Predictive Validity of the Sequential Organ Failure Assessment Score versus Claims-based Scores among Critically Ill Patients

Bosch, Nicholas A; Law, Anica C; Rucci, Justin M; Peterson, Dawn Taylor; Walkey, Allan J.

doi:10.1513/annalsats.202111-1251rl

Cited by 26 publications

(31 citation statements)

References 19 publications

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“…Although results were robust to sensitivity analyses, were similar to those from a prior clinical trial, and would only be altered in the presence of an unmeasured confounder with a 37% or greater association with treatment assignment and outcome (E-value, 1.37), the observational nature of our study increases the risk of residual unmeasured confounding as compared with a randomized trial. Although we used validated scores to estimate severity of acute organ dysfunction with similar performance to the sequential organ failure score and adjusted for admission hospital to account for between-center practice pattern variation, the Premier Healthcare Database does not contain comprehensive electronic medical record physiological/vital sign data or vasopressor doses that, because not included in models, may increase the risk of unmeasured cofounding. However, a difference-in-differences design sensitivity analysis less subject to residual confounding by individual patient characteristics yielded complementary results showing that higher vs lower hospital-level adoption of fludrocortisone after publication of the APROCCHSS trial was associated with improved outcomes.…”

Section: Discussionmentioning

confidence: 99%

Comparative Effectiveness of Fludrocortisone and Hydrocortisone vs Hydrocortisone Alone Among Patients With Septic Shock

et al. 2023

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ImportancePatients with septic shock may benefit from the initiation of corticosteroids. However, the comparative effectiveness of the 2 most studied corticosteroid regimens (hydrocortisone with fludrocortisone vs hydrocortisone alone) is unclear.ObjectiveTo compare the effectiveness of adding fludrocortisone to hydrocortisone vs hydrocortisone alone among patients with septic shock using target trial emulation.Design, Setting, and ParticipantsThis retrospective cohort study from 2016 to 2020 used the enhanced claims-based Premier Healthcare Database, which included approximately 25% of US hospitalizations. Participants were adult patients hospitalized with septic shock and receiving norepinephrine who began hydrocortisone treatment. Data analysis was performed from May 2022 to December 2022.ExposureAddition of fludrocortisone on the same calendar day that hydrocortisone treatment was initiated vs use of hydrocortisone alone.Main Outcome and MeasuresComposite of hospital death or discharge to hospice. Adjusted risk differences were calculated using doubly robust targeted maximum likelihood estimation.ResultsAnalyses included 88 275 patients, 2280 who began treatment with hydrocortisone-fludrocortisone (median [IQR] age, 64 [54-73] years; 1041 female; 1239 male) and 85 995 (median [IQR] age, 67 [57-76] years; 42 136 female; 43 859 male) who began treatment with hydrocortisone alone. The primary composite outcome of death in hospital or discharge to hospice occurred among 1076 (47.2%) patients treated with hydrocortisone-fludrocortisone vs 43 669 (50.8%) treated with hydrocortisone alone (adjusted absolute risk difference, −3.7%; 95% CI, −4.2% to −3.1%; P &lt; .001).Conclusions and RelevanceIn this comparative effectiveness cohort study among adult patients with septic shock who began hydrocortisone treatment, the addition of fludrocortisone was superior to hydrocortisone alone.

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Section: Discussionmentioning

confidence: 99%

Comparative Effectiveness of Fludrocortisone and Hydrocortisone vs Hydrocortisone Alone Among Patients With Septic Shock

et al. 2023

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“…Score range (0–20). b Acute organ dysfunction ( 7 , 8 ) assesses proportion of patients with ICD-10 codes for each acute organ dysfunction, present at admission. …”

Section: Resultsmentioning

confidence: 99%

“…As with most studies using administrative data, there is a risk of misclassification of patients requiring MV for acute respiratory failure and of practices measured as outcomes. However, we relied on billing codes for MV and practices (which are directly tied to reimbursement) and used validated ICD-10 codes for acute respiratory failure, COVID-19, comorbidities, and acute organ dysfunction (7)(8)(9)12); thus, it is unlikely that there was differential misclassification over time (29). Additionally, if indications to initiate MV fluctuated during the pandemic, cohort characteristics and indications for procedures/studies may also have changed; however, patient characteristics appeared to be generally stable throughout the study period.…”

Section: Discussionmentioning

confidence: 99%

“…We used the Premier Healthcare Database ( 6 ) from January 2016 to December 2020, containing enhanced multicenter claims data from ~25% of U.S. hospitalizations, to identify adult patients (≥ 18 yr) admitted to an ICU or step-down unit receiving MV (identified by billing codes) for acute respiratory failure (identified by International Classification of Diseases , 10th Edition, [ICD-10] codes [Supplemental Table 1, http://links.lww.com/CCX/B162 ] [ 7 , 8 ]) during a hospitalization. Patients were excluded if they had a diagnosis of COVID-19 (ICD-10 U07.1) (Supplemental Table 2, http://links.lww.com/CCX/B162 ) ( 9 ).…”

Section: Methodsmentioning

confidence: 99%

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Practice Changes Among Patients Without COVID-19 Receiving Mechanical Ventilation During the Early COVID-19 Pandemic

