Risk-adjusted Survival Research Articles

Trends in care processes and survival following prehospital resuscitation improvement initiatives for out-of-hospital cardiac arrest in British Columbia, 2006–2016

BackgroundBritish Columbia (BC) Emergency Health Services implemented a strategy to improve outcomes for out-of-hospital cardiac arrest (OHCA), focusing on paramedic-led high-quality on-scene resuscitation. We measured changes in care metrics and survival trends. MethodsThis was a post-hoc study of prospectively identified consecutive non-traumatic ambulance-treated adult OHCAs from 2006 to 2016 within BC’s four metropolitan areas. The primary outcome was survival to hospital discharge; we also described available favourable neurological outcomes (mRS ≤3). We tested the significance of year-by-year trends in baseline characteristics, and calculated risk-adjusted survival rates using multivariable Poisson regression. ResultsWe included 15 145 patients. In univariate analyses there were significant increases in bystander CPR, chest compression fraction, advanced life support attendance, duration of resuscitation until advanced airway placement, duration of resuscitation until termination, and overall scene time. There was a significant decrease in initial shockable rhythms, bystander witnessed arrests, and transports initiated prior to ROSC. Survival and the proportion of survivors with favourable neurological outcomes increased significantly. In adjusted analyses, there was an improvement in return of spontaneous circulation (risk-adjusted rate 41% in 2006 to 51% in 2016; adjusted rate ratio per year 1.02, 95% CI 1.01–1.02, p < 0.01 for trend) and survival at hospital discharge (risk-adjusted rate 8.6% in 2006 to 16% in 2016; adjusted rate ratio per year 1.05, 95% CI 1.04–1.06, p < 0.01 for trend). ConclusionFrom 2006 to 2016 BC’s provincial ambulance system prioritized paramedic-led on-scene resuscitation, during which time there were significant improvements in patient outcomes. Our data may assist other systems, providing a model for prehospital resuscitation quality improvement.

Trends in Survival After In-Hospital Cardiac Arrest During Nights and Weekends

BackgroundSurvival after in-hospital cardiac arrest (IHCA) is lower during nights and weekends (off-hours) compared with daytime during weekdays (on-hours). As overall IHCA survival has improved over time, it remains unknown whether survival differences between on-hours and off-hours have changed. ObjectivesThis study sought to examine temporal trends in survival differences between on-hours and off-hours IHCA. MethodsWe identified 151,071 adults at 470 U.S. hospitals in the Get with the Guidelines–Resuscitation registry during 2000 to 2014. Using multivariable logistic regression with generalized estimating equations, we examined whether survival trends in IHCA differed during on-hours (Monday to Friday 7:00 am to 10:59 pm) versus off-hours (Monday to Friday 11:00 pm to 6:59 am, and Saturday to Sunday, all day). ResultsAmong 151,071 participants, 79,091 (52.4%) had an IHCA during off-hours. Risk-adjusted survival improved over time in both groups (on-hours: 16.0% in 2000, 25.2% in 2014; off-hours: 11.9% in 2000, 21.9% in 2014; p for trend <0.001 for both). However, there was no significant change in the survival difference over time between on-hours and off-hours, either on an absolute (p = 0.75) or a relative scale (p = 0.059). Acute resuscitation survival improved significantly in both groups (on-hours: 56.1% in 2000, 71% in 2014; off-hours: 46.9% in 2000, 68.2% in 2014; p for trend <0.001 for both) and the difference between on-hours and off-hours narrowed over time (p = 0.02 absolute scale, p < 0.001 relative scale). In contrast, although post-resuscitation survival also improved over time in both groups (p for trend < 0.001 for both), the absolute and relative difference persisted. ConclusionsDespite an overall improvement in survival, lower survival in IHCA during off-hours compared with on-hours persists.

