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A Russell Localio

Publications and source records attributed to A Russell Localio.

At least 19 recordsLinked to original sources
PubMed2007

Properties of analysis methods that account for clustering in volume-outcome studies when the primary predictor is cluster size.

In recent years health services researchers have conducted 'volume-outcome' studies to evaluate whether providers (hospitals or surgeons) who treat many patients for a specialized condition have better outcomes than those that treat few patients. These studies and the inherent clustering of events by provider present an unusual statistical problem. The volume-outcome setting is unique in that 'volume' reflects both the primary factor under study and also the cluster size. Consequently, the assumptions inherent in the use of available methods that correct for clustering might be violated in this setting. To address this issue, we investigate via simulation the properties of three estimation procedures for the analysis of cluster correlated data, specifically in the context of volume-outcome studies. We examine and compare the validity and efficiency of widely-available statistical techniques that have been used in the context of volume-outcome studies: generalized estimating equations (GEE) using both the independence and exchangeable correlation structures; random effects models; and the weighted GEE approach proposed by Williamson et al. (Biometrics 2003; 59:36-42) to account for informative clustering. Using data generated either from an underlying true random effects model or a cluster correlated model we show that both the random effects and the GEE with an exchangeable correlation structure have generally good properties, with relatively low bias for estimating the volume parameter and its variance. By contrast, the cluster weighted GEE method is inefficient.

Aged↗
PubMed2007

Prevalence, risk factors, and outcomes for occult hepatitis B virus infection among HIV-infected patients.

BACKGROUND: Occult hepatitis B virus (HBV) is defined by the presence of HBV DNA in individuals with HBV core antibodies (anti-HBc) but without HBV surface antigen (HBsAg). The prevalence of occult HBV in HIV-infected patients remains controversial, and the risk factors and clinical significance are unknown. OBJECTIVES: To determine the prevalence, risk factors, and clinical significance of occult HBV among HIV-infected patients. Hypothesized risk factors include chronic hepatitis C virus (HCV), CD4 count < 200 cells/mm, HIV RNA level >1000 copies/mL, and lack of use of anti-HBV antiretrovirals. METHODS: We examined randomly selected HBsAg/anti-HBc HIV-infected patients in the Penn Center for AIDS Research Adult/Adolescent Database and Specimen Repository. HBV DNA was qualitatively detected using a transcription-mediated amplification assay. Risk factors and transaminases were ascertained at the time sera were collected. RESULTS: A total of 699 HBsAg/anti-HBc HIV-infected patients were identified. Of 179 randomly selected subjects, 17 (10%; 95% confidence interval [CI]: 5% to 14%) had occult HBV. Differences in the prevalence of HBV surface antibody (anti-HBs) between those with (7 [41%]) and without (94 [58%]) occult HBV were not statistically significant (P = 0.3). An HIV RNA level >1000 copies/mL (adjusted odds ratio [OR] = 4.88, 95% CI: 1.01 to 30.26) and the absence of chronic HCV (adjusted OR = 0.26, 95% CI: 0.05 to 0.95) were associated with occult HBV. Occult HBV did not increase the risk of transaminitis (adjusted OR = 0.42, 95% CI: 0.12 to 1.45). CONCLUSIONS: Occult HBV occurred in a sizable proportion of HIV-infected patients and was associated with detectable HIV and the absence of chronic HCV. It did not increase the risk of transaminitis. The presence of anti-HBs does not rule out occult HBV. Future studies should examine the long-term clinical implications of occult HBV in HIV-infected patients.

Adult↗
PubMed2007

Much ado about nothing: a comparison of the performance of meta-analytical methods with rare events.

For rare outcomes, meta-analysis of randomized trials may be the only way to obtain reliable evidence of the effects of healthcare interventions. However, many methods of meta-analysis are based on large sample approximations, and may be unsuitable when events are rare. Through simulation, we evaluated the performance of 12 methods for pooling rare events, considering estimability, bias, coverage and statistical power. Simulations were based on data sets from three case studies with between five and 19 trials, using baseline event rates between 0.1 and 10 per cent and risk ratios of 1, 0.75, 0.5 and 0.2. We found that most of the commonly used meta-analytical methods were biased when data were sparse. The bias was greatest in inverse variance and DerSimonian and Laird odds ratio and risk difference methods, and the Mantel-Haenszel (MH) odds ratio method using a 0.5 zero-cell correction. Risk difference meta-analytical methods tended to show conservative confidence interval coverage and low statistical power at low event rates. At event rates below 1 per cent the Peto one-step odds ratio method was the least biased and most powerful method, and provided the best confidence interval coverage, provided there was no substantial imbalance between treatment and control group sizes within trials, and treatment effects were not exceptionally large. In other circumstances the MH OR without zero-cell corrections, logistic regression and the exact method performed similarly to each other, and were less biased than the Peto method.

