Temporal Trends In Use Research Articles

Temporal Trends in the Use of Therapeutic Hypothermia for Out-of-Hospital Cardiac Arrest

ImportanceDespite evidence that therapeutic hypothermia improves patient outcomes for out-of-hospital cardiac arrest, use of this therapy remains low.ObjectiveTo determine whether the use of therapeutic hypothermia and patient outcomes have changed after publication of the Targeted Temperature Management trial on December 5, 2013, which supported more lenient temperature management for out-of-hospital cardiac arrest.Design, Setting, and ParticipantsA retrospective cohort was conducted between January 1, 2013, and December 31, 2016, of 45 935 US patients in the Cardiac Arrest Registry to Enhance Survival who experienced out-of-hospital cardiac arrest and survived to hospital admission.ExposuresCalendar time by quarter year.Main Outcomes and MeasuresUse of therapeutic hypothermia and patient survival to hospital discharge.ResultsAmong 45 935 patients (17 515 women and 28 420 men; mean [SD] age, 59.3 [18.3] years) who experienced out-of-hospital cardiac arrest and survived to admission at 649 US hospitals, overall use of therapeutic hypothermia during the study period was 46.4%. In unadjusted analyses, the use of therapeutic hypothermia dropped from 52.5% in the last quarter of 2013 to 46.0% in the first quarter of 2014 after the December 2013 publication of the Targeted Temperature Management trial. Use of therapeutic hypothermia remained at or below 46.5% through 2016. In segmented hierarchical logistic regression analysis, the risk-adjusted odds of use of therapeutic hypothermia was 18% lower in the first quarter of 2014 compared with the last quarter of 2013 (odds ratio, 0.82; 95% CI, 0.71-0.94; P = .006). Similar point-estimate changes over time were observed in analyses stratified by presenting rhythm of ventricular tachycardia or ventricular fibrillation (odds ratio, 0.89; 95% CI, 0.71-1.13, P = .35) and pulseless electrical activity or asystole (odds ratio, 0.75; 95% CI, 0.63-0.89; P = .001). Overall risk-adjusted patient survival was 36.9% in 2013, 37.5% in 2014, 34.8% in 2015, and 34.3% in 2016 (P < .001 for trend). In mediation analysis, temporal trends in use of hypothermia did not consistently explain trends in patient survival.Conclusions and RelevanceIn a US registry of patients who experienced out-of-hospital cardiac arrest, the use of guideline-recommended therapeutic hypothermia decreased after publication of the Targeted Temperature Management trial, which supported more lenient temperature thresholds. Concurrent with this change, survival among patients admitted to the hospital decreased, but was not mediated by use of hypothermia.

Trends and Outcomes Associated With Using Long-Acting Opioids During Delivery Hospitalizations.

To assess trends in use of long-acting opioids during delivery hospitalizations. The Perspective database, an administrative inpatient database that includes medication receipt, was analyzed to evaluate patterns of long-acting opioid use during delivery hospitalizations from January 2006 through March 2015. Medications evaluated included methadone, formulations including buprenorphine and extended-release formulations of oxycodone, morphine, fentanyl, and other opioids. Temporal trends in use of these medications were determined. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating both use of these medications and risk for severe morbidity. Risk for severe morbidity was determined based on Centers for Disease Control and Prevention criteria. Our analysis included 2,994,630 delivery hospitalizations meeting study criteria. Over the entire study period, use of long-acting opioids increased significantly from 457 to 844 per 100,000 deliveries. Although buprenorphine and methadone use increased, use of other long-acting opioids decreased. In 2006, methadone and buprenorphine accounted for less than one third of all long-acting opioids used during delivery hospitalizations. By 2015, buprenorphine and methadone represented 73.5% of long-acting opioids used. In adjusted and unadjusted models, risk for severe morbidity was significantly lower with buprenorphine or methadone compared with other long-acting opioids. Restricting the cohort to only women with drug abuse or dependence, risk for severe morbidity was lower with methadone and buprenorphine than without any long-acting opioids. Increased use of methadone and buprenorphine in this study supports the feasibility of use of these medications during pregnancy and uptake of clinical recommendations for women with opioid use disorder. Use of methadone and buprenorphine is associated with decreased maternal morbidity, although causation cannot be presumed from this study model.

