Annual Patient Volume Research Articles

Self-Reported Management of Inflammatory Breast Cancer Among the American Society of Breast Surgeons Membership: Consensus and Opportunities.

Inflammatory breast cancer (IBC) is rare and biologically aggressive. We sought to assess diagnostic and management strategies among the American Society of Breast Surgeons (ASBrS) membership. An anonymous survey was distributed to ASBrS members from March to May 2023. The survey included questions about respondents' demographics and information related to stage III and IV IBC management. Agreement was defined as a shared response by >80% of respondents. In areas of disagreement, responses were stratified by years in practice, fellowship training, and annual IBC patient volume. The survey was administered to 2337 members with 399 (17.1%) completing all questions and defining the study cohort. Distribution of years in practice was 26.0% 0-10 years, 26.6% 11-20 years and 47.4% > 20 years. Overall, 51.2% reported surgical oncology or breast fellowship training, 69.2% maintain a breast-only practice, and 73.5% treat < 5 IBC cases/year. Agreement was identified in diagnostic imaging, trimodal therapy, and mastectomy with wide skin excision for stage III IBC. Lack of agreement was identified in surgical management of the axilla; respondents with < 10 years in practice or fellowship training were more likely to perform axillary dissection for cN0-N2 stage III IBC. Locoregional management of stage IV IBC was variable. Among ASBrS members, there is consensus in diagnostic evaluation, treatment sequencing and surgical approach to the breast in stage III IBC. Differences exist in surgical management of the cN0-2 axilla with uptake of de-escalation strategies. Clinical trials are needed to evaluate oncologic safety of de-escalation in this high-risk population.

The Impact of Hospital Delivery Volumes of Newborns Born Very Preterm on Mortality and Morbidity

To examine if the annual patient volume of infants born very preterm (VPT, gestational age <32weeks) at a hospital is associated with neonatal mortality and morbidity. We performed an observational, secondary data analysis using a 20-year panel of birth certificates linked to hospital discharge abstracts, including transfers in California, Michigan, Missouri, Oregon, Pennsylvania, and South Carolina from 1996 through 2015. The study included all in-hospital VPT deliveries (n=208 261). Study outcomes were in-hospital mortality or serious morbidity (intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, or bronchopulmonary dysplasia), attributed to the hospital of birth. Poisson regression models estimated the risk-adjusted relative risk (RR) for mortality and serious morbidity across different patient volume categories within a given hospital using hospital fixed effects. The risk of mortality and serious morbidity for VPT infants increased as the number of infants born VPT at a hospital decreased. Compared with VPT delivery volumes >100 infants per year, the risk of mortality increased when a given hospital had VPT delivery volumes < 60 per year, ranging from a RR of 1.13 (95% C.I. 1.02-1.25) for volumes between 50 to 59 and 1.39 (1.19-1.62) for VPT volumes <10, and the risk of mortality or serious morbidity increased when a given hospital had VPT volumes <100, ranging from a RR of 1.05 (1.02-1.08) for volumes between 90 to 99 and 1.27 (1.19-1.36) for VPT volumes <10. These results suggest that, for VPT infants, the risk of both mortality and mortality or serious morbidity is increased as the VPT volume within a given hospital declines.

Clinical Practice Guideline Development in Pediatric Emergency Medicine Departments Across the United States: A Cross-sectional Study.

This cross-sectional study aimed to assess the process of clinical practice guideline (CPG) development in pediatric emergency medicine departments (PEDs) across the United States, with a focus on identifying areas for improvement to enhance the quality of CPGs. An electronic survey was distributed to PEDs with pediatric emergency medicine fellowship programs. Respondents were asked about their CPG development processes (ie, guideline committee composition, consideration of conflicts of interest, grading recommendations, guideline training opportunities) based on the Appraisal of Guidelines, Research, and Evaluation (AGREE II) tool as well as implementation and monitoring. Univariate analysis was used to assess associations between the number of AGREE II elements adhered to and annual patient volume. Of the 84 PEDs surveyed, 44 (52.4%) responded, representing institutions from 28 states. Most PEDs (97.7%, n = 43) reported developing their own guidelines, citing the need to improve care quality and standardize patient care as primary reasons. Although most guideline committees included multidisciplinary team members (74.4%, n = 32), routine patient involvement in committees was rare (11.6%, n = 5), and barriers such as time and resource constraints hindered their inclusion. Formal training for committee members in guideline development was uncommon (18.6%, n = 8). There was an association between higher annual patient volume and the number of AGREE II elements adhered to (P = 0.03). Few PEDs considered potential conflicts of interest among committee members (13.6%, n = 6). Over half of surveyed PEDs (54.5%, n = 24) lacked a systematic approach to grading recommendations. Educational materials and workshops were the most common guideline implementation strategies. Our findings highlight need for improvement in the CPG development process in PEDs. Including patients in committees, providing formal training for committee members, and adopting a rigorous approach to grading recommendations are crucial steps toward enhancing guideline quality. Emphasizing these improvements has the potential to improve the quality of CPGs for pediatric emergency care.

