Early Tocilizumab Dosing Is Associated With Improved Survival in Critically Ill Patients Infected With Severe Acute Respiratory Syndrome Coronavirus-2.

To identify the most efficacious timing for tocilizumab administration in critically ill patients infected with severe acute respiratory syndrome coronavirus-2. DESIGN: Observational multicenter cohort study. SETTING: A total of 23 acute care hospitals in four states. PATIENTS: One-hundred eighteen patients admitted between March 13, 2020, and April 16, 2020. Eighty-one patients received tocilizumab, and 37 were untreated and served as a control group. MEASUREMENTS AND MAIN RESULTS: The main outcome was mortality and was analyzed by timing of tocilizumab dosing. Early dosing was defined as a tocilizumab dose administered prior to or within 1 day of intubation. Late dosing was defined as a dose administered greater than 1 day after intubation. A control group that was treated only with standard of care, and without tocilizumab, was used for comparison. Early tocilizumab therapy was associated with a statistically significant decrease in mortality as compared to patients who were untreated (p = 0.003). Dosing tocilizumab late was associated with an increased mortality compared with the untreated group (p = 0.006). CONCLUSIONS: Early tocilizumab administration was associated with decreased mortality in critically ill severe acute respiratory syndrome coronavirus-2 patients, but a potential detriment was suggested by dosing later in a patient's course.

Tocilizumab as a Therapeutic Agent for Critically Ill Patients Infected with SARS-CoV-2.

Tocilizumab is an IL-6 receptor antagonist with the ability to suppress the cytokine storm in critically ill patients infected with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). We evaluated patients treated with tocilizumab for a SARS-CoV-2 infection who were admitted between March 13, 2020, and April 16, 2020. This was a multicenter study with data collected by chart review both retrospectively and concurrently. Parameters evaluated included age, sex, race, use of mechanical ventilation (MV), usage of steroids and vasopressors, inflammatory markers, and comorbidities. Early dosing was defined as a tocilizumab dose administered prior to or within 1 day of intubation. Late dosing was defined as a dose administered > 1 day after intubation. In the absence of MV, the timing of the dose was related to the patient's date of admission only. We evaluated 145 patients. The average age was 58.1 years, 64% were men, 68.3% had comorbidities, and 60% received steroid therapy. Disposition of patients was 48.3% discharged and 29.3% died, of which 43.9% were African American. MV was required in 55.9%, of which 34.5% died. Avoidance of MV (P = 0.002) and increased survival (P < 0.001) was statistically associated with early dosing. Tocilizumab therapy was effective at decreasing mortality and should be instituted early in the management of critically ill patients with coronavirus disease 2019) COVID-19).

Value and Clinical Impact of an Infectious Disease-Supervised Outpatient Parenteral Antibiotic Therapy Program.

Background. Outpatient parenteral antibiotic therapy (OPAT) is a safe and effective modality for treating serious infections. This study was undertaken to define the value of OPAT in a multicentered infectious disease (ID) private practice setting. Methods. Over a period of 32 months, 6120 patients were treated using 19 outpatient ID offices in 6 states. Analysis included patient demographics, indications of OPAT, diagnoses, therapeutic agent, duration of therapy, and site of therapy initiation. Outcomes were stratified by therapeutic success, clinical relapse, therapeutic complications, and hospitalizations after initiating therapy. Statistical analysis included an ordinal logistic regression analysis. Results. Forty-three percent of patients initiated therapy in an outpatient office, and 57% began therapy in a hospital. Most common diagnoses treated were bone and joint (32.2%), abscesses (18.8%), cellulitis (18.5%), and urinary tract infection (10.8%). Ninety-four percent of patients were successfully treated, and only 3% were hospitalized after beginning therapy. Most common cause of treatment failure was a relapse of primary infection (60%), progression of primary infection (21%), and therapeutic complication (19%). Conclusions. An ID-supervised OPAT program is safe, efficient, and clinically effective. By maximizing the delivery of outpatient care, OPAT provides a tangible value to hospitals, payers, and patients. This program is a distinctive competency available to ID physicians who offer this service to patients.

An exploratory analysis of the correlation of pain scores, patient satisfaction with relief from pain, and a new measure of pain control on the total dose of opioids in pain care.

