Demands of an aging population for critical care and pulmonary services.
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Aged↗
Biomedical subjects
M Breslow
Publications and source records attributed to M Breslow.
Variations in complication rates and opportunities for improvement in quality of care for patients having abdominal aortic surgery.
BACKGROUND: The purpose was to assess the current variation in complication rates and evaluate the association between specific types of complications and in-hospital mortality and total hospital charges for patients having abdominal aortic surgery. PATIENTS/METHODS: We studied 2987 patients for abdominal aortic surgery in Maryland from 1994 to 1996 and used discharge diagnoses and procedure codes to identify diagnoses that most likely represent major surgery complications. We evaluated how in-hospital mortality and total hospital charges related to specific complications, adjusting for patient demographics, severity of illness, comorbidity, and hospital and surgeon volumes. Discharge data was obtained from the hospital marketing departments. RESULTS: Complication rates varied widely among hospitals. Complications independently associated with increased risk of in-hospital death include cardiac arrest with an odds ratio (OR) of 90 and a 95% confidence interval (CI) of 32-251, septicemia (OR 6.1, CI 3.3-11.3), acute myocardial infarction (OR 5.7, CI 2.3-14.3), acute renal failure (OR 5.0, CI 2.3-11.0), surgical complications after a procedure (OR 3.1, CI 2.0-4.9), and reoperation for bleeding (OR 2.2, CI 1.1-4.8). The population-attributable risk for in-hospital mortality was 47% for cardiac arrest and 27% for acute renal failure. CONCLUSIONS: In abdominal aortic surgery on patients in Maryland, the rates of some complications vary widely and are independently associated with increased in-hospital mortality and hospital charges (charges differ from costs). Efforts to reduce these complications should help to decrease both levels.
Aortic Aneurysm, Abdominal↗
Assessing ICU performance using administrative data.
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Benchmarking↗
The eICU: it's not just telemedicine.
Intensive care units (ICUs) are major sites for medical errors and adverse events. Suboptimal outcomes reflect a widespread failure to implement care delivery systems that successfully address the complexity of modern ICUs. Whereas other industries have used information technologies to fundamentally improve operating efficiency and enhance safety, medicine has been slow to implement such strategies. Most ICUs do not even track performance; fewer still have the capability to examine clinical data and use this information to guide quality improvement initiatives. This article describes a technology-enabled care model (electronic ICU, or eICU) that represents a new paradigm for delivery of critical care services. A major component of the model is the use of telemedicine to leverage clinical expertise and facilitate a round-the-clock proactive care by intensivist-led teams of ICU caregivers. Novel data presentation formats, computerized decision support, and smart alarms are used to enhance efficiency, increase effectiveness, and standardize clinical and operating processes. In addition, the technology infrastructure facilitates performance improvement by providing an automated means to measure outcomes, track performance, and monitor resource utilization. The program is designed to support the multidisciplinary intensivist-led team model and incorporates comprehensive ICU re-engineering efforts to change practice behavior. Although this model can transform ICUs into centers of excellence, success will hinge on hospitals accepting the underlying value proposition and physicians being willing to change established practices.
Hospitalists↗
Differential gene expression in a murine model of cancer cachexia.
Murine adenocarcinoma 16 (MAC16) tumors and cell lines induce cachexia in NMRI nude mice, whereas histologically similar MAC13 tumors do not. After confirming these findings in BALB/c nude mice, we demonstrated that this tissue wasting was not related to decreased food intake or increased total body oxidative metabolism. Previous studies have suggested that MAC16's cachexigenic properties may involve the production of tumor-specific factors. We therefore screened for genes having increased expression in the MAC16 compared with the MAC13 cell line by performing hybridization to a murine cDNA expression array, by generation and comparison of cDNA libraries from each cell line, and by PCR-based subtractive hybridization. Northern blot hybridization was performed to confirm differences in transcript expression. Transcripts encoding insulin-like growth factor binding protein-4, cathepsin B, ferritin light and heavy chain, endogenous long-terminal repeat sequences, and a viral envelope glycoprotein demonstrated increased expression in the MAC16 cell line. The roles of a number of these genes in known metabolic pathways identify them as potential participants in the induction of cachexia.
Adenocarcinoma↗
Survival and functional outcome after prolonged intensive care unit stay.
