Patient, caregiver and other knowledge user engagement in consensus-building healthcare initiatives: a scoping review protocol.

INTRODUCTION: Patient engagement and integrated knowledge translation (iKT) processes improve health outcomes and care experiences through meaningful partnerships in consensus-building initiatives and research. Consensus-building is essential for engaging a diverse group of experienced knowledge users in co-developing and supporting a solution where none readily exists or is less optimal. Patients and caregivers provide invaluable insights for building consensus in decision-making around healthcare, policy and research. However, despite emerging evidence, patient engagement remains sparse within consensus-building initiatives. Specifically, our research has identified a lack of opportunity for youth living with chronic health conditions and their caregivers to participate in developing consensus on indicators/benchmarks for transition into adult care. To bridge this gap and inform our consensus-building approach with youth/caregivers, this scoping review will synthesise the extent of the literature on patient and other knowledge user engagement in consensus-building healthcare initiatives. METHODS AND ANALYSIS: Following the scoping review methodology from Joanna Briggs Institute, published literature will be searched in MEDLINE, EMBASE, CINAHL and PsycINFO databases from inception to July 2023. Grey literature will be hand-searched. Two independent reviewers will determine the eligibility of articles in a two-stage process, with disagreements resolved by a third reviewer. Included studies must be consensus-building studies within the healthcare context that involve patient engagement strategies. Data from eligible studies will be extracted and charted on a standardised form. Abstracted data will be analysed quantitatively and descriptively, according to specific consensus methodologies, and patient engagement models and/or strategies. ETHICS AND DISSEMINATION: Ethics approval is not required for this scoping review protocol. The review process and findings will be shared with and informed by relevant knowledge users. Dissemination of findings will also include peer-reviewed publications and conference presentations. The results will offer new insights for supporting patient engagement in consensus-building healthcare initiatives. PROTOCOL REGISTRATION: https://osf.io/beqjr.

Pediatric anesthesia in North America.

BACKGROUND AND OBJECTIVES: This educational review outlines the current landscape of pediatric anesthesia training, care delivery, and challenges across Canada, Barbados, and the United States. DESCRIPTIONS AND CONCLUSIONS: Approximately 5% of Canadian children undergo general anesthesia annually, administered by fellowship-trained pediatric anesthesiologists in children's hospitals, general anesthesiologists in community hospitals, or family practice anesthesiologists in underserved regions. In Canada, the focus is on national-level evaluation and accreditation of pediatric anesthesia fellowship training, addressing challenges arising from workforce shortages, particularly in remote areas. Barbados, a Caribbean nation, lacks dedicated pediatric hospitals but has provided pediatric anesthesia since 1972 through anesthetists with additional training. Challenges in its development, common to low-middle-income countries, include inadequate infrastructure and workforce shortages. Increased awareness of pediatric anesthesia as a sub-specialty could enhance perioperative care for Barbadian children. Pediatric anesthesia encompasses various specialties in the United States, with pediatric anesthesiologists playing a foundational role. Challenges faced include recruitment and retention difficulties, supply-chain shortages, and the proliferation of anesthesia sites, all impacting the delivery of modern, high-quality, and cost-effective patient care. Collaborative efforts at national and organizational levels strive to improve the quality and safety of pediatric anesthesia care in the United States.

Vitamin D is associated with visual memory in young northern adolescents.