Analysis of Variance↗
PubMed2006

Hepatitis C virus seropositivity in organ donors and survival in heart transplant recipients.

CONTEXT: Although liberalization of donor criteria could expand the donor pool, the use of certain "marginal donors," such as those who are hepatitis C virus (HCV) positive, is controversial. Little is known about the effect of donor HCV positivity on survival in cardiac transplantation. OBJECTIVES: To examine the association between donor HCV positivity and survival among heart transplant recipients and to determine the effects of recipient age and recipient HCV status on this association. DESIGN, SETTING, AND PARTICIPANTS: A multicenter cohort study was performed using the US Scientific Registry of Transplant Recipients. Adult heart transplant patients who received their transplants between April 1, 1994, and July 31, 2003, were eligible for inclusion. MAIN OUTCOME MEASURE: All-cause mortality. RESULTS: Of 10 915 patients meeting entry criteria, 261 received an HCV-positive donor heart. Mortality was higher among recipients of HCV-positive donor hearts at 1 year (16.9% vs 8.2%; P<.001), 5 years (41.8% vs 18.5%; P<.001), and 10 years (50.6% vs 24.3%; P<.001). Using Kaplan-Meier methods, 1-, 5-, and 10-year survival rates were 83%, 53%, and 25%, and 92%, 77%, and 53% for recipients of HCV-positive and HCV-negative donor hearts, respectively (P<.001, log-rank test). Recipients of HCV-positive donor hearts were more likely to die of liver disease and coronary vasculopathy. After propensity matching, the overall hazard ratio (HR) associated with receipt of an HCV-positive donor heart was 2.10 (95% confidence interval [CI], 1.60-2.75). Stratified analyses showed that HRs did not vary by recipient HCV status or by recipient age (for recipients aged 18-39 years: HR, 1.75 [95% CI, 0.70-4.40]; for recipients aged 40-59 years: HR, 2.23 [95% CI, 1.42-3.52]; and for recipients aged 60 years and older: HR, 2.07 [95% CI, 1.32-3.27]; overall P value for interaction, >.10). CONCLUSIONS: Receipt of a heart from an HCV-positive donor is associated with decreased survival in heart transplant recipients. This association appears to be independent of recipient HCV status and age. Preferential allocation of HCV-positive donors to HCV-positive recipients and/or older recipients is not warranted.

Adolescent↗
PubMed2006

Gliomatosis cerebri: 20 years of experience at the Children's Hospital of Philadelphia.

BACKGROUND: Gliomatosis cerebri (GC) is a rare and typically fatal glial neoplasm of the central nervous system. In this report, the authors describe the largest cohort of children to date with GC and explore relations between potential prognostic factors, treatment, and survival. METHODS: Imaging, pathologic, and outcome data were reviewed from 13 patients who were diagnosed with GC and were treated at the Children's Hospital of Philadelphia (CHOP) between 1982 and 2005. All patients had GC confirmed by biopsy. Twelve patients received cranial irradiation, and 8 of those patients received adjuvant chemotherapy. A single patient age 1 year received chemotherapy alone. A review of the literature identified 51 pediatric patients with GC. RESULTS: The progression-free survival rate in this study was 13% (range, 1.5-43 months), and the overall survival (OS) rate was 64% (range, 6.5-67 months) at 2 years. OS was significantly shorter for patients who presented in the first decade of life (P = .04). The time to progression was prolonged significantly for patients who had no evidence of tumor enhancement on imaging studies (P = .03). When survival data from patients reported in the literature were combined with the CHOP cohort, treatment prolonged OS significantly (P = .003). CONCLUSIONS: The outcome of pediatric patients with GC was extremely poor; however, the current results indicated that treatment may prolong OS. Age < 10 years and contrast enhancement on magnetic resonance imaging studies at diagnosis may be risk factors for shorter survival in pediatric patients with GC.

Adolescent↗
PubMed2006

Longitudinal and repeated cross-sectional cluster-randomization designs using mixed effects regression for binary outcomes: bias and coverage of frequentist and Bayesian methods.