Comparison of Survival After In-Hospital Cardiac Arrest in Patients With Versus Without Diabetes Mellitus

Diabetes mellitus (DM) increases the risk of sudden cardiac death, but the extent to which it influences survival after an in-hospital cardiac arrest (IHCA) remains unclear. We assessed the association of DM and survival after IHCA. The study included 1,009,073 patients aged ≥18 years who underwent cardiopulmonary resuscitation for IHCA between January 2003 and December 2013, recorded in the Nationwide Inpatient Sample database. The outcomes were survival to hospital discharge and discharge disposition assessed using multivariable logistic regression accounting for relevant covariates and clustering. Of the patients with IHCA, 30.8% (310,825) had DM and were more likely to be older and to have a higher prevalence of co-morbidities including hypertension, dyslipidemia, chronic kidney disease, and previous cardiovascular disease (all p <0.001). The rates of survival to hospital discharge after IHCA were 27.0% and 25.1% in patients with and without DM, respectively. After multivariable adjustment, DM was associated with a modestly lower risk-adjusted survival to hospital discharge (adjusted OR [aOR] 0.96, 95% confidence interval [95% CI] 0.95 to 0.97, p <0.001). This association was influenced by a number of factors (all interaction p <0.001), including a lower risk of survival among patients with DM who were younger (aOR 0.93, 95% CI 0.92 to 0.94 among those aged <75 years), those with a primary cardiovascular diagnosis (aOR 0.88, 95% CI 0.86 to 0.89), and those with ventricular fibrillation/ventricular tachycardia as the cardiac arrest rhythm (aOR 0.88, 95% CI 0.79 to 0.82). Patients with DM had lower odds of being discharged home with self-care after surviving an IHCA (p <0.001). In conclusion, preexisting DM was associated with a modestly lower risk-adjusted chance of survival after an IHCA.

Survival As a Quality Metric of Cancer Care: Use of the National Cancer Data Base to Assess Hospital Performance.

Survival is considered an important indicator of the quality of cancer care, but the validity of different methodologies to measure comparative survival rates is less well understood. We explored whether the National Cancer Data Base (NCDB) could serve as a source of unadjusted and risk-adjusted cancer survival data and whether these data could be used as quality indicators for individual hospitals or in the aggregate by hospital type. The NCDB, an aggregate of > 1,500 hospital cancer registries, was queried to analyze unadjusted and risk-adjusted hazards of death for patients with stage III breast cancer (n = 116,787) and stage IIIB or IV non-small-cell lung cancer (n = 252,392). Data were analyzed at the individual hospital level and by hospital type. At the hospital level, after risk adjustment, few hospitals had comparative risk-adjusted survival rates that were statistically better or worse. By hospital type, National Cancer Institute-designated comprehensive cancer centers had risk-adjusted survival ratios that were statistically significantly better than those of academic cancer centers and community hospitals. Using the NCDB as the data source, survival rates for patients with stage III breast cancer and stage IIIB or IV non-small-cell lung cancer were statistically better at National Cancer Institute-designated comprehensive cancer centers when compared with other hospital types. Compared with academic hospitals, risk-adjusted survival was lower in community hospitals. At the individual hospital level, after risk adjustment, few hospitals were shown to have statistically better or worse survival, suggesting that, using NCDB data, survival may not be a good metric to determine relative quality of cancer care at this level.

Heart Failure With Preserved, Borderline, and Reduced Ejection Fraction: 5-Year Outcomes

BackgroundPatients with heart failure (HF) have a poor prognosis and are categorized by ejection fraction (EF). ObjectivesThis study sought to characterize differences in outcomes in patients hospitalized with heart failure with preserved ejection fraction (HFpEF) (EF ≥50%), heart failure with borderline ejection fraction (HFbEF) (EF 41% to 49%), and heart failure with reduced ejection fraction (HFrEF) (EF ≤40%). MethodsData from GWTG-HF (Get With The Guidelines–Heart Failure) were linked to Medicare data for longitudinal follow-up. Multivariable models were constructed to examine 5-year outcomes and to compare survival to median survival of the U.S. population. ResultsA total of 39,982 patients from 254 hospitals who were admitted for HF between 2005 and 2009 were included: 18,299 (46%) had HFpEF, 3,285 (8.2%) had HFbEF, and 18,398 (46%) had HFrEF. Overall, median survival was 2.1 years. In risk-adjusted survival analysis, all 3 groups had similar 5-year mortality (HFrEF 75.3% vs. HFpEF 75.7%; hazard ratio: 0.99 [95% confidence interval: 0.958 to 1.022]; HFbEF 75.7% vs. HFpEF 75.7%; hazard ratio: 0.99 [95% confidence interval: 0.947 to 1.046]). In risk-adjusted analyses, the composite of mortality and rehospitalization was similar for all subgroups. Cardiovascular and HF readmission rates were higher in those with HFrEF and HFbEF compared with those with HFpEF. When compared with the U.S. population, HF patients across all age and EF groups had markedly lower median survival. ConclusionsAmong patients hospitalized with HF, patients across the EF spectrum have a similarly poor 5-year survival with an elevated risk for cardiovascular and HF admission. These findings underscore the need to improve treatment of patients with HF.