BACKGROUND: Vitamin D status has been linked to visual memory in adults. We hypothesized a similar association in young adolescents. METHODS: Participants were 9-13 years. The Rey-Osterrieth Complex Figure Task (ROCF), Rey Auditory Verbal Learning Task (RAVLT), Digit Span (Forward, Backward), and verbal fluency task assessed visual and verbal learning/memory, attention/working memory, and executive functioning/language, respectively. An at-home, mail-in blood spot test assessed 25(OH)D levels. RESULTS: Participants (N = 56) were 10.7 ± 1.3 years, 61% females, 25(OH)D levels 84.2 ± 25 nmol/L(39.9 - 167.2 nmol/L) and 41% had insufficient vitamin D status (<75 nmol/L). Only measures of visual memory (ROCF-Recall, -%Recall of Copy) were significantly correlated with 25(OH)D, r = .34, p < .01 and r = .33, p < .01, respectively, and 25(OH)D remained a significant independent predictor on multiple regression analyses, which included age and sex.(ROCF-Recall overall model: Adj R2 = .24, p < .001; for 25(OH)D: p = .009; ROCF-%Recall of Copy overall model: Adj R2 = .20 p < .002; for 25(OH)D: p = .01). Individuals with sufficient vitamin D performed significantly better only on these measures (t-tests; ROCF-Recall, p = .016, d = 0.68; ROCF-%Recall of Copy, p = .022, d = 0.64). Despite moderate effect sizes (d = 0.4-0.5) in the Younger Age Group (9-10 years), only in the Older Age Group (11-13 years) was 25(OH)D significantly correlated with ROCF-Recall, r = .64, p = .0001 and ROCF-%Recall of Copy, r = .64, p = .0001, as well as working memory (Digit Span-Backward), Spearman's r = .46, p = .013. Similarly, those in the Older Age Group with sufficient vitamin D performed significantly better on ROCF-Recall, p = .01, d = 1.07; and ROCF-%Recall of Copy, p = .009, d = 1.08. CONCLUSIONS: Vitamin D insufficiency was common in young adolescents. Similar to adults, visual memory was better among participants with higher 25(OH)D and those with sufficient levels. This effect was especially pronounced among older participants, suggesting possible time- and/or age-related implications of vitamin D status on cognition.

Social and Structural Drivers of Health and Transition to Adult Care.

CONTEXT: Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition. OBJECTIVES: This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth. DATA SOURCES: Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022. STUDY SELECTION: Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included. DATA EXTRACTION: SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance. RESULTS: 101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion. LIMITATIONS: Studies were heterogeneous and a meta-analysis was not possible. CONCLUSIONS: Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.

Using a Quality Improvement Approach to Implement Measurement-Based Care (MBC) in Outpatient General Psychiatry.

BACKGROUND: Measurement-based care (MBC) is the clinical practice of using patient-reported symptom measurement to inform treatment decisions. MBC has been shown to improve patient outcomes and quality of care in outpatient psychiatry. Despite these benefits, MBC is not routinely used in most psychiatric outpatient settings. This quality improvement (QI) project aimed to achieve 75% completion of symptom scales using an online MBC platform in a general psychiatry clinic in Toronto, Canada, by June 2022. METHODS: The QI team used the Model for Improvement methodology. The main outcome measure was completion of symptom scales using an online MBC platform. Process measures included counts of invitations to join the MBC platform, counts of online MBC account creation, and counts of symptom scale assignment by clinicians. Balancing measures included administrative task completion and physician workload assessment. Stakeholder interviews explored barriers and facilitators to MBC utilization. RESULTS: Completion of symptom scales increased from 7/65 (10.8%) preintervention to 40/70 (57.1%) during the 26-week intervention. Clinician reminders and coaching clinicians about how to incorporate MBC into the care process facilitated uptake of MBC. Stakeholders identified several barriers to implementation, particularly physician attitudes toward MBC and perceived administrative burden. CONCLUSION: Completion of symptom scales increased over the course of this QI initiative. Successful implementation of MBC in general psychiatry outpatient settings requires the availability of a broad range of measurement scales given the diversity of mental health diagnoses. Implementation must also consider health equity, including access to technology and availability of symptom scales in multiple languages.

Outcomes in orthotopic heart transplantation following pacemaker implantation.

