The effect of lead time bias on severity of illness scoring, mortality prediction and standardised mortality ratio in intensive care--a pilot study

The effect of lead time bias on severity of illness scoring, mortality prediction and standardised mortality ratios was examined in a pilot study of 76 intensive care (ICU) patients using APACHE II, APACHE III and SAPS II scoring systems. The inclusion of data collected in the period prior to ICU admission increased severity of illness scores and estimated risk of hospital mortality significantly for all three scoring systems (p < 0.01) by up to 14 points and 42.7% (APACHE II), 50 points and 26.3% (APACHE III) and 23 points and 33.4% (SAPS II), respectively. Standardised mortality ratios fell from 0.99 to 0.79 (APACHE II), 0.96 to 0.84 (APACHE III) and 0.75 to 0.64 (SAPS II), but these changes failed to reach statistical significance. Lead time bias had most effect in medical patients and on emergency admissions, and least effect in patients admitted from the operating theatre. These trends suggest that mortality ratios may not necessarily reflect intensive care unit performance and indicate that a larger study of the effect of lead time bias, case mix, pre-ICU care or post-ICU management on standardised mortality ratios is indicated.     

Hospital mortality under surgical care

INTRODUCTION

The ‘hospital standardised mortality ratio’ (HSMR) has been used in England since 1999 to measure NHS hospital performance. Large variations in reported HSMR between English hospitals have recently led to heavy criticism of their use as a surrogate measure of hospital performance. This paper aims to review the mortality data for a consultant general surgeon contributed by his NHS trust over a 3-year period as part of the trust''s HSMR calculation and evaluate the accuracy of coding the diagnoses and covariates for case mix adjustment.

SUBJECTS AND METHODS

The Dr Foster Intelligence database was interrogated to extract the NHS trust''s HSMR benchmark data on inpatient mortality for the surgeon from 1 April 2006 to 31 March 2009 and compared to the hospital notes.

RESULTS

30 patients were identified of whom 12 had no evidence of being managed by the surgeon. This represents a potential 40% inaccuracy rate in designating consultant responsibility. The remaining 18 patients could be separated into ‘operative’ (11 patients) and ‘non-operative’ (7 patients) groups. Only 27% in the operative group and 43% of the non-operative mortality group respectively had a Charlson co-morbidity index recorded despite 94% of the cases having significant co-morbidities

CONCLUSIONS

Highlighting crude and inaccurate clinician-specific mortality data when only 1-5% of deaths under surgical care may be associated with avoidable adverse events seems potentially irresponsible.     

Hemodialysis system privatization and patient survival: a report from a large registry Eastern Europe cohort

Abstract

Background: There has been a rapid increase in incident and prevalent rates of hemodialysis (HD) patients in Romania following the 2004 system privatization, but little is known about the impact of privatization on patient outcomes. Methods: We retrospectively examined the outcome during 1 year of 8161 prevalent HD patients registered in the Romanian Renal Registry at 31 December 2011. Standardized mortality ratio (SMR) was calculated for each for-profit (FP) and non-profit (NP) HD provider. Results: The 12-month SMR across all HD chain providers was 1.27. FP Chain 1 and the “other” group had SMR similar to the reference level. The mortality rate was two times higher in public NP dialysis centers than the national reference. A stepwise Cox regression analysis identified older age, male gender, DN as primary renal disease and the HD chain provider to be independently associated with a higher mortality. Excepting patients treated by FP Chain 4, patients treated by all the other dialysis providers had a better outcome than those treated in NP facilities. Conclusion: In conclusion, the increase in number of patients treated was not doubled by an increase in their survival. In the context of an expanding dialysis marketplace that tends to consolidate around large for-profit (FP) providers, further exploration of indicators associated with mortality may guide future healthcare policy to improve patient outcomes.     

Cause-Specific Mortality Trends Following Total Hip and Knee Arthroplasty

Background

While studies have demonstrated that mortality after total hip (THA) and total knee (TKA) arthroplasty is better than the general population, the causes of death are not well established. We evaluated cause-specific mortality after THA and TKA.

A survey of infection in an intensive care unit ''Forewarned is forearmed''

The infection (36%) and mortality rates (28%) were investigated in 433 patients admitted to a Respiratory Intensive Care Unit. It was found that the mortality rate was higher (45%) in the infected group than in the non-infected group (19%) and particularly so in patients who had had intra-abdominal surgery or who remained in the unit for longer than a week.     

