Reduction In Odds Of Death Research Articles

Sepsis mortality among patients with haematological malignancy admitted to intensive care 2000–2022: a binational cohort study

BackgroundSepsis occurs in 12–27% of patients with haematological malignancy within a year of diagnosis. Sepsis mortality has improved in non-cancer patients in the last two decades, but longitudinal trends in patients with haematological malignancy are not well characterised. We aimed to compare outcomes, including temporal changes, in patients with and without a haematological malignancy admitted to ICU with a primary diagnosis of sepsis in Australia and New Zealand over the past two decades.MethodsWe performed a retrospective cohort study of 282,627 patients with a primary intensive care unit (ICU) admission diagnosis of sepsis including 17,313 patients with haematological malignancy, admitted to 216 intensive care units (ICUs) in Australia or New Zealand between January 2000 and December 2022. Annual crude and adjusted in-hospital mortality were reported. Risk factors for in-hospital mortality were determined using a mixed methods logistic regression model and were used to calculate annual changes in mortality.ResultsIn-hospital sepsis mortality decreased in patients with haematological malignancy, from 55.6% (95% CI 46.5–64.6%) in 2000 to 23.1% (95% CI 20.8–25.5%) in 2021. In patients without haematological malignancy mortality decreased from 33.1% (95% CI 31.3–35.1%) to 14.4% (95% CI 13.8–14.8%). This decrease remained significant after adjusting for mortality predictors including age, SOFA score and comorbidities, as estimated by adjusted annual odds of in-hospital death. The reduction in odds of death was of greater magnitude in patients with haematological malignancy than those without (OR 0.954, 95% CI 0.947–0.961 vs. OR 0.968, 95% CI 0.966–0.971, p < 0.001). However, absolute risk of in-hospital mortality remained higher in patients with haematological malignancy. Older age, higher SOFA score, presence of comorbidities, and mechanical ventilation were associated with increased mortality. Leukopenia (white cell count < 1.0 × 109 cells/L) was not associated with increased mortality in patients with haematological malignancy (p = 0.60).ConclusionsSepsis mortality has improved in patients with haematological malignancy admitted to ICU. However, mortality remains higher in patients with haematological malignancy than those without.Graphical abstract

The Effect of Workload on Nurses Who Are Taking Care of COVID-19 Patients

Nurses, especially ICU staff, complain of high level of stress regarding the workload. This can be related to many factors such as: nurse-patient ratio, doctor’s orders, timing, hospital environment to name a few. Nursing workload can be defined as all nursing work that must be carried out over a defined period of time. For example the effect of workload on covid-19 patients in intensive care units (ICUs) showed that higher RN staffing was associated with lower levels of hospital related mortality. Each additional full time equivalent RN per patient day corresponds to a 9% reduction in odds of death in ICUs. The aim of this study was to determine the extent of the effect of workload on nurses and other associated factors. A descriptive cross-sectional study was conducted in July to September 2020. 406 staff nurses were enrolled in the study. Instrument of the study was a questionnaire on the effect of workload on nursing staff who were taking care of covid-19 patients. Multiple logistic regression was utilized to identify the factors associated with high nursing workload of nurses. By using bivariate analysis; workload was found to be significantly associated with: nurse patient ratio, duty hours and type of department; the critical care units such as ICU, CCU and HD complained of higher workload (28.8, SD 3.7) than general units (20.7, SD 3.0) the P-value was 0.033. There was no significant difference between the workload and other demographic variables such as: environmental status, nationality, and type of hospital.

Predictors of Time to Aneurysm Repair and Mortality in Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND : Prompt aneurysm repair is essential to prevent rebleeding after aneurysmal subarachnoid hemorrhage. To date, most studies on this topic have focused on 1 set of predictors (eg, hospital or patient characteristics) and on 1 outcome (either time to aneurysm repair or mortality). The purpose of this study was to test a model that includes hospital and patient characteristics as predictors of time to aneurysm repair and mortality, controlling for disease severity and comorbidity, and considering time to aneurysm repair as a potential influence in these relationships. METHODS : A sample of aneurysmal subarachnoid hemorrhage patients with a principal procedure of clipping or coiling was selected (n = 387) from a statewide administrative database for cross-sectional retrospective analysis. The primary study outcome was in-hospital mortality. Independent variables were level of stroke center, age, race, sex, and type of aneurysm repair. Hierarchical logistic regression was used to estimate the probability of in-hospital death. RESULTS : Patients who underwent a coiling procedure were more likely to be treated within the first 24 hours of admission compared with those undergoing clipping (odds ratio, 0.54; 95% CI, 0.35-0.84; P = .01). Patients treated at a certified comprehensive stroke center (CSC) had a 72% reduction in odds of death compared with those treated at primary stroke centers (odds ratio, 0.28; 95% CI, 0.10-0.77; P = .01), after controlling for disease severity and comorbid conditions. Time to aneurysm repair was not significantly associated with mortality and did not influence the relationship between hospital and patient characteristics and mortality. CONCLUSION : Our results indicate that treatment at a CSC was associated with a lower risk of in-hospital mortality. Time to aneurysm repair did not influence mortality and did not explain the mortality benefit observed in CSCs. Research is needed to explore interdisciplinary hospital factors including nursing and nurse-sensitive interventions that may explain the relationship between CSCs and mortality outcomes.