The relationship between patient volume and mortality in NSW major trauma service hospitals

IntroductionConventional wisdom is that Major Trauma Services (MTS) treating larger volumes of severe trauma patients will have better outcomes than lower volume centres, but recent studies from Europe have questioned this relationship. We aimed to determine if there is a relationship between patient volume and outcome in New South Wales (NSW) MTS hospitals. Materials and MethodsRetrospective observational study using data from the NSW State Trauma Registry from 2010 to 2019 inclusive. Adult patients with Injury Severity Score >15 transported directly to a NSW MTS were included. Outcome measures were mortality at hospital discharge, and intensive care unit and hospital length of stay. Generalised estimating equation models were created to determine the adjusted relationship between patient volume and the main outcome measures. ResultsThe mean annual patient volume of the MTS ranged from 127.4 to 282.0 patients whilst the observed mortality rates p.a. ranged from 10.4 % to 17.19 %. Multivariate analysis, using low volume MTS as the reference, did not demonstrate a significant difference in mortality between high and low volume MTS (adjusted OR: 1.14 95 % CI: 0.98–1.25, P = 0.087). There was however a significant correlation between volume and length of hospital stay (adjusted β; 0.024, 95 % CI, 0.182 – 1.089, P = 0.006). ConclusionsThere was no mortality difference between high and low volume MTS demonstrated. Length of hospital stay significantly increased with increasing volume however.

Understanding variation in treatment intensification for de novo metastatic castration-sensitive prostate cancer (mCSPC): A population-based cohort study.

69 Background: Treatment intensification using androgen receptor signaling inhibitors (ARSIs) or chemotherapy is guideline-recommended for patients with mCSPC based on improved survival and preserved quality of life. However, numerous studies across jurisdictions have shown relatively limited uptake, with most patients receiving androgen deprivation therapy (ADT) monotherapy. Therefore, we sought to understand patient, physician, and tumor characteristics associated with treatment intensification. Methods: This population-based cohort study in Ontario, Canada included older men (age ≥66 years) diagnosed with de novo mCSPC between Jan 2014 and Nov 2021 for whom the ADT-prescribing physician could be identified (&gt;99.5% of all mCSPC patients). We used hierarchical regression modelling to assess the association (presented as odds ratio, OR) between patient sociodemographic characteristics and comorbidities, tumor characteristics, and physician characteristics with receipt of intensified treatment for mCSPC, defined as receipt of an ARSI, docetaxel, or both within 6mo. We used Darlington’s method to assess the relative importance of these predictors (presented as standardized regression coefficients, SRC). Results: Among 4450 eligible older men newly diagnosed with de novo mCSPC, 18.8% received treatment intensification, with rates increasing from 6.3% in 2014 to 31.9% by 2021. In multivariable modeling, patient age was the most influential variable, with older patients significantly less likely to receive treatment intensification (SRC -43.8, OR 0.91, 95% CI 0.90-0.92). Socioeconomic status (SRC -12.2; OR 0.54, 95% CI 0.33-0.88 for quintile 1 vs 5) and a history of stroke (SRC -11.5, OR 0.28, 95% CI 0.09-0.86), but no other patient factors including comorbidity, were significantly associated with intensification. Patients prescribed ADT for mCSPC by radiation oncologists were less likely to receive intensification (SRC -16.5; OR 0.47, 95% CI 0.23-0.95) compared to other providers without significant differences between patients treated by urologists, medical oncologists, or other physicians. No other physician-level characteristic (age, sex, years in practice, or annual volume of prostate cancer patients) was associated with treatment intensification. More contemporary year of diagnosis was also strongly predictive (mean SRC 31.2) of intensification. We noted significant geographic variation (mean SRC 10.2; p&lt;0.0001), that could not be explained by rurality (p=0.08) and persisted after adjustment for socioeconomic status and patient characteristics. Conclusions: Patient, disease, and physician characteristics contribute to variation in treatment intensification for mCSPC. These data may allow focused intervention to improve guideline-concordant care for patients with mCSPC.

Abstract TP65: Mastering the Art of Herding Cats: Unraveling the Methods of Effective Communication in a Growing Stroke Program

Background: Since becoming a Comprehensive Stroke Center in 2008, our annual stroke patient volume doubled, and intervention volume grew nearly 6-fold. The program achieved multiple milestones over this time, transitioning from a combined ICU-progressive care unit to separate specialized units, and later relocating to a new facility with a dedicated Neuro ICU and two progressive care units. As the program expanded, innovative communication techniques and processes were adopted to accommodate the growing staff and infrastructure. Methods: The development and dissemination of intervention reports to stakeholders from each stroke case heightened awareness of time goals and fostered collaboration. Effective communication was further facilitated through the development of a SharePoint site, newsletter, and electronic handbook. Strategically designed dashboards provided crucial data on volumes, diversion, and treatment times. QR codes were introduced for convenient data and research request access. Moreover, detailed electronic follow-up reports facilitated external collaboration with referring facilities. Results: Embracing electronic communication enhanced information sharing, improving our team’s grasp of program data, outcomes, launches, and outreach initiatives. The monthly newsletter achieved a 60% open rate, contributing to nearly 5,000 SharePoint site visits. Monthly intervention reports to stroke team responders heightened time goal awareness, fostering collaboration, improving documentation, and reducing the need for case delay documentation clarification. Sending an average of 71 follow-up reports monthly to referring hospitals and EMS agencies strengthened external partnerships. Moreover, leveraging social media amplified community outreach for stroke education. Conclusion: We have found electronic communication to be successful for our growing program. To enhance engagement and accommodate diverse learners, we recommend utilizing a range of methods, including visuals, quizzes, and interactive content. Future plans involve expanding communication strategies with emerging techniques and conducting a formal analysis to assess stakeholders' comprehension of shared information in stroke care.