As medical applications for cluster randomization designs become more common, investigators look for guidance on optimal methods for estimating the effect of group-based interventions over time. This study examines two distinct cluster randomization designs: (1) the repeated cross-sectional design in which centres are followed over time but patients change, and (2) the longitudinal design in which individual patients are followed over time within treatment clusters. Simulations of each study design stipulated a multiplicative treatment effect (on the log odds scale), between 5 and 15 clusters in each of two treatment arms, and followed over two time periods. Estimation options included linear mixed effects models using restricted maximum likelihood (REML), generalized estimating equations (GEE), mixed effects logistic regression using both penalized quasi likelihood (PQL) and numerical integration, and Bayesian Monte Carlo analysis. For the repeated cross-sectional designs, most methods performed well in terms of bias and coverage when clusters were numerous (30) and variability across clusters of baseline risk and treatment effect was modest. With few clusters (two groups of five) and higher variability, only the Bayesian methods maintained coverage. In the longitudinal designs, the common methods of REML, GEE, or PQL performed poorly when compared to numerical integration, while Bayesian methods demonstrated less bias and better coverage for estimates of both log odds ratios and risk differences. The performance of common statistical tools for the analysis of cluster randomization designs depends heavily on the precise design, the number of clusters, and the variability of baseline outcomes and treatment effects across centres.

Bayes Theorem↗
PubMed2006

The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction.

BACKGROUND: Antibiotics within four hours of arrival for patients with pneumonia and percutaneous intervention (PCI) within two hours for patients with acute myocardial infarction (AMI) are standard measures of emergency department (ED) quality. OBJECTIVES: To assess the institutional-level association between measures of ED crowding and process measures for pneumonia and AMI. METHODS: The authors used summary data from 24 academic hospitals in the University Health Consortium. Analysis included the 2004 ED cycle time survey and performance data from January to December 2004 regarding the Joint Commission for Accreditation of Healthcare Organizations' PN-5b (initial antibiotic administration within four hours) for pneumonia and AMI-8a (PCI received within 120 minutes). Spearman correlation coefficients were used to determine associations between crowding and performance measures. RESULTS: Across all institutions, 59% (range 43%-77%) of pneumonia patients received antibiotics within four hours, and 57% (range 22%-95%) of AMI patients received PCI within two hours. An increase in overall ED length of stay (-0.44, p = 0.04) and for admitted patients (-0.37, p = 0.08) was associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. An increase in chest x-ray turnaround time (-0.83, p < 0.001) and an increase in the left-without-being-seen rate (-0.51, p = 0.01) were also associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. No measures of crowding exhibited an association with time to PCI for AMI patients. CONCLUSIONS: Administrative measures of ED crowding showed an association with poorer performance on pneumonia quality of care measures but not with AMI quality of care measures. Hospitals might consider improving ED throughput, reducing boarding times for admitted patients, and reducing chest x-ray turnaround times to improve pneumonia care.

Angioplasty, Balloon, Coronary↗
PubMed2006

Measuring screening intensity in case-control studies of the efficacy of mammography.

Of great interest in studies of screening for breast cancer is the relative efficacy of different screening frequencies (intensities). Prior work has suggested that estimates of the association between screening intensity and outcome in case-control studies would not produce valid results and that only binary indicators (no screens vs. one or more) of exposure can be used. Using case-control studies drawn from simulated cohorts of 30,000-40,000 women, the authors found that biases demonstrated in prior studies can be explained by 1) misclassification of true exposure groups by observed screening history, and 2) differential exposure misclassification of cases and controls. Binary as well as ordered categorical and interval measures can be biased unless they account for misclassification. By combining measurements of screening history from multiple periods of observation of varying lengths and using repeated-measures logistic regression models, the effect of screening intensity can be estimated in the presence of misclassification. Assessing the effect of screening intensity in case-control studies of mammography is possible if principles and methods for misclassification and measurement error guide the analysis.

Breast Neoplasms↗
PubMed2006

A meta-analysis of the performance characteristics of the free prostate-specific antigen test.