Are maternal and child health initiatives helping to reduce under-five mortality in Ghana? Results of a quasi-experimental study using coarsened exact matching

BackgroundDespite a 53 % decline in under-five mortality (U5M) worldwide during the period of the Millennium Development Goals (MDGs), U5M remains a challenge. Under-five mortality decline in Ghana is slow and not parallel with the level of coverage of child health interventions. The interventions promoted to improve child survival include early initiation of breastfeeding, clean postnatal care, and skilled delivery. This study sought to assess the effectiveness of these interventions on U5M in Ghana.MethodsA quasi-experimental study was conducted using secondary data of the 2008 and 2014 Ghana Demographic and Health Surveys. Coarsened Exact Matching and logistic regression were done. The interventions assessed were iron intake, early initiation of breastfeeding, clean postnatal care, hygienic disposal of stool, antenatal care visits, skilled delivery, intermittent preventive treatment of malaria in pregnancy, and tetanus toxoid vaccine.ResultsThere were 2,045 children under-five years and 40 (1.9 %) deaths in 2008. In 2014, the total number of children under-five years was 4,053, while deaths were 53(1.2 %). In 2014, children less than one month old formed 1.6 % of all children under-five years, but 47.8 % of those who died. Mothers who attended four or more antenatal care visits were 78.2 % in 2008 and 87.0 % in 2014. Coverage levels of improved sanitation and water connection in the home were among the lowest, with 11.6 % for improved sanitation and 7.3 % for water connection in the home in 2014. Fifty-eight (58), 1.4 %, of children received all the eight (8) interventions in 2014, and none of those who received all these interventions died. After controlling for potential confounders, clean postnatal care was associated with a 66% reduction in the average odds of death (aOR = 0.34, 95 %CI:0.14–0.82), while early initiation of breastfeeding was associated with a 62 % reduction in the average odds of death (aOR = 0.38, 95 % CI: 0.21–0.69).ConclusionsTwo (clean postnatal care and early initiation of breastfeeding) out of eight interventions were associated with a reduction in the average odds of death. Thus, a further decline in under-five mortality in Ghana will require an increase in the coverage levels of these two high-impact interventions.

Relation of prior statin and anti-hypertensive use to severity of disease among patients hospitalized with COVID-19: Findings from the American Heart Association's COVID-19 Cardiovascular Disease Registry.

Statins have anti-inflammatory and immunomodulatory effects that may reduce the severity of coronavirus disease 2019 (COVID-19), in which organ dysfunction is mediated by severe inflammation. Large studies with diverse populations evaluating statin use and outcomes in COVID-19 are lacking. We used data from 10,541 patients hospitalized with COVID-19 through September 2020 at 104 US hospitals enrolled in the American Heart Association's COVID-19 Cardiovascular Disease (CVD) Registry to evaluate the associations between statin use and outcomes. Prior to admission, 42% of subjects (n = 4,449) used statins (7% on statins alone, 35% on statins plus anti-hypertensives). Death (or discharge to hospice) occurred in 2,212 subjects (21%). Outpatient use of statins, either alone or with anti-hypertensives, was associated with a reduced risk of death (adjusted odds ratio [aOR] 0.59, 95% CI 0.50-0.69), adjusting for demographic characteristics, insurance status, hospital site, and concurrent medications by logistic regression. In propensity-matched analyses, use of statins and/or anti-hypertensives was associated with a reduced risk of death among those with a history of CVD and/or hypertension (aOR 0.68, 95% CI 0.58-0.81). An observed 16% reduction in odds of death among those without CVD and/or hypertension was not statistically significant. Patients taking statins prior to hospitalization for COVID-19 had substantially lower odds of death, primarily among individuals with a history of CVD and/or hypertension. These observations support the continuation and aggressive initiation of statin and anti-hypertensive therapies among patients at risk for COVID-19, if these treatments are indicated based upon underlying medical conditions.

