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Biomedical subjects

M M Pollack

Publications and source records attributed to M M Pollack.

At least 73 records · Page 4Linked to original sources
PubMed1991

Pediatric critical care cost containment: combined actuarial and clinical program.

OBJECTIVE: To determine if providing patients' daily survival probabilities to physicians and nurses along with a short videotape on the measurement of survival probabilities and costs of pediatric intensive care would reduce resource use. DESIGN: Prospective, randomized, controlled trial. SETTING: Pediatric ICU. PATIENTS: Medical patients in a prospective control period (n = 113), an intervention period (n = 226), and a follow-up control period (n = 97). INTERVENTIONS: The survival probabilities of 50% of the patients in the intervention period were displayed at the bedside and the staff viewed a short videotape on the measurement of survival probabilities and costs of pediatric intensive care. MEASUREMENTS AND MAIN RESULTS: Daily survival probabilities and resource use were evaluated each day. Resource use, adjusted for severity of illness, was evaluated using analysis of covariance. Compared with the prospective control group, reductions in the daily use of blood gases (p less than .01), hematology tests (p less than .001), hourly vital signs (p less than .001), and hourly neurologic vital signs (p less than .001) resulting in a composite reduction in daily laboratory and imaging charges from $759 +/- $22 to $622 +/- $18 (p less than .01) were observed in the patient group receiving the survival probabilities and whose physicians also viewed the videotape. Equivalent reductions in resource use also occurred in a simultaneous control group (patients did not receive survival probabilities but healthcare workers did view the videotape) and in a follow-up control group. CONCLUSION: Reduction in pediatric intensive care resource use can occur from the combined effects of actuarial and clinical interventions.

Actuarial Analysis↗
PubMed1991

Improved outcomes from tertiary center pediatric intensive care: a statewide comparison of tertiary and nontertiary care facilities.

OBJECTIVE: To compare outcomes from pediatric intensive care in hospitals with different levels of resources. DESIGN: Prospective, blinded comparison of outcome and care. SETTING: Tertiary (n = 3) and nontertiary (n = 71) hospitals in Oregon and southwestern Washington. PATIENTS: All critically ill children admitted with respiratory failure and head trauma for 6 months. MEASUREMENTS AND MAIN RESULTS: Severity of illness adjusted mortality rates were determined using admission day, physiologic profiles (Pediatric Risk of Mortality score) and care modalities were assessed daily. The crude mortality rate of the tertiary patients was four times higher than for the nontertiary patients (23.4% vs. 6.0%, p less than .0001). In the tertiary patients, the numbers of outcomes were accurately predicted by physiologic profiles (observed: 30 deaths and 98 survivors; predicted: 29.3 deaths and 98.7 survivors, z = -.25, p greater than .4). However, for the nontertiary patients, the number of the deaths were significantly different than predicted (observed: 20 deaths and 315 survivors; predicted: 14.4 deaths and 320.6 survivors, z = -2.08, p less than .05). The odds ratios of dying in a nontertiary vs. a tertiary facility were about 1.1, 2.3, and 8 (p less than .05) for mortality risk groups of less than 5%, 5% to 30%, and greater than 30%. Patients in tertiary facilities received more (p less than .05) invasive (e.g., arterial catheters) and complex (e.g., mechanical ventilation) care, whereas patients in nontertiary facilities received more (p less than .05) labor-intensive care (e.g., hourly vital signs). CONCLUSIONS: Care of the most seriously ill children in tertiary pediatric ICUs could improve their chances of survival.

Adolescent↗
PubMed1991

Objective assessment of changing mortality risks in pediatric intensive care unit patients.

