PubMed Health⌕ Search

Biomedical subjects

Thomas E Auble

Publications and source records attributed to Thomas E Auble.

12 recordsLinked to original sources
PubMed2006

A prediction rule to identify low-risk patients with pulmonary embolism.

BACKGROUND: A simple prognostic model could help identify patients with pulmonary embolism who are at low risk of death and are candidates for outpatient treatment. METHODS: We randomly allocated 15,531 retrospectively identified inpatients who had a discharge diagnosis of pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our rule to predict 30-day mortality using classification tree analysis and patient data routinely available at initial examination as potential predictor variables. We used data from a European prospective study to externally validate the rule among 221 inpatients with pulmonary embolism. We determined mortality and nonfatal adverse medical outcomes across derivation and validation samples. RESULTS: Our final model consisted of 10 patient factors (age > or = 70 years; history of cancer, heart failure, chronic lung disease, chronic renal disease, and cerebrovascular disease; and clinical variables of pulse rate > or = 110 beats/min, systolic blood pressure < 100 mm Hg, altered mental status, and arterial oxygen saturation < 90%). Patients with none of these factors were defined as low risk. The 30-day mortality rates for low-risk patients were 0.6%, 1.5%, and 0% in the derivation, internal validation, and external validation samples, respectively. The rates of nonfatal adverse medical outcomes were less than 1% among low-risk patients across all study samples. CONCLUSIONS: This simple prediction rule accurately identifies patients with pulmonary embolism who are at low risk of short-term mortality and other adverse medical outcomes. Prospective validation of this rule is important before its implementation as a decision aid for outpatient treatment.

Age Factors↗
PubMed2006

Factors associated with the hospitalization of low-risk patients with community-acquired pneumonia in a cluster-randomized trial.

BACKGROUND: Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting. OBJECTIVE: To identify the factors associated with the hospitalization of low-risk patients with pneumonia. METHODS: We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments. RESULTS: Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to outpatient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III. CONCLUSIONS: Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contraindications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.

Cluster Analysis↗
PubMed2005

Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial.

BACKGROUND: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice. OBJECTIVE: To compare the effectiveness and safety of 3 guideline implementation strategies. DESIGN: Cluster-randomized, controlled trial. SETTING: 32 emergency departments in Pennsylvania and Connecticut. PATIENTS: 3219 patients with a clinical and radiographic diagnosis of pneumonia. INTERVENTIONS: The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12). MEASUREMENTS: Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients. RESULTS: More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P = 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P < 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1%; low-intensity group, 23.0%; P < 0.001). No statistically significant differences in safety outcomes were observed across interventions. LIMITATIONS: Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial. CONCLUSIONS: Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients.

Aged↗
PubMed2005

Derivation and validation of a prognostic model for pulmonary embolism.

RATIONALE: An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment. OBJECTIVES: To develop a clinical prediction rule that accurately classifies patients with pulmonary embolism into categories of increasing risk of mortality and other adverse medical outcomes. METHODS: We randomly allocated 15,531 inpatient discharges with pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our prediction rule using logistic regression with 30-day mortality as the primary outcome, and patient demographic and clinical data routinely available at presentation as potential predictor variables. We externally validated the rule in 221 inpatients with pulmonary embolism from Switzerland and France. MEASUREMENTS: We compared mortality and nonfatal adverse medical outcomes across the derivation and two validation samples. MAIN RESULTS: The prediction rule is based on 11 simple patient characteristics that were independently associated with mortality and stratifies patients with pulmonary embolism into five severity classes, with 30-day mortality rates of 0-1.6% in class I, 1.7-3.5% in class II, 3.2-7.1% in class III, 4.0-11.4% in class IV, and 10.0-24.5% in class V across the derivation and validation samples. Inpatient death and nonfatal complications were <or= 1.1% among patients in class I and <or= 1.9% among patients in class II. CONCLUSIONS: Our rule accurately classifies patients with pulmonary embolism into classes of increasing risk of mortality and other adverse medical outcomes. Further validation of the rule is important before its implementation as a decision aid to guide the initial management of patients with pulmonary embolism.

Acute Disease↗
PubMed2005

Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia.

