Because pulmonary nodules are found in up to 25% of patients undergoing computed tomography of the chest, the question of whether to perform biopsy is becoming increasingly common. Data on ...complications after transthoracic needle lung biopsy are limited to case series from selected institutions.
To determine population-based estimates of risks for complications after transthoracic needle biopsy of a pulmonary nodule.
Cross-sectional analysis.
The 2006 State Ambulatory Surgery Databases and State Inpatient Databases for California, Florida, Michigan, and New York from the Healthcare Cost and Utilization Project.
15 865 adults who had transthoracic needle biopsy of a pulmonary nodule.
Percentage of biopsies complicated by hemorrhage, any pneumothorax, or pneumothorax requiring a chest tube, and adjusted odds ratios for these complications associated with various biopsy characteristics, calculated by using multivariate, population-averaged generalized estimating equations.
Although hemorrhage was rare, complicating 1.0% (95% CI, 0.9% to 1.2%) of biopsies, 17.8% (CI, 11.8% to 23.8%) of patients with hemorrhage required a blood transfusion. In contrast, the risk for any pneumothorax was 15.0% (CI, 14.0% to 16.0%), and 6.6% (CI, 6.0% to 7.2%) of all biopsies resulted in pneumothorax requiring a chest tube. Compared with patients without complications, those who experienced hemorrhage or pneumothorax requiring a chest tube had longer lengths of stay (P < 0.001) and were more likely to develop respiratory failure requiring mechanical ventilation (P = 0.020). Patients aged 60 to 69 years (as opposed to younger or older patients), smokers, and those with chronic obstructive pulmonary disease had higher risk for complications.
Estimated risks may be inaccurate if coding of complications is incomplete. The analyzed databases contain little clinical detail (such as information on nodule characteristics or biopsy pathology) and cannot indicate whether performing the biopsy produced useful information.
Whereas hemorrhage is an infrequent complication of transthoracic needle lung biopsy, pneumothorax is common and often necessitates chest tube placement. These population-based data should help patients and physicians make more informed choices about whether to perform biopsy of a pulmonary nodule.
Department of Veterans Affairs and National Cancer Institute.
Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians’ involvement in patients’ end-of-life ...decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19’s catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians’ demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents’ demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during “peak-Covid,” and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53–7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18–0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22–0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
OBJECTIVES:In 2001, a randomized trial showed decreased mortality with early, goal-directed therapy in septic shock, a strategy later recommended by the Surviving Sepsis Campaign. Placement of a ...central venous catheter is necessary to administer goal-directed therapy. We sought to evaluate nationwide trends in1) central venous catheter utilization and 2) the association between early central venous catheter insertion and mortality in patients with septic shock.
DESIGN:We retrospectively analyzed the proportion of septic shock cases receiving an early (day of admission) central venous catheter and the odds of hospital mortality associated with receiving early central venous catheter from years 1998 to 2001 compared with 2002 to 2009.
SETTING:Non-federal acute care hospitalizations from the Nationwide Inpatient Sample, 1998–2009.
PATIENTS:A total of 203,481 (population estimate999,545) patients admitted through an emergency department with principal diagnosis of septicemia and secondary diagnosis of shock.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:From 1998 to 2009, population-adjusted rates of septic shock increased from 12.6 cases per 100,000 U.S. adults to 78 cases per 100,000. During this time, age-adjusted hospital mortality associated with septic shock declined from 40.4% to 31.4%. Early central venous catheter insertion increased from 5.7% (95% confidence interval 5.1% to 6.3%) to 19.2% (95% confidence interval 18.7% to 19.5%) cases with septic shock, with an increased rate of early central venous catheter placement identified after 2007. The rate of decline in age-adjusted hospital mortality was significantly greater for patients who received an early central venous catheter (–4.2% per year, 95% confidence interval –3.2, –4.2%) as compared with no central venous catheter (–2.9% per year, 95% confidence interval –2.3, –3.5%; p = 0.016). Hospital mortality associated with early central venous catheter insertion significantly decreased from a multivariable-adjusted odds ratio of 1.29 (95% confidence interval 1.14–1.45) prior to 2001 to an adjusted odds ratio of 0.87 (95% confidence interval 0.84–0.90) after 2001.
CONCLUSIONS:Placement of a central venous catheter early in septic shock has increased three-fold since 1998. The mortality associated with early central venous catheter insertion decreased after publication of evidence-based instructions for central venous catheter use.
