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Pediatric Acute Stroke Protocol Implementation and Utilization Over 7 Years.
Wharton JD, Barry MM, Lee CA, Massey K, Ladner TR, Jordan LC
(2020) J Pediatr 220: 214-220.e1
MeSH Terms: Adolescent, Child, Child, Preschool, Female, Guideline Adherence, Humans, Male, Retrospective Studies, Stroke, Time Factors
Show Abstract · Added March 24, 2020
OBJECTIVE - To examine the implementation and utilization of a pediatric acute stroke protocol over a 7-year period, hypothesizing improvements in protocol implementation and increased protocol use over time.
STUDY DESIGN - Clinical and demographic data for this retrospective observational study from 2011 through 2018 were obtained from a quality improvement database and medical records of children for whom the acute stroke protocol was activated. The initial 43 months of the protocol (period 1) were compared with the subsequent 43 months (period 2).
RESULTS - Over the 7-year period, a total of 385 stroke alerts were activated, in 150 children (39%) in period 1 and 235 (61%) in period 2, representing a 56% increase in protocol activation. Stroke was the final diagnosis in 80 children overall (21%), including 38 (25%) in period 1 and 42 (19%) in period 2 (P = .078). The combined frequency of diagnosed stroke, transient ischemic attack (TIA), and other neurologic emergencies remained stable across the 2 time periods at 39% and 37%, respectively (P = .745). Pediatric National Institutes of Health Stroke Scale (PedNIHSS) documentation increased from 42% in period 1 to 82% in period 2 (P < .001). Magnetic resonance imaging (MRI) was the first neuroimaging study for 68% of the children in period 1 vs 78% in period 2 (P = .038). All children with acute stroke received immediate supportive care.
CONCLUSIONS - Pediatric stroke protocol implementation improved over time with increased use of the PedNIHSS and use of MRI as the first imaging study. However, with increased utilization, the frequency of confirmed strokes and other neurologic emergencies remained stable. The frequency of stroke and other neurologic emergencies in these children affirms the importance of implementing and maintaining a pediatric acute stroke protocol.
Copyright © 2020 Elsevier Inc. All rights reserved.
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10 MeSH Terms
Utilization of Cardiac Surveillance Tests in Survivors of Breast Cancer and Lymphoma After Anthracycline-Based Chemotherapy.
Ruddy KJ, Sangaralingham LR, Van Houten H, Nowsheen S, Sandhu N, Moslehi J, Neuman H, Jemal A, Haddad TC, Blaes AH, Villarraga HR, Thompson C, Shah ND, Herrmann J
(2020) Circ Cardiovasc Qual Outcomes 13: e005984
MeSH Terms: Administrative Claims, Healthcare, Adolescent, Adult, Aged, Anthracyclines, Antineoplastic Combined Chemotherapy Protocols, Breast Neoplasms, Cancer Survivors, Data Warehousing, Echocardiography, Female, Guideline Adherence, Heart Diseases, Humans, Lymphoma, Male, Middle Aged, Practice Guidelines as Topic, Practice Patterns, Physicians', Predictive Value of Tests, Retrospective Studies, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, United States, Young Adult
Show Abstract · Added May 29, 2020
BACKGROUND - The National Comprehensive Cancer Network and American Society of Clinical Oncology recommend consideration of the use of echocardiography 6 to 12 months after completion of anthracycline-based chemotherapy in at-risk populations. Assessment of BNP (B-type natriuretic peptide) has also been suggested by the American College of Cardiology/American Heart Association/Heart Failure Society of America for the identification of Stage A (at risk) heart failure patients. The real-world frequency of the use of these tests in patients after receipt of anthracycline therapy, however, has not been studied previously.