Left Without Being Seen: Nurse Work Environment and Timely Outcomes in New York and Illinois Emergency Departments

IntroductionThis study determined the relationship between the emergency nurse work environment and emergency department patient left without being seen rates and lengths of stay. MethodsCross-sectional analysis of 215 New York and Illinois emergency departments. The work environment (abbreviated Practice Environment Scale of the Nursing Work Index) was measured by emergency nurses in the 2021 RN4CAST-NY/IL survey and linked with outcomes from Hospital Compare. Regression models estimated the relationship between the nurse work environment and emergency department patient left without being seen rates, median length of stay (in minutes), and median behavioral health patient length of stay. Model coefficients were used to estimate expected additional care minutes gained if emergency department work environments improved. Results“Mixed” work environments had the longest median overall length of stay (3.4 hours) and the highest median left without being seen rates (2.2%), while “poor” work environments had the longest median length of stay for behavioral health patients (6 hours). Improving the emergency department work environment from poor to mixed (and mixed to better) was associated with a 13-minute reduction in overall length of stay (P ≤ .05), a 33-minute reduction in behavioral health length of stay (P ≤ .01), and a 19% reduction in left without being seen rates (P ≤ .01). We estimated 11,824 to 41,071 additional patients could be seen in emergency departments associated with work environment improvements from “poor” to “better,” depending on annual patient volumes. DiscussionHospital administrators should consider investing in nurse work environments as a foundation to improve timely outcomes.

Care Patterns and Barriers to Outpatient Care for Adults with Acute Myeloid Leukemia (AML) Following Intensive Chemotherapy at National Comprehensive Cancer Network (NCCN) Institutions

Background: Prolonged hospitalization following intensive (re)induction chemotherapy until resolution of cytopenias is the current standard of care for adults with acute myeloid leukemia (AML), but this approach is costly, resource intense, contributory to hospital bed shortages, and negatively impacts patients' quality of life (QOL). Early hospital discharge (EHD) immediately following completion of chemotherapy has been proposed as an alternative and has proven safe at select institutions. Here, we conducted a National Comprehensive Cancer Center (NCCN) survey, through its Best Practices Committee (BPC), to examine discharge practices for adults with AML at other major cancer centers to better understand interest in, and barriers to, adopting an EHD approach more broadly. Methods: NCCN is a non-profit alliance of 33 cancer centers in the U.S. The survey was developed by 2 physicians at one center and piloted at 2 other centers. The NCCN BPC, which is composed of senior physician, nursing, and administrative leaders from NCCN Member Institutions, distributed the survey in early 2023 via a web-based survey tool (SurveyMonkey, San Mateo, CA) to a representative at each center, requesting completion by a content area expert. No incentives were offered for completion. Data were analyzed using descriptive statistics. Results: 30/33 (91%) centers completed the survey, 60% of which treat &amp;gt;100 AML patients annually and 45% treat over half of their patients with intensive chemotherapy (7+3 or regimens with a high-dose cytarabine backbone). All centers perform allogeneic hematopoietic cell transplantations (HCT). There was no difference in the proportion of intensively treated patients across centers by patient volume. Following (re)induction therapy, 80% of institutions keep patients hospitalized until blood count recovery, whereas 20% attempt to discharge patients early if medically stable and logistics permit. Concerns regarding patient safety, housing, and caregiver availability were the main reasons for keeping patients hospitalized ( Figure 1). In contrast, following post-remission (“consolidation”) therapy, 87% of centers discharge patients early. Concerns regarding increased care needs, worse functional status, and higher complications risks following induction relative to post-remission therapy accounted for the main reasons for this difference ( Figure 2). 80% of centers were interested in exploring EHD after (re)induction but noted barriers including affordable local housing (71%), transportation (50%), high toxicity/infection rate (50%), high transfusion burden (50%) and limited bed availability when re-hospitalization is necessary (50%). Among the 6 centers that practice EHD, all have infusion centers with full weekday hours, 5 have full weekend/holiday hours, 3 more have evening hours, and 1 has reduced holiday/weekend hours. All can provide blood product support within 4 hours from ordering and administer IV antimicrobials within 1 hour from ordering in outpatient clinic. In 4 centers, evaluation of a patient with presumed neutropenia contacting the clinic with fever during regular hours can occur in the outpatient clinic, with subsequent admission if necessary; at one center the patient would be referred to the ED and at one center the patient would be directly admitted to an inpatient ward. If a patient needs admission, a bed would be available for direct admission to the inpatient ward in 4/6 of the centers &amp;gt;75% of the time, at 1 center 26-50% of the time, and at 1 center &amp;lt;25% of the time. EHD was not practiced at any centers in cities with population of &amp;gt;1 million, citing local housing availability as a major EHD barrier. There was no correlation between the ability to practice EHD and annual AML patient volume, treatment intensity patterns, or hospitalization practices following HCT. Conclusions: Hospitalization and care patterns following AML therapy are highly variable across major U.S. cancer institutions. While only 20% of major cancer centers surveyed practice EHD following intensive (re)induction chemotherapy, 87% do so following post-remission therapy. There is interest in exploring this approach despite medical and logistical barriers. Given potential advantages of EHD for both patients and healthcare systems, strategies to address these barriers should be explored to reduce healthcare resource utilization and improve patients' QOL.