The value of local registry data for describing cervical cancer management and outcomes over three decades in Australia.

Registry data on invasive cervical cancers (n=1,274) from four major hospitals (1984-2012) were analysed to determine their value for informing local service delivery in Australia. The methodology comprised disease-specific survival analyses using Kaplan-Meier product-limit estimates and Cox proportional hazards models and treatment analyses using logistic regression. Five- and 10-year survivals were 72% and 68%, respectively, equating with relative survival estimates for Australia and the USA. Most common treatments were surgery and radiotherapy. Systemic therapies increased in recent years, generally with radiotherapy, but were less common for residents from less accessible areas. Surgery was more common for younger women and early-stage disease, and radiotherapy for older women and regional and more advanced disease. The proportion of glandular cancers increased in-step with national trends. Little evidence of variation in risk-adjusted survival presented over time or by Local Health District. The study illustrates the value of local registry data for describing local treatment and outcomes. They show the lower use of systemic therapies among residents of less accessible areas which warrants further investigation. Risk-adjusted treatment and outcomes did not vary by socio-economic status, suggesting equity in service delivery. These data are important for local evaluation and were not available from other sources.

Temporal Changes in the Racial Gap in Survival After In-Hospital Cardiac Arrest

Previous studies have found marked differences in survival after in-hospital cardiac arrest by race. Whether racial differences in survival have narrowed as overall survival has improved remains unknown. To examine whether racial differences in survival after in-hospital cardiac arrest have narrowed over time and if such differences could be explained by acute resuscitation survival, postresuscitation survival, and/or greater temporal improvement in survival at hospitals with higher proportions of black patients. In this cohort study from Get With the Guidelines-Resuscitation, performed from January 1, 2000, through December 31, 2014, a total of 112 139 patients with in-hospital cardiac arrest who were hospitalized in intensive care units or general inpatient units were studied. Data analysis was performed from April 7, 2015, to May 24, 2017. Race (black or white). The primary outcome was survival to discharge. Secondary outcomes were acute resuscitation survival and postresuscitation survival. Multivariable hierarchical (2-level) regression models were used to calculate calendar-year rates of survival for black and white patients after adjusting for baseline characteristics. Among 112 139 patients with in-hospital cardiac arrest, 30 241 (27.0%) were black (mean [SD] age, 61.6 [16.4] years) and 81 898 (73.0%) were white (mean [SD] age, 67.5 [15.2] years). Risk-adjusted survival improved over time in black (11.3% in 2000 and 21.4% in 2014) and white patients (15.8% in 2000 and 23.2% in 2014; P for trend <.001 for both), with greater survival improvement among black patients on an absolute (P for trend = .02) and relative scale (P for interaction = .01). A reduction in survival differences between black and white patients was attributable to elimination of racial differences in acute resuscitation survival (black individuals: 44.7% in 2000 and 64.1% in 2014; white individuals: 47.1% in 2000 and 64.0% in 2014; P for interaction <.001). Compared with hospitals with fewer black patients, hospitals with a higher proportion of black patients with in-hospital cardiac arrest achieved larger survival gains over time. A substantial reduction in racial differences in survival after in-hospital cardiac arrest has occurred that has been largely mediated by elimination of racial differences in acute resuscitation survival and greater survival improvement at hospitals with a higher proportion of black patients. Further understanding of the mechanisms of this improvement could provide novel insights for the elimination of racial differences in survival for other conditions.

Influence of Cold Ischemia Time in Kidney Transplants From Small Pediatric Donors.

