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Annals of the American Thoracic Society | A00-203 genuine Questions and exam Questions

sufferers with ventilator-elegant respiratory failure (VDRF) journey excessive fees of morbidity and mortality and account for over half of admissions to intensive care devices (ICUs) (1, 2). The incidence of VDRF has been expanding during the last decade, driven through multiplied patient complexity and the growing older of the U.S. inhabitants (3). reports have proven that VDRF results are more suitable by means of intensivist-directed care and receiving care at greater-volume centers with more desirable journey (4–7). This association seemingly has many factors, together with variations within the adoption cost of evidence-based care (8), issuer capabilities/staffing models (7, 9, 10), and referral bias (11). therefore, various skilled companies are actively debating a tiered gadget of regionalization for sufferers with VDRF (12, 13) that might be akin to latest systems in trauma and high-possibility neonatology (14–16).

besides the fact that children interhospital switch of sufferers is a core element of a regionalization equipment for VDRF care, little is conventional about the present transfer observe during this inhabitants. in a single examine through which researchers evaluated Medicare claims statistics, approximately 5% of all seriously sick Medicare recipients had been reportedly transferred between hospitals (17), although the percentage of those sufferers who had VDRF is unknown. additional, two single-core experiences (18, 19) in which researchers evaluated the outcomes of interhospital transfer of significantly ill patients counseled that transferred sufferers experience better mortality and longer live than nontransferred sufferers, even after adjustment for affliction severity. although the adequacy of possibility adjustment of these stories limits their generalizability, they are provocative and spotlight the importance of a deeper understanding of factors linked to interhospital switch. it is especially important to verify whether this observe is pushed through scientific indication, patient/family, or clinic-stage variables.

the inability of insight into the scientific, demographic, and health facility-stage variables that have an impact on interhospital switch of sufferers with VDRF represents a important capabilities gap, specifically as U.S. health programs movement towards extra built-in care. They postulated that interhospital switch of sufferers with VDRF would be associated with a mix of affected person and sanatorium variables. as a consequence, the goal of this exploratory analyze became to identify abilities differences in demographic, medical, and health center variables between sufferers with VDRF who underwent interhospital switch and those that didn't to better bear in mind the components that influence the determination to transfer these susceptible sufferers between hospitals.

look at Design and facts source

We performed a retrospective cohort study of all adult patients (aged ≥18 12 months) admitted to nonfederal acute care hospitals in Florida in 2012 and 2013. They obtained administrative statistics from Florida’s Healthcare cost and Utilization assignment (HCUP) state inpatient database (SID). They selected Florida as a result of its SID facts include enjoyable identifiers that allow tracking of individual patients between distinctive acute care hospitals, therefore allowing for the advent of an interhospital transfer cohort. additionally, the Florida HCUP dataset retains particular digits in the nameless health facility identification numbers, which enables for the identification of long-term acute care (LTAC) hospitals such that transfers into these facilities can be excluded to attain the cohort of hobby.

Cohort Identification and Exclusions

All adult sufferers with an international Classification of sickness, Ninth Revision, clinical amendment (ICD-9-CM), diagnosis code akin to acute respiratory failure (518.xx) and a process code corresponding to mechanical air flow (ninety six.70, 96.71, and 96.72) were recognized as the VDRF cohort (20). They excluded sufferers who had been transferred both to or from facilities specific as LTAC hospitals in the HCUP dataset because this became no longer their inhabitants of interest. To extra be sure that sufferers receiving care at LTAC hospitals were no longer covered because of medical institution miscoding, patients were also excluded in the event that they had been transferred to or from hospitals with a standard affected person length of stay more advantageous than 25 days as a result of this attribute is indicative of LTAC amenities (21, 22). in addition, they also excluded sufferers in psychiatric hospitals and one big medical institution gadget the place the health facility identification number was shared by using a couple of smaller device hospitals.