Abstract P823: Evaluating Time-To-Aneurysm Repair as a Performance Measure in Aneurysmal Subarachnoid Hemorrhage

Background: Implementation of evidence-based performance metrics drive standardized care and improve patient outcomes. Limited performance metrics have been developed for implementation in the aneurysmal subarachnoid hemorrhage (aSAH) population. Timely aneurysm repair following an aSAH is associated with rebleeding prevention and mortality. The purpose of this study was to evaluate time to aneurysm repair as a candidate performance metric by testing a model that includes hospital and patient characteristics as predictors of time to aneurysm repair and mortality, with time to aneurysm repair as a potential influence on these relationships in aSAH. Methods: A retrospective, cross-sectional analysis of patient discharge data from 2014 in the state of Florida was conducted. Data were derived from The Agency for Healthcare Research and Quality, HealthCare Utilization Project, State Inpatient Dataset, and the American Hospital Association Annual Survey. Patients with a primary ICD-9 diagnosis of aSAH and principle procedure of clipping or coiling were included (n=387). The study outcome was in-hospital mortality. Independent variables were level of stroke center, age, race, sex, and type of aneurysm repair. Hierarchical logistic regression was used to estimate the probability of in-hospital death. Results: Patients who underwent endovascular repair of an aneurysm were more likely to be treated in &lt;24 hours compared to those undergoing aneurysm clipping (OR = 0.54, CI = .35-.84, p =0.01). Patients treated at a comprehensive stroke center (CSC) had a 72% reduction in odds of death compared to those treated at primary stroke centers (OR =0.28, CI = 0.10-0.77, p =0.01), controlling for disease severity and comorbidity. Time to aneurysm repair was not significantly associated with mortality and did not influence the relationship between hospital and patient characteristics and mortality. Conclusions: Treatment at a certified CSC was the only significant predictor of surviving aSAH. Time to aneurysm repair did not influence the relationship between hospital and patient characteristics associated with mortality. Further research is needed to identify appropriate measures and to define what should be tracked for performance in the aSAH population.

Association of the Paediatric Admission Quality of Care score with mortality in Kenyan hospitals: a validation study.

SummaryBackgroundMeasuring the quality of hospital admission care is essential to ensure that standards of practice are met and continuously improved to reduce morbidity and mortality associated with the illnesses most responsible for inpatient deaths. The Paediatric Admission Quality of Care (PAQC) score is a tool for measuring adherence to guidelines for children admitted with acute illnesses in a low-income setting. We aimed to explore the external and criterion-related validity of the PAQC score by investigating its association with mortality using data drawn from a diverse sample of Kenyan hospitals.MethodsWe identified children admitted to Kenyan hospitals for treatment of malaria, pneumonia, diarrhoea, or dehydration from datasets from three sources: an observational study, a clinical trial, and a national cross-sectional survey. We extracted variables describing the process of care provided to patients at admission and their eventual outcomes from these data. We applied the PAQC scoring algorithm to the data to obtain a quality-of-care score for each child. We assessed external validity of the PAQC score by its systematic replication in datasets that had not been previously used to investigate properties of the PAQC score. We assessed criterion-related validity by using hierarchical logistic regression to estimate the association between PAQC score and the outcome of mortality, adjusting for other factors thought to be predictive of the outcome or responsible for heterogeneity in quality of care.FindingsWe found 19 065 eligible admissions in the three validation datasets that covered 27 hospitals, of which 12 969 (68%) were complete cases. Greater guideline adherence, corresponding to higher PAQC scores, was associated with a reduction in odds of death across the three datasets, ranging between 9% (odds ratio 0·91, 95% CI 0·84–0·99; p=0·031) and 30% (0·70, 0·63–0·78; p<0·0001) adjusted reduction per unit increase in the PAQC score, with a pooled estimate of 17% (0·83, 0·78–0·89; p<0·0001). These findings were consistent with a multiple imputation analysis that used information from all observations in the combined dataset.InterpretationThe PAQC score, designed as an index of the technical quality of care for the three commonest causes of admission in children, is also associated with mortality. This finding suggests that it could be a meaningful summary measure of the quality of care for common inpatient conditions and supports a link between process quality and outcome. It might have potential for application in low-income countries with similar disease profiles and in which paediatric practice recommendations are based on WHO guidelines.FundingThe Wellcome Trust.