OBJECTIVES: To conduct a meta-analysis of the diagnostic performance of the percent free prostate-specific antigen (%fPSA) test in determining prostate cancer status and to assess its value in helping to decide whether to biopsy the prostate. METHODS: Articles identified through a MEDLINE search were included if they presented adequate original primary data to calculate a receiver operating characteristic (ROC) curve in subjects possessing histopathologically verified diagnoses. Articles containing subjects with concurrent, non-prostate-related genitourinary conditions were excluded. Percent free PSA sensitivity, specificity, ROC curves, and positive likelihood ratios were calculated for all PSA ranges and for the reflex range of PSA between 4 and 10 ng/mL. RESULTS: Among the 41 studies, containing 19,643 subjects, area under the curve for %fPSA was 0.70 for all PSA levels, decreasing to 0.68 in the reflex range. A test cutoff of 20% would lead to 92% sensitivity and 23% specificity. Positive likelihood ratios ranged from 1.0 to 4.0, exceeding 2.0 at %fPSA of 15% or less. Within the reflex range, however, likelihood ratios exceeded 2.0 only at %fPSA of 7% or less. CONCLUSIONS: Percent free PSA can be a useful adjunct to PSA for primary prostate cancer screening only under certain defined situations. In the "gray zone," or reflex range, of PSA testing, %fPSA improves clinical information only when levels reach extreme values.

Blood Chemical Analysis↗
PubMed2006

Predictors of recall of over-the-counter and prescription non-steroidal anti-inflammatory drug exposure.

PURPOSE: Because of the difficulty in establishing a gold standard, data on accuracy of recall of over-the-counter (OTC) medication use are sparse. METHODS: We studied a cohort of 1889 persons living in the Philadelphia area to assess recall of non-aspirin non-steroidal anti-inflammatory drug (NANSAID) use during the preceding 8 weeks. Our analyses were based on the assumption that among the group of subjects, on average, the reported usage of NANSAIDs should not vary over the previous 8 weeks. To model the effect of time on reported usage while allowing for the inherent correlation of responses within subjects over time, we employed alternating logistic regression. RESULTS: We documented a significant decline in reported use of OTC NANSAIDs but not prescription NANSAIDs during the 8-week study period (p = 0.3 for frequent prescription NANSAIDs, p = 0.2 for infrequent prescription NANSAIDs, p < 0.001 for frequent OTC NANSAIDs, and p < 0.001 for infrequent OTC NANSAIDs). Reported rates of frequent and infrequent OTC NANSAID consumption declined from 6.3 to 4.6% and from 17.1 to 12.8% between the most recent week and eight weeks prior, respectively. CONCLUSIONS: Interviews focusing on medications used on an as needed basis should be performed as close as possible to the index date. Likewise, data on frequent use of OTC NANSAIDs may be more reliable than that on infrequent use, particularly when subjects are asked to recall more than a few weeks back in time.

Adult↗
PubMed2006

Benefit of screening mammography in reducing the rate of late-stage breast cancer diagnoses (United States).

OBJECTIVE: We studied the benefit of modern mammography screening in community settings, evaluating age-related differences in rates of late-stage breast cancer detection. METHODS: Our multicenter population-based case-control study included 931 black and white women with incident breast cancer (American Joint Commission on Cancer Stage IIB or higher) diagnosed 1994-1998 and 4,016 randomly sampled controls never diagnosed with breast cancer. Adjusted odds ratios (ORs) estimated the relative rate of late-stage diagnosis in screened and non-screened women. RESULTS: Women aged 50-64 at diagnosis with at least one screening mammogram in the previous 2 years were significantly less likely to have late-stage diagnosis (OR = 0.41, 95% CI 0.33-0.52). Results for women aged 40-49 were consistent with a screening benefit, although the confidence interval marginally overlapped the null (OR = 0.81, 95% CI 0.64-1.02). Mammography screening was associated with lower rates of late-stage breast cancer among both premenopausal (OR = 0.64, 95% CI 0.50-0.81) and postmenopausal (OR = 0.44, 95% CI 0.35-0.56) women. CONCLUSIONS: With modern mammography in the community, rates of late-stage breast cancer diagnoses are lower in screened compared to non-screened women ages 40 and older, but age-related differences persist.

Adult↗
PubMed2006

Pressure ulcers among elderly patients early in the hospital stay.