2954. Coordinated Antimicrobial Stewardship Efforts to Produce Sustained Reductions in Outpatient Fluoroquinolone Consumption

Abstract Background Starting in 2020, antimicrobial stewardship efforts were coordinated to reduce outpatient consumption of FQs prescribed in 20 urgent care centers (UCCs) throughout a not-for-profit healthcare system. Coordinated efforts included clinician education on FQ treatment alternatives and direct prescriber audit and feedback in specific cases. Additionally, a shorter duration of a FQ regimen was introduced in automated pharmacy dispensing machines located throughout the UCCs. The study's objective was to assess if these coordinated efforts resulted in sustained reductions in FQ consumption several years after implementation. Automated Pharmacy Dispensing Machine Example of an automated pharmacy dispensing machine found in UCCs throughout the healthcare system. Each machine contains frequently prescribed outpatient regimens for antibiotics, analgesics, antihistamines, and more. In cases where a patient is prescribed a stocked regimen, the machine is able to safely and conveniently dispense the medication prior to the patient leaving the UCC. Literature has shown automated pharmacy dispensing machines can promote patient medication adherence. Methods The Cerner Discern Reporting Portal was used to generate FQ electronic prescription (eRx) data during 2019 (pre-intervention) and 2022 (post-intervention) to assess any potential sustained impact of the targeted interventions from 2020. The primary endpoint was a 10% reduction in total FQ eRx count, total FQ days of therapy (DOT), and median FQ DOT per monthly UCC patient volume compared to the pre-intervention period. UCC monthly patient volume was used to standardize days of therapy comparisons among the pre-intervention and post-intervention periods. Total calendar-year FQ DOT was assessed by summing up monthly values. The secondary endpoint was a median monthly FQ eRx count of less than 550 in the post-intervention period. Continuous data were analyzed using an unpaired t-test. Institutional Review Board approval was granted. Results Total UCC annual patient volume was 337,941 in 2019 and 285,865 in 2022. Total FQ eRx count decreased from 7,214 in 2019 to 3,883 in 2022 (46% reduction, p=&amp;lt; 0.0001). The total FQ DOT in the calendar year decreased from 58,761 days in the pre-intervention period to 29,578 days in the post-intervention period (50% reduction, p=&amp;lt; 0.0001). Median monthly DOT per UCC patient volume decreased from 176 days per UCC monthly volume in 2019 to 106 days per UCC monthly volume in 2022 (40% reduction, p=&amp;lt; 0.0001). The median monthly FQ eRx count in 2022 was 318 which was substantially below our target of 550 and the median count of 602 in 2019. Conclusion Coordinated antimicrobial stewardship efforts in urgent care centers to reduce outpatient FQ consumption had a sustained impact following intervention implementation. Disclosures Timothy P. Gauthier, PharmD, BCPS, BCIDP, American Pharmacist Association: Honoraria|Belmont University CME Office: Honoraria|Compact: Honoraria|European Society for Clinical Microbiology and Infectious Diseases: Honoraria|Ferring Pharma: Advisor/Consultant|Firstline Mobile Health: Advisor/Consultant|Florida Society of Health-System Pharmacists: Honoraria|Gilead Biosciences: Advisor/Consultant|GlaxoSmithKline Inc.: Advisor/Consultant|Learn Antibiotics and IDstewardship.com: Owner of all published content|Learn Antibiotics and IDstewardship.com: Owner|Learn Antibiotics and IDstewardship.com: Ownership Interest|Melinta Therapuetics: Advisor/Consultant|Pattern Bioscience: Advisor/Consultant|Pfizer, Inc.: Advisor/Consultant

Taking Shared Decision Making from Concept to Clinical Practice: What Do Sickle Cell Healthcare Providers Need?