Treatment Trends and Outcomes for Patients With Lymph Node–Positive Cancer of the Penis

Penile cancer is an uncommon disease with minimal level I evidence to guide therapy. The National Comprehensive Cancer Network (NCCN) guidelines advocate a lymph node dissection (LND) or radiotherapy with consideration of perioperative chemotherapy for all patients with lymph node-positive (LN+) penile cancer without metastasis. To determine temporal trends in use of chemotherapy for patients with LN+ penile cancer without metastasis and to evaluate outcomes between those who did or did not receive LND, chemotherapy, and radiotherapy. The US National Cancer Database (NCDB) was queried for all 1123 patients with LN+, squamous cell carcinoma of the penis without metastasis from January 1, 2004, through December 31, 2014. Temporal trends were assessed using Cochran-Armitage tests. Multivariable logistic models were used to examine the association between treatments, clinicopathologic variables, and receipt of chemotherapy. Kaplan-Meier analyses with log-rank tests and multivariable Cox regressions were used to analyze overall survival. Data were analyzed between January 2017 and September 2017. Use of chemotherapy over time. Survival outcomes by receipt or nonreceipt of LND, radiotherapy, and chemotherapy. Of 1123 patients identified, most were white (924 [82.3%]) vs African American (141 [12.6%]) or of other or unknown race (58 [5.2%]). The age of most patients (727 [64.7%]) was between 50 and 75 years, and 750 patients (66.8%) underwent an LND. From 2004 to 2014, the use of systemic therapy significantly increased (26 of 68 patients, 38.2% vs 65 of 136, 47.8%; P < .001). However, only 177 of 335 patients with N3 disease (52.8%) received chemotherapy (N1: 106 of 338, 31.4%; N2: 178 of 450, 39.6%). Following adjustment, older patients (>76 years: OR, 0.28; 95% CI, 0.15-0.50; P < .001) were less likely to receive chemotherapy. Patients who received radiotherapy (OR, 4.38; 95% CI, 3.10-6.18; P < .001) and those patients with N2 (OR, 1.62; 95% CI, 1.16-2.27; P = .005) or N3 (OR, 2.32; 95% CI, 1.67-3.22; P < .001) cancer were more likely to receive chemotherapy. On multivariable analysis, LND (HR, 0.64; 95% CI, 0.52-0.78; P < .001) was associated with better overall survival, while neither chemotherapy (HR, 1.01; 95% CI, 0.80-1.26; P = .95) nor radiotherapy (HR, 0.85; 95% CI, 0.70-1.04; P = .11) was associated with overall survival. In hospitals reporting to the NCDB, only 66.8% of patients with LN+ penile cancer received an LND. While chemotherapy use has increased since 2004, rates remain low (52.8% for patients with N3 cancer). Receipt of LND, but not chemotherapy or radiotherapy, is associated with overall survival. This may reflect the aggressive natural history of penile cancer as well as the inherent analysis limitation of a relatively small sample size. These data highlight opportunities to improve adherence to guideline-recommended care.

Use of Antihypertensive Medications During Delivery Hospitalizations Complicated by Preeclampsia.

To evaluate temporal trends in use of antihypertensive medications during delivery hospitalizations complicated by preeclampsia and risk of maternal stroke over the same time period. The Perspective database was used to perform a retrospective cohort study evaluating antihypertensive drugs dispensed during delivery hospitalizations complicated by preeclampsia from 2006 to the first quarter of 2015. Medications evaluated included nifedipine, hydralazine, and oral and intravenous labetalol. Adjusted models for receipt of antihypertensive agents accounting for demographic and hospital factors were created. Hospital-level rates of antihypertensive administration for women with severe preeclampsia were analyzed. Risk of stroke during delivery hospitalization was evaluated. A total of 239,454 patients with preeclampsia were included in the analysis including 126,595 women with mild, 31,628 with superimposed, and 81,231 with severe preeclampsia. Overall, 105,409 women received a hypertensive agent. From 2006 to 2014, for all patients with preeclampsia, receipt of oral labetalol increased from 20.3% to 31.4%, intravenous labetalol from 13.3% to 21.4%, hydralazine from 12.8% to 16.9%, nifedipine from 15.0% to 18.2%, and more than one medication from 16.5% to 25.8%. The proportion of patients with preeclampsia receiving any antihypertensive medication rose from 37.8% in 2006 to 49.4% in 2015. In adjusted models, temporal trends retained significance. Rates of antihypertensive administration for severe preeclampsia varied significantly by hospital. For severe preeclampsia, the risk for stroke decreased from 13.5 per 10,000 deliveries in 2006-2008 (n=27) to 9.7 in 2009-2011 (n=25) to 6.0 in 2012-2014 (n=20) (P=.02). Use of multiple antihypertensive agents to treat preeclamptic women increased over the study period for women with mild, superimposed, and severe preeclampsia. There was substantial hospital variation in use of antihypertensive agents. This trend was associated with decreased risk of maternal stroke.