BackgroundClinicians may be reluctant to transplant small pediatric kidneys that have prolonged cold ischemia time (CIT) for fear of an additional deleterious effect because pediatric grafts are thought to be more sensitive to ischemia. We aimed to assess the risks associated with transplantation of small pediatric kidneys with prolonged CIT.MethodsWe performed a retrospective cohort study examining US registry data between 1998 and 2013 of adult first-time kidney-only recipients of small pediatric kidneys from donors weighing 10 to 20 kg, stratified by CIT levels of 0 to 18 (n = 1413), 19 to 30 (n = 1116), and longer than 30 (n = 338) hours.ResultsAll-cause graft survival by CIT groups at 1-year was 92%, 88%, and 89%, respectively. 1-year risk-adjusted graft survival hazard ratios were significantly higher with CIT of 19 to 30 hours (adjusted hazard ratios, 1.37; 95% confidence interval, 1.04-1.81) and somewhat higher with CIT greater than 30 hours (adjusted hazard ratios, 1.24; 95% confidence interval, 0.82-1.88) relative to recipients with CIT 0 to 18 hours. There was little variation in the effect of CIT on graft survival when restricted to single kidney transplants only and no significant interaction of CIT category and single kidney transplantation (P = 0.93).ConclusionsAlthough prolonged CIT is associated with lower early graft survival in small pediatric donor kidney transplants, absolute decreases in 1-year graft survival rates were 3% to 4%.

Maximum Market Price of Longevity Risk under Solvency Regimes: The Case of Solvency II

Longevity risk constitutes an important risk factor for life insurance companies, and it can be managed through longevity-linked securities. The market of longevity-linked securities is at present far from being complete and does not allow finding a unique pricing measure. We propose a method to estimate the maximum market price of longevity risk depending on the risk margin implicit within the calculation of the technical provisions as defined by Solvency II. The maximum price of longevity risk is determined for a survivor forward (S-forward), an agreement between two counterparties to exchange at maturity a fixed survival-dependent payment for a payment depending on the realized survival of a given cohort of individuals. The maximum prices determined for the S-forwards can be used to price other longevity-linked securities, such as q-forwards. The Cairns–Blake–Dowd model is used to represent the evolution of mortality over time that combined with the information on the risk margin, enables us to calculate upper limits for the risk-adjusted survival probabilities, the market price of longevity risk and the S-forward prices. Numerical results can be extended for the pricing of other longevity-linked securities.

One-year mortality and costs associated with surgical ablation for atrial fibrillation concomitant to coronary artery bypass grafting.

While surgical ablation (SA) for persistent atrial fibrillation (AF) can reduce recurrence of AF, its impact on longitudinal survival and health-care costs remains controversial. This study defines the clinical outcomes and costs associated with SA in patients with prior AF undergoing coronary artery bypass grafting (CABG). A total of 3745 Medicare beneficiaries with prior AF who underwent CABG in 2013 were divided into 2 groups: those with and those without concomitant SA. Risk-adjusted early (0-90 days) and late (91-364 days) postoperative outcomes and inpatient costs were compared. SA was performed in 17% of CABG patients with prior AF. Preoperative characteristics favoured patients with SA: emergent presentation (15% vs 22%), heart failure in the 2 weeks prior to CABG (31% vs 36%), chronic lung disease (27% vs 33%) and renal failure (4% vs 7%) (all P < 0.05). Risk-adjusted operative mortality and perioperative stroke rates were similar in the 2 groups. Risk-adjusted survival was similar through 90 days, but significantly better with SA after 90 days [hazard ratio (HR) = 0.58; P = 0.03]. At 1 year, the risk-adjusted incidence of cardiovascular implantable electronic device implantation was greater with SA (HR = 1.20; P = 0.01). Risk-adjusted costs for the CABG admission (HR = 1.11; P < 0.01) and inpatient care through 1 year (HR = 1.06; P = 0.02) were also greater with SA. In the US Medicare population, SA was performed in 17% of CABG-AF patients in 2013. Operative risks for mortality and stroke did not increase with SA but costs did. Patients receiving SA, however, had significantly better risk-adjusted late survival.

