy guided by a PCT protocol or standard guidelines. Overall, the study failed to demonstrate noninferiority of a PCT-based strategy to reduce exposure to antibiotics. Specifically, the adjusted difference in mortality was 6.6% higher (90% confidence interval, 0.3%-13.5%) in the intervention group with no significant reduction in antibiotic exposure.

One limitation of this study was that it was an open trial in which clinicians were aware that their management was being observed.

Bottom line: A PCT-based algorithm was not effective in safely reducing antibiotic exposure in patients with acute exacerbations of COPD admitted to the ICU.

Citation: Daubin C et al. Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: A randomized multicenter study. Intensive Care Med. 2018 Apr;44(4):428-37.

Dr. Agith is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Can a procalcitonin (PCT)–guided strategy safely reduce antibiotic exposure in patients admitted to the ICU with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) with or without pneumonia?

Background: Studies have demonstrated PCT-based strategies can safely reduce antibiotic use in patients without severe lower respiratory tract infections, community-acquired pneumonia, or acute exacerbations of COPD. The data on safety of PCT-based strategies in critically ill patients is limited.

Study design: Prospective, multicenter, randomized, controlled trial.

Setting: ICUs of 11 hospitals in France, including 7 tertiary care hospitals.

Synopsis: In this study 302 patients admitted to the ICU with severe exacerbations of COPD with or without pneumonia were randomly assigned to groups with antibiotic therapy guided by a PCT protocol or standard guidelines. Overall, the study failed to demonstrate noninferiority of a PCT-based strategy to reduce exposure to antibiotics. Specifically, the adjusted difference in mortality was 6.6% higher (90% confidence interval, 0.3%-13.5%) in the intervention group with no significant reduction in antibiotic exposure.

One limitation of this study was that it was an open trial in which clinicians were aware that their management was being observed.

Bottom line: A PCT-based algorithm was not effective in safely reducing antibiotic exposure in patients with acute exacerbations of COPD admitted to the ICU.

Citation: Daubin C et al. Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: A randomized multicenter study. Intensive Care Med. 2018 Apr;44(4):428-37.

Dr. Agith is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.

Clinical question: Can a procalcitonin (PCT)–guided strategy safely reduce antibiotic exposure in patients admitted to the ICU with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) with or without pneumonia?

Background: Studies have demonstrated PCT-based strategies can safely reduce antibiotic use in patients without severe lower respiratory tract infections, community-acquired pneumonia, or acute exacerbations of COPD. The data on safety of PCT-based strategies in critically ill patients is limited.

Study design: Prospective, multicenter, randomized, controlled trial.

Setting: ICUs of 11 hospitals in France, including 7 tertiary care hospitals.

Synopsis: In this study 302 patients admitted to the ICU with severe exacerbations of COPD with or without pneumonia were randomly assigned to groups with antibiotic therapy guided by a PCT protocol or standard guidelines. Overall, the study failed to demonstrate noninferiority of a PCT-based strategy to reduce exposure to antibiotics. Specifically, the adjusted difference in mortality was 6.6% higher (90% confidence interval, 0.3%-13.5%) in the intervention group with no significant reduction in antibiotic exposure.

One limitation of this study was that it was an open trial in which clinicians were aware that their management was being observed.

Bottom line: A PCT-based algorithm was not effective in safely reducing antibiotic exposure in patients with acute exacerbations of COPD admitted to the ICU.

Citation: Daubin C et al. Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: A randomized multicenter study. Intensive Care Med. 2018 Apr;44(4):428-37.

Dr. Agith is a hospitalist in the division of hospital medicine in the department of medicine at Loyola University Chicago, Maywood, Ill.