Temporal trends in head injury outcomes from 2003 to 2009 in England and Wales

Background: Case fatality rates after blunt head injury (HI) did not improve in England and Wales between 1994 and 2003. The United Kingdom National Institute of Clinical Excellence subsequently published HI management guidelines, including the recommendation that patients with severe head injuries (SHIs) should be treated in specialist neuroscience units (NSU). The aim of this study was to investigate trends in case fatality and location of care since the introduction of national HI clinical guidelines. Methods: We conducted a retrospective cohort study using prospectively recorded data from the Trauma and Audit Research Network (TARN) database for patients presenting with blunt trauma between 2003 and 2009. Temporal trends in log odds of death adjusted for case mix were examined for patients with and without HI. Location of care for patients with SHI was also studied by examining trends in the proportion of patients treated in non-NSUs. Results: Since 2003, there was an average 12% reduction in adjusted log odds of death per annum in patients with HI (n=15,173), with a similar but smaller trend in non-HI trauma mortality (n=48,681). During the study period, the proportion of patients with HI treated entirely in non-NSUs decreased from 31% to 19%, (p <0.01). Interpretation: The reduction in odds of death following HI since 2003 is consistent with improved management following the introduction of national HI guidelines and increased treatment of SHI in NSUs.

Survival of Patients with Newly Diagnosed Glioblastoma Treated with Radiation and Temozolomide in Research Studies in the United States

Novel agents are currently combined with radiation and temozolomide (RT + TMZ) in newly diagnosed glioblastoma using overall survival as the primary end point. Results of these phase II studies are typically compared with the phase III European Organization for Research and Treatment of Cancer (EORTC) survival data that resulted in RT + TMZ becoming standard therapy. The New Approaches to Brain Tumor Therapy (NABTT) Consortium assigned 365 patients with glioblastoma to four single-cohort studies with similar eligibility criteria. Patients received RT + TMZ with talampanel (n = 72), poly-ICLC (n = 97), or cilengitide (n = 112) or RT + TMZ alone with monitoring of CD4 counts (n = 84). Overall survival of those ages 18 to 70 years with glioblastoma was compared with published EORTC data. NABTT and EORTC patients had comparable performance status and debulking surgery. Median, 12-month, and 24-month survival rates for the EORTC patients (n = 287) and the comparable NABTT patients receiving RT + TMZ and novel agents (n = 244) are 14.6 versus 19.6 months, 61% versus 81%, and 27% versus 37%, respectively. This represents a 37% reduction in odds of death (P < 0.0001) through 2 years of follow-up. NABTT and EORTC patients receiving only RT + TMZ had similar survival. Newly diagnosed glioblastoma treated recently with RT + TMZ and talampanel, poly-ICLC, or cilengitide had significantly longer survival than similar patients treated with only RT + TMZ accrued internationally from 2000 to 2002. These differences could result from the novel agents or changing patterns of care. Until the reasons for these different survival rates are clarified, comparisons of outcomes from phase II studies with published RT + TMZ survival data should be interpreted with caution.

Effect of Antenatal Corticosteroids on Survival for Neonates Born at 23 Weeks of Gestation

To estimate if exposure to antenatal corticosteroids was associated with decreased rate of death in neonates born at 23 weeks of gestation. This is a retrospective cohort study performed at three tertiary centers of neonates born at 23 weeks of gestation between 1998 and 2007. Stillbirths, voluntary terminations, or parental elected nonresuscitations were excluded. Clinical and demographic variables were examined to determine possible confounding variables. A multivariable logistic regression model was used to assess the effect of steroids on the odds of death after adjustment for these confounders. The sample included 181 neonates. Of the multiple variables examined (institution, race, diagnosis, illicit drug use, antibiotics, assisted reproduction, birth weight, gender, and route of delivery), only multiple gestations were significantly associated (P<or=.15) with steroid use and increased odds of death (odds ratio [OR] 3.66, 95% confidence interval [CI] 1.05-12.73) and controlled for in the final model. The multivariable model revealed those exposed to antenatal corticosteroids had decreased odds of death (OR 0.32, 95% CI 0.12-0.84), with no significant differences in the occurrence of necrotizing enterocolitis among survivors (15.4% compared with 28.6%, P=.59) or severe intraventricular hemorrhage (23.1% compared with 57.1%, P=.17). In analyzing the effect of steroid dose, only a complete course of corticosteroids was associated with a decreased odds of death (OR 0.18, 95% CI 0.06-0.54). Neonates at 23 weeks of gestation whose mothers completed a course of antenatal corticosteroids had an associated 82% reduction in odds of death.