A National Study of Survival Trends and Conditional Survival in Nasopharyngeal Carcinoma: Analysis of the National Population-Based Surveillance Epidemiology and End Results Registry.

PurposeConditional survival (CS) provides important information on survival for a period of time after diagnosis. Currently, information on CS patterns of patients with nasopharyngeal carcinoma (NPC) is lacking. We aimed to analyze survival rate over time and estimate CS for NPC patients using a national population-based registry.Materials and MethodsPatients diagnosed with NPC between 1973 and 2007 with at least 5-year follow-up were identified from the Surveillance Epidemiology End Results registry. Traditional survival rates and crude CS estimateswere calculated using Kaplan-Meier analysis. Risk-adjusted survival curves were plotted from the proportional hazards model using the correct group prognosis method.Results registry. Traditional survival rates and crude CS estimateswere calculated using Kaplan-Meier analysis. Risk-adjusted survival curves were plotted from the proportional hazards model using the correct group prognosis method.ResultsFor 7,713 patients analyzed, adjusted baseline 5-year overall survival improved significantly from 36.0% in patients diagnosed in 1973-1979, 41.7% in 1980-1989, 46.6% in 1990-1999, to 54.7% in 2000-2007 (p < 0.01). CS analysis demonstrated that for every additional year survived, adjusted probability of surviving the next 5 years increased from 66.7% (localized), 54.0% (regional), and 35.3% (distant) at the time of diagnosis, to 83.7% (localized), 75.0% (regional), and 62.2% (distant) for patients who had survived 5 years. Adjusted 5-year CS differed among age, sex, tumor histology, ethnicity, and stage subgroups initially, but converged with time.ConclusionTreatment outcomes of NPC patients have greatly improved over the decades. Increases in CS become more prominent in patients with distant disease than in those with localized or regional disease as patients survive longer. CS provides more dynamic prognostic information for patients who have survived a period of time after diagnosis.

OS11.2 Risk-adjusted survival outcomes for and features of 1p/19q codeletion oligodendrogliomas

Background: Oligodendrogliomas (OGs) are diffuse gliomas defined by IDH mutation and 1p/19q codeletion, in which response to treatment and survival are dictated not by histology, but by molecular subtypes. Methods: The US NCDB was queried for OG patients newly-diagnosed from 2004–2014. Patient and tumor factors were compared by Chi2 or t test. Overall survival (OS) was assessed by Cox proportional hazards and Kaplan-Meier methods, stratified by histology, grade, and codeletion status, and risk adjusted for age, sex, race, Charlson’s comorbidity index, insurance, facility location, chemoradiotherapy, and tumor location, laterality, and size. Results: 14,948 patients with gliomas with OG histology remained after exclusion, 67% (n=10,075) were WHO gr2, 33% were WHO gr3 (i.e. anaplastic), and 36% displayed mixed oligoastrocytoma histology. Complete 1p/19q data were available in 20% (n=2,920). Compared to gr2 non-codeleted cases, codeleted OGs presented at an older median age of 43 yrs (IQR: 25–52; vs. 38 yrs, IQR: 25–51, p<0.0001). Notably, 67% were MGMT methylated (vs. 38%, p<0.001) and 75% arose in the frontal lobe (vs. 56%, p<0.001), and 12% in the temporal lobe (vs. 30%). For treatment, 41% of gr2 codeleted OGs received chemotherapy (vs. 36%, p<0.01), 28% received radiotherapy (vs. 41%, p<0.001), 86% underwent surgery, 55% of which were GTR. In risk-adjusted analysis of gr2 OGs, codeletion was associated with significantly improved OS (HR 0.44, 95%CI: 0.27–0.72, p=0.001), with 2-yr and 5-yr OS rates of 96% (95%CI; 94–97) and 87% (95%CI: 84–90), respectively; vs. 87% (95%CI: 84–90) and 70% (95%CI: 63–76) in non-codeleted OG. Mixed histology was not significant (HR 1.49, 95%CI; 0.92–2.44, p=0.11). Compared to gr3 non-codeleted cases, codeleted anaplastic OGs presented at a median age of 46 yrs (IQR: 37–56; vs. 43 yrs, IQR: 40–46, p=0.066). 75% were MGMT methylated (vs. 46%, p<0.001) and a majority arose in frontal lobes (78% vs. 62%, p<0.001); involving temporal lobes in 9% (vs. 23%). For treatment, 84% of gr3 codeleted OGs received chemotherapy, 70% received radiotherapy, and 96% underwent surgery, 52% of which were GTR. In risk-adjusted analysis of gr3 OGs, codeletion was associated with significantly improved OS (HR 0.36, 95%CI: 0.22–0.59, p<0.001), with 2-yr and 5-yr OS rates of 90% (95%CI; 87–93) and 72% (95%CI: 64–77), respectively; vs. non-codeleted OGs’ 73% (95%CI: 68–78) and 47% (95%CI: 37–56). Mixed histology portends a worse OS (HR 1.72, 95%CI; 1.08–2.74, p=0.02). Conclusion: Although previously referred to as OGs, grade 2 and 3 diffuse gliomas without 1p/19q codeletion are markedly different from molecularly-defined OGs; particularly demonstrating reduced rates of MGMT methylation and significantly worse OS. In cases where a high grade OG is suspected histologically but 1p/19q are not codeleted, careful evaluation and management for IDH-wildtype GBM should be considered.