OBJECTIVE: To develop and validate a mortality risk predictor based on physiologic data that estimates daily the probability of a patient dying within the next 24 hrs as that probability changes with disease and recovery. SETTING: Nine pediatric ICUs in tertiary care centers. PATIENTS: Data from 1,401 patients (116 deaths, 5,521 days of care) were used for predictor development, and 1,227 patients (105 deaths, 4,597 days of care) provided data for predictor validation. METHODS: The predictor was developed by logistic regression analysis using the Pediatric Risk of Mortality scores of all previous days as potential predictor variables. Performance was measured by the area under the receiver operating characteristic curve (Az), and by the comparison of the daily predicted vs. observed patient status in five mortality risk groups (less than 0.01, 0.01 to 0.05, 0.05 to 0.15, 0.15 to 0.3, greater than 0.3) using chi-square goodness-of-fit tests. MEASUREMENTS AND MAIN RESULTS: Only the most recent and the admission day Pediatric Risk of Mortality scores (with a weighting ratio of 3:1) contributed significantly (p less than .05) to the prediction. The overall prediction attained an accuracy of Az = 0.904. The daily number and distribution of survivors and nonsurvivors in the five mortality risk groups were well predicted in the total sample (chi 2 [5 degrees of freedom] = 2.51; p greater than .75), and each ICU separately (chi 2 [5 degrees of freedom] range 2.41 to 7.96; all p greater than .15). This dynamic predictor improved (p less than .01) ICU outcome prediction over an admission-day predictor and, in the opinion of the authors, is essential for pediatric ICU efficiency analysis. CONCLUSIONS: The predictor is valid for assessing the 24-hr mortality risk in pediatric ICU patients hospitalized in other tertiary care institutions, different from those used for predictor development. The predicted mortality risks allow prospective patient stratification into risk groups. The ability of this predictor to follow risk changes over time expands its applicability over static predictors by enabling the charting of patient courses, and permitting ICU efficiency analysis.

Child↗
PubMed1991

Home care cost-effectiveness for respiratory technology-dependent children.

We evaluated home care costs and the cost-effectiveness of home care vs alternative institutional care for respiratory technology-dependent children in a Medicaid Model Waiver Program. "Cost-savings" was measured as the difference between the established Medicaid reimbursable charges to enact an individualized care plan at a long-term care institution and the actual Medicaid reimbursements for home care. Ten patients--six dependent on mechanical ventilation and four with a tracheostomy who were receiving oxygen--were included in the analysis. The mean (+/- SD) annual home care costs were $109,836 +/- $20,781 for ventilator-dependent children and $63,650 +/- $12,350 for oxygen-dependent patients with a tracheostomy, representing annual savings of approximately $79,000 per patient and $83,000 per patient, respectively. The largest portion of home care reimbursements was for nursing care, accounting for 69.0% and 59.0% of the two patient groups. The full program (50 patients) has the potential for a savings of $4 million per year.

Child↗
PubMed1990

Cost, resource utilization, and severity of illness in intensive care.

The relationship between health care resource use and severity of illness is important to hospitals providing care to sicker patients, so we investigated the relationship between resource utilization, cost, and severity of illness in 229 consecutive patients admitted to a pediatric intensive care unit. Resources measured included length of stay and number and cost of laboratory and imaging studies. Pediatric intensive care unit and daily mortality risks (assessed by the Physiologic Stability Index and the Dynamic Risk Index) were stratified as very low risk (less than 1%), low risk (1% to 2.5%), moderate risk (2.5% to 5.0%), and high risk (greater than 5%). Increasing daily resource use was directly related to increasing gradations of severity of illness. For very low, low-, moderate-, and high-risk patient days, the daily numbers of diagnostic studies were (mean +/- SEM) 20.1 +/- 0.6, 31.4 +/- 1.1, 37.7 +/- 1.6, and 43.0 +/- 1.8, respectively. Total resource use, including diagnostic tests and length of stay, also increased with pediatric intensive care unit mortality risk. Diagnostic testing and corresponding costs were significantly higher for infants who died in the pediatric intensive care unit than for survivors on a day-by-day basis as well as for the entire stay in the care unit. We conclude that there is a direct, positive relationship between resource use, cost, and gradations of severity of illness that, if accounted for, would result in more equitable health care reimbursement.

Adolescent↗
PubMed1990

Effect of blood transfusion on oxygen consumption in pediatric septic shock.

Treatment plans for pediatric septic shock advocate increasing oxygen consumption (VO2). Recent studies in septic shock indicate that improving oxygen delivery (DO2) by increasing blood flow will increase VO2. We prospectively examined the effect on VO2 of improving DO2 by increasing oxygen content (CO2) with blood transfusion in eight hemodynamically stable septic shock patients. Transfusion consisted of 8 to 10 ml/kg of packed RBC over 1 to 2 h. Hemodynamic and oxygen transport measurements were obtained before and after blood transfusion. Transfusion significantly (p less than .05) increased Hgb and Hct from 10.2 +/- 0.8 g/dl and 30 +/- 2% to 13.2 +/- 1.4 g/dl and 39 +/- 4%, respectively (mean +/- SD). DO2 significantly (p less than .05) increased after transfusion (599 +/- 65 to 818 +/- 189 ml/min.m2), but VO2 did not change (166 +/- 68 to 176 +/- 74 ml/min.m2; NS). In pediatric septic shock patients, increasing CO2 by blood transfusion may not increase VO2.