CONTEXT The American Diabetes Association and Surviving Sepsis Campaign recommend tight glucose control in critically ill patients based largely on 1 trial that shows decreased mortality in a ...surgical intensive care unit. Because similar studies report conflicting results and tight glucose control can cause dangerous hypoglycemia, the data underlying this recommendation should be critically evaluated. OBJECTIVE To evaluate benefits and risks of tight glucose control vs usual care in critically ill adult patients. DATA SOURCES MEDLINE (1950-2008), the Cochrane Library, clinical trial registries, reference lists, and abstracts from conferences from both the American Thoracic Society (2001-2008) and the Society of Critical Care Medicine (2004-2008). STUDY SELECTION We searched for studies in any language in which adult intensive care patients were randomly assigned to tight vs usual glucose control. Of 1358 identified studies, 34 randomized trials (23 full publications, 9 abstracts, 2 unpublished studies) met inclusion criteria. DATA EXTRACTION AND ANALYSIS Two reviewers independently extracted information using a prespecified protocol and evaluated methodological quality with a standardized scale. Study investigators were contacted for missing details. We used both random- and fixed-effects models to estimate relative risks (RRs). RESULTS Twenty-nine randomized controlled trials totaling 8432 patients contributed data for this meta-analysis. Hospital mortality did not differ between tight glucose control and usual care overall (21.6% vs 23.3%; RR, 0.93; 95% confidence interval CI, 0.85-1.03). There was also no significant difference in mortality when stratified by glucose goal (1 very tight: ≤110 mg/dL; 23% vs 25.2%; RR, 0.90; 95% CI, 0.77-1.04; or 2 moderately tight: <150 mg/dL; 17.3% vs 18.0%; RR, 0.99; 95% CI, 0.83-1.18) or intensive care unit setting (1 surgical: 8.8% vs 10.8%; RR, 0.88; 95% CI, 0.63-1.22; 2 medical: 26.9% vs 29.7%; RR, 0.92; 95% CI, 0.82-1.04; or 3 medical-surgical: 26.1% vs 27.0%; RR, 0.95; 95% CI, 0.80-1.13). Tight glucose control was not associated with significantly decreased risk for new need for dialysis (11.2% vs 12.1%; RR, 0.96; 95% CI, 0.76-1.20), but was associated with significantly decreased risk of septicemia (10.9% vs 13.4%; RR, 0.76; 95% CI, 0.59-0.97), and significantly increased risk of hypoglycemia (glucose ≤40 mg/dL; 13.7% vs 2.5%; RR, 5.13; 95% CI, 4.09-6.43). CONCLUSION In critically ill adult patients, tight glucose control is not associated with significantly reduced hospital mortality but is associated with an increased risk of hypoglycemia.
There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by ...all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.
To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.
A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.
Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.
This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.
CONTEXT Although there is now substantial evidence that pulmonary artery (PA) catheterization does not reduce mortality in critically ill patients, it is unknown whether national utilization has ...decreased in response. OBJECTIVE To determine trends in PA catheterization use in the United States. DESIGN, SETTING, AND PARTICIPANTS A time trend analysis on national estimates of PA catheterization utilization from 1993-2004 using data from all US states contributing to the Nationwide Inpatient Sample. Hospital admissions for those participants aged 18 years or older were assessed, with primary analysis focused on admissions with a medical diagnosis related group and a secondary analysis focused on surgical admissions. PA catheterization was identified by 5 International Classification of Diseases, Ninth Revision procedure codes describing PA or wedge-pressure monitoring, measurement of mixed venous blood gases, or monitoring of cardiac output by oxygen consumption or other technique. MAIN OUTCOME MEASURE Annual PA catheterization use per 1000 medical admissions. RESULTS Between 1993 and 2004, PA catheterization use decreased by 65% from 5.66 to 1.99 per 1000 medical admissions (risk ratio RR, 0.35; 95% confidence interval CI, 0.29-0.42). Among patients who died during hospitalization, a group whose disease severity may be consistent across time, the relative decline was similar, decreasing from 54.7 to 18.1 per 1000 deaths (RR, 0.33; 95% CI, 0.28-0.38). A significant change in trend occurred following a 1996 study that suggested increased mortality with PA catheterization. The decline in utilization was similar in surgical patients (RR, 0.37; 95% CI, 0.25-0.49). Among common diagnoses associated with PA catheterization, the decline was most prominent for myocardial infarction, which decreased by 81% (RR, 0.19; 95% CI, 0.15-0.23), and least prominent for septicemia, which decreased by 54% (RR, 0.46; 95% CI, 0.38-0.54). Sensitivity analyses suggested findings were not due to artifact of changing procedure coding practice. CONCLUSION Use of the PA catheter, previously a hallmark of critical care practice, has decreased in the United States during the last decade, possibly due to growing evidence that this invasive procedure does not reduce mortality.
ABSTRACT
Background
Guidelines recommend, and Medicare requires, shared decision-making between patients and clinicians before referring individuals at high risk of lung cancer for chest CT ...screening. However, little is known about the extent to which shared decision-making about lung cancer screening is achieved in real-world settings.