Improving Risk Adjustment for Mortality After Pediatric Cardiac Surgery: The UK PRAiS2 Model

Partial Risk Adjustment in Surgery (PRAiS), a risk model for 30-day mortality after children's heart surgery, has been used by the UK National Congenital Heart Disease Audit to report expected risk-adjusted survival since 2013. This study aimed to improve the model by incorporating additional comorbidity and diagnostic information. The model development dataset was all procedures performed between 2009 and 2014 in all UK and Ireland congenital cardiac centers. The outcome measure was death within each 30-day surgical episode. Model development followed an iterative process of clinical discussion and development and assessment of models using logistic regression under 25× 5 cross-validation. Performance was measured using Akaike information criterion, the area under the receiver-operating characteristic curve (AUC), and calibration. The final model was assessed in an external 2014 to 2015 validation dataset. The development dataset comprised 21,838 30-day surgical episodes, with 539 deaths (mortality, 2.5%). The validation dataset comprised 4,207 episodes, with97deaths (mortality, 2.3%). The updated risk model included 15 procedural, 11 diagnostic, and 4 comorbidity groupings, and nonlinear functions of age and weight. Performance under cross-validation was: median AUC of 0.83 (range, 0.82 to 0.83), median calibration slope and intercept of 0.92 (range, 0.64 to 1.25) and -0.23 (range, -1.08 to 0.85) respectively. In the validation dataset, the AUC was 0.86 (95% confidence interval [CI], 0.82 to 0.89), and the calibration slope andintercept were 1.01 (95% CI, 0.83 to 1.18) and 0.11 (95% CI,-0.45 to 0.67), respectively, showing excellent performance. A more sophisticated PRAiS2 risk model for UK use was developed with additional comorbidity and diagnostic information, alongside age and weight as nonlinear variables.

ED05.04 What’s New in Esophageal Cancer Staging?

ED05.04 What’s New in Esophageal Cancer Staging?

ECMO Cardio-Pulmonary Resuscitation (ECPR), trends in survival from an international multicentre cohort study over 12-years

BackgroundUse of Extracorporeal Membrane Oxygenation during cardiopulmonary resuscitation (ECPR) is increasingly being deployed as an adjunct to conventional CPR. It is unknown if this has been associated with improved outcomes. AimsTo describe trends in survival and patient demographics for ECPR patients in the international Extracorporeal Life Support Organisation (ELSO) database over the past 12 years and identify factors associated with changes in survival. MethodsPatients greater than 16 years of age who received ECPR between January 2003 and December 2014 were extracted from the ELSO registry and were divided into three 4-year cohorts (Cohort 1: 2003–2006, Cohort 2: 2007–2010, Cohort 3: 2011–2014). Univariable analysis was performed to compare demographics and outcomes of patients across the three cohorts. Univariable and multivariable analyses were then performed to identify factors independently associated with survival. Results1796 patients treated with ECPR were extracted from the registry, aged 50 (±18.5) years. Annual ECPR episodes increased over 10-fold, from 35 to over 400 per year. Survival to hospital discharge was 29% overall (27% cohort 1, 28% cohort 2, 30% cohort 3 (p=0.71)). Age, body weight and documented comorbidities increased over time. There was a reduction in complications associated with ECMO usage. After adjusting for confounders there was no change in the odds of survival over the time period examined. InterpretationOver the period 2003–2014, survival to hospital discharge was 29% for patients who require ECPR. Despite advances in provision of ECMO care and increasing co-morbidities of patients, there has been no change in risk-adjusted survival over time.