METHODS AND RESULTS - In this retrospective study, using administrative claims data from the OptumLabs Data Warehouse, we identified 31 447 breast cancer and lymphoma patients (age ≥18 years) who were treated with an anthracycline in the United States between January 1, 2008 and January 31, 2018. Continuous medical and pharmacy coverage was required for at least 6 months before the initial anthracycline dose and 12 months after the final dose. Only 36.1% of patients had any type of cardiac surveillance (echocardiography, BNP, or cardiac imaging) in the year following completion of anthracycline therapy (29.7% echocardiography). Surveillance rate increased from 37.5% in 2008 to 42.7% in 2018 (25.6% in 2008 to 40.5% echocardiography in 2018). Lymphoma patients had a lower likelihood of any surveillance compared with patients with breast cancer (odds ratio, 0.79 [95% CI, 0.74-0.85]; <0.001). Patients with preexisting diagnoses of coronary artery disease and arrhythmia had the highest likelihood of cardiac surveillance (odds ratio, 1.54 [95% CI, 1.39-1.69] and odds ratio, 1.42 [95% CI, 1.3-1.53]; <0.001 for both), although no single comorbidity was associated with a >50% rate of surveillance.
CONCLUSIONS - The majority of survivors of breast cancer and lymphoma who have received anthracycline-based chemotherapy do not undergo cardiac surveillance after treatment, including those with a history of cardiovascular comorbidities, such as heart failure.
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Communication About the Probability of Cancer in Indeterminate Pulmonary Nodules.
Maiga AW, Deppen SA, Massion PP, Callaway-Lane C, Pinkerman R, Dittus RS, Lambright ES, Nesbitt JC, Grogan EL
(2018) JAMA Surg 153: 353-357
MeSH Terms: Aged, Communication, Documentation, Female, Guideline Adherence, Humans, Lung Neoplasms, Male, Medical Records, Middle Aged, Practice Guidelines as Topic, Probability, Retrospective Studies, Risk Assessment, Risk Factors, Solitary Pulmonary Nodule
Show Abstract · Added January 29, 2018
Importance - Clinical guidelines recommend that clinicians estimate the probability of malignancy for patients with indeterminate pulmonary nodules (IPNs) larger than 8 mm. Adherence to these guidelines is unknown.
Objectives - To determine whether clinicians document the probability of malignancy in high-risk IPNs and to compare these quantitative or qualitative predictions with the validated Mayo Clinic Model.
Design, Setting, and Participants - Single-institution, retrospective cohort study of patients from a tertiary care Department of Veterans Affairs hospital from January 1, 2003, through December 31, 2015. Cohort 1 included 291 veterans undergoing surgical resection of known or suspected lung cancer from January 1, 2003, through December 31, 2015. Cohort 2 included a random sample of 239 veterans undergoing inpatient or outpatient pulmonary evaluation of IPNs at the hospital from January 1, 2003, through December 31, 2012.
Exposures - Clinician documentation of the quantitative or qualitative probability of malignancy.
Main Outcomes and Measures - Documentation from pulmonary and/or thoracic surgery clinicians as well as information from multidisciplinary tumor board presentations was reviewed. Any documented quantitative or qualitative predictions of malignancy were extracted and summarized using descriptive statistics. Clinicians' predictions were compared with risk estimates from the Mayo Clinic Model.
Results - Of 291 patients in cohort 1, 282 (96.9%) were men; mean (SD) age was 64.6 (9.0) years. Of 239 patients in cohort 2, 233 (97.5%) were men; mean (SD) age was 65.5 (10.8) years. Cancer prevalence was 258 of 291 cases (88.7%) in cohort 1 and 110 of 225 patients with a definitive diagnosis (48.9%) in cohort 2. Only 13 patients (4.5%) in cohort 1 and 3 (1.3%) in cohort 2 had a documented quantitative prediction of malignancy prior to tissue diagnosis. Of the remaining patients, 217 of 278 (78.1%) in cohort 1 and 149 of 236 (63.1%) in cohort 2 had qualitative statements of cancer risk. In cohort 2, 23 of 79 patients (29.1%) without any documented malignancy risk statements had a final diagnosis of cancer. Qualitative risk statements were distributed among 32 broad categories. The most frequently used statements aligned well with Mayo Clinic Model predictions for cohort 1 compared with cohort 2. The median Mayo Clinic Model-predicted probability of cancer was 68.7% (range, 2.4%-100.0%). Qualitative risk statements roughly aligned with Mayo predictions.