BACKGROUND: Bradyarrhythmias including sinus node dysfunction (SND) and atrioventricular block (AVB) can necessitate pacemaker (PPM) implantation in orthotopic heart transplant (OHT) recipients. Prior studies have shown conflicting findings regarding the effect of PPM implantation on survival. We evaluated the effect of PPM indication on long-term re-transplant-free survival in OHT patients. METHODS: We conducted a retrospective cohort study of OHT patients at UCLA Medical Center from 1985 to 2018. Indication for PPM (SND, AVB) was identified. Cox proportional hazards model with pacemaker implantation as a time-varying covariate was used to evaluate its effect on the primary endpoint of retransplant or death. We included 1609 OHTs in 1511 adult patients with median follow-up of 12 years. RESULTS: At transplant, patients were aged 53 ± 13 years and 1125 (74.5%) were male. Pacemakers were implanted in 109 (7.2%) patients; 65 for SND (4.3%) and 43 for AVB (2.8%). Repeat OHT was performed in 103 (6.4%) cases and 798 (52.8%) patients died during the follow-up period. The risk of the primary endpoint was significantly higher in patients requiring PPM for AVB (HR 3.0, 95% CI 2.1-4.2, p < .01) after controlling for age at OHT, gender, hypertension, diabetes, renal disease, history of repeat OHT, acute rejection, transplant coronary vasculopathy, and atrial fibrillation, but not PPM for SND (HR 1.0, 95% CI 0.70-1.4, p = 1.0). CONCLUSIONS: Patients who required PPM for AVB, but not SND, were at significantly higher risk of death or retransplant compared to patients who did not require PPM.

Quality Indicators for Youth Transitioning to Adult Care: A Systematic Review.

BACKGROUND AND OBJECTIVE: Transition from pediatric to adult care is associated with adverse health outcomes for many adolescents with chronic illness. We identified quality indicators for transition to adult care that are broadly applicable across chronic illnesses and health systems. METHODS: Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature were searched, covering earliest available date to July 2021. The Gray Matters framework was used to search gray literature. Two independent reviewers screened articles by title and abstract, followed by full-text review. Disagreements were resolved by a third reviewer. Studies were included that identified quality indicators developed via consensus-building methods. Indicators were organized into a framework categorized by illness specificity, level of care, Donabedian model, and Institute of Medicine quality domain. Appraisal of Guidelines for Research and Evaluation tool was used for critical appraisal. RESULTS: The search identified 4581 articles, of which 321 underwent full-text review. Eight peer-reviewed studies and 1 clinical guideline were included, identifying 169 quality indicators for transition. Of these, 56% were illness specific, 43% were at the patient level of care, 44% related to transition processes, and 51% were patient centered and 0% equity focused. Common indicator themes included education (12%), continuity of care (8%), satisfaction (8%), and self-management/self-efficacy (7%). The study was limited by quality indicators developed through consensus-building methodology. CONCLUSIONS: Although most quality indicators for transition were patient-centered outcomes, few were informed by youth and parents/caregivers, and none focused on equity. Further work is needed to prioritize quality indicators across chronic illness populations while engaging youth and parents/caregivers in the process.

Competency-Based Medical Education: Are Canadian Pediatric Anesthesiologists Ready?

Background With the introduction of Competency-Based Medical Education (CBME), the Canadian Pediatric Anesthesia Society (CPAS) surveyed its members to assess their awareness of and prior experience with CBME concepts and evaluation tools, and identify methods for faculty development of CBME teaching strategies for pediatric anesthesia residents and fellows. Methods An online survey was sent to CPAS members. Outcomes included respondents' previous exposure to CBME and the educational support they had received in anticipation of the curriculum. Questions used multi-item Likert scales and a general feedback question.  Results The response rate was 39% (60/155). Eighty-eight percent of respondents spent ≥50% of their time practicing pediatric anesthesia; 78% and 45% spent at least a quarter of their time teaching residents and fellows respectively. Eighty-three percent were familiar with CBME concepts, and 58% were familiar with Milestones, Competencies, and Entrustable Professional Activities (EPAs). However, 64% had not received any formal training and 52% had not used any CBME evaluation tools. Learning preferences included small group discussions (72%), lectures with questions and answers (Q&A) (62%), seminars (50%), and workshops (50%). Conclusions Despite widespread awareness of CBME concepts, there is a need to educate Canadian pediatric anesthesiologists regarding CBME evaluation tools. Faculty development support will increase the utilization of these tools in teaching practice.