Association of Freestanding Children's Hospitals With Outcomes in Children With Critical Illness.

Little is known about the relationship between freestanding children's hospitals and outcomes in children with critical illness. The purpose of this study was to evaluate the association of freestanding children's hospitals with outcomes in children with critical illness. Propensity score matching was performed to adjust for potential confounding variables between patients cared for in freestanding or nonfreestanding children's hospitals. We tested the sensitivity of our findings by repeating the primary analyses using inverse probability of treatment weighting method and regression adjustment using the propensity score. Retrospective study from an existing national database, Virtual PICU Systems (LLC) database. Patients less than 18 years old admitted to one of the participating PICUs in the Virtual PICU Systems, LLC database were included (2009-2014). None. A total of 538,967 patients from 140 centers were included. Of these, 323,319 patients were treated in 60 freestanding hospitals. In contrast, 215,648 patients were cared for in 80 nonfreestanding hospitals. By propensity matching, 134,656 patients were matched 1:1 in the two groups (67,328 in each group). Prior to matching, patients in the freestanding hospitals were younger, had greater comorbidities, had higher severity of illness scores, had higher incidence of cardiac arrest, had higher resource utilization, and had higher proportion of patients undergoing complex procedures such as cardiac surgery. Before matching, the outcomes including mortality were worse among the patients cared for in the freestanding hospitals (freestanding vs nonfreestanding, 2.5% vs 2.3%; p < 0.001). After matching, the majority of the study outcomes were better in freestanding hospitals (freestanding vs nonfreestanding, mortality: 2.1% vs 2.8%, p < 0.001; standardized mortality ratio: 0.77 [0.73-0.82] vs 0.99 [0.87-0.96], p < 0.001; reintubation: 3.4% vs 3.8%, p < 0.001; good neurologic outcome: 97.7% vs 97.1%, p = 0.001). In this large observational study, we demonstrated that ICU care provided in freestanding children's hospitals is associated with improved risk-adjusted survival chances compared to nonfreestanding children's hospitals. However, the clinical significance of this change in mortality should be interpreted with caution. It is also possible that the hospital structure may be a surrogate of other factors that may bias the results.

THE IMPACT OF BYPASS OF NON-SPECIALIST ACUTE HOSPITALS IN FAVOUR OF SPECIALIST NEUROSCIENCE CENTRES AS THE PRIMARY HOSPITAL DESTINATION FOR TRAUMATIC BRAIN INJURY PATIENTS

Objectives & BackgroundSince the introduction of the regional trauma networks in the UK, the practice of transporting traumatic brain injury (TBI) patients past the nearest non-specialist acute hospital (NSAH) in...

Abstract 13260: Trends in Survival From In-hospital Cardiac Arrests During Nights and Weekends