The VDRF cohort turned into then partitioned into a switch cohort and a nontransfer cohort. The switch cohort turned into recognized using two strategies: first, all sufferers with VDRF with a discharge destination code of interfacility transfer to a 2nd acute care medical institution were at the beginning protected; second, all patients with VDRF discharged and then because of this admitted to a special acute care clinic inside the same calendar day were blanketed. This strategy turned into used to compensate for coding errors in discharge vacation spot. additionally, they accessed the Florida Emergency department Database to establish sufferers transferred from the emergency branch to an extra health facility, and they found that they represented under three% of all transferred sufferers with VDRF and hence excluded them from the closing evaluation. All sufferers who were not categorized into the switch cohort were assigned into the nontransfer cohort.

Variable construction

We hypothesized that each affected person-level and sanatorium-degree variables would impact no matter if a patient with VDRF obtained interhospital switch. as a consequence, they selected sets of variables a priori and examined their associations with interhospital transfer.

affected person and medical Variables

affected person variables covered demographics corresponding to age, sex, race, coverage, and comorbidities (Charlson comorbidity index [23]). scientific variables covered length of dwell for transferred (at initial health facility) and nontransferred patients. additionally, they wanted to check associations between the timing of mechanical ventilation initiation and sanatorium switch; therefore, they developed an early mechanical ventilation variable the use of the date and time of the admission mixed with the date for the primary manner code akin to mechanical air flow (ninety six.7x).

We then categorized any patient receiving mechanical air flow within 0–2 days of the admission date and time as having had early mechanical ventilation (24). furthermore, diagnoses/methods average to patients with VDRF had been examined. These included a prognosis of outrage (ICD-9-CM codes 785.5x, 040.82, 276.5x), renal failure requiring dialysis (ICD-9-CM code 39.95), tracheostomy (medical Classifications software for capabilities and approaches variable 34), and primary surgery (via a particular indicator within the SID). For the switch cohort, these variables were assessed at the preliminary health center.

clinic-level Variables

We hypothesized that health center-degree variables contribute to patient transfers, however informative sanatorium-particular variables don't seem to be accessible in HCUP. for that reason, they used a combination of purchasable HCUP health facility variables and variables they built on the foundation of affected person-degree facts associated with each clinic. These developed variables blanketed medical institution-certain case volume(s) and inferred attainable vital care elements in response to particular process codes.

We first characterized hospitals on the groundwork of mattress dimension (>300, 100–300, and <one hundred), income popularity, and concrete versus rural area the use of purchasable HCUP variables; although, they believed these variables had been inadequate to thoroughly symbolize health center skills and capabilities. therefore, they used affected person statistics associated with each medical institution to check health facility-particular annual case volumes of VDRF (in increments of a hundred VDRF cases) (25), annual emergency department case quantity and annual typical ICU case volume. They also examined patient-level technique codes for strong organ transplant (39.65) and/or extracorporeal membrane oxygenation now not associated with cardiac surgery (fifty five.6x) as measures of superior essential care elements.

using these patient-degree variables, they created clinic categories ranging from excessive-quantity, high-aid, big hospitals to decrease-quantity, reduce-aid, small hospitals. They had at the start deliberate to group hospitals into greater discrete classes, but HCUP requires sanatorium confidentiality, and extremely few websites in Florida provided certain advanced treatments; for this reason, they simplified and collapsed the medical institution categories into small, medium-dimension for-income, medium nonprofit, and large. Medium-measurement hospitals were the most effective health facility class separated into for-income and nonprofit popularity, as a result of they identified tremendous model between both corporations in barely the medium-dimension hospitals and not for the other hospital classes.

Statistical and Analytic method

Descriptive records of each the transferred and nontransferred cohorts had been calculated; however, speculation trying out of bivariate statistical ameliorations between the transferred and nontransferred groups are not displayed, since the colossal trial size resulted in statistically large however clinically inappropriate adjustments in well-nigh all variables (26, 27). Manually outfitted multivariable logistic regression become used to identify the associations between affected person variables and clinic class and the percentages of an interhospital transfer. fashions had been estimated the use of clinical variables first, then including affected person demographic variables, and eventually including medical institution categories. huge predictors have been chosen by using together with all predictors within the model and doing away with them manually, one after the other, according to a collection of predictive model–building criteria known as purposeful selection (28). Predictors with magnitude levels less than 0.25 have been examined intently ahead of their talents removing the use of acceptance instructions of elimination in accordance with here statistical criteria: (1) no more than 20% trade in other parametric estimates after removal; (2) smaller Akaike tips criterion/Bayesian tips criterion, indicating a higher mannequin fit without the covariate; and (three) probability ratio examine.