Conclusions and Relevance - Clinicians rarely provide quantitative documentation of cancer probability for high-risk IPNs, even among patients drawn from a broad range of cancer probabilities. Qualitative statements of cancer risk in current practice are imprecise and highly variable. A standard scale that correlates with predicted cancer risk for IPNs should be used to communicate with patients and other clinicians.
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Impact of a National Guideline on Antibiotic Selection for Hospitalized Pneumonia.
Williams DJ, Hall M, Gerber JS, Neuman MI, Hersh AL, Brogan TV, Parikh K, Mahant S, Blaschke AJ, Shah SS, Grijalva CG, Pediatric Research in Inpatient Settings Network
(2017) Pediatrics 139:
MeSH Terms: Adolescent, Anti-Bacterial Agents, Child, Child, Preschool, Databases, Factual, Female, Guideline Adherence, Hospitals, Pediatric, Humans, Infant, Inpatients, Male, Pneumonia
Show Abstract · Added July 27, 2018
BACKGROUND - We evaluated the impact of the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pneumonia guideline and hospital-level implementation efforts on antibiotic prescribing for children hospitalized with pneumonia.
METHODS - We assessed inpatient antibiotic prescribing for pneumonia at 28 children's hospitals between August 2009 and March 2015. Each hospital was also surveyed regarding local implementation efforts targeting antibiotic prescribing and organizational readiness to adopt guideline recommendations. To estimate guideline impact, we used segmented linear regression to compare the proportion of children receiving penicillins in March 2015 with the expected proportion at this same time point had the guideline not been published based on a projection of a preguideline trend. A similar approach was used to estimate the short-term (6-month) impact of local implementation efforts. The correlations between organizational readiness and the impact of the guideline were estimated by using Pearson's correlation coefficient.
RESULTS - Before guideline publication, penicillin prescribing was rare (<10%). After publication, an absolute increase in penicillin use was observed (27.6% [95% confidence interval: 23.7%-31.5%]) by March 2015. Among hospitals with local implementation efforts ( = 20, 71%), the median increase was 29.5% (interquartile range: 19.6%-39.1%) compared with 20.1% (interquartile rage: 9.5%-44.5%) among hospitals without such activities ( = .51). The independent, short-term impact of local implementation efforts was similar in magnitude to that of the national guideline. Organizational readiness was not correlated with prescribing changes.
CONCLUSIONS - The publication of the Pediatric Infectious Diseases Society/Infectious Diseases Society of America guideline was associated with sustained increases in the use of penicillins for children hospitalized with pneumonia. Local implementation efforts may have enhanced guideline adoption and appeared more relevant than hospitals' organizational readiness to change.
Copyright © 2017 by the American Academy of Pediatrics.
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Omission of Adjuvant Chemotherapy Is Associated With Increased Mortality in Patients With T3N0 Colon Cancer With Inadequate Lymph Node Harvest.
Wells KO, Hawkins AT, Krishnamurthy DM, Dharmarajan S, Glasgow SC, Hunt SR, Mutch MG, Wise P, Silviera ML
(2017) Dis Colon Rectum 60: 15-21
MeSH Terms: Adenocarcinoma, Aged, Aged, 80 and over, Chemotherapy, Adjuvant, Colectomy, Colon, Colonic Neoplasms, Databases, Factual, Female, Guideline Adherence, Humans, Lymph Node Excision, Lymph Nodes, Male, Middle Aged, Neoplasm Staging, Practice Guidelines as Topic, Retrospective Studies, Survival Rate
Show Abstract · Added March 21, 2017
BACKGROUND - Adjuvant chemotherapy for T3N0 colon cancer is controversial. National guidelines recommend its use in patients with stage II with high-risk features, including lymph node harvest of less than 12, yet this treatment is underused.