PURPOSE: We assessed the performance of 3 validated prognostic rules in predicting 30-day mortality in community-acquired pneumonia: the 20 variable Pneumonia Severity Index and the easier to calculate CURB (confusion, urea nitrogen, respiratory rate, blood pressure) and CURB-65 severity scores. SUBJECTS AND METHODS: We prospectively followed 3181 patients with community-acquired pneumonia from 32 hospital emergency departments (January-December 2001) and assessed mortality 30 days after initial presentation. Patients were stratified into Pneumonia Severity Index risk classes (I-V) and CURB (0-4) and CURB-65 (0-5) risk strata. We compared the discriminatory power (area under the receiver operating characteristic curve) of these rules to predict mortality and their accuracy based on sensitivity, specificity, predictive values, and likelihood ratios. RESULTS: The Pneumonia Severity Index (risk classes I-III) classified a greater proportion of patients as low risk (68% [2152/3181]) than either a CURB score <1 (51% [1635/3181]) or a CURB-65 score <2 (61% [1952/3181]). Low-risk patients identified based on the Pneumonia Severity Index had a slightly lower mortality (1.4% [31/2152]) than patients classified as low-risk based on the CURB (1.7% [28/1635]) or the CURB-65 (1.7% [33/1952]). The area under the receiver operating characteristic curve was higher for the Pneumonia Severity Index (0.81) than for either the CURB (0.73) or CURB-65 (0.76) scores (P <0.001, for each pairwise comparison). At comparable cut-points, the Pneumonia Severity Index had a higher sensitivity and a somewhat higher negative predictive value for mortality than either CURB score. CONCLUSIONS: The more complex Pneumonia Severity Index has a higher discriminatory power for short-term mortality, defines a greater proportion of patients at low risk, and is slightly more accurate in identifying patients at low risk than either CURB score.

Aged↗
PubMed2005

Using randomized controlled trial data, the agreement between retrospectively and prospectively collected data comprising the pneumonia severity index was substantial.

OBJECTIVE: To assess the agreement between prospectively and retrospectively determined variables comprising the Pneumonia Severity Index (PSI), assignment to PSI risk class, and designation as low risk, based on these two methods of data collection. STUDY DESIGN AND SETTING: We analyzed data from a randomized trial of patients with community-acquired pneumonia managed in 32 hospital emergency departments (EDs). For all enrolled patients, the 20 PSI variables were collected prospectively by ED providers and retrospectively by medical record abstractors. We examined the agreement for each of the 20 PSI variables, assignment to the five PSI risk classes, and classification of patients as low (classes I-III) vs. high (classes IV and V) risk. Agreement was measured using total percent agreement and the kappa statistic. RESULTS: Among the 3,220 enrolled patients, percent agreement was >90% for 18 of the 20 variables comprising the PSI, with most unweighted kappa's being >0.6. Agreement was substantial for assignment to PSI risk class (percent agreement: 92.7%; weighted kappa: 0.79) and for classification as low vs. high risk (percent agreement: 88.5%; unweighted kappa: 0.74). CONCLUSION: There was substantial agreement between retrospective and prospective assignment to PSI risk class, classification as low vs. high risk, and the determination of most individual variables that constitute the PSI.

Adolescent↗
PubMed2005

A prediction rule to identify low-risk patients with heart failure.

OBJECTIVES: To derive a prediction rule using data available in the emergency department (ED) to identify a group of patients hospitalized for the treatment of heart failure who are at low risk of death and serious complications. METHODS: The authors analyzed data for all 33,533 patients with a primary hospital discharge diagnosis of heart failure in 1999 who were admitted from EDs in Pennsylvania. Candidate predictors were demographic and medical history variables and the most abnormal examination or diagnostic test values measured in the ED (vital signs only) or on the first day of hospitalization. The authors constructed classification trees to identify a subgroup of patients with an observed rate of death or serious medical complications before discharge < 2%; the tree that identified the subgroup with the lowest rate of this outcome and an inpatient mortality rate < 1% was chosen. RESULTS: Within the entire cohort, 4.5% of patients died and 6.8% survived to hospital discharge after experiencing a serious medical complication. The prediction rule used 21 prognostic factors to classify 17.2% of patients as low risk; 19 (0.3%) died and 59 (1.0%) survived to hospital discharge after experiencing a serious medical complication. CONCLUSIONS: This clinical prediction rule identified a group of patients hospitalized from the ED for the treatment of heart failure who were at low risk of adverse inpatient outcomes. Model performance needs to be examined in a cohort of patients with an ED diagnosis of heart failure and treated as outpatients or hospitalized.

Aged↗
PubMed2004

The emergency department community-acquired pneumonia trial: Methodology of a quality improvement intervention.