All last fashions had been assessed for standard goodness of healthy the usage of the Hosmer-Lemeshow goodness-of-healthy statistic (29). If covariates superior the model fit, they remained in the mannequin, regardless of whether or not they met the statistical importance level of less than 0.05. To assess if variation ameliorations caused through the nesting of patients within hospitals drastically impacted model efficiency, a final parsimonious multilevel generalized linear mixed mannequin, often known as a hierarchical mannequin, become outfitted the usage of the SAS/STAT 9.1 construction GLIMMIX procedure, which permits for the clustering of sufferers within hospitals (30). The equal purposeful choice standards as described above had been used for the multilevel model (27). mannequin efficiency become evaluated by way of c-records.

Referent values for nondichotomous variables in the models covered white race, industrial coverage, age over eighty years, and big-clinic class. All introduced odds ratios (ORs) signify adjusted odds from the multivariable model. They examined interplay phrases between variables, and none had been found to be big. facts have been analyzed using SAS 9.4 application (SAS Institute, Cary, NC), and they regarded a two-sided α < 0.05 because the threshold for statistical magnitude.

We examined a total of 89,943 acute care hospital facts of sufferers with VDRF, of whom 2,580 (2.9%) had passed through an interhospital switch. They excluded 489 switch sufferers whom they were unable to locate in a 2nd receiving health facility, creating a total interhospital transfer cohort of 2,091 sufferers and a total pattern measurement of 89,454 (determine 1). Transferred patients have been greater more likely to be younger than 65 years (53.4% vs. forty four.1%) and to have business insurance (22.6% vs. 17.2%) than nontransferred patients. Transferred patients had been more doubtless than nontransferred sufferers to have undergone a tracheostomy (19.4% vs. 9.9%). Conversely, the nontransferred cohort had greater percentages of patients with shock (33.1% vs. 29.9%) or who had passed through important surgical procedure (37.2% vs. 31.9%) (desk 1). a big majority (>70%) in each the transferred and nontransferred cohorts bought early mechanical air flow (inside the first 2 d of admission).

desk 1. traits of patients with ventilator-stylish respiratory failure transferred versus now not transferred (n = 89,454)

Variable Transferred (n = 2,091) no longer Transferred (n = 87,363) Age, yr, imply (SD) 61.1 (16.4) 65.three (sixteen.8) feminine intercourse, n (%) 901 (forty three.1) 39,736 (45.5) Race/ethnicity, n (%)      White 1,445 (69.6) 58,743 (67.2)  Black 326 (15.6) 14,036 (16.0)  Hispanic 239 (eleven.4) 11,636 (13.three)  other 81 (3.eight) 2,948 (3.3) assurance, n (%)      Medicare 1,225 (58.6) 56,109 (64.2)  Medicaid 393 (18.7) sixteen,166 (18.5)  advertisement473 (22.6) 15,088 (17.2) hospital size of reside, median (IQR) 9 (4–18)* 10 (5–18) Early mechanical ventilation† 1,498 (71.6%) sixty two,965 (seventy two.1%) Shock, n (%) 626 (29.9) 28,959 (33.1) most important surgery, n (%) 667 (31.9) 32,469 (37.2) Dialysis, n (%) 243 (eleven.6) 9,148 (10.four) Tracheostomy, n (%) 405 (19.four) 8,663 (9.9) Charlson comorbidity index, mean (SD) 2.10 (2.00) 2.31 (2.30)

The health facility classes and linked health facility variables, proportion of overall VDRF cases, and proportion of VDRF transfers are offered in table 2. One-half of sufferers offered to massive hospitals; the last 50% presented to medium-sized and small hospitals. in spite of health center class, the incidence of interhospital switch for patients with VDRF turned into rather low at 2.9% overall and ranging from a highest of 10% of VDRF circumstances being transferred at small hospitals to a low of 1.6% at enormous hospitals.

