Dataset Information

Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation.

ABSTRACT:

Importance

Guidelines from December 2011 recommended against obtaining daily chest radiographs (CXRs) for patients requiring mechanical ventilation (MV). Daily CXR use for patients receiving MV in US hospitals is unknown and, if high, may represent an opportunity to reduce low-value care and unnecessary radiation.

Objectives

To determine frequency of daily CXR use for US patients receiving MV, assess variability across hospitals, and evaluate whether use has decreased over time.

Design, setting, and participants

Retrospective cohort study of hospitalized adults (aged ≥18 years) receiving MV for 3 days or longer. Mechanical ventilation was defined by having an International Classification of Diseases, Ninth Revision, Clinical Modification code of 96.7x and an MV charge on more than 1 hospital day. Hospital discharges in the Premier Perspectives database were examined from July 1, 2008, to December 31, 2014. Data analysis was conducted from July 28, 2017, to December 13, 2017.

Exposures

Hospital discharge date (quarter of the year) and hospital in which patients received MV.

Main outcomes and measures

The outcome was daily CXR use (up to 7 days) during MV. We used standard statistics to describe CXR use, multilevel multivariable regression modeling with adjusted median odds ratio (OR) to evaluate variability by hospital, and multivariable piecewise regression (breakpoint: fourth quarter of 2011) with adjusted OR to evaluate time trends and response to guideline recommendations.

Results

The primary cohort included 512 518 patients receiving MV (mean [SD] age, 63.0 [16.1] years; 46% female) in 416 hospitals, of whom 321 093 (63%) received daily CXRs. Wide variability was seen across hospitals; hospitals performed daily CXRs on a median of 66% of patients (interquartile range, 50%-77%; full range, 12%-97%). The adjusted median OR was 2.43 (95% CI, 2.29-2.59), suggesting the same patient had 2.43-fold higher odds of receiving a daily CXR if admitted to a higher- vs lower-use hospital; the odds of receiving daily CXRs were unchanged through quarter 3 of 2011 (adjusted OR, 1.00; 95% CI, 0.99-1.01), after which there was a 3% relative reduction in the odds of daily CXR use per quarter (adjusted OR, 0.97; 95% CI, 0.96-0.98).

Conclusions and relevance

Three-fifths of US patients receiving MV also received daily CXRs from 2008 to 2014, although use declined slowly after new guidelines were published. The hospital at which a patient received care was associated with the odds of daily CXR receipt.

SUBMITTER: Gershengorn HB

PROVIDER: S-EPMC6324260 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation.

Gershengorn Hayley B HB Wunsch Hannah H Scales Damon C DC Rubenfeld Gordon D GD

JAMA network open 20180803 4

<h4>Importance</h4>Guidelines from December 2011 recommended against obtaining daily chest radiographs (CXRs) for patients requiring mechanical ventilation (MV). Daily CXR use for patients receiving MV in US hospitals is unknown and, if high, may represent an opportunity to reduce low-value care and unnecessary radiation.<h4>Objectives</h4>To determine frequency of daily CXR use for US patients receiving MV, assess variability across hospitals, and evaluate whether use has decreased over time.<h ...[more]