OBJECTIVE - The purpose of this study was to demonstrate that the use of adjuvant chemotherapy in patients with T3N0 adenocarcinoma with inadequate lymph node harvest is beneficial.
DESIGN - This was a retrospective population-based study of patients with resected T3N0 adenocarcinoma of the colon.
SETTINGS - The National Cancer Database was queried from 2003 to 2012.
PATIENTS - A total of 134,567 patients with T3N0 colon cancer were included in this analysis.
MAIN OUTCOME MEASURES - The use of chemotherapy, short-term outcomes, and overall survival was evaluated. Clinicopathologic factors associated with omission of chemotherapy were also analyzed.
RESULTS - Inadequate lymph node harvest was observed in 23.3% of patients, and this rate decreased over the study period from 46.8% in 2003 to 12.5% in 2012 (p < 0.0001). Overall 5-year survival for patients with T3N0 cancer was 66.8%. Inadequate lymph node harvest among these patients was associated with lower overall 5-year survival (58.7% vs 69.8%; p < 0.001). The use of adjuvant chemotherapy among patients with T3N0 cancer after inadequate lymph node harvest was only 16.7%. In a multivariable analysis, factors associated with failure to receive chemotherapy included advanced age (OR = 0.44 (95% CI, 0.43-0.45)), increased comorbidities (OR = 0.7 (95% CI, 0.66-0.76)), and postoperative readmission (OR = 0.78 (95% CI, 0.67-0.91)). Patients with inadequate lymph node harvest who received adjuvant chemotherapy had improved 5-year survival (chemotherapy, 78.4% vs no chemotherapy, 54.7%; p < 0.001). Even when controlling for all of the significant variables, the administration of chemotherapy remained a predictor of decreased mortality (HR = 0.57 (95% CI, 0.54-0.60); p < 0.001).
LIMITATIONS - This study was limited by its retrospective, population-based design.
CONCLUSIONS - Patients with T3N0 colon cancer with inadequate lymph node harvest who receive adjuvant chemotherapy have increased overall survival. Despite this survival benefit, a fraction of these patients receive adjuvant chemotherapy. Barriers to chemotherapy are multifactorial.
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Improved Guideline Adherence With Integrated Sickle Cell Disease and Asthma Care.
McClain BL, Ivy ZK, Bryant V, Rodeghier M, DeBaun MR
(2016) Am J Prev Med 51: S62-8
MeSH Terms: Anemia, Sickle Cell, Asthma, Child, Delivery of Health Care, Integrated, Female, Guideline Adherence, Humans, Male, Patient Care Team, Prospective Studies, Respiratory Function Tests, Respiratory Therapy, Spirometry
Show Abstract · Added July 20, 2016
INTRODUCTION - In children with sickle cell disease (SCD), concomitant asthma is associated with increased morbidity and mortality when compared with children with SCD without asthma. Despite the well-established burden of asthma in children with SCD, no paradigm of care exists for the co-management of these two diseases.
METHODS - To address this gap, an integrated SCD and asthma clinic was created in a community health center that included (1) a dual respiratory therapist/asthma case manager; (2) an SCD nurse practitioner with asthma educator certification; (3) an onsite pulmonary function test laboratory; (4) a pediatric hematologist with expertise in managing SCD and asthma; and (5) application of the National Asthma Education and Prevention Program guidelines. A before (2010-2012) and after (2013-2014) study design was used to assess for improved quality of care with implementation of an integrative care model among 61 children with SCD and asthma followed from 2010 to 2014.
RESULTS - Asthma action plan utilization after initial diagnosis increased with the integrative care model (n=16, 56% before, 100% after, p=0.003), as did the use of spirometry in children aged ≥5 years (n=41, 65% before, 95% after, p<0.001) and correction of lower airway obstruction (n=10, 30% before, 80% after, p=0.03).