Blood Gas Analysis↗
PubMed1990

Iatrogenic illness in pediatric critical care.

Iatrogenic illness may be an important determinant of the need for pediatric intensive care. We prospectively evaluated consecutive admissions to a pediatric ICU (PICU) over two time periods totaling 6 months. Twenty-five (4.6%) admissions were necessitated by iatrogenic illnesses. Drug-induced conditions accounted for eight (32%) of the iatrogenic patients, and complications of medical-surgical acts accounted for 17 (68%). Diagnoses included six respiratory failures due to seizure medications, six chronic upper airway complications of neonatal intensive care, four posttonsillectomy and postadenoidectomy complications, two chronic postcardiac surgery complications, two cardiac catheterization complications, and five miscellaneous conditions. One (3.7%) patient with iatrogenic illness died. As a group, patients with iatrogenic illness were at a risk of dying similar to other patients. We conclude that iatrogenic illness is a significant cause of PICU admission.

Cardiac Catheterization↗
PubMed1990

Resource use, efficiency, and outcome prediction in pediatric intensive care of trauma patients.

To study the impact of trauma patients on Pediatric Intensive Care Units (PICUs), 164 trauma patients' data from 1,075 consecutive admissions to five PICUs were reviewed. Resource use (Therapeutic Intervention Scoring System [TISS] points) and mortality risks (Physiologic Stability Index [PSI] and Pediatric Risk of Mortality [PRISM] scores) were obtained daily for all patients. Trauma patients constituted 15.2% of all PICU patients, and used 14.9% of patient care days and 14.5% of TISS points. Efficiency of trauma patient care was 75% overall compared to 79% overall for nontrauma patients (p less than 0.001). Trauma patient mortality was 9.8%. Tests for goodness of fit showed the PSI and PRISM scores to be accurate outcome predictors for trauma patients (PSI: chi 2 (4) = 2.852, p greater than 0.50; PRISM: chi 2 (4) = 1.216, p greater than 0.50). Trauma patients are a minority of PICU patients and deaths. Their resource use is proportional to their numbers, although less efficient than for nontrauma patients. PSI and PRISM are accurate mortality risk predictors for trauma patients.

Child↗
PubMed1989

Comparisons of French and U.S.A. pediatric intensive care units.

Consecutive admissions to two pediatric intensive care units (PICUs) in France (n = 93) and the United States (n = 248) were compared using admission demographics, and daily therapeutic and severity of illness data. Analysis of the major demographic characteristics revealed that patients in the French PICU were younger (median age; 3 months vs. 31 months, P less than 0.001), and more commonly admitted for emergency reasons (92% vs. 66%, P less than 0.05). General resource utilization was similar in both units. However, important differences in the incidences of use of individual monitoring and therapeutic modalities were present. The United States PICU had higher incidences of invasive monitoring modalities (arterial catheters, 66% vs. 4%, P less than 0.001; central venous catheters, 38% vs. 11%, P less than 0.001; pulmonary artery catheters, 8% vs. 1%, P less than 0.01), while the French PICU had higher incidences of labor-intensive monitoring modalities (strict input/output, 75% vs. 47%, P less than 0.0001; greater than 3 stat blood studies/shift, 69% vs. 45%, P less than 0.0001). Patients in France were more likely to receive mechanical ventilation (81% vs. 56%, P less than 0.0001) and nutritional support (40% vs. 7%, P less than 0.05). Mortality rates in both PICUs were similar and accurately predicted by admission-day severity of illness scores. We conclude that differential resource utilization, possibly arising from different care philosophies, may result in equivalent care.

Critical Care↗
PubMed1989

Sequential physiologic interactions in pediatric cardiogenic and septic shock.

We report that the pediatric cardiogenic shock and septic shock populations show similar hemodynamic and oxygen utilization physiologic relationships during aggressive intensive care therapy. We examined the mathematical relationships between vascular tone and flow, and oxygen utilization and oxygen delivery (DO2) in the early and middle stages of cardiogenic and septic shock. The fitted curves between cardiac index and systemic vascular resistance, and oxygen consumption (VO2) and DO2 were clinically and statistically similar in both shock populations. We found no evidence for decreased oxygen extraction in sepsis as compared to the cardiogenic shock population. In addition, it appears that the major determinant of VO2 in these populations is DO2, not oxygen extraction. We suggest that patients with cardiogenic or septic shock can be treated according to similar physiologic principles.

Child, Preschool↗
PubMed1989

Efficacy of chest radiography in pediatric intensive care.