Introduction:The landscape of therapies for sickle cell disease (SCD) is rapidly evolving. While hydroxyurea remains the gold standard treatment, since 2017 the FDA has approved three additional drugs (i.e., L-glutamine, voxelotor, crizanlizumab), and many others are under investigation. Thus, new therapies and multi-agent treatment approaches for SCD are on the horizon, along with increasingly complex treatment decisions for patients, caregivers, and clinicians. Best practice SCD guidelines recommend shared decision making (SDM; NHLBI, 2014) and SCD patients and caregivers strongly prefer a SDM approach when considering disease-modifying therapies (Jabour et al., 2019; Ross et al., 2016). SDM is a collaborative process in which patients, caregivers, and clinicians work in partnership to reach healthcare decisions based on scientific evidence and the patient's/caregiver's values, preferences, and treatment goals (Stiggelbout et al., 2012). SDM enhances patient and parent knowledge, engagement in the decision making process, and satisfaction with care (Stacey et al., 2014; Wyatt et al., 2015) and is particularly beneficial for marginalized groups (Durand et al., 2014). Evidence also suggests positive impacts of SDM on more distal outcomes, including adherence to the selected treatment (Hauser et al., 2015; Joosten et al., 2008) and health outcomes (Hauser et al., 2015; Tapp et al., 2017). However, few tools are available to facilitate SDM for SCD therapies (Crosby et al., 2019), and most healthcare providers who care for youth with SCD have not had specific training in SDM (Yawn et al., 2014). This study examined clinician perspectives on resources needed to foster SDM in the context of disease-modifying treatment decisions for SCD. Methods:SCD providers were recruited from across the United States using maximum variation purposeful sampling to ensure diversity in provider characteristics (age, sex, race, discipline, years in profession) and clinics (region, patient volume). After electronic consent, providers completed a demographics survey and joined a private online “crowd” on Slack. There were five waves of data collection; during each wave, a series of 4-5 questions were posed to the crowd. Providers were paid for each question they answered and encouraged to view and respond to others' posts. Thematic content analysis was used to summarize perspectives on resources needed to help healthcare providers better engage patients and caregivers in SDM for sickle cell therapies. Two raters independently coded each provider's responses; coding discrepancies were resolved via group discussion to consensus. Results:Of the 59 SCD providers who enrolled, approximately two-thirds were female (67%) and 61% were White; the remainder of the sample identified as Asian (20%), Black or African American (10%), or Middle Eastern (3%). Most were non-Hispanic or Latino (95%). Providers included physicians (73%), nurse practitioners or advanced practice nurses (22%), and nurses (5%) with a wide range of years in practice (2 - 57, M=12.8, SD=10.6). Providers were employed at care centers serving pediatric patients (37%), adult patients (29%), or both pediatric and adult patients with SCD (34%), with annual patient volume ranging from 16 to 2200 (M=420.5, SD=405.1). Across the waves of data collection, response rates ranged from 53-59%. These clinicians identified five resources necessary to optimize SDM for disease-modifying therapies: 1) well-staffed multidisciplinary care teams; 2) high quality patient education materials; 3) billing and reimbursement policies that incentivize SDM; 4) resources to address social determinants of health barriers; and, 5) peer mentoring and support programs for patients. See Table 1 for illustrative quotes. Conclusions:Providers identified several supports and resources to facilitate SDM with individuals with SCD. Findings from this study will inform the development of a multi-component SDM intervention, including decision support tools for patients, caregivers, and healthcare providers and clinic-based implementation tools. Acknowledgements: This research was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number P20GM109021. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

A national survey on the medical physics workload of external beam radiotherapy in Japan†.

Several staffing models are used to determine the required medical physics staffing, including radiotherapy technologists, of radiation oncology departments. However, since Japanese facilities tend to be smaller in scale than foreign ones, those models might not apply to Japan. Therefore, in this study, we surveyed workloads in Japan to estimate the optimal medical physics staffing in external beam radiotherapy. A total of 837 facilities were surveyed to collect information regarding radiotherapy techniques and medical physics specialists (RTMPs). The survey covered facility information, staffing, patient volume, equipment volume, workload and quality assurance (QA) status. Full-time equivalent (FTE) factors were estimated from the workload and compared with several models. Responses were received from 579 facilities (69.2%). The median annual patient volume was 369 at designated cancer care hospitals (DCCHs) and 252 across all facilities. In addition, the median FTE of RTMPs was 4.6 at DCCHs and 3.0 at all sites, and the average QA implementation rate for radiotherapy equipment was 69.4%. Furthermore, advanced treatment technologies have increased workloads, particularly in computed tomography simulations and treatment planning tasks. Compared to published models, larger facilities (over 500 annual patients) had a shortage of medical physics staff. In very small facilities (about 140 annual patients), the medical physics staffing requirement was estimated to be 0.5 FTE, implying that employing a full-time medical physicist would be inefficient. However, ensuring the quality of radiotherapy is an important issue, given the limited number of RTMPs. Our study provides insights into optimizing staffing and resource allocation in radiotherapy departments.