Health research priorities for wildland firefighters: a modified Delphi study with stakeholder interviews.

OBJECTIVES: The increase in global wildland fire activity has accelerated the urgency to understand health risks associated with wildland fire suppression. The aim of this project was to identify occupational health research priorities for wildland firefighters and related personnel. DESIGN: In order to identify, rank and rate health research priorities, we followed a modified Delphi approach. Data collection involved a two-stage online survey followed by semi-structured interviews. SETTING: British Columbia, Canada. PARTICIPANTS: Participants included any current or past wildland firefighter or individuals engaged in related roles. There were 132 respondents to the first survey. Responses to the first survey were analysed to produce 10 research topics which were ranked by 75 participants in the second survey (response rate: 84%). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the identification, ranking and level of agreement of research priorities through a two-round online survey. We contextualised these findings through deductive and inductive qualitative content analysis of semi-structured interviews. RESULTS: The most important research priorities identified were (% consensus): effects of smoke inhalation on respiratory health (89%), fatigue and sleep (80%), mental health (78%), stress (76%) and long-term risk of disease (67%). Interviews were completed with 14 individuals. Two main themes were developed from an inductive content analysis of interview transcripts: (1) understanding the dynamic risk environment; and (2) organisational fit of mitigation strategies. CONCLUSIONS: Participants expressed a general concern with the unknown mental and physical health impacts of their jobs, including the long-term risk of morbidity and mortality. Future research must address knowledge gaps in our understanding of the health impacts of wildland fire and work to develop appropriate mitigation strategies while considering the needs of workers and unpredictable workplace environment. TRIAL REGISTRATION NUMBER: Open Science Framework, https://osf.io/ugz4s/.

Health risks and mitigation strategies from occupational exposure to wildland fire: a scoping review.

OBJECTIVES: Due to accelerating wildland fire activity, there is mounting urgency to understand, prevent, and mitigate the occupational health impacts associated with wildland fire suppression. The objectives of this review of academic and grey literature were to: 1. Identify the impact of occupational exposure to wildland fires on physical, mental, and emotional health; and 2. Examine the characteristics and effectiveness of prevention, mitigation, or management strategies studied to reduce negative health outcomes associated with occupational exposure to wildland fire. METHODS: Following established scoping review methods, academic literature as well as government and industry reports were identified by searching seven academic databases and through a targeted grey literature search. 4679 articles were screened using pre-determined eligibility criteria. Data on study characteristics, health outcomes assessed, prevention or mitigation strategies studied, and main findings were extracted from each included document. The results of this scoping review are presented using descriptive tables and a narrative summary to organize key findings. RESULTS: The final sample was comprised of 100 articles: 76 research articles and 24 grey literature reports. Grey literature focused on acute injuries and fatalities. Health outcomes reported in academic studies focused on respiratory health (n = 14), mental health (n = 16), and inflammation and oxidative stress (n = 12). The identified studies evaluated short-term outcomes measuring changes across a single shift or wildland fire season. Most research was conducted with wildland firefighters and excluded personnel such as aviation crews, contract crews, and incident management teams. Five articles reported direct study of mitigation strategies, focusing on the potential usage of masks, advanced hygiene protocols to reduce exposure, fluid intake to manage hydration and core temperature, and glutamine supplementation to reduce fatigue. CONCLUSIONS: While broad in scope, the evidence base linking wildland fire exposure to any one health outcome is limited. The lack of long-term evidence on changes in health status or morbidity is a clear evidence gap and there is a need to prioritize research on the mental and physical health impact of occupational exposure to wildland fire.

Quality indicators for transition from paediatric to adult care for adolescents with chronic physical and mental illness: protocol for a systematic review.