BACKGROUND: Pressure ulcers among elderly hospital patients diminish quality of life and increase the cost of hospital care. Evidence suggests that pressure ulcers can arise after only a few hours of immobility. The goals of this study were to estimate the incidence of hospital-acquired pressure ulcers in the first 2 days of the hospital stay and to identify patient characteristics associated with higher incidence. METHODS: A prospective cohort study was performed between 1998 and 2001. A total of 3233 patients 65 years old or older admitted through the Emergency Department to the inpatient Medical Service at two study hospitals were examined by a research nurse on the third day of hospitalization. Pressure ulcers were ascertained using standard criteria and were classified as either preexisting, possibly hospital-acquired, or definitely hospital-acquired. RESULTS: There were 201 patients with one or more possibly or definitely hospital-acquired pressure ulcers for a cumulative incidence of 6.2% (95% confidence interval, 5.4%-7.1%). Most of the pressure ulcers were stage 2, and the majority were in the sacral area or on the heels. In multivariable analysis, pressure ulcer incidence was significantly associated with increasing age, male gender, dry skin, urinary and fecal incontinence, difficulty turning in bed, nursing home residence prior to admission, recent hospitalization, and poor nutritional status. CONCLUSIONS: A small but significant proportion of elderly emergently admitted hospital patients acquire pressure ulcers soon after their admission. New models of care may be required to ensure that preventive interventions are provided very early in the elderly person's hospital stay.

Aged↗
PubMed2005

Role of computerized physician order entry systems in facilitating medication errors.

CONTEXT: Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. OBJECTIVE: To identify and quantify the role of CPOE in facilitating prescription error risks. DESIGN, SETTING, AND PARTICIPANTS: We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders. MAIN OUTCOME MEASURE: Examples of medication errors caused or exacerbated by the CPOE system. RESULTS: We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction. CONCLUSIONS: In this study, we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.

Clinical Pharmacy Information Systems↗
PubMed2005

Risk of serious upper gastrointestinal toxicity with over-the-counter nonaspirin nonsteroidal anti-inflammatory drugs.

BACKGROUND & AIMS: Use of prescription nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDs) increases the risk of serious upper gastrointestinal toxicity. Less is known about over-the-counter (OTC) NANSAIDs, which are typically used at lower doses and for shorter durations. This study assessed the risk of toxicity with OTC NANSAIDs. METHODS: A total of 359 case subjects hospitalized for upper gastrointestinal bleeding, perforation, or benign gastric outlet obstruction were recruited from 28 hospitals. A total of 1889 control subjects were recruited by random digit dialing from the same region. Data on medication use were collected via structured telephone interview. RESULTS: Use of OTC NANSAIDs on > or = 4 days during the most recent week had an adjusted odds ratio (OR) of 1.83 (95% confidence interval [CI], 1.14-2.95). Use of high-dose OTC NANSAIDs during the index week had an adjusted OR of 5.21 (95% CI, 2.32-11.69). In contrast, use of OTC NANSAIDs <4 times during the index week (adjusted OR, 0.67; 95% CI, 0.43-1.06) and use of very low doses of prescription or OTC NANSAIDs during the index week (adjusted OR, 0.74; 95% CI, 0.49-1.12) were not significantly associated with an increased risk of serious gastrointestinal toxicity. We did not observe a significant difference between the risk of toxicity with OTC naproxen versus OTC ibuprofen (adjusted OR, 0.84; 95% CI, 0.26-2.70). CONCLUSIONS: Use of OTC NANSAIDs at recommended doses has a relatively good safety profile compared with prescription NANSAIDs. However, use of high-dose OTC NANSAIDs (comparable to a prescription dose) is associated with serious gastrointestinal toxicity.

Adult↗
PubMed2005

Association between primary care practice characteristics and emergency department use in a medicaid managed care organization.

BACKGROUND: Many patients use emergency departments (EDs) for primary care. Previous studies have found that patient characteristics affect ED utilization. However, such studies have led to few policy changes. OBJECTIVES: We sought to determine whether Medicaid patients' ED use is associated with characteristics of their primary care practices. RESEARCH DESIGN: This was a cohort study. SUBJECTS: A total of 57,850 patients, assigned to 353 primary care practices affiliated with a Medicaid HMO, were included. MEASURES: Predictor variables were characteristics of primary care practices, which were measured by visiting each practice. The outcome variable was ED use adjusted for patient characteristics. RESULTS: On average, patients made 0.80 ED visits/person/yr. Patients from practices with more than 12 evening hours/wk used the ED 20% less than patients from practices without evening hours. A higher ratio of the number of active patients per clinician-hour of practice time was associated with more ED use. When more Medicaid patients were in a practice, these patients used the ED more frequently. Other factors associated with ED use included equipment for the care of asthma and presence of nurse practitioners and physician assistants. DISCUSSION: Modifiable characteristics of primary care practices were associated with ED use. Because the observational design of this study does not allow definitive conclusions about causality, future studies should include intervention trials to determine whether changing practice characteristics can reduce ED use. CONCLUSIONS: Improving primary care access and scope of services may reduce ED use. Focusing on systems issues rather than patient characteristics may be a more productive strategy to improve appropriate use of emergency medical care.