CONTEMPORARY TRENDS IN THE USE OF IABP AND PERCUTANEOUS VENTRICULAR ASSIST DEVICES IN FEMALES WITH ACUTE MYOCARDIAL INFARCTION

Circulatory support devices (CSD) are frequently used in the management of patients with AMI. We sought to describe temporal trends in use and outcomes of IABP and PVAD for AMI. ICD-9 codes were used in HCUP-NIS database for the years 2004-2013 to identify patients presenting with AMI in 3 groups -

Temporal Trends in Use of Composite End Points in Major Cardiovascular Randomized Clinical Trials in Prominent Medical Journals.

Cardiovascular mortality has decreased over the past 5 decades, making it increasingly difficult to demonstrate significant benefits of new therapies in randomized clinical trials. We sought to determine whether the use of composite end points in major cardiovascular trials has changed over time and examine temporal trends in the clinical importance of individual components of these composite end points. Using a validated search strategy, we searched MEDLINE for randomized trials of therapies for primary or secondary cardiovascular prevention published in New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association between 1986 and 2015. We abstracted and categorized study population demographics, type of intervention, and primary and secondary outcomes. Composite end point components were ranked according to importance (minor, moderate, major, critical, and death) and temporal trends analyzed. In total, 604 of 2607 trials retrieved met inclusion criteria. Use of composite end points increased significantly over time from 18.8% between 1986 and 1990 to 83.0% between 2011 and 2015 (P<0.001). The number of components in the primary end point also increased significantly (median 1 in 1986-1990, median 3 in 2011-2015; P<0.001). Contemporary trials were more likely to include end points of lesser importance to patients (minor 3.1% and moderate 6.3% in 1986-1990, minor 4.5% and moderate 44.6% in 2011-2015; P<0.001). Use of death as the sole primary end point declined significantly over time (53.1% in 1986-1990, 17.9% in 2011-2015; P<0.001). Contemporary cardiovascular randomized clinical trials are more likely to use primary composite end points that contain a larger number of components. Furthermore, these composite end points have increasingly incorporated components of lesser clinical importance. Clinicians and policymakers interpreting results of randomized trials should recognize that the significance of individual components in a composite end point is often heterogeneous.

Temporal Trends in Use of Biologic DMARDs for Rheumatoid Arthritis in the United States: A Cohort Study of Publicly and Privately Insured Patients.

Ten biologic disease-modifying antirheumatic drugs (bDMARDs) are available as treatment for rheumatoid arthritis (RA), but relatively little is known about population-level time trends in the use of these agents. To describe time trends in the use of bDMARDs in RA patients with private or public insurance in the United States. Claims data from private (Optum Clinformatics, 2004-2015) and public (Medicaid Analytic eXtract [MAX], 2000-2010) insurance programs were used. Patients with RA diagnosis codes and continuous health plan enrollment for 1-year baseline and 1-year follow-up periods were identified into 2 separate cohorts: (1) patients not using any bDMARD or (2) patients using a single bDMARD during the baseline period. Initiation of the first bDMARD from group 1 and switch to a second bDMARD from group 2 was identified as the outcome of interest during the 1-year follow-up period. Using mixed-effects regression models, we calculated yearly rates of initiation and switch for bDMARDs, adjusted for case-mix. We also described the proportion of all initiations and switches accounted for by each agent. There were 113,031 RA patients with public insurance and 97,751 RA patients with private insurance who were included in the study. The rates of initiation of bDMARDs (per 100 patients) increased significantly over time in Medicaid data for incident RA patients (from 1.1 to 3.1, P = 0.0006) and prevalent RA patients (from 4.6 to 10.9, P = 0.008). In Optum Clinformatics data, the rates were stable, with 7.7 to 8.3 per 100 incident RA patients (P = 0.10) and 11.0 to 11.5 per 100 prevalent RA patients (P = 0.12). The rates of switching (per 100 patients) increased over time from 6.4 to 16.0 (P = 0.04) in Medicaid data and 9.1 to 17.0 (P = 0.00003) in Optum Clinformatics data. Use of etanercept as the most common first-line agent was stable at approximately 50% of all biologic initiations, but use of infliximab decreased and the use of newer agents increased. More RA patients used bDMARDs in recent years, and use of newer agents, including certolizumab, golumumab, and tocilizuamab, is rising, which highlights a need for further comparative safety and effectiveness research of these agents to better guide evidence-based decision making. This study was supported by an investigator-initiated research grant from Pfizer. The study was conducted by the authors independent of the sponsor. The sponsor was given the opportunity to make nonbinding comments on a draft of the manuscript, but the authors retained the right of publication and determined the final wording. Solomon receives salary support through research support to his hospital from Amgen, Pfizer, AstraZeneca, Genentech, Lilly, Bristol-Myers Squibb, and CORRONA. Kim receives research grants from AstraZeneca, Lilly, Pfizer, Bristol-Myers Squibb, and Genentech. Desai receives research grants from Merck. Study concept and design were contributed by Desai and Kim. Liu took the lead in data collection, along with Jin, Desai, and Kim. All authors contributed equally in the interpretation of the results. The manuscript was written and revised primarily by Desai, along with Kim and the other authors.