Shankar¹,

Bosch²,

Walkey³

et al. 2023

Critical Care Explorations

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OBJECTIVES: The COVID-19 pandemic led to rapid changes in care delivery for critically ill patients, due to factors including increased numbers of ICU patients, shifting staff roles, and changed care locations. As these changes may have impacted the care of patients without COVID-19, we assessed changes in common ICU practices for mechanically ventilated patients with non-COVID acute respiratory failure at the onset of and during the COVID-19 pandemic. DESIGN: Interrupted time series analysis, adjusted for seasonality and autocorrelation where present, evaluating trends in common ICU practices prior to the pandemic (March 2016 to February 2020), at the onset of the pandemic (April 2020) and intra-pandemic (April 2020 to December 2020). SETTING: Premier Healthcare Database, containing data from 25% of U.S. discharges from January 1, 2016, to December 31, 2020. PATIENTS: Patients without COVID-19 receiving mechanical ventilation for acute respiratory failure. INTERVENTIONS: We assessed monthly rates of chest radiograph (CXR), chest CT scans, lower extremity noninvasive vascular testing (LENI), bronchoscopy, arterial catheters, and central venous catheters. MEASUREMENTS AND MAIN RESULTS: We identified 742,096 mechanically ventilated patients without COVID-19 at 545 hospitals. At the onset of the pandemic, CXR (–0.5% [–0.9% to –0.2%; p = 0.001]), LENI (LENI: –2.1% [–3.3% to –0.9%; p = 0.001]), and bronchoscopy rates (–1.0% [–1.5% to –0.6%; p < 0.001]) decreased; use of chest CT increased (1.5% [0.5–2.5%; p = 0.006]). Use of arterial lines and central venous catheters did not change significantly. Intra-pandemic, LENI (0.5% [0.3–0.7%; p < 0.001]/mo) and bronchoscopy (0.1% [0.05–0.2%; p < 0.001]/mo) trends increased relative to pre-pandemic trends, while the remainder of practices did not change significantly. CONCLUSIONS: We observed several statistically significant changes to practice patterns among patients without COVID-19 early during the pandemic. However, most of the changes were small or temporary, suggesting that routine practices in the care of mechanically ventilated patients in the ICU was not drastically affected by the pandemic.

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“…Boston University’s institutional review board waived approval and the requirement for informed consent because this study was designated not human participants research. The protocol for this study was previously deposited in an online repository . The design of this study was informed by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline and the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) reporting guideline …”

Section: Methodsmentioning

confidence: 99%

Comparison of Propylthiouracil vs Methimazole for Thyroid Storm in Critically Ill Patients

et al. 2023

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ImportanceThyroid storm is the most severe form of thyrotoxicosis, with high mortality, and is treated with propylthiouracil and methimazole. Some guidelines recommend propylthiouracil over methimazole, although the difference in outcomes associated with each treatment is unclear.ObjectiveTo compare outcomes associated with use of propylthiouracil vs methimazole for the treatment of thyroid storm.Design, Setting, and ParticipantsThis comparative effectiveness study comprised a large, multicenter, US-based cohort from the Premier Healthcare Database between January 1, 2016, and December 31, 2020. It included 1383 adult patients admitted to intensive or intermediate care units with a diagnosis of thyroid storm per International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes and treated with either propylthiouracil or methimazole. Analyses were conducted from July 2022 to February 2023.ExposurePatients received either propylthiouracil or methimazole for treatment of thyroid storm. Exposure was assigned based on the initial thionamide administered.Main Outcomes and MeasuresThe primary outcome was the adjusted risk difference of in-hospital death or discharge to hospice between patients treated with propylthiouracil and those treated with methimazole, assessed by targeted maximum likelihood estimation.ResultsA total of 1383 patients (656 [47.4%] treated with propylthiouracil; mean [SD] age, 45 [16] years; 473 women [72.1%]; and 727 [52.6%] treated with methimazole; mean [SD] age, 45 [16] years; 520 women [71.5%]) were included in the study. The standardized mean difference for age was 0.056, and the standardized mean difference for sex was 0.013. The primary composite outcome occurred in 7.4% of of patients (102 of 1383; 95% CI, 6.0%-8.8%). A total of 8.5% (56 of 656; 95% CI, 6.4%-10.7%) of patients who initiated propylthiouracil and 6.3% (46 of 727; 95% CI, 4.6%-8.1%) who initiated methimazole died in the hospital (adjusted risk difference, 0.6% [95% CI, −1.8% to 3.0%]; P = .64). There were no significant differences in duration of organ support, total hospitalization costs, or rates of adverse events between the 2 treatment groups.Conclusion and RelevanceIn this comparative effectiveness study of a multicenter cohort of adult patients with thyroid storm, no significant differences were found in mortality or adverse events in patients who were treated with propylthiouracil or methimazole. Thus, current guidelines recommending propylthiouracil over methimazole for treatment of thyroid storm may merit reevaluation.

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Predictive Validity of the Sequential Organ Failure Assessment Score versus Claims-based Scores among Critically Ill Patients

Cited by 26 publications

References 19 publications

Comparative Effectiveness of Fludrocortisone and Hydrocortisone vs Hydrocortisone Alone Among Patients With Septic Shock

Comparative Effectiveness of Fludrocortisone and Hydrocortisone vs Hydrocortisone Alone Among Patients With Septic Shock

Practice Changes Among Patients Without COVID-19 Receiving Mechanical Ventilation During the Early COVID-19 Pandemic

Comparison of Propylthiouracil vs Methimazole for Thyroid Storm in Critically Ill Patients

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