CONCLUSIONS - Although the use of an integrative care model for SCD and asthma improved evidence-based asthma care, longer follow-up and evaluation will be needed to determine the impact on SCD-related morbidity.
Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
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Effect of a Clinical Practice Guideline for Pediatric Complicated Appendicitis.
Willis ZI, Duggan EM, Bucher BT, Pietsch JB, Milovancev M, Wharton W, Gillon J, Lovvorn HN, O'Neill JA, Di Pentima MC, Blakely ML
(2016) JAMA Surg 151: e160194
MeSH Terms: Adolescent, Appendectomy, Appendicitis, Catheterization, Peripheral, Child, Child, Preschool, Female, Guideline Adherence, Humans, Interrupted Time Series Analysis, Length of Stay, Male, Patient Readmission, Practice Guidelines as Topic, Reoperation, Surgical Wound Infection, Tomography, X-Ray Computed, Treatment Outcome
Show Abstract · Added November 30, 2020
IMPORTANCE - Complicated appendicitis is a common condition in children that causes substantial morbidity. Significant variation in practice exists within and between centers. We observed highly variable practices within our hospital and hypothesized that a clinical practice guideline (CPG) would standardize care and be associated with improved patient outcomes.
OBJECTIVE - To determine whether a CPG for complicated appendicitis could be associated with improved clinical outcomes.
DESIGN, SETTING, AND PARTICIPANTS - A comprehensive CPG was developed for all children with complicated appendicitis at Monroe Carell Jr Children's Hospital at Vanderbilt, a freestanding children's hospital in Nashville, Tennessee, and was implemented in July 2013. All patients with complicated appendicitis who were treated with early appendectomy during the study period were included in the study. Patients were divided into 2 cohorts, based on whether they were treated before or after CPG implementation. Clinical characteristics and outcomes were recorded for 30 months prior to and 16 months following CPG implementation.
EXPOSURE - Clinical practice guideline developed for all children with complicated appendicitis at Monroe Carell Jr Children's Hospital at Vanderbilt.
MAIN OUTCOMES AND MEASURES - The primary outcome measure was the occurrence of any adverse event such as readmission or surgical site infection. In addition, resource use, practice variation, and CPG adherence were assessed.
RESULTS - Of the 313 patients included in the study, 183 were boys (58.5%) and 234 were white (74.8%). Complete CPG adherence occurred in 78.7% of cases (n = 96). The pre-CPG group included 191 patients with a mean (SD) age of 8.8 (4.0) years, and the post-CPG group included 122 patients with a mean (SD) age of 8.7 (4.1) years. Compared with the pre-CPG group, patients in the post-CPG group were less likely to receive a peripherally inserted central catheter (2.5%, n = 3 vs 30.4%, n = 58; P < .001) or require a postoperative computed tomographic scan (13.1%, n = 16 vs 29.3%, n = 56; P = .001), and length of hospital stay was significantly reduced (4.6 days post-CPG vs 5.1 days pre-CPG, P < .05). Patients in the post-CPG group were less likely to have a surgical site infection (relative risk [RR], 0.41; 95% CI, 0.27-0.74) or require a second operation (RR, 0.35; 95% CI, 0.12-1.00). In the pre-CPG group, 30.9% of patients (n = 59) experienced any adverse event, while 22.1% of post-CPG patients (n = 27) experienced any adverse event (RR, 0.72; 95% CI, 0.48-1.06).
CONCLUSIONS AND RELEVANCE - Significant practice variation exists among surgeons in the management of pediatric complicated appendicitis. In our institution, a CPG that standardized practice patterns was associated with reduced resource use and improved patient outcomes. Most surgeons had very high compliance with the CPG.