Objective
To characterize patient and clinician impressions of early experiences with communication and decision-making about lung cancer screening and perceived barriers to achieving shared decision-making.
Design
Qualitative study entailing semi-structured interviews and focus groups.
Participants
We enrolled 36 clinicians who refer patients for lung cancer screening and 49 patients who had undergone lung cancer screening in the prior year. Participants were recruited from lung cancer screening programs at four hospitals (three Veterans Health Administration, one urban safety net).
Approach
Using content analysis, we analyzed transcripts to characterize communication and decision-making about lung cancer screening. Our analysis focused on the recommended components of shared decision-making (information sharing, deliberation, and decision aid use) and barriers to achieving shared decision-making.
Key Results
Clinicians varied in the information shared with patients, and did not consistently incorporate decision aids. Clinicians believed they explained the rationale and gave some (often purposely limited) information about the trade-offs of lung cancer screening. By contrast, some patients reported receiving little information about screening or its trade-offs and did not realize the CT was intended as a screening test for lung cancer. Clinicians and patients alike did not perceive that significant deliberation typically occurred. Clinicians perceived insufficient time, competing priorities, difficulty accessing decision aids, limited patient comprehension, and anticipated patient emotions as barriers to realizing shared decision-making.
Conclusions
Due to multiple perceived barriers, patient-clinician conversations about lung cancer screening may fall short of guideline-recommended shared decision-making supported by a decision aid. Consequently, patients may be left uncertain about lung cancer screening’s rationale, trade-offs, and process.
National trends in tracheostomy for mechanical ventilation (MV) patients are not well characterized.
To investigate trends in tracheostomy use, timing, and outcomes in the United States.
We ...calculated estimates of tracheostomy use and outcomes from the National Inpatient Sample from 1993 to 2012. We used hierarchical models to determine factors associated with tracheostomy use among MV patients.
We identified 1,352,432 adults who received tracheostomy from 1993 to 2012 (9.1% of MV patients). Tracheostomy was more common in surgical patients, men, and racial/ethnic minorities. Age-adjusted incidence of tracheostomy increased by 106%, rising disproportionately to MV use. Among MV patients, tracheostomy rose from 6.9% in 1993 to 9.8% in 2008, and then it declined to 8.7% in 2012 (P < 0.0001). Increases in tracheostomy use were driven by surgical patients (9.5% in 1993; 15.0% in 2012; P < 0.0001), with little change among nonsurgical patients (5.8% in 1993; 5.9% in 2012; P < 0.0001). Over time, tracheostomies were performed earlier (median, 11 d in 1998; 10 d in 2012; P < 0.0001), whereas hospital length of stay declined (median, 39 d in 1993; 26 d in 2012; P < 0.0001), discharges to long-term facilities increased (40.1% vs. 71.9%; P < 0.0001), and hospital mortality declined (38.1% vs. 14.7%; P < 0.0001).
Over the past two decades, tracheostomy use rose substantially in the United States until 2008, when use began to decline. The observed dramatic increase in discharge of tracheostomy patients to long-term care facilities may have significant implications for clinical care, healthcare costs, policy, and research. Future studies should include long-term facilities when analyzing outcomes of tracheostomy.
Lung cancer is the leading cause of cancer-related mortality. Intensive care unit (ICU) use among patients with cancer is increasing, but data regarding ICU outcomes for patients with lung cancer are ...limited.
We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare registry (1992 to 2007) to conduct a retrospective cohort study of patients with lung cancer who were admitted to an ICU for reasons other than surgical resection of their tumor. We used logistic and Cox regression to evaluate associations of patient characteristics and hospital mortality and 6-month mortality, respectively. We calculated adjusted associations for mechanical ventilation receipt with hospital and 6-month mortality.
Of the 49,373 patients with lung cancer admitted to an ICU for reasons other than surgical resection, 76% of patients survived the hospitalization, and 35% of patients were alive 6 months after discharge. Receipt of mechanical ventilation was associated with increased hospital mortality (adjusted odds ratio, 6.95; 95% CI, 6.89 to 7.01; P < .001), and only 15% of these patients were alive 6 months after discharge. Of all ICU patients with lung cancer, the percentage of patients who survived 6 months from discharge was 36% for patients diagnosed in 1992 and 32% for patients diagnosed in 2005, whereas it was 16% and 11% for patients who received mechanical ventilation, respectively.
Most patients with lung cancer enrolled in Medicare who are admitted to an ICU die within 6 months of admission. To improve patient-centered care, these results should guide shared decision making between patients with lung cancer and their clinicians before an ICU admission.
PDF
