Wide variations in the cost-effectiveness of critical care.
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Cost-Benefit Analysis↗
Biomedical subjects
Andrew L Rosenberg
Publications and source records attributed to Andrew L Rosenberg.
The quality of randomized controlled trials in major anesthesiology journals.
Increased attention has been directed at the quality of randomized controlled trials (RCTs) and how they are being reported. We examined leading anesthesiology journals to identify if there were specific areas for improvement in the design and analysis of published clinical studies. All RCTs that appeared between January 2000 and December 2000 in leading anesthesiology journals (Anesthesiology,Anesthesia & Analgesia,Anaesthesia, and Canadian Journal of Anaesthesia) were retrieved by a MEDLINE search. We used a previously validated assessment tool, including 14 items associated with study quality, to determine a quality score for each article. The overall mean weighted quality score was 44% +/- 16%. Overall average scores were relatively high for appropriate controls (77% +/- 7%) and discussions of side effects (67% +/- 6%). Scores were very low for randomization blinding (5% +/- 2%), blinding observers to results (1% +/- 1%), and post-beta estimates (16% +/- 13%). Important pretreatment clinical predictors were absent in 32% of all studies. Significant improvement in the reporting and conduct of RCTs is required and should focus on randomization methodology, the blinding of investigators, and sample size estimates. Repeat assessments of the literature may improve the adoption of guidelines for the improvement of the quality of randomized controlled trials.
Anesthesiology↗
Anesthetic implications for lung transplantation.
Anesthetic challenges regarding lung transplantation are related to the expanded spectrum of diseases for which lung transplantation is offered and to the interval changes in health status likely to occur as patients wait longer for an organ to become available. Particular attention to avoiding or reducing the impact of increases in pulmonary vascular resistance and right heart failure are important and may necessitate cardiopulmonary bypass. Intraoperative and postoperative ventilator management should account for differences in pulmonary compliance after the new lung is implanted. Minimizing intravenous fluids without compromising end organ perfusion may avoid or reduce postoperative respiratory insufficiency.
Anesthesia↗
Optimal head rotation for internal jugular vein cannulation when relying on external landmarks.
External anatomic landmarks have traditionally been used to approximate the location of the neck blood vessels to optimize central venous cannulation of the internal jugular vein (IJV) while avoiding the common carotid artery (CCA). Head rotation affects vessel orientation, but most landmark techniques do not specify its optimal degree. We simulated catheter insertion via both an anterior and central approach to the right IJV using an ultrasound probe held in the manner of a syringe and needle in 49 volunteers. Increased head rotation from 0 degrees, 15 degrees, 30 degrees, 45 degrees, and 60 degrees to the left of midline was associated with higher probability of a simulated needle contacting the IJV and the CCA. For both approaches, the risk of CCA contact was <10% for head rotations of <or=45 degrees. Increased body surface area (BSA) and body mass index (BMI) were associated with more CCA contact at head rotations of 45 degrees or 60 degrees. To optimize IJV contact while reducing the likelihood of inadvertent contact with the CCA, the head should be rotated no more than 30 degrees in patients with high BMI or BSA, but it may be turned to 60 degrees if BMI or BSA is low.
Adult↗
Neoadjuvant chemotherapy and radiotherapy for large extremity soft-tissue sarcomas.
PURPOSE: Treatment of extremity soft-tissue sarcomas yields excellent local control, but distant failure is common with large, high-grade tumors. A regimen of preoperative chemotherapy consisting of mesna, adriamycin, ifosfamide, and dacarbazine (MAID) interdigitated with radiotherapy followed by resection and postoperative chemotherapy with or without radiotherapy was designed to improve treatment outcome. We report the mature outcome data on 48 treated patients and compare them with the data of an historical matched control patient population. METHODS AND MATERIALS: Adult patients with high-grade extremity soft-tissue sarcomas >or=8 cm were treated with three cycles of preoperative chemotherapy combined with 44 Gy of radiotherapy followed by surgery. Three cycles of postoperative MAID were planned. For patients with positive surgical margins, 16 Gy was delivered postoperatively. RESULTS: All 48 patients (M0) received the MAID protocol treatment, and their outcome was superior to that of the historical control patients. The 5-year actuarial local control, freedom from distant metastasis, disease-free survival, and overall survival rate was 92% and 86% (p = 0.1155), 75% and 44% (p = 0.0016), 70% and 42% (p = 0.0002), and 87% and 58% (p = 0.0003) for the MAID and control patient groups, respectively. Acute hematologic toxicity in the MAID group included febrile neutropenia in 12 patients (25%). Wound healing complications occurred in 14 (29%) of 48 MAID patients. One MAID patient developed late fatal myelodysplasia. CONCLUSION: After aggressive chemoradiation and surgery, these patients showed a significant reduction in distant metastases, with a highly significant gain in disease-free and overall survival compared with a historical control group. On the basis of this experience, the Radiation Therapy Oncology Group conducted a multi-institutional trial.