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Treatment Gaps in Adults With Heterozygous Familial Hypercholesterolemia in the United States: Data From the CASCADE-FH Registry.
deGoma EM, Ahmad ZS, O'Brien EC, Kindt I, Shrader P, Newman CB, Pokharel Y, Baum SJ, Hemphill LC, Hudgins LC, Ahmed CD, Gidding SS, Duffy D, Neal W, Wilemon K, Roe MT, Rader DJ, Ballantyne CM, Linton MF, Duell PB, Shapiro MD, Moriarty PM, Knowles JW
(2016) Circ Cardiovasc Genet 9: 240-9
MeSH Terms: Adult, Aged, Biomarkers, Chi-Square Distribution, Cholesterol, LDL, Comorbidity, Coronary Disease, Cross-Sectional Studies, Diabetes Mellitus, Down-Regulation, Early Diagnosis, Female, Genetic Predisposition to Disease, Guideline Adherence, Heterozygote, Humans, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hyperlipoproteinemia Type II, Hypertension, Logistic Models, Male, Middle Aged, Multivariate Analysis, Odds Ratio, Phenotype, Practice Guidelines as Topic, Practice Patterns, Physicians', Predictive Value of Tests, Prevalence, Professional Practice Gaps, Registries, Risk Factors, Time Factors, Treatment Outcome, United States
Show Abstract · Added April 10, 2018
BACKGROUND - Cardiovascular disease burden and treatment patterns among patients with familial hypercholesterolemia (FH) in the United States remain poorly described. In 2013, the FH Foundation launched the Cascade Screening for Awareness and Detection (CASCADE) of FH Registry to address this knowledge gap.
METHODS AND RESULTS - We conducted a cross-sectional analysis of 1295 adults with heterozygous FH enrolled in the CASCADE-FH Registry from 11 US lipid clinics. Median age at initiation of lipid-lowering therapy was 39 years, and median age at FH diagnosis was 47 years. Prevalent coronary heart disease was reported in 36% of patients, and 61% exhibited 1 or more modifiable risk factors. Median untreated low-density lipoprotein cholesterol (LDL-C) was 239 mg/dL. At enrollment, median LDL-C was 141 mg/dL; 42% of patients were taking high-intensity statin therapy and 45% received >1 LDL-lowering medication. Among FH patients receiving LDL-lowering medication(s), 25% achieved an LDL-C <100 mg/dL and 41% achieved a ≥50% LDL-C reduction. Factors associated with prevalent coronary heart disease included diabetes mellitus (adjusted odds ratio 1.74; 95% confidence interval 1.08-2.82) and hypertension (2.48; 1.92-3.21). Factors associated with a ≥50% LDL-C reduction from untreated levels included high-intensity statin use (7.33; 1.86-28.86) and use of >1 LDL-lowering medication (1.80; 1.34-2.41).
CONCLUSIONS - FH patients in the CASCADE-FH Registry are diagnosed late in life and often do not achieve adequate LDL-C lowering, despite a high prevalence of coronary heart disease and risk factors. These findings highlight the need for earlier diagnosis of FH and initiation of lipid-lowering therapy, more consistent use of guideline-recommended LDL-lowering therapy, and comprehensive management of traditional coronary heart disease risk factors.
© 2016 American Heart Association, Inc.
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Aggregate and hospital-level impact of national guidelines on diagnostic resource utilization for children with pneumonia at children's hospitals.
Parikh K, Hall M, Blaschke AJ, Grijalva CG, Brogan TV, Neuman MI, Williams DJ, Gerber JS, Hersh AL, Shah SS
(2016) J Hosp Med 11: 317-23
MeSH Terms: Adolescent, Child, Child, Preschool, Community-Acquired Infections, Diagnostic Tests, Routine, Female, Guideline Adherence, Hospitals, Pediatric, Humans, Infant, Male, Pneumonia, Retrospective Studies
Show Abstract · Added July 27, 2018
BACKGROUND - National guidelines for the management of community-acquired pneumonia (CAP) in children were published in 2011. These guidelines discourage most diagnostic testing for outpatients, as well as repeat testing for hospitalized patients who are improving. We sought to evaluate the temporal trends in diagnostic testing associated with guideline implementation among children with CAP.