OBJECTIVE: We explored the associations between opioid dose and multiple measures of pain. STUDY DESIGN AND MEASURES: Thirty-two consecutive patients admitted solely for an acute exacerbation of cancer-related pain or for surgery were followed for their entire hospital stay (115 days of pain). For each hospital day, we collected pain scores, the number of pain scores, trends in pain scores, the percentage of time patients had 100% acceptable relief from pain, and the number of times patients were asked about acceptable pain relief. Finally, we asked those who had 100% relief of pain whether they could have used more pain medicine. Linear regression models were fit to estimate the amount of variation explained (R) in dose of medication, by each pain measurement variable. RESULTS: Nineteen patients with cancer (74 days of pain) and 13 patients undergoing surgery (41 days of pain) were evaluated. Pain scores, the number of pain scores, trends in pain scores, and 100% acceptable relief scores poorly correlated with the use of medication in the linear regression models (R for all models ≤0.2). A question about needing more pain medicine explained the greatest amount of variation in opioid dose. CONCLUSIONS: Pain and acceptable relief scores do not adequately reflect the use of medication. A prospective study is needed to further assess the value of additional measures of the adequacy of pain care.

Hospital care may not affect the risk of readmission.

BACKGROUND: : Thirty-day readmissions have become a focal point for reducing health care spending, because they are viewed as a marker of the quality of hospital care. However, if increased time in the hospital is associated with better care, attempts to shorten length of stay (LOS) may result in increased rates of readmission. As such, we sought to explore the association of an incremental added day in LOS with the rate of readmission. METHODS: : We examined the rate of readmission at 30 and 120 days for 4151 patients admitted to a general internal medicine unit between July 2004 and March 2006. We used binary logistic regression to examine the relationship between an incremental added day in LOS and the probability of readmission. RESULTS: : Readmission rates were 8.7% at 30 days and 21.0% at 120 days, respectively. After controlling for demographic characteristics and severity of illness, we found that the probability of readmission varied little for an incremental added day in LOS. CONCLUSIONS: : Our findings suggest that more hospital care may not affect the likelihood of readmission and thus denying payment for readmission may be unwarranted.

Change in MS-DRG assignment and hospital reimbursement as a result of Centers for Medicare & Medicaid changes in payment for hospital-acquired conditions: is it coding or quality?

CONTEXT: In October 2008, the Centers for Medicare & Medicaid Services reduced payments to hospitals for a group of hospital-acquired conditions (HACs) not documented as present on admission (POA). It is unknown what proportion of Medicare severity diagnosis related group (MS-DRG) assignments will change when the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis code for the HAC is not taken into account even before considering the POA status. OBJECTIVES: The primary objectives were to estimate the proportion of cases that change MS-DRG assignment when HACs are removed from the calculation, the subsequent changes in reimbursement to hospitals, and the attenuation in changes in MS-DRG assignment after factoring in those that may be POA. Last, we explored the effect of the numbers of ICD-9-CM diagnosis codes on MS-DRG assignment. METHODS: We obtained 2 years of discharge data from academic medical centers that were members of the University Health System Consortium and identified all cases with 1 of 7 HACs coded through ICD-9-CM diagnosis codes. We calculated the MS-DRG for each case with and without the HAC and, hence, the proportion where MS-DRG assignment changed. Next, we used a bootstrap method to calculate the range in the proportion of cases changing assignment to account for POA status. Changes in reimbursement were estimated by using the 2008 MS-DRG weights payment formula. RESULTS: Of 184,932 cases with at least 1 HAC, 27.6% (n = 52,272) would experience a change in MS-DRG assignment without the HAC factored into the assignment. After taking into account those conditions that were potentially POA, 7.5% (n = 14,176) of the original cases would change MS-DRG assignment, with an average loss in reimbursement per case ranging from $1548 with a catheter-associated urinary tract infection to $7310 for a surgical site infection. These reductions would translate into a total reimbursement loss of $50 261,692 (range: $38 330,747-$62 344,360) for the 86 academic medical centers. Those cases, for all conditions, with reductions in payment also have fewer additional ICD-9-CM codes associated. CONCLUSIONS: Removing HACs from MS-DRG assignment may result in significant cost savings for the Centers for Medicare & Medicaid Services through reduced payment to hospitals. As more conditions are added, the negative impact on hospital reimbursement may become greater. However, it is possible that variation in coding practice may affect cost savings and not reflect true differences in quality of care.

Electronic algorithmic prediction of central vascular catheter use.