INTRODUCTION: Transition from paediatric to adult care is a complex process, which poses significant challenges for adolescents with chronic physical and mental illnesses. For many, transfer to adult care is associated with poor health and psychosocial outcomes. Quality indicators to evaluate transition to adult care are needed to benchmark and compare performance across conditions and health systems. This systematic review aims to identify quality indicators for successful transition to adult care which can be applied across chronic physical and/or mental illnesses. METHODS: Published literature will be searched using MEDLINE, Embase and CINHAL from earliest available date to July 2021. Grey literature will be searched using the Grey Matters tool. Using a set of inclusion/exclusion criteria, two independent reviewers will screen titles and abstracts, followed by full-text review. Disagreements will be resolved by a third reviewer. Study selection and data extraction will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Study appraisal will be completed using the Appraisal of Guidelines for Research and Evaluation for Quality Indicators instrument. Extracted quality indicators will be categorised into a conceptual framework. ETHICS AND DISSEMINATION: Results from this review will offer novel insights into quality indicators that may be used to measure and evaluate transition success across conditions, which will be disseminated via a Canadian transition collaborative, workshops and peer-reviewed publication. Extracted quality indicators will be further prioritised in a Delphi study with patients, caregivers and providers. This is a critical step in developing a core set of metrics to evaluate transitions to adult care. Ethics approval is not required as this review will identify and synthesise findings from published literature. PROSPERO REGISTRATION NUMBER: CRD42020198030.

Comparison of the diagnostic performance and impact on management of 18F-FDG PET/CT and whole-body MRI in multiple myeloma.

PURPOSE: Comparative data on the impact of imaging on management is lacking for multiple myeloma. This study compared the diagnostic performance and impact on management of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and whole-body magnetic resonance imaging (WBMRI) in treatment-naive myeloma. METHODS: Forty-six patients undergoing 18F-FDG PET/CT and WBMRI were reviewed by a nuclear medicine physician and radiologist, respectively, for the presence of myeloma bone disease. Blinded clinical and imaging data were reviewed by two haematologists in consensus and management recorded following clinical data ± 18F-FDG PET/CT or WBMRI. Bone disease was defined using International Myeloma Working Group (IMWG) criteria and a clinical reference standard. Per-patient sensitivity for lesion detection was established. McNemar test compared management based on clinical assessment ± 18F-FDG PET/CT or WBMRI. RESULTS: Sensitivity for bone lesions was 69.6% (32/46) for 18F-FDG PET/CT (54.3% (25/46) for PET component alone) and 91.3% (42/46) for WBMRI. 27/46 (58.7%) of cases were concordant. In 19/46 patients (41.3%) WBMRI detected more focal bone lesions than 18F-FDG PET/CT. Based on clinical data alone, 32/46 (69.6%) patients would have been treated. Addition of 18F-FDG PET/CT to clinical data increased this to 40/46 (87.0%) patients (p = 0.02); and WBMRI to clinical data to 43/46 (93.5%) patients (p = 0.002). The difference in treatment decisions was not statistically significant between 18F-FDG PET/CT and WBMRI (p = 0.08). CONCLUSION: Compared to 18F-FDG PET/CT, WBMRI had a higher per patient sensitivity for bone disease. However, treatment decisions were not statistically different and either modality would be appropriate in initial staging, depending on local availability and expertise.

Outcomes and Resource Utilization in Robotic Mitral Valve Repair: Beyond the Learning Curve.

BACKGROUND: After the initial learning curve associated with mastering a robotic procedure, there is a plateau where operative time and complication rates stabilize. Our objective was to evaluate one surgeon's experience with robotic mitral valve repairs (MVRep) beyond the learning curve and to compare its effectiveness against the traditional open approach. METHODS: Data from Ronald Reagan University of California, Los Angeles Medical Center was prospectively collected from January 2008 to March 2016 to identify adult patients undergoing robotic MVRep. Operative times, complication rates, and cost for robotic versus open MVRep were compared using multivariate regressions, adjusting for comorbidities and previous cardiac surgeries. RESULTS: During the study period, 175 robotic (41%) and 259 open (59%) MVRep cases were performed at our institution. As the surgeon performed more robotic operations, there was a decrease in room time (554-410 min, P < 0.001), surgery time (405-271 min, P < 0.001), and cross-clamp times (179-93 min, P < 0.001). After application of a multivariate regression model, robotic MVRep was associated with lower odds of complications (odds ratio = 0.42, P = 0.001), shorter length of stay (ß = -2.51, P < 0.001), and a reduction of 11% in direct (P = 0.003) and 24% in room costs (P < 0.001), but a 51% increase in surgery cost (P < 0.001). CONCLUSIONS: As the surgeon gained experience with robotic MVRep, operative times decreased in a steady manner. Robotic MVRep had comparable outcomes to open MVRep and lower overall cost. The observed difference in costs is likely related to shorter length of stay and lower room cost with the robotic approach.