Antipsychotic Medication Use Among Publicly Insured Pregnant Women in the United States.

Given the increasing use and broadening of indications for use of antipsychotic medications in the general population, as well as the paucity of information on the safety of this drug class during pregnancy, the study documented patterns of antipsychotic medication use among pregnant women. Medicaid Analytic eXtract data (2001-2010) from pregnant women who delivered live-born infants were used. Antipsychotic use at both the class and the individual drug level was defined based on dispensed outpatient prescriptions. Users' characteristics, including mental disorder diagnoses, were described. Temporal trends in use, as well as discontinuation patterns and psychotropic polytherapy, during pregnancy were evaluated. Among 1,522,247 pregnancies, the prevalence of use of second-generation antipsychotics at any time during pregnancy increased threefold, from .4% to 1.3%, over the ten-year period, while the use of first-generation antipsychotics remained stable at around .1%. The increased use of second-generation antipsychotics was largely driven by more frequent use among patients with bipolar disorder. Quetiapine and aripiprazole were the most frequently dispensed drugs, and polytherapy with antipsychotics and antidepressants (65.2%), benzodiazepines (24.9%), and other mood stabilizers (22.0%) was common. More than 50% of women receiving an antipsychotic in the three months prior to pregnancy discontinued the drug during pregnancy. A growing number of pregnant women in Medicaid are exposed to second-generation antipsychotics, frequently in combination with other psychotropic medications. This study highlights the importance of documenting the use and safety of these drugs during pregnancy to inform therapeutic decision making for pregnant women with psychiatric disorders.

Temporal Trends of Digoxin Use in Patients Hospitalized With Heart Failure: Analysis From the American Heart Association Get With The Guidelines-Heart Failure Registry

ObjectivesThe aim of this study was to assess temporal trends and factors associated with digoxin use at discharge among patients admitted with heart failure (HF). BackgroundDigoxin has class IIa recommendations for treating HF with reduced ejection fraction (HFrEF) in the United States. Digoxin use, temporal trends, and clinical characteristics of HF patients in current clinical practice in the United States have not been well studied. MethodsAn observational analysis of 255,901 patients hospitalized with HF (117,761 with HFrEF and 138,140 with preserved EF [HFpEF]) from 398 hospitals participating in the Get With The Guidelines–HF registry between January 2005 and June 2014 was conducted to assess the temporal trends and factors associated with digoxin use. ResultsAmong 117,761 HFrEF patients, only 19.7% received digoxin at discharge. Digoxin prescriptions decreased from 33.1% in 2005 to 10.7% in 2014 (ptrend < 0.0001). Factors associated with digoxin use in HFrEF included atrial fibrillation (AF) (odds ratio [OR]: 2.14; 95% confidence intervals [CI]: 2.02 to 2.28), history of implantable cardioverter defibrillator use (OR: 1.39; 95% CI: 1.32 to 1.46), chronic obstructive pulmonary disease (OR: 1.13, 95% CI: 1.08 to 1.18), diabetes mellitus (OR: 1.10, 95% CI: 1.06 to 1.14), younger age (OR: 0.96, 95% CI: 0.95 to 0.97), lower blood pressure (OR: 0.96, 95% CI: 0.96 to 0.97), and having no history of renal insufficiency (OR: 0.91, 95% CI: 0.85 to 0.97). Use of digoxin in patients with HFpEF (n = 138,140) without AF was 9.8% in 2005, which decreased to 2.2% in 2014 (ptrend < 0.0001). ConclusionsOne in 5 HFrEF patients received digoxin at discharge, with a significant downward temporal trend in use over the study period. Use of digoxin in HFpEF patients without AF was very low and decreased over the study period.