We prospectively evaluated the efficacy and clinical usefulness of bedside chest radiography in a pediatric intensive-care unit. Seven hundred ninety-five radiographs were evaluated in 126 patients over a 10-week period. Eighty-one percent of all radiographs showed one or more cardiopulmonary abnormalities, and 25% of routine radiographs had findings that altered management of patients. Nineteen percent of radiographs, including 17% of routine radiographs, showed a malpositioned tube or catheter. Thirty-five percent of endotracheal tubes shown on postintubation radiographs and 41% of central venous catheters shown on post-catheter placement radiographs were malpositioned. Forty-five percent of radiographs with a previous reading showed a significant interval change. Radiographs in patients 1 year old or younger showed more cardiopulmonary abnormalities (p less than .04), tube or catheter malpositions (p less than .03), and significant interval changes (p less than .03), and they elicited more changes in clinical management (p less than .01) than did radiographs in patients over 1 year old. The frequency of management changes dictated by radiographs increased with increasing amounts of respiratory support (p less than .01). Our data indicate that bedside radiography in the pediatric intensive-care setting has a high efficacy and clinical utility.

Adolescent↗
PubMed1989

Routine chest radiographs in pediatric intensive care: a prospective study.

The clinical value of routine chest radiographs was prospectively evaluated in a pediatric intensive care unit. Physicians were asked to predict findings of clinical impact in 353 routine morning chest radiographs performed in 101 patients after examining the patients. In 81 instances (23%), the clinical impact of the chest radiographs was incorrectly predicted and significant alterations in management would have potentially been missed had the chest radiographs not been available. These 81 chest radiographs included 72 unpredicted radiographic changes of clinical significance, and nine chest radiographs in which a significant radiographic change was incorrectly predicted. Thirty five (43.2%) of these 81 chest radiographs had unpredicted pulmonary findings and 46 (56.8%) showed unpredicted appliance malpositions. Incorrect predictions were significantly associated with radiographs from patients who were younger, intubated, mechanically ventilated, and had indwelling central venous catheters. Level of training of the predicting physicians did not affect prediction accuracy. In analysis of 43 routine postintubation chest radiographs and 39 routine postcentral venous catheter placement chest radiographs, appliance malpositions were disclosed in 34.9% and 43.6%, respectively. Routine daily and post-appliance placement chest radiographs have significant clinical value in the pediatric intensive care unit.

Adolescent↗
PubMed1988

Improving the outcome and efficiency of intensive care: the impact of an intensivist.

Data from two 3-month time periods before and after the arrival of a pediatric intensivist were collected prospectively and compared to determine the intensivist's impact on ICU mortality, use of monitoring and therapeutic modalities, and efficiency of ICU bed utilization. Severity of illness and care modalities were determined daily for all patients with the Physiologic Stability Index and the Therapeutic Intervention Scoring System. The only major organizational change in the postintensivist period was the organization and implementation of a daytime ICU team. Case mix variables, including sex; medical/surgical, emergency/elective, and diagnostic distributions; and nursing hours/patient day, were equivalent in the pre-intensivist and postintensivist samples. After the intensivist's arrival, there was a significant decrease in admissions with very low severity of illness (Physiologic Stability Index less than 4; 52% vs. 34%; p less than .05) and a significant decrease in bed utilization by patients who received only monitoring services (27% vs. 17% of bed days; p less than .001). The severity of the illness-adjusted ICU mortality rate was significantly higher in the pre-intensivist period than in the postintensivist period (weighted mean mortality difference 5.3 +/- 2.6%; p less than .05). The incidence of both therapeutic and monitoring modalities increased in the postintensivist period. These results indicate that a pediatric intensivist can improve mortality rates and efficiency of bed utilization in the pediatric ICU.

Critical Care↗
PubMed1988

Pediatric risk of mortality (PRISM) score.

