Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study
BACKGROUND: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. RESEARCH QUESTION: What...
Autores principales: | , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Published by Elsevier Inc under license from the American College of Chest Physicians.
2021
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176896/ https://www.ncbi.nlm.nih.gov/pubmed/34089739 http://dx.doi.org/10.1016/j.chest.2021.05.047 |
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author | Qadir, Nida Bartz, Raquel R. Cooter, Mary L. Hough, Catherine L. Lanspa, Michael J. Banner-Goodspeed, Valerie M. Chen, Jen-Ting Giovanni, Shewit Gomaa, Dina Sjoding, Michael W. Hajizadeh, Negin Komisarow, Jordan Duggal, Abhijit Khanna, Ashish K. Kashyap, Rahul Khan, Akram Chang, Steven Y. Tonna, Joseph E. Anderson, Harry L. Liebler, Janice M. Mosier, Jarrod M. Morris, Peter E. Genthon, Alissa Louh, Irene K. Tidswell, Mark Stephens, R. Scott Esper, Annette M. Dries, David J. Martinez, Anthony Schreyer, Kraftin E. Bender, William Tiwari, Anupama Guru, Pramod K. Hanna, Sinan Gong, Michelle N. Park, Pauline K. |
author_facet | Qadir, Nida Bartz, Raquel R. Cooter, Mary L. Hough, Catherine L. Lanspa, Michael J. Banner-Goodspeed, Valerie M. Chen, Jen-Ting Giovanni, Shewit Gomaa, Dina Sjoding, Michael W. Hajizadeh, Negin Komisarow, Jordan Duggal, Abhijit Khanna, Ashish K. Kashyap, Rahul Khan, Akram Chang, Steven Y. Tonna, Joseph E. Anderson, Harry L. Liebler, Janice M. Mosier, Jarrod M. Morris, Peter E. Genthon, Alissa Louh, Irene K. Tidswell, Mark Stephens, R. Scott Esper, Annette M. Dries, David J. Martinez, Anthony Schreyer, Kraftin E. Bender, William Tiwari, Anupama Guru, Pramod K. Hanna, Sinan Gong, Michelle N. Park, Pauline K. |
author_sort | Qadir, Nida |
collection | PubMed |
description | BACKGROUND: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. RESEARCH QUESTION: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? STUDY DESIGN AND METHODS: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao(2) to Fio(2) ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H(2)O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. RESULTS: A total of 2,466 patients were enrolled. Median baseline Pao(2) to Fio(2) ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H(2)O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. INTERPRETATION: Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov |
format | Online Article Text |
id | pubmed-8176896 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | Published by Elsevier Inc under license from the American College of Chest Physicians. |
record_format | MEDLINE/PubMed |
spelling | pubmed-81768962021-06-04 Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study Qadir, Nida Bartz, Raquel R. Cooter, Mary L. Hough, Catherine L. Lanspa, Michael J. Banner-Goodspeed, Valerie M. Chen, Jen-Ting Giovanni, Shewit Gomaa, Dina Sjoding, Michael W. Hajizadeh, Negin Komisarow, Jordan Duggal, Abhijit Khanna, Ashish K. Kashyap, Rahul Khan, Akram Chang, Steven Y. Tonna, Joseph E. Anderson, Harry L. Liebler, Janice M. Mosier, Jarrod M. Morris, Peter E. Genthon, Alissa Louh, Irene K. Tidswell, Mark Stephens, R. Scott Esper, Annette M. Dries, David J. Martinez, Anthony Schreyer, Kraftin E. Bender, William Tiwari, Anupama Guru, Pramod K. Hanna, Sinan Gong, Michelle N. Park, Pauline K. Chest Critical Care: Original Research BACKGROUND: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. RESEARCH QUESTION: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? STUDY DESIGN AND METHODS: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao(2) to Fio(2) ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H(2)O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. RESULTS: A total of 2,466 patients were enrolled. Median baseline Pao(2) to Fio(2) ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H(2)O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. INTERPRETATION: Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov Published by Elsevier Inc under license from the American College of Chest Physicians. 2021-10 2021-06-04 /pmc/articles/PMC8176896/ /pubmed/34089739 http://dx.doi.org/10.1016/j.chest.2021.05.047 Text en © 2021 Published by Elsevier Inc under license from the American College of Chest Physicians. Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. |
spellingShingle | Critical Care: Original Research Qadir, Nida Bartz, Raquel R. Cooter, Mary L. Hough, Catherine L. Lanspa, Michael J. Banner-Goodspeed, Valerie M. Chen, Jen-Ting Giovanni, Shewit Gomaa, Dina Sjoding, Michael W. Hajizadeh, Negin Komisarow, Jordan Duggal, Abhijit Khanna, Ashish K. Kashyap, Rahul Khan, Akram Chang, Steven Y. Tonna, Joseph E. Anderson, Harry L. Liebler, Janice M. Mosier, Jarrod M. Morris, Peter E. Genthon, Alissa Louh, Irene K. Tidswell, Mark Stephens, R. Scott Esper, Annette M. Dries, David J. Martinez, Anthony Schreyer, Kraftin E. Bender, William Tiwari, Anupama Guru, Pramod K. Hanna, Sinan Gong, Michelle N. Park, Pauline K. Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study |
title | Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study |
title_full | Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study |
title_fullStr | Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study |
title_full_unstemmed | Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study |
title_short | Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study |
title_sort | variation in early management practices in moderate-to-severe ards in the united states: the severe ards: generating evidence study |
topic | Critical Care: Original Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176896/ https://www.ncbi.nlm.nih.gov/pubmed/34089739 http://dx.doi.org/10.1016/j.chest.2021.05.047 |
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