Adolescent↗
PubMed2005

The effect of cardiac troponin testing on clinical care in a veterans population: a randomized controlled trial.

BACKGROUND: Cardiac troponin is more accurate than creatine kinase (CK) testing for detecting myocardial injury in patients with acute coronary syndromes (ACS), but its effects on clinical care compared with CK testing alone is open to question. OBJECTIVE: To test the effects of troponin I on medical decisions for patients undergoing cardiac enzyme testing. DESIGN: Randomized, controlled trial. SETTING: Urban academic Veterans Affairs medical center. PATIENTS: Three hundred ninety-two patients presenting to the emergency department (ED) and outpatient settings with symptoms and/or electrocardiograms suggestive but not diagnostic of ACS. INTERVENTION: Random assignment to linked CK-troponin I (CKTnI) testing or CK testing alone. MEASUREMENTS: ED discharge and cardiac catheterization incidence (primary); ED medication use, inpatient noninvasive testing, revascularization procedures, discharge medications, and 8-week ED visits, hospitalizations, and procedures (secondary). RESULTS: Groups were similar in all variables except history of heart failure (CK 26.8% vs CKTnI 17.0%). ACS comprised 12.2% of the cohort. ED discharge incidence was greater in the CKTnI arm (18% vs 9.6%; relative risk [RR], 1.83; 95% CI, 1.08 to 3.31; P=.02; number needed to test=12.6; 95% CI, 4.5 to 130). Troponin testing had no significant effect on catheterization incidence (18.2% vs 14.5%; RR, 1.19; 95% CI, 0.72 to 1.92; P>.20) or other outcomes except follow-up echocardiography (13.4% vs 7.4%; RR, 2.24; 95% CI, 1.11 to 4.69; P=.02). CONCLUSIONS: In a veterans population undergoing cardiac enzyme testing, CKTnI testing led to more ED discharges than CK testing alone but had no effect on inpatient care and was associated with more echocardiograms in a follow-up period.

Acute Disease↗
PubMed2005

Trends in operative management of pediatric splenic injury in a regional trauma system.

OBJECTIVE: Selective nonoperative management of pediatric blunt splenic injury became the standard of care in the late 1980s. The extent to which this practice has been adopted in both trauma centers and nontrauma hospitals has been investigated sporadically. Several studies have demonstrated significant variations in practice patterns; however, most published studies capture only a selective population over a relatively short time interval, often without simultaneous adjustment for confounding variables. The objective of this study was to characterize the variation in operative versus nonoperative management of blunt splenic injury in children in nontrauma hospitals and in trauma centers with varying resources for pediatric care within a regionalized trauma system in the past decade. METHODS: The study population included all children who were younger than 19 years and had a diagnosis of blunt injury to the spleen (International Classification of Diseases code 865.00-865.09) and were admitted to each of the 175 acute care hospitals in Pennsylvania between 1991 and 2000. The proportion of patients who were treated operatively was stratified by trauma-level certification and adjusted for age and splenic injury severity. Multivariable logistic regression models were used to generate probabilities of splenectomy by age, injury severity, and hospital type. RESULTS: From 1991 through 2000 in Pennsylvania, 3245 children sustained blunt splenic injury that required hospitalization; 752 (23.2%) were treated operatively. Generally, as age and splenic injury severity increased, the proportion of patients who were treated operatively increased. Compared with pediatric trauma centers, the relative risk (with associated 95% confidence interval) of splenectomy was 4.4 (3.0-6.3) for level 1 trauma centers with additional qualifications in pediatrics; 6.2 (4.4-8.7) for level 1 trauma centers, 6.3 (5.3-7.4) for level 2 trauma centers, and 5.0 (4.2-5.9) for nontrauma centers. Significant variation in practice pattern was seen among hospital types and over time even after adjustment for age and injury severity. CONCLUSIONS: The operative management of splenic injury in children varied significantly by hospital trauma status and over time during the past decade in Pennsylvania. Given the relative benefits of nonoperative treatment for children with blunt splenic injury, these results highlight the need for more widespread and standardized adoption of this treatment, particularly in hospitals without a large volume of pediatric trauma patients.

Abdominal Injuries↗