Correlation of microalbuminuria and outcome in patients with extensive burns

Background. Microalbuminuria, often referred to as the urinaryalbumin–creatinine ratio (ACR), is thought to be a reflectionof increased capillary permeability associated with the systemicinflammatory response syndrome, and has been found to be predictiveof outcome in several studies. Therefore, we explored the usefulnessof ACR as a predictor of mortality, and whether there was acorrelation between ACR and     

Long-Term Mortality Trends After Revision Total Knee Arthroplasty

Background

Long-term mortality following primary total knee arthroplasty (TKA) is lower than the general population. However, it is unknown whether this is true in the setting of revision TKA. We examined long-term mortality trends following revision TKA.

Mortality After Shoulder Arthroplasty

One year post-operative mortality among patients with primary elective total shoulder arthroplasty (ETSA) and traumatic shoulder arthroplasty (TSA) were compared to the general population of a large healthcare system. Standardized mortality ratios (SMRs) and 95% confidence intervals (CIs) were calculated. 614 ETSA patients, 1.0% one year mortality, and 168 TSA patients, 5.4% mortality rate, were evaluated. Patients with ETSA (SMR = 0.4, 95% CI 0.1–0.7) had lower odds of mortality than expected, while patients with TSA (SMR = 1.8, 95% CI 0.6–3.0) did not have higher than expected odds of mortality compared to the reference population. Understanding excess mortality following shoulder arthroplasty surgery allows providers to evaluate current practices and identify ways to optimize patients prior to surgery.     

Thrombocytosis in intensive care

We conducted a retrospective study of platelet count in 226patients admitted for critical care over a 5-month period, toexplore the incidence of thrombocytosis and its relation toadmission category, duration of ICU stay and outcome. Our findingsindicate that thrombocytosis is not rare in ICU patients. Atleast one platelet count greater than 450x10⁹ litre^–1was found in 21.7% of patients and was associated with lowerICU mortality (P=0.003), lower hospital mortality (P=0.006),but longer duration of ICU stay (P<0.0001). Thrombocytosismay serve as an independent predictor of favourable outcomein ICU patients. Br J Anaesth 2001; 87: 926–8     

Platelet-to-albumin ratio: a risk factor associated with technique failure and mortality in peritoneal dialysis patients

BackgroundPeritoneal dialysis (PD) patients have a high incidence of poor clinical outcomes, which is related to the inflammatory and nutritional status of this population. Platelet-to-albumin ratio (PAR), recently identified as a useful biomarker to monitor inflammation and nutrition, can predict a poor prognosis in various diseases. The aim of this study was to investigate the association between PAR and technique failure and mortality in PD patients.MethodsThis single-center retrospective study enrolled 405 PD patients from 1 January 2011 to 31 December 2019 and collected complete demographic characteristics, clinical laboratory baseline data. The outcomes were technique failure and mortality. The associations between PAR and technique failure, death were analyzed by Cox proportional hazard models and competing risk regression models with kidney transplantation as a competing event. The areas under the curve (AUC) of receiver-operating characteristic analysis were used to determine the predictive values of PAR for technique failure and mortality.ResultsDuring a median follow-up period of 24.0 (range, 4.0–91.0) months, 139 (34.3%) PD patients experienced technique failure, 61 (15.1%) PD patients died. The patients with higher PAR levels had increased risk of technique failure and mortality. After adjustment for confounding factors, we found that high PAR levels were risk factor for both technique failure (subdistribution hazard ratio [SHR] 1.775; 95%CI, 1.157–2.720; p = 0.033] and mortality [SHR 3.710; 95%CI, 1.870–7.360; p < 0.001]. The predictive ability of PAR was superior to platelet and albumin based on AUC calculations for technique failure and mortality.ConclusionsPAR was a risk factor associated with technique failure and mortality in PD patients.     