PMID: 30646104

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Project description:BackgroundRecruitment manoeuvres involve transient elevations in airway pressure applied during mechanical ventilation to open ('recruit') collapsed lung units and increase the number of alveoli participating in tidal ventilation. Recruitment manoeuvres are often used to treat patients in intensive care who have acute respiratory distress syndrome (ARDS), but the effect of this treatment on clinical outcomes has not been well established. This systematic review is an update of a Cochrane review originally published in 2009.ObjectivesOur primary objective was to determine the effects of recruitment manoeuvres on mortality in adults with acute respiratory distress syndrome.Our secondary objective was to determine, in the same population, the effects of recruitment manoeuvres on oxygenation and adverse events (e.g. rate of barotrauma).Search methodsFor this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), the Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCO), Latin American and Caribbean Health Sciences (LILACS) and the International Standard Randomized Controlled Trial Number (ISRCTN) registry from inception to August 2016.Selection criteriaWe included randomized controlled trials (RCTs) of adults who were mechanically ventilated that compared recruitment manoeuvres versus standard care for patients given a diagnosis of ARDS.Data collection and analysisTwo review authors independently assessed trial quality and extracted data. We contacted study authors for additional information.Main resultsTen trials met the inclusion criteria for this review (n = 1658 participants). We found five trials to be at low risk of bias and five to be at moderate risk of bias. Six of the trials included recruitment manoeuvres as part of an open lung ventilation strategy that was different from control ventilation in aspects other than the recruitment manoeuvre (such as mode of ventilation, higher positive end-expiratory pressure (PEEP) titration and lower tidal volume or plateau pressure). Six studies reported mortality outcomes. Pooled data from five trials (1370 participants) showed a reduction in intensive care unit (ICU) mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.72 to 0.97, P = 0.02, low-quality evidence), pooled data from five trials (1450 participants) showed no difference in 28-day mortality (RR 0.86, 95% CI 0.74 to 1.01, P = 0.06, low-quality evidence) and pooled data from four trials (1313 participants) showed no difference in in-hospital mortality (RR 0.88, 95% CI 0.77 to 1.01, P = 0.07, low-quality evidence). Data revealed no differences in risk of barotrauma (RR 1.09, 95% CI 0.78 to 1.53, P = 0.60, seven studies, 1508 participants, moderate-quality evidence).Authors' conclusionsWe identified significant clinical heterogeneity in the 10 included trials. Results are based upon the findings of several (five) trials that included an "open lung ventilation strategy", whereby the intervention group differed from the control group in aspects other than the recruitment manoeuvre (including co-interventions such as higher PEEP, different modes of ventilation and higher plateau pressure), making interpretation of the results difficult. A ventilation strategy that included recruitment manoeuvres in participants with ARDS reduced intensive care unit mortality without increasing the risk of barotrauma but had no effect on 28-day and hospital mortality. We downgraded the quality of the evidence to low, as most of the included trials provided co-interventions as part of an open lung ventilation strategy, and this might have influenced results of the outcome.

Project description:ImportanceThe effectiveness of daily sedation interruption (DSI, defined as temporary interruption of sedation) has yet to be demonstrated in critically ill pediatric patients.ObjectiveTo compare the clinical outcomes of DSI vs continuous intravenous (IV) sedation in patients receiving invasive mechanical ventilation (MV) support in the pediatric intensive care unit (PICU).Data sourcesA systematic search for studies was conducted using predefined keywords and Medical Subject Headings in 5 major databases (PubMed, Embase, Web of Science, CINAHL [Cumulated Index to Nursing and Allied Health Literature], and Cochrane Central Register of Controlled Trials) from database inception to October 31, 2023.Study selectionRetrospective and prospective observational studies, randomized clinical trials (RCTs), and systematic reviews were assessed for inclusion. Studies were eligible if they compared DSI to continuous IV sedation in patients aged 18 years or younger requiring MV in the PICU.Data extraction and synthesisStudy characteristics, including the types of sedation, sedation protocols, and clinical outcomes, were extracted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was followed. A random-effects model was used to pool results from articles for the meta-analysis.Main outcomes and measuresThe primary outcomes of interest were duration of MV and length of PICU stay. Secondary outcomes included total sedative dose requirement, adverse events (eg, complications associated with MV, withdrawal, and delirium), and mortality.ResultsA total of 6 RCTs with 2810 pediatric patients (1569 males [55.8%]; mean age, 26.5 [95% CI, 15.0-37.9] months) were included in the final analysis; patients had a mean PRISM (Pediatric Risk of Mortality) score of 13.68 (95% CI, 10.75-16.61). Compared with continuous IV sedation, DSI was associated with a reduction in length of PICU stay (5 studies, n = 2770; mean difference [MD], -1.45 [95% CI, -2.75 to -0.15] days; P = .03]. There was no difference in MV duration (5 studies, n = 2750; MD, -0.93 [95% CI, -1.89 to 0.04] days; P = .06), total doses of midazolam (3 studies, n = 191; MD, -1.66 [95% CI, -3.95 to 0.63] mg/kg) and morphine used (2 studies, n = 189; MD, -2.63 [95% CI, -7.01 to 1.75] mg/kg), or adverse events (risk ratio [RR], 1.03 [95% CI, 0.74-1.42]; P = .88). There was no difference in mortality between patients exposed vs not exposed to DSI (RR, 0.89 [95% CI, 0.55-1.46]; P = .65).Conclusions and relevanceThis systematic review and meta-analysis found that use of DSI in pediatric patients was associated with reduced length of PICU stay with no increase in adverse events. Further research is needed to ascertain whether this strategy is associated with improved neurodevelopmental outcomes in PICU survivors.

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Dataset Information

Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation.

Importance

Objectives

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Conclusions and relevance

Publications

Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation.

Similar Datasets

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