The Pediatric Risk of Mortality (PRISM) score was developed from the Physiologic Stability Index (PSI) to reduce the number of physiologic variables required for pediatric ICU (PICU) mortality risk assessment and to obtain an objective weighting of the remaining variables. Univariate and multivariate statistical techniques were applied to admission day PSI data (1,415 patients, 116 deaths) from four PICUs. The resulting PRISM score consists of 14 routinely measured, physiologic variables, and 23 variable ranges. The performance of a logistic function estimating PICU mortality risk from the PRISM score, age, and operative status was tested in a different sample from six PICUs (1,227 patients, 105 deaths), each PICU separately, and in diagnostic groups using chi-square goodness-of-fit tests and receiver operating characteristic (ROC) analysis. In all groups, the number and distribution of survivors and nonsurvivors in adjacent mortality risk intervals were accurately predicted: total validation group (chi 2(5) = 0.80; p greater than .95), each PICU separately (chi 2(5) range 0.83 to 7.38; all p greater than .10), operative patients (chi 2(5) = 2.03; p greater than .75), nonoperative patients (chi 2(5) = 2.80, p greater than .50), cardiovascular disease patients (chi 2(5) = 4.72; p greater than .25), respiratory disease patients (chi 2(5) = 5.82; p greater than .25), and neurologic disease patients (chi 2(5) = 7.15; p greater than .10). ROC analysis also demonstrated excellent predictor performance (area index = 0.92 +/- 0.02).

Child, Preschool↗
PubMed1987

Efficiency of intensive care. A comparative analysis of eight pediatric intensive care units.

To calculate overall pediatric intensive care unit (PICU) efficiency rates, 1668 patients representing 6962 patient-days were studied in eight PICUs. The contributions to inefficiency by two patient groups--low-risk monitored patients and potential early-discharge patients--were quantified using measures of daily mortality risk and therapeutic assessments. Low-risk monitored patients never received a unique PICU therapy and had daily mortality risks less than 1%. Potential early-discharge patients were similar to the low-risk monitored patients except that their unnecessary PICU use came only on their last consecutive day(s) of PICU stay. Efficiency ratings ranged from 0.894 to 0.547 in the eight PICUs. Low-risk monitored patients constituted from 16% to 58% of the PICU patient populations and used from 5.4% to 34.5% of the total days of care. Potential early-discharge patients constituted from 12% to 29% of the populations and the potential early-discharge days of care ranged from 5.1% to 17.2% of the total days of care. These results indicate that large disparity exists in efficiency among PICUs. Efficiency rates of greater than 0.80 seem to be a reasonable goal.

Child↗
PubMed1987

Accurate prediction of the outcome of pediatric intensive care. A new quantitative method.

We surveyed nine pediatric intensive care units (ICUs) to compare patient populations and to test prospectively the hypothesis that differences in mortality rates were due to differences in severity of illness. Age, clinical service, the reason for admission (emergency or scheduled), and the seriousness of the underlying chronic disease were recorded on admission. The severity of illness was assessed on the day of admission with a physiology-based measure, the Physiologic Stability Index. The resulting score was used to group patients according to mortality risk. The observed numbers of ICU survivors and nonsurvivors in each mortality-risk group from eight of the pediatric ICUs were compared with the predicted numbers of survivors and nonsurviors calculated from a mathematical function (logistic model) derived earlier from data on 822 patients at one of the institutions. Patient populations in the ICUs differed significantly with respect to age (range of medians, 15 to 36 months; P less than 0.0001), medical admissions (range, 39 to 81 percent; P less than 0.0001), emergency admissions (range, 53 to 91 percent; P less than 0.0001), and the percentage of patients with serious underlying chronic disease (range, 18 to 48 percent; P less than 0.0001). Mortality rates also differed significantly (range, 3.0 to 17.6 percent; P less than 0.0001), as did the Physiologic Stability Index scores (P less than 0.0001). The mathematical function based on the Physiologic Stability Index score and on age reliably predicted the outcomes in all ICUs. We conclude that differences in mortality rates among pediatric ICUs can be explained by differences in the severity of illness.

Age Factors↗
PubMed1987

Mortality associated with multiple organ system failure and sepsis in pediatric intensive care unit.

Seven hundred twenty-six patients from five pediatric intensive care units were studied to determine the association of multiple organ system failure (MOSF) with mortality and to test the hypothesis that MOSF associated with sepsis has a higher mortality rate than MOSF without sepsis. There were 177 (24%) patients with MOSF and 83 (11%) nonsurvivors of MOSF. The mortality rates for two, three, or four or more failed organ systems were 26%, 62%, and 88%, respectively (P less than 0.001). Eighty-four (47%) patients with MOSF had associated sepsis. Sepsis (both bacteremia and clinical sepsis syndrome) did not significantly increase mortality rates in the groups with organ system failure. Mortality rates for patients with sepsis before or within 24 hours of development of MOSF (early sepsis) did not differ from mortality rates for those patients with onset of sepsis more than 24 hours after developing MOSF (late sepsis, 53% vs 33%, P = NS). We conclude that underlying pathophysiologic mechanisms of MOSF other than sepsis are as important as sepsis in critically ill pediatric patients.

Child↗