Community-acquired pneumonia causes more than 4 million episodes of illness each year and has high morbidity, mortality, and total cost of care. Nationwide, nearly 75% of community-acquired pneumonia patients are initially evaluated and treated in hospital-based emergency departments (EDs). Substantial variation exists in illness severity assessment, hospital admission decisions, and performance of recommended processes of care. We designed an ED-based quality improvement trial focused on the initial care of patients with community-acquired pneumonia. We used the Pneumonia Severity Index and level of arterial oxygenation to identify patients at low risk for 30-day mortality and to guide admission decisionmaking. We assessed the performance of recommended "best practices," consisting of assessment of arterial oxygenation, the collection of blood cultures for inpatients, and the timely initiation of appropriate empiric antibiotic therapy for inpatients and outpatients. We conducted a 32-site, cluster-randomized trial in Pennsylvania and Connecticut, comparing the effectiveness and safety of 3 guideline implementation strategies of increasing intensity. The multifaceted implementation plans were carried out in conjunction with each state's quality improvement organization. This article describes the background, objectives, and methodology of this trial to translate evidence-based knowledge on the quality and efficiency of care for community-acquired pneumonia into clinical practice.

Anti-Bacterial Agents↗
PubMed2002

Evaluation of guidelines for ordering prothrombin and partial thromboplastin times.

OBJECTIVES: Existing clinical practice guidelines for ordering prothrombin time (PT) and partial thromboplastin time (PTT) tests in the emergency department (ED) include physician expectation of an invasive procedure as a criterion. This study sought to determine whether this criterion accurately identifies patients who undergo an invasive procedure and whether an amalgam of these guidelines identifies patients at low risk of an adverse medical outcome. METHODS: A prospective observational cohort study of adults treated in a university medical center ED between July 1997 and March 1998. Physicians were surveyed at order placement to determine the presence of guideline criteria. Adverse clinical outcomes defined as an International Normalized Ratio [INR] > 1.3 or PTT > 39.9 seconds combined with consequent directed medical therapy were abstracted from ED and the first 24 hours of inpatient medical records. RESULTS: The sensitivity of ED physician expectation of an invasive procedure was 60.0%; therefore, it was excluded from both the PT and PTT guidelines. There were 553 patients with a PT test order; test order indications were absent in 190 (34.4%), of which one (0.5%, 95% CI = 0.1% to 2.9%) had adverse outcomes. There were 547 patients with a PTT test; test order indications were absent in 226 (41.3%), of which three (1.3%, 95% CI = 0.4 to 3.8%) had adverse outcomes. All three were taking warfarin when they presented to the ED. CONCLUSIONS: Emergency department physician expectation of an invasive procedure for patients with PT or PTT test orders is an insensitive predictor of patients who undergo such procedures. Clinical practice guidelines that exclude this criterion identify ED patients at the time of ED presentation at low risk for adverse medical outcomes in the ED or shortly after admission.

Aged↗
PubMedDate not supplied

Influenza immunizations provided by EMS agencies: the MEDICVAX Project.

OBJECTIVE: Emergency medical services (EMS) agencies may be an underutilized resource for provision of preventive health services. This study sought to demonstrate the feasibility for EMS agencies to provide influenza immunizations. METHODS: This prospective, observational cohort study was conducted with urban, suburban, and rural EMS agencies that volunteered to participate. EMS managers and paramedics attended an orientation program, and then developed and implemented recruitment strategies. Adult volunteer subjects who met Centers for Disease Control and Prevention criteria for influenza vaccination were enrolled. Paramedics obtained informed consent, determined subject eligibility, administered the vaccine, and observed each subject for 10 minutes. Paramedics, EMS managers, and subjects completed surveys; EMS managers reported costs and resource utilization. Data were analyzed descriptively. RESULTS: Ninety paramedics from 15 EMS agencies in three counties participated. Subjects were recruited by print and broadcast media and enrolled at 73 events held at retail establishments, community events, EMS stations, churches, senior citizen complexes, and private residences. Of the 2,075 adults immunized, 1,014 (49%) did not receive influenza vaccination in the previous year. Seven hundred five (34%) reported that they probably would not have been vaccinated elsewhere. Fixed cost for each immunization was $3.42. The EMS managers estimated their variable costs to range from zero dollars (volunteer agencies with all donated expenses) to $15.31 per immunization. No adverse events were reported. Subjects, paramedics, and EMS managers indicated a high level of satisfaction with the project. CONCLUSION: The MEDICVAX Project demonstrated the feasibility of EMS agencies to safely provide influenza immunizations. The project reached some adults who likely would not have been immunized.

Adult↗