Adult↗
Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures.
BACKGROUND: Common methods of benchmarking clinical performance rarely, if ever, account for admission source and, in particular, the effect of a patient being transferred from one medical center to another. Small biases in comparisons of observed versus expected deaths can substantially affect how high-quality institutions compare with peer hospitals. With the most sophisticated and validated set of case-mix measures available for patients, the intensive care unit is an ideal setting in which to study the effect of a patient's being transferred from another hospital. OBJECTIVE: To determine the extent of bias in benchmarking outcomes when performance measures do not account for transfer patients' greater severity of illness. DESIGN: Prospectively developed cohort study. SETTING: Medical intensive care unit (MICU) at a tertiary care university hospital. PATIENTS: 4579 consecutive admissions for 4208 patients from 1 January 1994 to 1 April 1998. MEASUREMENTS: MICU and hospital lengths of stay, MICU readmission, and hospital mortality rates. RESULTS: Compared with directly admitted patients, MICU patients transferred from another hospital had significantly higher Acute Physiology Scores at the time of admission and discharge (P = 0.001). Even after full adjustment for case mix and severity of illness, transfer patients had a 38% longer MICU stay (95% CI, 32% to 45%), a 41% longer hospital stay (CI, 34% to 50%), and a 2.2 times greater odds of hospital mortality (CI, 1.7 to 2.8) than directly admitted patients. With identical efficiency and quality, a referral hospital with a 25% MICU transfer rate compared with another with a 0% transfer rate would be penalized by 14 excess deaths per 1000 admissions when a benchmarking program adjusts only for case mix and severity of illness and not for the source of admission. CONCLUSIONS: In a setting with the most thorough diagnostic-based, case-mix adjustment and the most physiologically precise severity-of-illness information, accepting transfer patients can adversely affect efficiency and quality benchmarks. Benchmarking and profiling efforts beyond intensive care units must also recognize and account for this phenomenon; otherwise, referral centers may have an incentive to refuse care for patients who could benefit from being transferred to their facility.
APACHE↗
Fluid management in patients with acute respiratory distress syndrome.
In a recent review of the data for fluid strategies and ARDS, fluid restriction or diuretic use was graded as "reasonably justifiable by available scientific evidence" and as "strongly supported by expert critical care opinion". Until the ARDS Network trial is published, only general guidelines regarding fluid management with or without specific vascular filling pressures from a pulmonary artery catheter can be made. Ultimately, the rationale for restricting fluid is to reduce hydrostatic pressures as much as possible. It seems most reasonable to maintain the lowest PAOP in ARDS patients that still maintains adequate circulating blood volume, mean arterial perfusion pressures, and cardiac output to provide sufficient oxygen delivery. Other clinical variables such as central venous pressure, urinary output, acid-base status, and lactate, serum urea nitrogen, and serum creatinine levels may help in judging the adequacy of a patient's intravascular volume, especially if central vascular pressure measurements are not available. Measures to reduce total body water, including flood restriction and diuretic use, seem to be of some benefit. Vasopressor use is especially important when systemic perfusion pressures are inadequate to maintain organ blood flow but should not be used to create supranormal levels of oxygen delivery.
Fluid Therapy↗
Recent innovations in intensive care unit risk-prediction models.
During the past 20 years, ICU risk-prediction models have undergone significant development, validation, and refinement. Among the general ICU severity of illness scoring systems, the Acute Physiology and Chronic Health Evaluation (APACHE), Mortality Prediction Model (MPM), and the Simplified Acute Physiology Score (SAPS) have become the most accepted and used. To risk-adjust patients with longer, more severe illnesses like sepsis and acute respiratory distress syndrome, several models of organ dysfunction or failure have become available, including the Multiple Organ Dysfunction Score (MODS), the Sequential Organ Failure Assessment (SOFA), and the Logistic Organ Dysfunction Score (LODS). Recent innovations in risk adjustment include automatic physiology and diagnostic variable retrieval and the use of artificial intelligence. These innovations have the potential of extending the uses of case-mix and severity-of-illness adjustment in the areas of clinical research, patient care, and administration. The challenges facing intensivists in the next few years are to further develop these models so that they can be used throughout the IUC stay to assess quality of care and to extend them to more specific patient groups such as the elderly and patients with chronic ICU courses.
Artificial Intelligence↗