Background: In-hospital cardiac arrest (IHCA) survival is worse during nights and weekends. Although survival and neurologic outcomes after IHCA have improved in recent years, it remains unknown whether the above trends are consistent in patients with IHCA during nights and weekends. Methods: We identified 151,071 adults at 470 U.S. hospitals in the Get with the Guidelines-Resuscitation registry during 2000-2014. Using multivariable logistic regression with generalized estimating equations, we examined temporal trends in survival to discharge and determined whether trends in IHCA differed during on-hours (Monday - Friday 7:00 am - 10:59 pm) vs. off-hours (Monday - Friday 11:00 pm - 6:59 am, Saturday-Sunday, all day). We also examined acute resuscitation and post-resuscitation survival as secondary outcomes. Results: Among 151,071 participants, 79,091 (52.4%) had an IHCA during off-hours. Risk-adjusted survival proportions improved over time in both groups ( on-hours : 16.0% in 2000, 25.2% in 2014; off-hours : 11.9% in 2000, 21.9% in 2014; P for trend &lt; .001 for both). However, temporal trends in survival did not differ between on-hours and off-hours both on absolute (P=0.75) and relative scale (P = .059, Table). Acute resuscitation survival improved significantly in both groups ( on-hours : 56.1% in 2000, 71% in 2014; off-hours : 46.9% in 2000, 68.2% in 2014; P for trend &lt; .001 for both) such that difference between on-hours and off-hours narrowed over time (P=0.02 absolute scale, P &lt; .001 relative scale, Table). In contrast, although post-resuscitation survival improved over time in both groups (P for trend &lt; .001), the absolute and relative differences persisted in both groups (Table). Conclusions: Despite a significant temporal reduction in acute resuscitation survival difference for IHCA during on-hours compared to off-hours, differences in overall survival persist between the groups, highlighting an important area for quality improvement.

Recommendations for neoadjuvant pathologic staging (ypTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals

We report analytic and consensus processes that produced recommendations for neoadjuvant pathologic stage groups (ypTNM) of esophageal and esophagogastric junction cancer for the AJCC/UICC cancer staging manuals, 8th edition. The Worldwide Esophageal Cancer Collaboration provided data for 22,654 patients with epithelial esophageal cancers; 7,773 had pathologic assessment after neoadjuvant therapy. Risk-adjusted survival for each patient was developed. Random forest analysis identified data-driven neoadjuvant pathologic stage groups wherein survival decreased monotonically with increasing group, was distinctive between groups, and homogeneous within groups. An additional analysis produced data-driven anatomic neoadjuvant pathologic stage groups based only on ypT, ypN, and ypM categories. The AJCC Upper GI Task Force, by smoothing, simplifying, expanding, and assessing clinical applicability, produced consensus neoadjuvant pathologic stage groups. Grade and location were much less discriminating for stage grouping ypTNM than pTNM. Data-driven stage grouping without grade and location produced nearly identical groups for squamous cell carcinoma and adenocarcinoma. However, ypTNM groups and their associated survival differed from pTNM. The need for consensus process was minimal. The consensus groups, identical for both cell types were as follows: ypStage I comprised ypT0-2N0M0; ypStage II ypT3N0M0; ypStage IIIA ypT0-2N1M0; ypStage IIIB ypT3N1M0, ypT0-3N2, and ypT4aN0M0; ypStage IVA ypT4aN1-2, ypT4bN0-2, and ypTanyN3M0; and ypStage IVB ypTanyNanyM1. Absence of equivalent pathologic (pTNM) categories for the peculiar neoadjuvant pathologic categories ypTisN0-3M0 and ypT0N0-3M0, dissimilar stage group compositions, and markedly different early- and intermediate-stage survival necessitated a unified, unique set of stage grouping for patients of either cell type who receive neoadjuvant therapy.

Risk-adjusted monitoring of time to event in the presence of long-term survivors.

The use of control charts for monitoring schemes in medical context should consider adjustments to incorporate the specific risk for each individual. Some authors propose the use of a risk-adjusted survival time cumulative sum (RAST CUSUM) control chart to monitor a time-to-event outcome, possibly right censored, using conventional survival models, which do not contemplate the possibility of cure of a patient. We propose to extend this approach considering a risk-adjusted CUSUM chart, based on a cure rate model. We consider a regression model in which the covariates affect the cure fraction. The CUSUM scores are obtained for Weibull and log-logistic promotion time model to monitor a scale parameter for nonimmune individuals. A simulation study was conducted to evaluate and compare the performance of the proposed chart (RACUF CUSUM) with RAST CUSUM, based on optimal control limits and average run length in different situations. As a result, we note that the RAST CUSUM chart is inappropriate when applied to data with a cure rate, while the proposed RACUF CUSUM chart seems to have similar performance if applied to data without a cure rate. The proposed chart is illustrated with simulated data and with a real data set of patients with heart failure treated at the Heart Institute (InCor), at the University of São Paulo, Brazil.