Short-Term Readmissions After Open, Thoracoscopic, and Robotic Lobectomy for Lung Cancer Based on the Nationwide Readmissions Database.

BACKGROUND: Readmission after surgery is an established surrogate indicator of quality of care. We aimed to compare short-term readmission rates and patient outcomes between open, video-assisted thoracoscopic (VATS), and robotic lobectomies in the Nationwide Readmissions Database (NRD). METHODS: Adults who underwent open, VATS, or robotic lobectomy for lung cancer from 2010 to 2014 were evaluated. Propensity-matched analysis was used to assess differences in readmission characteristics, GDP-adjusted cost, and mortality. RESULTS: Of the 129,539 lobectomies for lung cancer, 74,493 (57.5%) were open, 48,185 (37.2%) VATS, and 6861 (5.3%) robotic. Open surgery was associated with significantly higher readmission rate (10.5 vs 9.3%, p < 0.001), mortality (2 vs 1.2%, p < 0.001), index hospitalization cost [$21,846 (16,158-31,034) vs $20,779 (15,619-27,920), p < 0.001], and length of stay [6 (5-9) vs 4 (3-7) days, p < 0.001] compared to minimally invasive surgery. The robotic approach had similar mortality, readmission rate, and length of stay compared to VATS, but higher index cost [$23,870 (18,372-31,300) vs $20,279 (15,275-27,375), p < 0.001] and incidence of pulmonary complication (35.9 vs 31.6%, p < 0.001). The robotic approach was associated with greater direct discharges to home. CONCLUSIONS: Analysis of the NRD revealed significantly reduced readmission rates, better clinical outcomes, and lower cost in the minimally invasive approach compared to open surgery. Although VATS and robotic surgery had similar readmission and mortality rates, VATS is associated with significantly reduced risk of short-term complications and lower cost.

Trends in mortality and resource utilization for extracorporeal membrane oxygenation in the United States: 2008-2014.

BACKGROUND: Extracorporeal membrane oxygenation is used as a life-sustaining measure in patients with acute or end-stage cardiac or respiratory failure. We analyzed national trends in extracorporeal membrane oxygenation use and outcomes and assessed the influence of hospital demographics. METHODS: Adult extracorporeal membrane oxygenation patients in the 2008-2014 National Inpatient Sample were evaluated. Patient and hospital characteristics, extracorporeal membrane oxygenation indication, mortality, and hospital costs were analyzed. RESULTS: A total 17,020 adult extracorporeal membrane oxygenation patients were considered: 47.4% respiratory failure, 38.6% postcardiotomy, 5.5% lung transplantation, 5.5% cardiogenic shock, and 3.2% heart transplantation. Admissions rose 361% from 1,026 in 2008 to 4,815 in 2014 (P < .0001), and the fraction of respiratory failure increased 40.5%-49.8% (P < .001). Elixhauser scores rose from 3.1 to 4.1 (P < .0001). Mortality decreased among total admissions from 62.4% to 42.7% (P < .0001) associated with an observed decline in postcardiotomy mortality. Mean hospital costs and length of stay remained stable throughout the study period. Although extracorporeal membrane oxygenation occurred most frequently at large hospitals, small and medium-sized hospitals showed significant expansion (P < .001). The Northeast exhibited a sustained three-fold per capita increase in extracorporeal membrane oxygenation rate (P < .0001). CONCLUSION: The past decade has seen an exponential growth of ECMO extracorporeal membrane oxygenation in the United States, with the fraction for respiratory failure displaying considerable growth. Overall extracorporeal membrane oxygenation patients experienced substantially reduced mortality, driven by improved outcomes for postcardiotomy patients, along with a trend toward an increased risk profile. Disproportionate use of extracorporeal membrane oxygenation in the Northeast warrants investigation of access to this technology across the United States.