Neutrophil–lymphocyte ratio predicts cardiovascular and all-cause mortality in hemodialysis patients

Neutrophil–lymphocyte ratio (NLR) is a marker of systemic inflammation that has been shown to predict mortality in patients with malignancies, ischemic heart disease and peripheral vascular disease. Its prognostic value in hemodialysis patients is unclear. The aims of this study were to: (i) explore the relationship between NLR and other biochemical parameters and (ii) to examine the value of NLR as a predictor of cardiovascular and all-cause mortality in hemodialysis patients. The study included all the incident hemodialysis patients from a single center between 2007 and 2012. NLR was calculated using samples obtained 3 months after commencing hemodialysis. One hundred seventy hemodialysis patients were included with a median follow-up of 37 months. There were 54 deaths (32%). NLR was positively correlated with C-reactive protein (r?=?0.24, p?=?0.0023) and negatively correlated with hemoglobin (r?=??0.27, p?=?0.00048), albumin (r?=??0.23, p?=?0.0034) and total cholesterol (r?=??0.17, p?=?0.049) levels. In multivariate Cox regression, NLR was independently associated with both all-cause mortality (adjusted hazard ratio [HR] 1.4; 95% confidence interval [CI], 1.2–1.6; p?≤?0.0001) and cardiovascular death (HR 1.3, 95% CI 1.1–1.6, p?=?0.0032). Other predictors of all-cause mortality were age (HR 1.6 per decade; 95% CI, 1.2–2.1; p?=?0.0017), body mass index (HR 0.93; 95% CI, 0.88–0.98; p?=?0.0047), albumin (HR 0.91; 95% CI, 0.86–0.97; p?=?0.0035) and peripheral vascular disease (HR 2.7; 95% CI, 1.4–5.1; p?=?0.0023). NLR is a practical, cost-efficient and easy to use predictor of cardiovascular and all-cause mortality in incident hemodialysis patients.     

Prognostic efficacy of C-reactive protein/albumin ratio in ST elevation myocardial infarction

Objective: Although the prognostic efficacy of C-reactive protein (mg/L) and albumin levels (g/L) has been previously associated with poor prognosis in ST elevation myocardial infarction (STEMI), to the best of our knowledge, the prognostic efficacy of C-reactive protein/Albumin ratio (CAR) (mg/g) has not been investigated yet. Thus, this study aimed to investigate the potential efficacy of the CAR in predicting prognosis in STEMI patients.

Method: We conducted a detailed investigation of 2437 patients with first STEMI treated with a primary percutaneous coronary intervention. After evaluation regarding to exclusion criteria, 2243 patients were found to be eligible for analysis. The mean follow-up of the study was 34?±?15 months.

Results: The median CAR value of the study population was 2.70 (range: 1.44–4.76), and the patients were divided into three tertiles according to their CAR values. Kaplan-Meier survival analysis showed significantly lower in-hospital and long-term survival rates for the patients in a high CAR tertile. In addition, the CAR was found to be an independent predictor of all-cause mortality (Hazards ratio: 1.033, 95% Confidence Interval: 1.007–1.061, p?=?.033), and the prognostic performance of the CAR was superior to that of C-reactive protein, albumin, and neutrophil to lymphocyte ratio in the receiver operating characteristic curve comparison.

Conclusion: The CAR, a newly introduced inflammation-based risk index, was found to be a potentially useful prognostic tool for predicting a poor prognosis in STEMI patients. However, this finding needs to be validated in the future prospective studies.     

Dutch case-control study of anaesthesia-related morbidity and mortalityRationale and methods

To date, anaesthesia-related mortality, morbidity and risk factors have almost exclusively been studied qualitatively rather than quantitatively. Therefore, knowledge of the relative risk associated with many anaesthesia-related factors is still lacking. Recently, a quantitative study of the determinants and prevention of morbidity and mortality in anaesthesia was started in the Netherlands. Its objective is to study severe peri-operative morbidity and mortality as a function of anaesthesia-related risk factors. The study is designed as a case-control study within a prospectively defined cohort. The cohort comprises all patients undergoing an anaesthetic procedure, either general, regional or a combination, in one of 61 hospitals between 1 January 1995 and 1 January 1997. A 'case' is a patient who dies within 24 h of undergoing an anaesthetic procedure or who remains comatose 24 h after an anaesthetic procedure. A 'control' patient is a randomly chosen patient who has undergone anaesthesia and is matched for gender and age. The present report discusses the study protocol.     