Retraction notice to “Trends in use of Swan-Ganz Catheter Among Patients with Acute Decompensated Heart Failure Hospitalization in United States, 2004-2012: Did the ESACPE Trial Make a Difference?”

zation among heart failure patients in the post-ESCAPE era are not known. In this study, we aim to determine the temporal trends in use of swan-ganz catheterization among hospitalized heart failure patients between 2004 and 2012. Methods: The 2004-2012 Nationwide Inpatient Sample (NIS), the largest database of in-patient hos- pital stays in the US, was used to identify hospitalizations with primary diagnosis of heart failure among patients $16 years using ICD-9 codes 402.xx, 404.xx, and 428.xx. Use of swan-ganz catheterization for monitoring among these patients was identified using the clinical classification software procedure code 204. Primary outcome of interest was annual swan ganz catheterization per 1000 heart failure ad- missions during the study period. Results: There were 9.2 million hospitalizations with a principal diagnosis of heart failure from 2004 - 2012 (mean age 72.6 years, 51% were women). The overall rate of utilization of swan-ganz catheterization was 6.2 per 1000 heart failure hospitalizations. There was a significant increase in the proportional utilization of swan-ganz catheterization from 5.7 per 1000 heart fail- ure admissions in 2004 to 8.9 per 1000 heart failure admissions in 2012 (p!0.001 for linear trend). In contrast, among patients who died during hospitalization, a group whose disease severity may be consistent across time, there was a relative decline in proportional utilization of swan ganz catheterization (3.05 per 1000 heart failure admissions in 2004 to 2.54 per 1000 heart failure admissions in 2012 (P-trend 5 0.02). Conclusions: Proportional utilization of swan-ganz catheters among patients hospitalized for heart failure has increased over time in the post ESCAPE era. This increase is likely due to its greater use in patients with less severe disease. ally, HFrEF was diagnosed in 0.045% in the total population, 0.69% of HbSS, 0.48% of HbS, 1.47% of HbSb, and 1.85% of HbSC. Compared with the total population, there was an increased prevalence of HFrEF in patients with HbSS (OR 15.4 (95% CI: 11.5-20.5), p!0.001), HbS (OR 10.6 (95% CI:8.3-13.5), p!0.001), HbSb (OR 33.1 (95% CI:16.7-63.4), p!0.001), and HbSC (OR 41.8 (95% CI:21.1-80.3), p!0.001). Conclusions: Patients with sickle cell variants are at an increased risk of heart failure with increased age. The prevalence of heart failure is higher in males compared to females except for HgSc. Patients with sickle cell variants are at an

Minute Ventilation-Targeted Adaptive Servo Ventilation Protects Renal Function In Acute Decompensated Heart Failure Patients

Introduction: Findings from The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial, published in October 2005, suggested that use of swan-ganz catheterization in patients with acute decompensated heart failure was not associated with an improvement in clinical outcomes. However, the temporal trends in national utilization of swan-ganz catheterization among heart failure patients in the post-ESCAPE era are not known. In this study, we aim to determine the temporal trends in use of swan-ganz catheterization among hospitalized heart failure patients between 2004 and 2012. Methods: The 2004-2012 Nationwide Inpatient Sample (NIS), the largest database of in-patient hospital stays in the US, was used to identify hospitalizations with primary diagnosis of heart failure among patients $16 years using ICD-9 codes 402.xx, 404.xx, and 428.xx. Use of swan-ganz catheterization for monitoring among these patients was identified using the clinical classification software procedure code 204. Primary outcome of interest was annual swan ganz catheterization per 1000 heart failure admissions during the study period. Results: There were 9.2 million hospitalizations with a principal diagnosis of heart failure from 2004 2012 (mean age 72.6 years, 51% were women). The overall rate of utilization of swan-ganz catheterization was 6.2 per 1000 heart failure hospitalizations. There was a significant increase in the proportional utilization of swan-ganz catheterization from 5.7 per 1000 heart failure admissions in 2004 to 8.9 per 1000 heart failure admissions in 2012 (p!0.001 for linear trend). In contrast, among patients who died during hospitalization, a group whose disease severity may be consistent across time, there was a relative decline in proportional utilization of swan ganz catheterization (3.05 per 1000 heart failure admissions in 2004 to 2.54 per 1000 heart failure admissions in 2012 (P-trend 5 0.02). Conclusions: Proportional utilization of swan-ganz catheters among patients hospitalized for heart failure has increased over time in the post ESCAPE era. This increase is likely due to its greater use in patients with less severe disease.