desk 2. sanatorium categories and defining variables

Variables medical institution categories bigMedium-sized For-benefitMedium-sized Nonprofit Small number of hospitals in each and every class forty two 67 25 19 bed quantity class >300one hundred–three hundreda hundred–300 <100 Annual VDRF case quantity, mean (SD) 683 (415) 337 (172) 200 (eighty two) ninety five (forty eight) Annual ED case extent, mean (SD) 16,173 (6,754) 10,562 (4,593) 6,608 (2,526) three,138 (1,292) Annual ICU case extent, suggest (SD) eight,646 (7,250) four,444 (2,683) three,310 (2,395) 1,132 (704) Noncardiac ECMO* yesNo No No solid organ transplant* convincedNo No No number (%) of all VDRF admissions† 45,528 (50.9%) 32,511 (36.three%) 9,341 (10.four%) 2,073 (2.three%) number (%) of patients with VDRF present process interhospital transfer‡ 768 (1.sixty eight%) 639 (1.97%) 476 (5.10%) 208 (10.03%)

The transfer pattern of each health center category is proven in (desk 3). In commonplace, patients with VDRF from medium-sized nonprofit (66.6%) and small (60.5%) hospitals have been transferred to tremendous hospitals. besides the fact that children, medium-sized for-profit hospitals transferred as many situations (forty one.6%) to other medium-sized for-income hospitals (44.2%) as significant hospitals.

table three. Interhospital switch patterns through medical institution category for ventilator-dependent respiratory failure situations (n = 2,091)

Transferring health facility class Receiving medical institution category Small Medium-sized For-gainMedium-sized Nonprofit hugeSmall 7 (3.three) 59 (28.3) sixteen (7.6) 126 (60.5) Medium-sized for-benefit38 (5.9) 266 (forty one.6) 52 (8.1) 283 (forty four.2) Medium-sized nonprofit 30 (6.three) 78 (16.three) fifty one (10.7) 317 (sixty six.6) large60 (7.8) 158 (20.5) 167 (21.7) 383 (49.8)

Multivariable logistic regression and generalized linear blended hierarchical fashions (table four) were used to identify predictors for interhospital transfer in the VDRF inhabitants. Use of the remaining parsimonious hierarchical model accounted for model of clustered sufferers with hospitals and essentially more desirable the health center class variable. Of significant word among demographic variables, odds of switch for sufferers under age 65 years had been 2.09 larger than these over eighty years of age (OR, 2.09; 95% self belief interval [CI], 1.seventy seven–2.45). additionally, transferred sufferers have been 35% much less likely to have Medicaid (OR, 0.65; 95% CI, 0.fifty six–0.75) than industrial coverage.

desk 4. Predictors of switch amongst patients with ventilator-dependent respiratory failure, adjusted model results (n = 89,454)