OBJECTIVE: To examine the functional outcome and costs of a prolonged illness requiring a stay in the surgical intensive care unit (SICU) of 7 of more days. SUMMARY BACKGROUND DATA: The long-term benefits and costs after a prolonged SICU stay have not been well studied. METHODS: All patients with an SICU length of stay of 7 or more days from July 1, 1996, to June 30, 1997, were enrolled. One hundred twenty-eight patients met the entry criteria, and mortality status was known in 127. Functional outcome was determined at baseline and at 1, 3, 6, and 12 months using the Sickness Impact Profile score, which ranges from 0 to 100, with a score of 30 being severely disabled. Hospital costs for the index admission and for all readmissions to Johns Hopkins Hospital were obtained. All data are reported as median values. RESULTS: For the index admission, age was 57 and APACHE II score was 23. The initial length of stay in the ICU was 11 days; the hospital length of stay was 31 days. The Sickness Impact Profile score was 20.2 at baseline, 42.9 at 1 month, 36.2 at 3 months, and 20.3 at 6 months, and was lower than baseline at 1 year. The actual 1-year survival rate was 45.3%. The index admission median cost was $85,806, with 65 total subsequent admissions to this facility. The cost for a single 1-year survivor was $282,618 (1996). CONCLUSIONS: An acute surgical illness that results in a prolonged SICU stay has a substantial in-hospital death rate and is costly, but the functional outcome from both a physical and physiologic standpoint is compatible with a good quality of life.
APACHE↗
The association between preoperative patient characteristics and both clinical and economic outcomes after abdominal aortic surgery.
OBJECTIVE: To evaluate the association between patient characteristics and both clinical and economic outcomes in patients having abdominal aortic surgery in Maryland between 1994 and 1996. DESIGN: Retrospective study using an administrative data set. SETTING: All Maryland hospitals that performed abdominal aortic surgery from 1994 through 1996 (n = 46). PARTICIPANTS: All patients who had abdominal aortic surgery in Maryland from 1994 through 1996 (n = 2,987). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors obtained discharge abstracts from the Maryland Health Services Cost Review Commission for patients with a primary procedure code for abdominal aortic surgery. Primary outcome variables were in-hospital mortality, hospital length of stay, and intensive care unit (ICU) days. The authors evaluated the following groups of independent variables: demographic characteristics, severity of illness, comorbid disease, and preoperative admission days. In multivariate analysis, independent predictors of in-hospital mortality were age 61 to 70 years (odds ratio [OR], 3.1; confidence interval [CI], 1.4 to 6.9), age 71 to 84 years (OR, 7.2; CI, 3.7 to 14.1), age 85 years or older (OR, 9.3; CI, 3.9 to 21.9), ruptured aneurysm (OR, 5.3; CI, 3.5 to 8.2), urgent operation (OR, 2.3; CI, 1.1 to 5.2), emergent operation (OR, 3.0; CI, 1.9 to 4.7), mild liver disease (OR, 4.6; CI, 2.0 to 10.9), and chronic renal disease (OR, 6.9; CI, 3.9 to 12.1). Hospital admission 1 to 2 days preoperatively was not associated with a difference in in-hospital mortality but was associated with a 31% increase in hospital days (CI, 23% to 40%) and a 38% increase in ICU days (CI, 19% to 60%). CONCLUSION: In patients having aortic surgery, several patient characteristics such as mild liver disease and chronic renal failure, were associated with increased in-hospital mortality and length of stay. The practice of admitting patients to the hospital 1 to 2 days before surgery should be reevaluated because this was not associated with reduced in-hospital mortality but was associated with increased hospital and ICU stay.
Aged↗
Endotoxin-induced alteration in the expression of leptin and beta3-adrenergic receptor in adipose tissue.
Cytokines, such as tumor necrosis factor (TNF) and interleukin-6, may contribute to the anorexia and cachexia of infection, cancer, and AIDS. The present study tests the hypothesis that endotoxin alters the expression of two key fat cell proteins, leptin and beta3-adrenergic receptor (beta3-AR), through a mechanism involving TNF-alpha. Increasing doses of Escherichia coli endotoxin (lipopolysaccharide, LPS) resulted in dose-dependent elevations of plasma leptin (maximal response approximately 7-fold, half-maximal effective dose of approximately 16 microg/100 g body wt) and white fat leptin mRNA in C3/HeOUJ mice. LPS also produced a large decrease in adipose tissue beta3-AR mRNA and a parallel reduction in beta-agonist-induced activation of adenylyl cyclase. Changes in plasma leptin and beta3-AR mRNA were preceded by an approximately threefold increase in white fat TNF mRNA. TNF administration resulted in changes similar to those seen with LPS. We conclude that endotoxemia results in an induction of leptin mRNA and a decrease in beta3-AR mRNA in adipose tissue, an effect that may be mediated by alterations in TNF-alpha.
Adenylyl Cyclases↗