Long‐term mortality after tuberculosis treatment among persons living with HIV in Haiti

IntroductionLong‐term mortality among TB survivors appears to be higher than control populations without TB in many settings. However, data are limited among persons with HIV (PWH). We assessed the association between cured TB and long‐term mortality among persons with PWH in Haiti.MethodsA prospective cohort of PWH from the CIPRA HT‐001 trial was followed from study enrolment (August 2005 to July 2008) to study closure (December 2018) to compare mortality between participants with and without TB. The index date for the survival analysis was defined as 240 days after TB diagnosis or randomization date. Time to death was described using Kaplan–Meier curves, and log‐rank tests were used to compare time to death between the TB and no‐TB cohorts. The association between TB and long‐term mortality was estimated with multivariable Cox models.ResultsOf the 816 participants in the CIPRA HT‐001 trial, 77 were excluded for a history of TB prior to study enrolment and 31 were excluded due to death or attrition prior to the index date, leaving 574 in the no‐TB and 134 in the TB cohort. Twenty‐four (17.9%) participants in the TB and 48 (8.4%) in the no‐TB cohort died during follow‐up. Five and 10‐year mortality rates were 14.2% and 17.9% respectively, in the TB cohort, and 6.1% and 8.4% in the no‐TB cohort. In Kaplan–Meier analysis, participants in the TB cohort had a significantly shorter time to death (log‐rank p < 0.001). In multivariable analysis, TB treatment was the only predictor of mortality (HR: 2.78; 95% CI: 1.61, 4.79). Sensitivity analyses, which included only baseline TB cases, an index date of two years after TB diagnosis, and study enrolment and case‐control matching yielded results that were consistent with primary analyses.ConclusionsPWH who are successfully treated for TB have higher long‐term mortality than those who are never diagnosed with TB, even after accounting for acute TB‐related mortality. A better understanding of the underlying mechanisms associated with TB sequelae is critically needed to guide specific interventions. Until then, more aggressive measures for health promotion and disease prevention are essential to improve long‐term survival for PWH after TB treatment.     

The Impact of Nutrition on the Development and Prognosis of Breast Cancer

SUMMARY: Breast cancer is the most frequent type of cancer in women. Recent data suggest that lifestyle factors including dietary factors play a significant role in the development of and survival from breast cancer. In particular, there is convincing evidence that obesity is a potent risk factor for both cancer development and prognosis, increasing the risk for overall and breast cancer mortality by approximately 30%. In contrast, there is still only limited evidence that specific dietary patterns or dietary components affect breast cancer outcomes. However, current knowledge suggests that a healthy/Mediterranean-like diet characterized by high intake of fruit, vegetables, fiber, fish and unsaturated oils, particularly n-3 fatty acids, has a modest protective effect on breast cancer, whereas a typical Western diet characterized by high intake of total/saturated fat, refined carbohydrates, processed and red meat and low fiber intake is associated with modestly poorer outcome. Based on this evidence, weight control is a key recommendation for primary and secondary prevention of breast cancer. Adherence to a healthy/Mediterranean-like diet and avoidance of a Western diet may confer additional, although still unproven, benefit.     

C-reactive protein and mortality in mild to moderate chronic obstructive pulmonary disease

BACKGROUND: Although C-reactive protein (CRP) levels are increased in chronic obstructive pulmonary disease (COPD), it is not certain whether they are associated with adverse clinical outcomes. METHODS: Serum CRP levels were measured in 4803 participants in the Lung Health Study with mild to moderate COPD. The risk of all-cause and disease specific causes of mortality was determined as well as cardiovascular event rates, adjusting for important covariates such as age, sex, cigarette smoking, and lung function. Cardiovascular events were defined as death from coronary heart disease or stroke, or non-fatal myocardial infarction or stroke requiring admission to hospital. RESULTS: CRP levels were associated with all-cause, cardiovascular, and cancer specific causes of mortality. Individuals in the highest quintile of CRP had a relative risk (RR) for all-cause mortality of 1.79 (95% confidence interval (CI) 1.25 to 2.56) compared with those in the lowest quintile of CRP. For cardiovascular events and cancer deaths the corresponding RRs were 1.51 (95% CI 1.20 to 1.90) and 1.85 (95% CI 1.10 to 3.13), respectively. CRP levels were also associated with an accelerated decline in forced expiratory volume in 1 second (p < 0.001). The discriminative property of CRP was greatest during the first year of measurement and decayed over time. Comparing the highest and lowest CRP quintiles, the RR was 4.03 (95% CI 1.23 to 13.21) for 1 year mortality, 3.30 (95% CI 1.38 to 7.86) for 2 year mortality, and 1.82 (95% CI 1.22 to 2.68) for > or =5 year mortality. CONCLUSIONS: CRP measurements provide incremental prognostic information beyond that achieved by traditional markers of prognosis in patients with mild to moderate COPD, and may enable more accurate detection of patients at a high risk of mortality.