Modelling of intensive care unit (ICU) length of stay as a quality measure: a problematic exercise

BackgroundIntensive care unit (ICU) length of stay (LOS) and the risk adjusted equivalent (RALOS) have been used as quality metrics. The latter measures entail either ratio or difference formulations or ICU random effects (RE), which have not been previously compared.MethodsFrom calendar year 2016 data of an adult ICU registry-database (Australia & New Zealand Intensive Care Society (ANZICS) CORE), LOS predictive models were established using linear (LMM) and generalised linear (GLMM) mixed models. Model fixed effects quality-metric formulations were estimated as RALOSR for LMM (geometric mean derived from log(ICU LOS)) and GLMM (day) and observed minus expected ICU LOS (OMELOS from GLMM). Metric confidence intervals (95%CI) were estimated by bootstrapping; random effects (RE) were predicted for LMM and GLMM. Forest-plot displays of ranked quality-metric point-estimates (95%CI) were generated for ICU hospital classifications (metropolitan, private, rural/regional, and tertiary). Robust rank confidence sets (point estimate and 95%CI), both marginal (pertaining to a singular ICU) and simultaneous (pertaining to all ICU differences), were established.ResultsThe ICU cohort was of 94,361 patients from 125 ICUs (metropolitan 16.9%, private 32.8%, rural/regional 6.4%, tertiary 43.8%). Age (mean, SD) was 61.7 (17.5) years; 58.3% were male; APACHE III severity-of-illness score 54.6 (25.7); ICU annual patient volume 1192 (702) and ICU LOS 3.2 (4.9). There was no concordance of ICU ranked model predictions, GLMM versus LMM, nor for the quality metrics used, RALOSR, OMELOS and site-specific RE for each of the ICU hospital classifications. Furthermore, there was no concordance between ICU ranking confidence sets, marginal and simultaneous for models or quality metrics.ConclusionsInference regarding adjusted ICU LOS was dependent upon the statistical estimator and the quality index used to quantify any LOS differences across ICUs. That is, there was no “one best model”; thus, ICU “performance” is determined by model choice and any rankings thereupon should be circumspect.

The elderly population are more vulnerable for the management of colorectal cancer during the COVID-19 pandemic: a nationwide, population-based study.

The impact of coronavirus disease 2019 (COVID-19) on the management of colorectal cancer (CRC) may worse in elderly population, as almost all COVID-19 deaths occurred in the elderly patients. This study aimed to evaluate the impact of COVID-19 on CRC management in the elderly population. The numbers of patients who underwent colonoscopy, who visited hospitals or operated for CRC in 2020 and 2021 (COVID-19 era) were compared with those in 2019, according to 3 age groups (≥70 years, 50-69 years, and ≤49 years), based on the nationwide, population-based database (2019-2021) in South Korea. The annual volumes of colonoscopy and hospital visits for CRC in 2020 were more significantly declined in the old age group than in the young age group (both P<0.001). In addition, the annual volume of patients operated for CRC numerically more declined in old age group than in young age group. During the first surge of COVID-19 (March and April 2020), old age patients showed statistically significant declines for the monthly number of colonoscopies (-46.5% vs. -39.3%, P<0.001), hospital visits (-15.4% vs. -7.9%, P<0.001), CRC operations (-33.8% vs. -0.7%, P<0.05), and colonoscopic polypectomies (-41.8% vs. -38.0%, P<0.001) than young age patients, compared with those of same months in 2019. Elderly population are more vulnerable for the management of CRC during the COVID-19 pandemic. Therefore, the elderly population are more carefully cared for in the management of CRC during the next pandemic.

Association Between Emergency Medical Service Agency Volume and Mortality in Trauma Patients.

The aim of this study was to evaluate the association of annual trauma patient volume on outcomes for emergency medical services (EMS) agencies. Regionalization of trauma care saves lives. The underlying concept driving this is a volume-outcome relationship. EMS are the entry point to the trauma system, yet it is unknown if a volume-outcome relationship exists for EMS. A retrospective analysis of prospective cohort including 8 trauma centers and 20 EMS air medical and metropolitan ground transport agencies. Patients 18 to 90 years old with injury severity scores ≥9 transported from the scene were included. Patient and agency-level risk-adjusted regression determined the association between EMS agency trauma patient volume and early mortality. A total of 33,511 were included with a median EMS agency volume of 374 patients annually (interquartile range: 90-580). Each 50-patient increase in EMS agency volume was associated with 5% decreased odds of 6-hour mortality (adjusted odds ratio=0.95; 95% CI: 0.92-0.99, P =0.03) and 3% decreased odds of 24-hour mortality (adjusted odds ratio=0.97; 95% CI: 0.95-0.99, P =0.04). Prespecified subgroup analysis showed EMS agency volume was associated with reduced odds of mortality for patients with prehospital shock, requiring prehospital airway placement, undergoing air medical transport, and those with traumatic brain injury. Agency-level analysis demonstrated that high-volume (>374 patients/year) EMS agencies had a significantly lower risk-standardized 6-hour mortality rate than low-volume (<374 patients/year) EMS agencies (1.9% vs 4.8%, P <0.01). A higher volume of trauma patients transported at the EMS agency level is associated with improved early mortality. Further investigation of this volume-outcome relationship is necessary to leverage quality improvement, benchmarking, and educational initiatives.

Pediatric emergency care coordinator workforce: A survey study.