Predictors affected person clinical mannequin AOR (ninety five% CI) affected person Demographic model AOR (ninety five% CI) health facility model AOR (95% CI) Full Logistic model AOR (ninety five% CI) Full Hierarchical mannequin AOR (95% CI) patient scientific variables            LOS lower than median 1.sixty six (1.49–1.85)     1.fifty eight (1.forty two–1.76) 1.fifty three (1.37–1.seventy one)  Early mechanical ventilation* 0.eighty one (0.seventy three–0.90)     0.82 (0.seventy four–0.92) 0.81 (0.seventy three–0.90)  surprise0.88 (0.eighty–0.ninety seven)     0.87 (0.79–0.ninety six) 0.sixty eight (0.78–0.95)  major surgery 0.74 (0.67–0.82)     0.87 (0.seventy eight–0.96) 0.eighty five (0.77–0.95)  Dialysis 1.22 (1.06–1.40)     1.17 (1.01–1.35) 1.14 (0.98–1.31)  Tracheostomy 2.99 (2.64–three.39)     three.25 (2.86–3.70) 3.19 (2.80–3.65)  Charlson comorbidity index rating 0.96 (0.94–0.ninety eight)     0.96 (0.ninety four–0.ninety eight) 0.ninety five (0.ninety three–0.ninety seven) patient demographic variables            Age class, 12 months              80+   Reference   Reference Reference   <65   2.17 (1.86–2.55)   2.16 (1.eighty four–2.53) 2.09 (1.seventy seven–2.45)   65–seventy nine   1.79 (1.55–2.07)   1.seventy eight (1.fifty five–2.06) 1.79 (1.fifty five–2.08)  female sex   0.ninety five (0.87–1.04)   NS NS  Race class             White   Reference   Reference Reference   Black   0.eighty five (0.seventy five–0.97)   NS NS   different   0.ninety one (0.81–1.03)   NS NS  coverage company             industrial   Reference   Reference Reference   Medicare   0.94 (0.83–1.07)   0.86 (0.75–0.ninety eight) 0.eighty four (0.73–0.96)   Medicaid   0.75 (0.sixty five–0.86)   0.seventy one (0.sixty one–0.eighty one) 0.sixty five (0.fifty six–0.seventy five) medical institution characteristic variables            health center category             huge medical institution     Reference Reference Reference   Medium-sized for-profit     0.86 (0.seventy seven–0.98) 0.86 (0.seventy seven–0.ninety seven) 1.37 (0.ninety seven–1.ninety five)   Medium-sized nonprofit     1.ninety nine (1.74–2.28) 1.ninety nine (1.seventy four–2.28) 2.70 (1.74–4.16)   Small medical institution     3.49 (2.ninety one–four.20) 3.forty nine (2.ninety one–4.20) 7.67 (four.60–12.seventy nine)  Annual VDRF admissions (in 100s)     0.88 (0.86–0.90) 0.88 (0.86–0.ninety) 0.95 (0.ninety two–0.ninety nine) mannequin c-statistic 0.62 0.65 0.seventy two 0.seventy two —

sufferers who were ventilated early of their hospital path had a 19% lessen odds of transfer (OR, 0.eighty one; 95% CI, 0.seventy three–0.ninety), whereas patients who had got a tracheostomy had a superior than threefold larger odds of being transferred (OR, three.19; ninety five% CI, 2.80–3.65). Even after adjustment for patient demographic and clinical variables, sufferers in small hospitals had 7.sixty nine instances bigger odds of transfer (OR, 7.69; ninety five% CI, four.60–12.79) than those in significant hospitals. however, sufferers in medium-sized nonprofit hospitals were tons more more likely to be transferred (OR, 2.70; ninety five% CI, 1.seventy four–four.sixteen), whereas sufferers in medium-sized for-profit hospitals had an OR of 1.37 (95% CI, 0.97–1.ninety five) of being transferred.

The closing hierarchical parsimonious model carefully resembled the full logistic mannequin as well as the smaller logistic fashions of affected person demographics, clinical characteristics, and hospital qualities, despite the fact demographic variables similar to intercourse and race were not associated with transfer (desk four). Multivariable logistic mannequin performance turned into evaluated via the c-statistic (concordance index) and ranged from a low of 0.sixty two–0.sixty five (full model) to a high of 0.seventy two (ultimate parsimonious mannequin), indicating ideal performance (29).

To their knowledge, here's the first study to use claims records to evaluate interhospital transfer among sufferers admitted with VDRF. They found that just about 50% of sufferers are handled in small and medium-sized hospitals with reduce competencies; yet, interhospital switch is rare, regardless of the merits of medicine in bigger hospitals with extra amazing case volumes (25). moreover, they discovered that early mechanical air flow become associated with reduced likelihood of switch, suggesting that hospitals are doubtlessly greater likely to pursue transfer for greater complex sufferers who developed VDRF despite the care acquired early of their health center path. last, their statistics imply that the ordinary patient with VDRF who's transferred between hospitals is more youthful, commercially ensured, and requires extended mechanical air flow, as evidenced via tracheostomy expanding the chances of switch.