Underutilization of Radial Access in Patients Undergoing Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

The purpose of this study was to evaluate the frequency and temporal trends in use of transradial access (TRA) for percutaneous coronary intervention (PCI) in ST-segment-elevation myocardial infarction (STEMI). The use of TRA has been associated with less bleeding and improved clinical outcomes in patients undergoing PCI for STEMI. The frequency of TRA compared with transfemoral access for patients undergoing PCI for STEMI or other indications (non-ST-segment-elevation myocardial infarction, unstable angina, and non-acute coronary syndrome) in The Blue Cross Blue Shield of Michigan Cardiovascular Consortium database between 2010 and 2013 was evaluated. Propensity matching was used to assess the relationship of TRA with in-hospital clinical end points of major bleeding, transfusion, and death. The TRA cohort of patients was stratified into deciles based on their predicted bleeding risk and compared with PCI indication. Of 122,728 PCI procedures, 17,912 (14.6%) were via TRA. Among patients with STEMI cases, 8.3% of the PCI cases were performed via TRA. The use of TRA increased over the study period although the growth was slower for STEMI than for other indications, P<0.001. The use of TRA for PCI in STEMI was associated with a lower rate of bleeding (11.7% versus 20.0%; P<0.001) and vascular complications (0.7% versus 2.6%; P=0.001), but no mortality difference (1.25% versus 2.33%; P=0.175). There was a strong negative association between the predicted risk of bleeding and the use of TRA (P<0.001). The use of radial access for PCI in STEMI is increasing but at a slower pace than for patients with other indications. TRA was associated with a reduction in bleeding and transfusion, but there is a strong negative correlation between the predicted risk of bleeding and actual use of TRA in STEMI.

Temporal Trends in the Use of Parenteral Nutrition in Critically Ill Patients

Clinical practice guidelines recommend enteral over parenteral nutrition in critical illness and do not recommend early initiation. Few data are available on parenteral nutrition use or timing of initiation in the ICU or how this use may have changed over time. We used the Project IMPACT database to evaluate temporal trends in parenteral nutrition use (total and partial parenteral nutrition and lipid supplementation) and timing of initiation in adult ICU admissions from 2001 to 2008. We used χ2 tests and analysis of variance to examine characteristics of patients receiving parenteral nutrition and multilevel multivariate logistic regression models to assess parenteral nutrition use over time, in all patients and in specific subgroups. Of 337,442 patients, 20,913 (6.2%) received parenteral nutrition. Adjusting for patient characteristics, the use of parenteral nutrition decreased modestly over time (adjusted probability, 7.2% in 2001-2002 vs 5.5% in 2007-2008, P<.001). Enteral nutrition use increased simultaneously (adjusted probability, 11.5% in 2001-2002 vs 15.3% in 2007-2008, P<.001). Use of parenteral nutrition declined most rapidly in emergent surgical patients, patients with moderate illness severity, patients in the surgical ICU, and patients admitted to an academic facility (P≤.01 for all interactions with year). When used, parenteral nutrition was initiated a median of 2 days (interquartile range, 1-3), after ICU admission and >90% of patients had parenteral nutrition initiated within 7 days; timing of initiation of parenteral nutrition did not change from 2001 to 2008. Use of parenteral nutrition in US ICUs declined from 2001 through 2008 in all patients and in all examined subgroups, with the majority of parenteral nutrition initiated within the first 7 days in ICU; enteral nutrition use coincidently increased over the same time period.

Temporal Trends in Use of Sildenafil among Pediatric Patients

Temporal Trends in Use of Sildenafil among Pediatric Patients

Racial and ethnic differences in the treatment of acute myocardial infarction: findings from the Get With the Guidelines-Coronary Artery Disease program.

Racial/ethnic differences in cardiovascular care have been well documented. We sought to determine whether racial/ethnic differences in evidence-based acute myocardial infarction care persist among hospitals participating in a national quality improvement program. We analyzed 142 593 acute myocardial infarction patients (121 528 whites, 10 882 blacks, and 10 183 Hispanics) at 443 hospitals participating in the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) program between January 2002 and June 2007. We examined individual and overall composite rates of defect-free care, defined as the proportion of patients receiving all eligible performance measures. In addition, we examined temporal trends in use of performance measures according to race/ethnicity by calendar quarter. Overall, individual performance measure use was high, ranging from 78% for use of angiotensin-converting enzyme inhibitors to 96% for use of aspirin at discharge. Use of each of these improved significantly over the 5 years of study. Overall, defect-free care was 80.9% for whites, 79.5% for Hispanics (adjusted odds ratio versus whites 1.00, 95% confidence interval 0.94 to 1.06, P=0.94), and 77.7% for blacks (adjusted odds ratio versus whites 0.93, 95% confidence interval 0.87 to 0.98, P=0.01). A significant gap in defect-free care was observed for blacks mostly during the first half of the study, which was no longer present during the remainder of the study. Overall, progressive improvements in defect-free care were observed regardless of race/ethnic groups. Among hospitals engaged in a national quality monitoring and improvement program, evidence-based care for acute myocardial infarction appeared to improve over time for patients irrespective of race/ethnicity, and differences in care by race/ethnicity care were reduced or eliminated.