The appointment of pediatric emergency care coordinators (PECC) in emergency departments (EDs) enhances pediatric readiness, yet little is understood regarding this workforce. We describe PECC role characteristics, responsibilities, barriers, and threats to the role among a national cohort. We surveyed a sample of PECCs from all regions of the United States who participated in the Emergency Medical Services for Children PECC Workforce and Trauma Collaboratives (2021-2022). EDs were categorized by annual pediatric patient volume: low (<1800), medium (1800-4999), medium-high (5000-9999), and high (≥10,000). Trend tests were performed to explore the relationship between pediatric volume and PECC characteristics. Among 187 PECCs, 114 (61.0%) responded. The majority (75.2%) identified as a nurse. There was a significant difference in median hours per week spent on PECC activities by pediatric volume ranging from a median of 2 hours (interquartile range [IQR] 0.0-2.3) for low pediatric volume to 16 hours (IQR 4.0-37.0) for high pediatric volume (P<0.001). Most respondents reported more time was needed for PECC activities (58.4%), and desired additional training to support the role (70.8%). Most (74.6%) felt the PECC position should be paid, yet 30.7% reported the role was voluntary. The most frequently assigned responsibilities were education of staff (77.2%) and oversight of quality improvement (QI) efforts (72.8%). Characteristics of PECC workforce vary but PECC activities of education and QI work are common among all. There is a reported need for additional training and support. Further studies will determine the impact of PECC characteristics on pediatric readiness.

Mortality of necrotizing enterocolitis does not vary across tertiary care children's hospitals

ObjectiveNecrotizing enterocolitis (NEC) continues to have high surgical mortality despite progressive regionalization to children's hospitals. It is unclear whether outcomes for patients with NEC undergoing surgery vary depending on volume of these children's hospitals. This study aimed to examine the relationship between operative outcomes and a hospital's overall NEC patient volume, as well as operative volume for NEC across children's hospitals. MethodsA retrospective, cross sectional analysis was performed using the Pediatric Health Information System (PHIS). NEC patients were identified using ICD-10 codes from 2016-2021. Two hospital volume metrics were used: annual volume of NEC patients treated in the NICU, and annual volume of NEC patients undergoing surgery. Primary outcome was mortality and secondary outcome was complication. Regression models were estimated to determine the association between each volume metric and patient outcomes. ResultsA total of 1780 children who had surgery for NEC from 47 tertiary children's hospitals were included. Overall mortality rate was 23.3%. Median overall and surgical NEC patient volume per hospital were 53 [IQR 41-65] and 11 [IQR 7-16], respectively. A chi-squared test comparing mortality to volume metrics for total NEC volume, and surgical NEC volume showed no significant associations (p=0.07, p=0.74). Simple logistic regression demonstrated total NEC patient volume to have best fit with mortality outcome. ConclusionNo statistically significant association was found between the two volume metrics and discharge mortality. This lack of association suggests that the volume in these tertiary children's hospitals may be higher than the threshold for optimized outcomes. Level of EvidenceIII

The effect of patient volume on mortality and morbidity of extremely low birth weight infants in Taiwan

To assess whether the number of extremely low birth weight (ELBW) infants treated annually in neonatal intensive care units (NICUs) in Taiwan affects the mortality and morbidity of this patient population. This retrospective cohort study included preterm infants with ELBW (≤1000g). NICUs were divided into three subgroups according to the annual admissions of ELBW infants (low, ≤10; medium, 11-25; and high, >25). Perinatal characteristics, mortality, and short-term morbidities were compared between groups. A total of 1945 ELBW infants from 17 NICUs were analyzed (low-volume, n=263; medium-volume, n=420; and high-volume, n=1262). After risk adjustments, infants from NICUs with low patient volumes were at a higher risk of death. The risk-adjusted odds ratios (aOR) for mortality were 0.61 (95% CI, 0.43-0.86) in the high-volume NICUs and 0.65 (95% CI, 0.43-0.98) in medium-volume NICUs, compared with infants admitted to low-volume NICUs. Infants in medium-volume NICUs had the lowest incidence of prenatal steroid exposure (58.1%, P<0.001) and were associated with the highest risk of necrotizing enterocolitis (aOR, 2.35 [95% CI, 1.48-3.72]), severe intraventricular hemorrhage (aOR, 1.55 [95% CI, 1.01-2.28]), and bronchopulmonary dysplasia (aOR, 1.61 [95% CI, 1.10-2.35]). However, survival without major morbidity did not differ between the groups. The mortality risk was higher among ELBW infants admitted to NICUs with a low annual patient volume. This may emphasize the importance of systematically referring patients from these vulnerable populations to appropriate care settings.

Radiation Therapy Use in Refractory and Relapsed Adolescent and Young Adult Hodgkin Lymphoma: A Report from the Children's Oncology Group

