Abstract
Despite its efficacy, low tidal volume ventilation (LTVV) remains severely underutilized for patients with acute respiratory distress syndrome (ARDS). Physician under-recognition of ARDS is a significant barrier to LTVV use. We propose a computational method that addresses some of the limitations of the current approaches to automated measurement of whether ARDS is recognized by physicians. To quantify patient and physician factors affecting physicians' tidal volume selection and to build a computational model of physician recognition of ARDS that accounts for these factors. In this cross-sectional study, electronic health record data were collected for 361 ARDS patients and 388 non-ARDS hypoxemic (control) patients in nine adult intensive care units at four hospitals between June 24 and December 31, 2013. Standardized tidal volumes (mL/kg predicted body weight) were chosen as a proxy for physician decision-making behavior. Using data-science approaches, we quantified the effect of eight factors (six severity of illness, two physician behaviors) on selected standardized tidal volumes in ARDS and control patients. Significant factors were incorporated in computational behavioral models of physician recognition of ARDS. Hypoxemia severity and ARDS documentation in physicians' notes were associated with lower standardized tidal volumes in the ARDS cohort. Greater patient height was associated with lower standardized tidal volumes (which is already normalized for height) in both ARDS and control patients. The recognition model yielded a mean (99% confidence interval) physician recognition of ARDS of 22% (9%-42%) for mild, 34% (19%-49%) for moderate, and 67% (41%-100%) for severe ARDS. In this study, patient characteristics and physician behaviors were demonstrated to be associated with differences in ventilator management in both ARDS and control patients. Our model of physician ARDS recognition measurement accounts for these clinical variables, providing an electronic approach that moves beyond relying on chart documentation or resource intensive approaches.
Highlights
Despite a broad consensus on the virtues of translating evidence into clinical practice, adoption of evidence-based practices remains slow.[1,2] The use of low tidal volume ventilation (LTVV) for the treatment of acute respiratory distress syndrome (ARDS) is a prime example
Greater patient height was associated with lower standardized tidal volumes in both ARDS and control patients
Patient characteristics and physician behaviors were demonstrated to be associated with differences in ventilator management in both ARDS and control patients
Summary
Despite a broad consensus on the virtues of translating evidence into clinical practice, adoption of evidence-based practices remains slow.[1,2] The use of low tidal volume ventilation (LTVV) for the treatment of acute respiratory distress syndrome (ARDS) is a prime example. [8] Despite this substantial evidence, LTVV use in clinical practice remains as low as 19%.[9,10,11,12,13,14,15,16,17] Several studies have examined the barriers to LTVV use, including the primary role of physician under-recognition of ARDS.[3,6,10,12,13,14,15,16,17,18,19,20] the identification of these barriers has not led to a substantial increase in LTVV use, suggesting a need for further investigation ARDS is a syndrome of severe acute hypoxemia and non-cardiogenic inflammatory lung injury with high prevalence (10% of intensive care unit (ICU) admissions) and mortality (35– 46%).[3,4,5,6] In the 2000 ARDS Network trial, it was shown that lowering the volume of each breath–i.e. using LTVV—is an effective therapy for ARDS, with a relative mortality reduction of 20–25%[7]; since LTVV has become recommended practice for the management of ARDS. [8] Despite this substantial evidence, LTVV use in clinical practice remains as low as 19%.[9,10,11,12,13,14,15,16,17] Several studies have examined the barriers to LTVV use, including the primary role of physician under-recognition of ARDS.[3,6,10,12,13,14,15,16,17,18,19,20] the identification of these barriers has not led to a substantial increase in LTVV use, suggesting a need for further investigation
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