OBJECTIVE: To develop prediction algorithms for the presence of a central vascular catheter in hospitalized patients with use of data present in an electronic health record. Such algorithms could be used for measurement of device utilization rates and for clinical decision support rules. DESIGN: Criterion standard. SETTING: John H. Stroger, Jr, Hospital of Cook County, a 464-bed public hospital in Chicago, Illinois. PARTICIPANTS: Patients admitted to the medical intensive care unit from May 31, 2005 through June 26, 2006 (derivation data set, May 31, 2005-September 28, 2005; validation data set, September 29, 2005-June 28, 2006). METHODS: Covariates were collected from the electronic medical record for each patient; the outcome variable was presence of a central vascular device. Multivariate models were developed using the derivation set and the generalized estimating equation. Three models, each with increasing database requirements, were validated using the validation set. Device utilization ratios and performance characteristics were calculated. RESULTS: Although Charlson score and duration of intensive care unit stay were significant predictors in all models, factors that indicated use or presence of a central line were also important. Device utilization rates derived from the algorithmic models were as accurate as those obtained using manual sampling. CONCLUSIONS: Automated calculation of central vascular catheter use is both feasible and accurate, providing estimates statistically similar to those obtained using manual surveillance. Prediction modeling of central vascular catheter use may enable automated surveillance of bloodstream infections and enhance important prevention interventions, such as timely removal of unnecessary central lines.

Computer-based simulation as a teaching tool for residents treating patients with cancer-related pain crises.

CONTEXT: Residents often fail to escalate narcotics to ensure pain relief in patients with cancer because of fear of overdose. A computer simulation of patients in pain may provide a way to improve management without fear of harm. We developed a pain care simulation to train residents. STUDY DESIGN/MEASURES: Thirty-one residents trained on 2 to 3 consecutive simulated patients. Simulated cases were assigned variable tolerances to narcotics and starting pain scores. The goals of training were as follows: (1) rapid induction of pain relief, (2) measurement of pain response at appropriate times, and (3) early institution and escalation in care long-acting pain medication to ensure stable pain control for 48 hours. Seven reviewers judged graphical summaries of care and assessed if pain improved, worsened, or stayed the same. RESULTS: Thirty-one residents participated: 25 completed 3 simulations; 6 completed only 2. Sixty-eight percent improved from case 1 to 2; 90% improved by 3. The average pain score declined from 2.5 in case 1 to 1.9 in case 3 (P = .04). Rescue medication use declined from 37% for the first case to 23% by the third (P = .18). Reviewers' intraclass correlation for improved pain care was 0.821 (95% CI, 0.721-0.895). CONCLUSIONS: Residents improved using a pain treatment simulator. A graphical representation of pain scores more than 48 hours of care that provides a useful way to assess pain control. Lessons learned may translate into improved patient care.

Effects of training on a simulator of pain care on the quality of pain care for patients with cancer-related pain.

CONTEXT: A computer simulator of pain care provided an environment for residents to learn to (1) rapidly induce pain relief; (2) measure pain scores at appropriate time intervals; (3) use induction doses to estimate, early in care, the long-acting pain medication requirements; and (4) escalate long-acting agents to ensure a smooth and nonvarying pain-control curve. We studied whether lessons learned on the simulator translated into improved pain control for patients with cancer-related pain crises. STUDY DESIGN AND MEASURES: We compared pain scores for 48 hours in 2 groups: 20 patients admitted consecutively, solely because of an acute exacerbation of pain, prior to training our residents on a simulator and 20 patients post-training. Training at the beginning of an oncology rotation consisted of education about pain control followed by practice on simulated cases of patients with cancer-related pain crises. Outcome measures were average pain scores compared using linear regression and the frequency of using long-acting agents early in a patient's care. RESULTS: Pain control in the first 48 hours of care improved in the postintervention period; the slope of the pain scores actually increased in the preintervention period and declined in the postintervention period (P < .0005). Residents used long-acting agents early in patients' care in 35% (7/20) in the preperiod and 90% (18/20) in the postperiod (P < .001). CONCLUSIONS: Residents developed pain care treatment skills on a computer-based simulator that translated into improved control of acute, cancer-related pain.

University HealthSystem Consortium quality performance benchmarking study of the insertion and care of central venous catheters.

We report data from an observational benchmarking study of adherence to recommended practices for insertion and maintenance of central venous catheters at a heterogeneous group of academic medical centers. These centers demonstrated a need for significant improvement in implementation and documentation of quality performance measures for the prevention of catheter-related bloodstream infections.