Role of Early Supported Discharge in Acute Stroke Patients

Role of Early Supported Discharge in Acute Stroke Patients

Trends in trauma care in England and Wales 1989–97

In 1988, the Royal College of Surgeons reported major deficiencies in trauma care in UK hospitals. We investigated whether and how that care has changed in the last decade by use of data collected by the UK Trauma Audit and Research Network. We analysed injury-severity, process, and outcome variables from 91602 patients' records on the database at the end of 1997, collected from 97 (49% of trauma-receiving) hospitals in England, Wales, and two in Ireland. We did longitudinal analyses of odds of death, process variables, and individual hospitals' performance. We took account of potential selection bias from missing data and recruitment of new hospitals. The severity-adjusted odds of death after trauma declined gradually from 1989 (odds ratio 1997/1989 0.63 [95% CI [0.49-0.82]). In 1997, the reduction in odds of death was significant even after adjustment for missing data (ratio 1997/1989 0.72 [0.55-0.92]) and recruitment of new hospitals (0.64 [0.44-0.93]). There was significant variability in the proportion of survivors (adjusted for severity of injury and age) between the highest and lowest 10% of UK hospitals. The time between the call to the emergency services and arrival at hospital increased from 32 min in 1989 to 45 min in 1997, irrespective of injury severity. The proportion of severely injured patients seen first by senior doctors increased from 32% to 60%. Hospital care has made a valuable but variable contribution to reductions in case fatality after injury in the UK in the past 10 years, though further improvement is possible.

Chemotherapy for carcinoma of the esophagus: A comparison of evidence from meta-analyses of randomized trials and of historical control studies

Chemotherapy (CT) has been used as an adjunct to local treatment (surgery or radiotherapy) in esophageal carcinoma. A meta-analysis of all published randomized clinical trials and historical control studies which have used cisplatinum-based combination CT was carried out to asses the effect of chemotherapy on survival for esophageal cancer. A computer-based literature search was performed for the period from January 1988 to March 1995 using the index terms "Esophageal neoplasms' and "Chemotherapy'. The frame of reference was further narrowed to include only cisplatinum-based combination chemotherapy. Twelve randomized clinical trials (RCT) and eight historical control (HC) studies were included in the meta-analysis. In the overview of HC studies a highly significant reduction in odds of death with CT was observed (68% +/- 8% OR = 0.32, 95% CI 0.24-0.42). On the other hand, the overview of RCTs showed a relative reduction in odds of death for the CT group of 4.2% +/- 23.7% (OR = 0.96, 95% CI 0.75-1.22). There was a gross overestimation of treatment effect in the studies using HC as compared to RCTs, despite the use of cisplatinum-based chemotherapy in both groups. The meta-analysis of RCTs reveal no significant survival benefit from cisplatinum-based adjuvant/neoadjuvant chemotherapy in esophageal cancer.

Aspirin and fibrinolysis in acute myocardial infarction: Meta-analytic evidence for synergy

A meta-analysis of randomized clinical trials of fibrinolysis was performed, examining the interaction between aspirin and fibrinolysis in treating patients with acute myocardial infarction. Reductions in the odds of death up to 35 days were assessed for patients receiving tissue plasminogen activator or streptokinase up to 6 hours after the onset of symptoms. No significant difference in effectiveness between tissue plasminogen activator and streptokinase was demonstrated. The overall reduction in odds of death due to fibrinolytic therapy was 28%. However, there was a significant difference between the odds reduction of 24% when fibrinolysis is compared to placebo, and 40% when fibrinolysis and aspirin combined are compared to aspirin alone ( p = 0.02). This difference indicates that there exists a synergistic interaction between coronary fibrinolysis and aspirin rather than independence of their beneficial effects, as is generally believed. These results illustrate the perils of assessing drug efficacy, even in an overview of all relevant trials, without consideration of identifiable sources of heterogeneity such as the interaction between the treatment of interest and co-interventions. They also demonstrate the potential application of logistic regression diagnostic techniques to meta-analyses.