Changes in the Use of HIV Antiretroviral Resistance Testing in a Large Cohort of U.S. Patients, 1999 to 2006

Monitoring antiretroviral (ARV) drug resistance is of growing importance in the management of persons infected with HIV, but few reports document how genotypic and phenotypic resistance testing (GPT) has been used among patients receiving routine outpatient care. We studied data from participants in the HIV Outpatient Study seen at 10 HIV clinics in the United States during 1999 to 2006. We restricted analyses to patients whom we considered eligible for GPT (i.e., had a documented HIV viral load >1000 copies/mL). We used multivariable general modeling to evaluate temporal trends in use of GPT among eligible patients and to identify factors associated with being tested during 1999 to 2002 and 2003 to 2006. Of 5594 active patients, 3995 (71%) were considered eligible for GPT in at least one year during 1999 to 2006 (declining from 50.2% in 1999 to 31.2% in 2006). The fraction of eligible patients receiving GPT increased from 11.2% in 1999 to 31.0% in 2003 (P < 0.001 for trend) and then stabilized at approximately 30% through 2006. Among persons tested, the annual percentage receiving only genotype testing declined over time (90% to 56%), whereas the percentage receiving genotype and phenotype testing increased (5.4% to 39.1%). The annual use of GPT for ARV-naïve patients increased over time and after 2003 exceeded the corresponding rates for ARV-experienced patients. In multivariable analyses, low CD4 count and high HIV viral load were consistently associated with GPT. Compared with other ARV-experienced patients, those who were triple ARV-class experienced were consistently more likely to be tested, whereas ARV-naïve were less likely to be tested during 1999 to 2002 and more likely during 2003 to 2006. In addition, women and heterosexual men (vs. men who have sex with men) and black patients (vs. white) were less likely to be tested during 1999 to 2002, whereas older patients were less likely to be tested during 2003 to 2006. The annual frequency of GPT use has increased almost threefold since 1999. GPT use among ARV-naïve patients has increased coincident with dissemination of recommendations. Although earlier sex and racial/ethnic disparities in testing have waned, older patients were significantly less likely to be tested in recent years.

The effect of evidence‐based medication use on long‐term survival in patients hospitalised for heart failure in Western Australia

To examine trends and predictors of prescription medications on discharge after first (index) hospitalisation for heart failure (HF), and the effect on all-cause mortality of evidence-based therapy. A retrospective multicentre cohort study, with medical record review. Three tertiary-care hospitals in Perth, Western Australia. WA Hospital Morbidity Data were used to identify a random sample of 1006 patients with an index admission to hospital for HF between 1996 and 2006. Proportion of patients prescribed evidence-based therapy for HF on discharge from hospital; and 1-year all-cause mortality. Among 944 patients surviving to hospital discharge, the prescription rate of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) (74.3%) and loop diuretics (85.5%) remained high over the study period, whereas that of beta-blockers and spironolactone increased (10.5% to 51.3% and 1.4% to 23.3%, respectively), and digoxin prescription decreased (38.1% to 20.7%). The temporal trends in use of beta-blockers, spironolactone and digoxin were in line with clinical trial evidence. Age > or = 75 years was a significant, negative predictor of beta-blocker and spironolactone prescription. In-hospital echocardiography, performed in 53% of patients, was associated with a significantly greater likelihood of treatment with ACE inhibitors/ARBs, beta-blockers and spironolactone. Both ACE inhibitors/ARBs and beta-blockers prescribed on discharge were associated with a lower adjusted hazard ratio (HR) for mortality at 1-year (HR, 0.71; P = 0.003; and HR, 0.68; P = 0.002, respectively). ACE inhibitors/ARBs and beta-blockers, prescribed during initial hospitalisation for HF, are associated with improved long-term survival. Therapy became more evidence based over the study period, but echocardiography, an important predictor of evidence-based therapy, was underutilised.