METHODS - Children 1 to 18 years old who were discharged with pneumonia after emergency department (ED) evaluation or hospitalization from January 1, 2008 to June 30, 2014 at any of 32 children's hospitals participating in the Pediatric Health Information System were included. We excluded children with complex chronic conditions and those requiring intensive care or who underwent early pleural drainage. We compared use of diagnostic testing (blood culture, complete blood count [CBC], C-reactive protein [CRP], and chest radiography [CXR]) before and after release of the guidelines, and assessed for temporal trends using interrupted time series analysis. We also calculated the cost impact of these changes on diagnostic utilization and evaluated the variability of the guideline's impact across hospitals.
RESULTS - Overall, 220,539 patients were included; 53% were male and the median age was 4 years (interquartile range, 2-7). For patients discharged from the ED with CAP, diagnostic utilization rates for blood culture, CBC, CRP, and CXR were higher after guideline publication compared with expected utilization rates without guidelines. In contrast, initial testing and repeat testing among patients hospitalized with CAP was lower after guideline publication. There were modest reductions in estimated costs associated with these changes. However, wide variability was observed in the impact of the guidelines across hospitals.
CONCLUSIONS - Publication of national pneumonia guidelines in 2011 was associated with modest changes in diagnostic testing for children with CAP. However, the changes varied across hospitals, and the financial impact was modest. Local implementation efforts are warranted to ensure widespread guideline adherence. Journal of Hospital Medicine 2016;11:317-323. © 2016 Society of Hospital Medicine.
© 2015 Society of Hospital Medicine.
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Parenteral Prostanoid Use at a Tertiary Referral Center: A Retrospective Cohort Study.
Hay BR, Pugh ME, Robbins IM, Hemnes AR
(2016) Chest 149: 660-6
MeSH Terms: Adult, Cause of Death, Cohort Studies, Comorbidity, Connective Tissue Diseases, Death, Sudden, Endothelin Receptor Antagonists, Familial Primary Pulmonary Hypertension, Female, Guideline Adherence, HIV Infections, Heart Defects, Congenital, Heart Failure, Humans, Hypertension, Pulmonary, Infusions, Parenteral, Male, Middle Aged, Patient Selection, Phosphodiesterase 5 Inhibitors, Practice Guidelines as Topic, Prostaglandins, Quality Improvement, Retrospective Studies, Severity of Illness Index, Tertiary Care Centers
Show Abstract · Added March 8, 2020
BACKGROUND - Evidence-based guidelines recommend the use of parenteral prostaglandin (PP) therapy in patients with advanced pulmonary arterial hypertension (PAH). Despite this, many patients with PAH die without PP therapy. We sought to examine the frequency of PP use at a large referral center and characterize patients with PAH who died without receiving PP.
METHODS - We conducted a single-center retrospective cohort analysis of consecutive patients with PAH between 2008 and 2012. Clinical data and cause of death were compared between patients with PAH treated with PP (PAH-PP) and those who were not but were not documented as poor PP candidates (PAH-nonPP).
RESULTS - Of the 101 patients who received a diagnosis of PAH and died, 61 received PP therapy. Of the 40 patients not treated with PP, 10 did not have documented evaluations for PP therapy (PAH-nonPP) whereas 30 were not considered candidates or refused PP therapy. Compared with PAH-PP, PAH-nonPP had a longer 6-min walk distance, had a longer duration between time of diagnosis and date of worse functional class visit, were less likely to be diagnosed as functional class IV, and had significantly lower right atrial pressure. None of the PAH-nonPP died of progressive PAH.
CONCLUSIONS - We found that most patients who die with PAH are evaluated for PP therapy at a large referral center and the small minority of PAH-nonPP tended to have less severe disease and die of non-PAH-related causes. Our data suggest that at large pulmonary hypertension (PH) centers, the vast majority of patients who are appropriate candidates receive PP therapy.
Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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