moreover, they observed that medium-sized nonprofit hospitals have been extra prone to transfer sufferers with VDRF, usually to better centers, than have been medium-sized for-earnings hospitals. The motivations behind this difference aren't ordinary; despite the fact, one speculation is that for-income hospitals are reluctant to lose revenue by using transferring patients elsewhere. extra, sufferers with industrial insurance had extended odds of transfer; consequently, it is possible that receiving hospitals may additionally preferentially settle for patients on the foundation of assurance fame.

although these hypotheses cannot be proven with the accessible facts, these observations lift the query even if monetary bias influences the switch patterns of patients with VDRF. as a result of previous literature has demonstrated worse effects in for-income hospitals for a whole lot of situations, including coronary heart ailment (31) and end-stage renal sickness requiring dialysis (32, 33), it is essential to extra study the reasons for this discrepant transfer apply to keep in mind the diploma to which sanatorium mission and economic components have an effect on scientific decision making and effects.

There is limited insight into how ICU sufferers are selected for switch because the best analyze in which researchers evaluated key stakeholder perceptions established bad consensus between sufferers, transferring physicians, and receiving physicians (34). They observed in their latest analyze that older sufferers were less likely to be transferred. This finding is congruent with previous studies (35, 36) displaying that older, critically ill sufferers are handled less aggressively than their more youthful counterparts.

Commercially insured patients in their study had bigger odds of switch than sufferers with executive payer coverage (Medicare or Medicaid), which is consistent with prior results demonstrating that smartly-reimbursed coverage became associated with interhospital switch (37). it's remarkable that different reviews have proven that Medicaid patients offering to the emergency department usually tend to be transferred; youngsters, this relationship may be influenced via the Emergency scientific medicine and Labor Act, which mandates that acute care hospitals settle for sufferers in switch from emergency departments when a request has been issued for a stronger level of care (38).

Our findings indicate that sufferers who boost VDRF later of their hospital direction, despite receiving inpatient care, are more likely to be transferred than people who Excellerate it early. This may well be because hospitals are extra inclined to pursue switch for patients who're deemed medically complex or as not responding to therapy.

similarly, patients who bear tracheostomy can also additionally symbolize a more complicated and resource-intense inhabitants, which can also explain the followed relationship between this manner and affected person transfer. This hypothesis is supported by the work of Unroe and colleagues (39), who validated that chronically unwell, useful resource-severe patients usually tend to endure interfacility transfer numerous instances and as a result experience negative consequences. Future potential experiences examining the relationship between medical complexity and affected person switch might also offer extra insight into these findings.


the usage of billing codes to identify patients, techniques, and diagnoses may also misclassify patients as a result of they aren't all the time correctly coded. additionally, these facts lack insight into the motivations and determination-making methods of the individuals worried in the interhospital switch. they are able to only speculate related to components equivalent to family unit requests, availability of consultants or procedures, and ICU structure; besides the fact that children, it is likely that these and other factors influence switch practices (34).

as a result of they used claims-primarily based records, they were unable to adjust for sickness severity aside from comorbidities. This lack of ability, mixed with the evident bias between transferred and nontransferred groups, limits their capacity to compare medical consequences. additionally, as HCUP datasets are state selected, these results may additionally no longer be generalizable. The retrospective nature of the study prohibited us from establishing causality. Geographic ameliorations in interhospital transfer practices may additionally restrict generalization of their consequences to other states and regions of the us.


To their abilities, here's the first study which identifies patient and clinic factors that have an impact on interhospital switch of sufferers with VDRF. They discovered that one-half of patients in Florida with VDRF were handled in small and medium-sized hospitals and that interhospital transfer turned into very infrequent. those sufferers who were transferred were more more likely to be younger, commercially insured, aid intensive, and medically complicated. moreover, medium-sized for-profit and medium-sized nonprofit hospitals had very distinct odds of transfer regardless of in any other case equivalent health facility qualities, raising the query even if earnings reputation affects scientific determination making. Future efforts should still be made to evaluate the scientific effects linked to VDRF transfers, to are seeking for capabilities concerning patient organizations absolutely to improvement from transfer, and to test for geographic model in interhospital VDRF switch practices.

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