Multimodality Noninvasive Imaging for Assessment of Congenital Heart Disease

Major advances in the field of pediatric cardiology and cardiac surgery over the last several decades have led to a dramatic improvement in survival rates for most forms of congenital heart disease (CHD). For example, hypoplastic left heart syndrome, a previously lethal defect, now has early survival rates up to 90% at major centers.1 These improved outcomes have produced a growing population of survivors with complex CHD who are now reaching adulthood (Figure 1). During this period, improvements in surgical and medical treatments have been accompanied by developments in diagnostic modalities. Echocardiography has replaced catheterization as the primary diagnostic modality, and it is now uncommon for newborn infants to undergo catheterization for purely diagnostic purposes. Although echocardiography remains the bedrock of noninvasive cardiac imaging, the array of diagnostic modalities and techniques available continue to grow and this has spawned the specialty of “noninvasive cardiac imaging” and the need for the “cardiac imager” to be adept in all the different modalities. Figure 1. Percentage of patients under the age of 1 year (grey bars) and over the age of 18 years (black bars) undergoing echocardiography at Children’s Hospital Boston from 1983 through 2006. Note the reverse trends of these age groups reflecting the steady increase in the proportion of adult patients with congenital heart disease. Although the absolute number of infants undergoing echocardiography during this time period has increased, their proportion has steadily declined. Echocardiography, cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT) are the primary modalities used for noninvasive cardiac imaging in patients with CHD. Nuclear scintigraphy is used in selected circumstances. The Table summarizes the strengths and weaknesses of each modality. Figure 2 shows temporal trends in utilization for the various noninvasive cardiac imaging techniques at our center. It is clear that echocardiography is the most frequently …

Longitudinal Trends in Use of Bone Mass Measurement Among Older Americans, 1999–2005

Bone mass measurement (BMM) is useful to identify persons with low bone mass who are at increased risk for fracture. Given the increased emphasis that is being placed on preventive services such as screening for osteoporosis, we evaluated trends in BMM among Medicare beneficiaries. We studied a 5% sample of Medicare beneficiaries >or=65 yr of age in 1999-2005. We identified claims for BMM tests performed in both facility and nonfacility settings, evaluated temporal trends in use of these tests, and described the proportion of tests attributable to each specialty of physicians submitting claims. We also assessed patterns of serial testing among individuals who were tested more than once. Claims data from all years were pooled to describe the proportion of persons in the population ever tested. From 1999 to 2005, use of central DXA increased by approximately 50%, and use of peripheral DXA declined. The greatest increases in central DXA occurred among internists, family practitioners, and gynecologists. In 1999, the proportion of 65-yr-old women tested was 8.4%; this increased to 12.9% in 2005. Corresponding proportions for men were 0.6% and 1.7%, respectively. Between 40% and 73% of persons receiving central DXA were retested, most at approximately 2-yr intervals. Aggregating data across all years for whites and blacks, 30.0% of women and 4.4% of men underwent central DXA at least once. We conclude that, although use of DXA steadily increased from 1999 to 2005, only approximately 30% of women and 4% of men at least 65 yr old had a central DXA study. Given the importance of central DXA to assess the risk of osteoporotic fractures, strategies to increase central DXA use to test at-risk persons are warranted.

Temporal trends in use of fauna-friendly underpasses and overpasses

The impact of roads on local biodiversity is a major issue associated with urbanisation. A major arterial road in the southern suburbs of Brisbane, south-east Queensland, was upgraded in 2004–05 from two to four lanes. In an attempt to minimise the impact of the larger road on local wildlife populations, a range of fauna crossing structures were constructed at the site. Monitoring of road-kill was undertaken for 4 months before construction and after the completion of construction. Assessment of the use of two underpasses and a large overpass (‘land-bridge’) started 6 months after construction using sand tracking in underpasses and scat sampling on the land-bridge. An initial 26-week period of intensive monitoring was undertaken from August 2005 to February 2006 followed by monthly monitoring from June 2006 to June 2007. On average, 1–5 tracks per day were detected in the underpasses at the start of the survey, increasing steadily to ~42 tracks per day by February 2006. The monthly survey showed regular use of the underpasses by a wide range of species and species-groups, the most abundant being ‘rodents’, most likely Rattus species, both native and introduced. The land-bridge was also used continuously by three species of macropod (red-necked wallaby, Macropus rufogriseus; swamp wallaby, Wallabia bicolor; and eastern grey kangaroo, Macropus giganteus) with brown hare (Lepus capensis) becoming increasingly common in summer 2006. The exclusion fencing was extremely effective in preventing most road-kill, at least of larger species, except following human-related breaches in the fence.