Impact of New-Onset Postoperative Depression on Readmission Outcomes After Surgical Coronary Revascularization.

BACKGROUND: Depression affects between 10% and 40% of cardiac surgery patients and is associated with significantly worse outcomes. The incidence and impact of new-onset depression beyond acute follow-up remain ill-defined. The present study aimed to evaluate the incidence, risk factors, and prognostic implication of depression on 90-d readmission rates after coronary artery bypass grafting (CABG) surgery. METHODS: A retrospective cohort study was performed identifying adult patients without prior depression who underwent CABG surgery using the 2010-2014 National Readmissions Database. CABG patients who were readmitted more than 2 wk but within 90 d of discharge were categorized based on the presence of new-onset depression. Association between the development of new-onset depression and rehospitalization were morbidity, mortality, costs, and length of stay (LOS) and were examined using multivariable regression. RESULTS: During the study period, 1,001,945 patients underwent CABG. Of these, 11.7% of patients were readmitted after 14 d but within 90 d of discharge with 5.1% of these patients having a diagnosis of new-onset depression. Postoperative new-onset depression was not associated with increased readmission morbidity, costs, or LOS. Mortality in new-onset depression readmissions was 1.2%, compared with 2.3% in all readmitted patients (P = 0.014). Depression was associated with lower odds of mortality (OR = 0.56, P = 0.02). CONCLUSIONS: New-onset depression following CABG discharge was not associated with increased odds of mortality, morbidity, costs, or increased LOS on readmission. Rather, new-onset depression is associated with decreased odds of readmission mortality. Overall, CABG readmissions are decreasing, whereas the rate of new-onset depression is slightly increasing. Implementation of routine depression screening tools in postoperative CABG care may aid in early detection and management of depression to enhance postoperative recovery and quality of life.

National trends in volume-outcome relationships for extracorporeal membrane oxygenation.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) has emerged as a common therapy for severe cardiopulmonary dysfunction. We aimed to describe the relationship of institutional volume with patient outcomes and examine transfer status to tertiary ECMO centers. MATERIALS AND METHODS: Using the National Inpatient Sample, we identified adult patients who received ECMO from 2008 to 2014. Individual hospital volume was calculated as tertiles of total institutional discharges for each year independently. RESULTS: Of the total 18,684 adult patients placed on ECMO, 2548 (13.6%), 5278 (28.2%), and 10,858 (58.1%) patients were admitted to low-, medium-, and high-volume centers, respectively. Unadjusted mortality at low-volume hospitals was less than that of medium- (43.7% versus 50.3%, P = 0.03) and high-volume hospitals (43.7% versus 55.6%, P < 0.001). Length of stay and cost were reduced at low-volume hospitals compared to both medium- and large-volume institutions (all P < 0.001). In high-volume institutions, transferred patients had greater postpropensity-matched mortality (58.5% versus 53.7%, P = 0.05) and cost ($190,299 versus $168,970, P = 0.009) compared to direct admissions. On exclusion of transferred patients from propensity analysis, mortality remained greater in high-volume compared to low-volume centers (50.2% versus 42.8%, P = 0.04). Predictors of mortality included treatment at high-volume centers, respiratory failure, and cardiogenic shock (all P < 0.001). CONCLUSIONS: Our findings show increased in-hospital mortality in high-volume institutions and in patients transferred to tertiary centers. Whether this phenomenon represents selection bias or transfer from another facility deserves further investigation and will aid with the identification of surrogate markers for quality of high-risk interventions.