Clear indications do not exist for consolidative radiotherapy (CRT) in relapsed and refractory pediatric Hodgkin lymphoma (rrpHL). Increasing numbers of rrpHL patients are radiation naïve, as response-adapted front-line therapies omit CRT for favorable responses. We evaluated practice patterns among treating oncologists for rrpHL. A survey developed by pediatric and radiation oncologists was distributed to Children's Oncology Group (COG) Hodgkin Lymphoma Committee members during the Fall 2021 COG meeting. Questions ascertained respondent specialty and annual rrpHL patient volumes. Respondents provided treatment recommendations for two cases. Case 1: 21-year-old female with stage IIB bulky mediastinal HL treated with ABVDx6 without initial radiotherapy with neck and mediastinal relapse and Deauville 4 (D4) response after 2 second-line chemotherapies. Case 1 was modified (modCase1) to a D2 response after second-line therapy. Case 2: 21-year-old female with non-bulky stage IIB disease treated with ABVDx6 without initial radiotherapy with splenic, mediastinal, and neck relapse and D4 activity in those sites after 2 second-line therapies. Descriptive statistics are presented. 20 (83%) pediatric hematologist/oncologists and 4 (17%) radiation oncologists completed the survey. After autologous stem cell transplant (ASCT) for Case 1, 58% recommended CRT followed by brentuximab vedotin (Bv) maintenance and 33% recommended involved-site radiotherapy (ISRT) alone. For modCase1, 63% would consider CRT instead of ASCT. With ASCT, 21% would recommend CRT to bulk and 38% to all sites at initial relapse. After ASCT for Case 2, 75% recommended ISRT followed by Bv and 17% ISRT alone. In a sample of predominantly pediatric-oncologist COG members, most respondents considered that CRT has a role for patients with radiation-naive rrpHL both for groups with D4 disease as well as D2 disease pre-ASCT.

Higher center volume is significantly associated with lower mortality in trauma patients with shock

IntroductionInjured patients presenting in shock are at high risk of mortality despite numerous efforts to improve resuscitation. Identifying differences in outcomes among centers for this population could yield insights to improve performance. We hypothesized that trauma centers treating higher volumes of patients in shock would have lower risk-adjusted mortality. MethodsWe queried the Pennsylvania Trauma Outcomes Study from 2016 to 2018 for injured patients ≥16 years of age at Level I&II trauma centers who had an initial systolic blood pressure (SBP) of <90 mmHg. We excluded patients with critical head injury (abbreviated injury score [AIS] head ≥5) and patients coming from centers with a shock patient volume of ≤10 for the study period. The primary exposure was tertile of center-level shock patient volume (low, medium, or high volume). We compared risk-adjusted mortality by tertile of volume using multivariable Cox proportional hazards model incorporating age, injury severity, mechanism, and physiology. ResultsOf 1,805 included patients at 29 centers, 915 (50.7%) died. The median annual shock trauma patient volume was 9 patients for low volume centers, medium 19.5, and high 37. Median ISS was higher at high volume compared to low volume centers (22 vs 18, p <0.001). Raw mortality was 54.9% at high volume centers, 46.7% for medium, and 42.9% for low. Time elapsed from arrival to emergency department (ED) to the operating room (OR) was lower at high volume than low volume centers (median 47 vs 78 min) p = 0.003. In adjusted analysis, hazard ratio for high volume centers (referenced to low volume) was 0.76 (95% CI 0.59–0.97, p = 0.030). ConclusionAfter adjusting for patient physiology and injury characteristics, center-level volume is significantly associated with mortality. Future studies should seek to identify key practices associated with improved outcomes in high-volume centers. Furthermore, shock patient volume should be considered when new trauma centers are opened.

Impact of the COVID-19 pandemic on critical care utilization in Japan: a nationwide inpatient database study

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has disrupted critical care services worldwide. Examining how critical care systems responded to the COVID-19 pandemic on a national level will be useful in setting future critical care plans. The present study aimed to describe the utilization of critical care services before and during the COVID-19 pandemic using a nationwide Japanese inpatient administrative database.MethodsAll patients admitted to an intensive care unit (ICU) or a high-dependency care unit (HDU) from February 9, 2019, to February 8, 2021, in the Japanese Diagnosis Procedure Combination inpatient database were included. February 9, 2020, was used as the breakpoint separating the periods before and during COVID-19 pandemic. Hospital and patient characteristics were compared before and during the COVID-19 pandemic. Change in ICU and HDU bed occupancy before and during the COVID-19 pandemic was evaluated using interrupted time-series analysis.ResultsThe number of ICU patients before and during the COVID-19 pandemic was 297,679 and 277,799, respectively, and the number of HDU patients was 408,005 and 384,647, respectively. In the participating hospitals (383 ICU-equipped hospitals and 460 HDU-equipped hospitals), the number of hospitals which increased the ICU and HDU beds capacity were 14 (3.7%) and 33 (7.2%), respectively. Patient characteristics and outcomes in ICU and HDU were similar before and during the COVID-19 pandemic except main etiology for admission of COVID-19. The mean ICU bed occupancy before and during the COVID-19 pandemic was 51.5% and 47.5%, respectively. The interrupted time-series analysis showed a downward level change in ICU bed occupancy during the COVID-19 pandemic (− 4.29%, 95% confidence intervals − 5.69 to − 2.88%), and HDU bed occupancy showed similar trends. Of 383 hospitals with ICUs, 232 (60.6%) treated COVID-19 patients in their ICUs. Their annual hospital case volume of COVID-19 ICU patients varied greatly, with a median of 10 (interquartile range 3–25, min 1, max 444).ConclusionsThe ICU and HDU bed capacity did not increase while their bed occupancy decreased during the COVID-19 pandemic in Japan. There was no change in clinicians’ decision-making to forego ICU/HDU care for selected patients, and there was no progress in the centralization of critically ill COVID-19 patients.