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Background: Statins are prescribed to lower cholesterol, but also have anti-inflammatory properties. Some observational studies suggest that statins may reduce mortality from sepsis.Methods: Using a highly detailed administrative database, we conducted an observational cohort study of all patients aged ≥18 years who received a discharge diagnosis of pneumonia from 2003-2005 at 376 hospitals. Patients with contraindications to statins, and those unable to take oral medications or discharged within 2 days were excluded. We used multivariable logistic regression and propensity matching to compare mortality among patients who did and did not receive statins on hospital day 1 or 2.Results: Of the 121,254 patients who met the inclusion criteria, median age was 74; 56% were female and 70% were white; 19% received a statin on day 1 or 2. Compared to patients who did not receive statins, statin-treated patients were less likely to be admitted to intensive care (15.7% vs 18.1%, p < 0.001), require mechanical ventilation (6.9% vs. 9.3%, p < 0.001), or die in hospital (3.9% vs 5.7%, p < 0.001). After multivariable adjustment, including the propensity for statin treatment and severity at presentation, mortality was lower in statin-treated patients [OR for propensity-adjusted 0.86 (95% CI 0.79 to 0.93) OR for propensity-matched 0.90, (0.82 to 0.99)]. For patients admitted to intensive care the adjusted odds ratio for mortality with statins was 0.93 (95% CI 0.81 to 1.06), whereas outside intensive care it was 0.79 (95% CI 0.71 to 0.87).Conclusions: Inpatient treatment with statins is associated with a modest reduction in pneumonia mortality outside of intensive care. [ABSTRACT FROM AUTHOR]

Study Objective: Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE., Methods: We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment., Results: Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81)., Conclusions: Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Behavioral health crises in pediatric emergency department (ED) patients are increasingly common. Chemical restraints can be utilized for patients who present imminent danger to self or others. We sought to describe the use of intravenous (IV)/intramuscular (IM) chemical restraints for pediatric behavioral health ED patients across a nationwide sample of hospitals and describe factors associated with restraint use., Methods: This was a retrospective study of patients ages 8-17 treated at 822 EDs contributing data to the Premier Healthcare Database between January 1, 2018, and December 31, 2020, with a behavioral health discharge diagnosis. The primary outcome was the use of IV/IM chemical restraint medication. We developed a hierarchical model to examine patient and hospital-level factors associated with treatment with IV/IM chemical restraint medications., Results: Of 630,384 cases, 4.8% received IV/IM chemical restraint. Patient factors associated with higher odds of chemical restraint were older age (ages 13-17 years [adjusted odds ratio {AOR} 1.53, 95% confidence interval {CI} 1.48-1.58]), anxiety disorders (AOR 1.69, 95% CI 1.64-1.74), disruptive disorders (AOR 1.61, 95% CI 1.53-1.69), suicide/self-injury (AOR 1.3, 95% CI 1.26-1.34), substance use (AOR 1.24, 95% CI 1.20-1.28), and bipolar disorder (AOR 1.23, 95% CI 1.17-1.30). Participants with complex comorbidities were more likely to receive chemical restraint (AOR 1.32, 95% CI 1.26-1.39). After patient and hospital factors were adjusted for, the median OR indicating the influence of the individual hospital on the odds of chemical restraint was 1.43 (95% CI 1.40-1.47)., Conclusions: We found that age and certain behavioral health diagnoses were associated with receipt of IV/IM chemical restraint during pediatric behavioral health ED visits. Additionally, whether a patient was treated with chemical restraints was strongly influenced by the hospital to which they presented for treatment., (© 2023 Society for Academic Emergency Medicine.)

Background Accountable care organizations (ACOs) aim to improve health care quality and reduce costs, including among patients with heart failure (HF). However, variation across ACOs in admission rates for patients with HF and associated factors are not well described. Methods and Results We identified Medicare fee-for-service beneficiaries with HF who were assigned to a Medicare Shared Savings Program ACO in 2017 and survived ≥30 days into 2018. We calculated risk-standardized acute admission rates across ACOs, assigned ACOs to 1 of 3 performance categories, and examined associations between ACO characteristics and performance categories. Among 1 232 222 beneficiaries with HF, 283 795 (mean age, 81 years; 54% women; 86% White; 78% urban) were assigned to 1 of 467 Medicare Shared Savings Program ACOs. Across ACOs, the median risk-standardized acute admission rate was 87 admissions per 100 people, ranging from 61 (minimum) to 109 (maximum) admissions per 100 beneficiaries. Compared to the overall average, 13% of ACOs performed better on risk-standardized acute admission rates, 72% were no different, and 14% performed worse. Most ACOs with better performance had fewer Black beneficiaries and were not hospital affiliated. Most ACOs that performed worse than average were large, located in the Northeast, had a hospital affiliation, and had a lower proportion of primary care providers. Conclusions Admissions are common among beneficiaries with HF in ACOs, and there is variation in risk-standardized acute admission rates across ACOs. ACO performance was associated with certain ACO characteristics. Future studies should attempt to elucidate the relationship between ACO structure and characteristics and admission risk.

Purpose: Pulmonary rehabilitation (PR) improves outcomes for patients with chronic obstructive pulmonary disease (COPD); however, very few patients attend. We sought to describe strategies used to promote participation in PR after a hospitalization for COPD., Methods: A random sample of 323 United States based PR programs was surveyed. Using a positive deviance approach, a 39-item survey was developed based on interviews with clinicians at hospitals demonstrating high rates of participation in PR. Items focused on strategies used to promote participation as well as relevant contextual factors., Results: Responses were received from 209 programs (65%), of which 88% (n = 184) were hospital-based outpatient facilities. Most (91%, n = 190) programs described enrolling patients continuously, and 80% (n = 167) reported a wait time from referral to the initial PR visit of <4 wk. Organization-level strategies to increase referral to PR included active surveillance (48%, n = 100) and COPD-focused staff (49%, n = 102). Provider-level strategies included clinician education (45%, n = 94), provider outreach (43%, n = 89), order sets (45%, n = 93), and automated referrals (23%, n = 48). Patient-level strategies included bedside education (53%, n = 111), flyers (49%, n = 103), motivational interviewing (33%, n = 69), financial counseling (64%, n = 134), and transportation assistance (35%, n = 73). Fewer than one-quarter (18%, n = 38) of PR programs reported using both bedside education and automatic referral, and 42% (n = 88) programs did not use either strategy., Conclusions: This study describes current practices in the United States, and highlights opportunities for improvement at the organization, provider, and patient level. Future research needs to demonstrate the effectiveness of these strategies, alone or in combination., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc.)

Rationale: Pulmonary rehabilitation (PR) after hospitalization for chronic obstructive pulmonary disease (COPD) is recommended by guidelines; however, few patients participate, and rates vary between hospitals. Objectives: To identify contextual factors and strategies that may promote participation in PR after hospitalization for COPD. Methods: Using a positive-deviance approach, we calculated hospital-specific rates of PR after hospitalization for COPD among a cohort of Medicare beneficiaries. At a purposive sample of high-performing and innovative hospitals in the United States, we conducted in-depth interviews with key stakeholders. We defined high-performing hospitals as having a PR rate above the 95th percentile, at least 6.58%. To learn from hospitals that demonstrated a commitment to improving rates of PR, regardless of PR rates after discharge, we identified innovative hospitals on the basis of a review of American Thoracic Society conference research presentations from prior years. Interviews were audio-recorded and transcribed verbatim. Using a directed content analysis approach, transcripts were coded iteratively to identify themes. Results: Interviews were conducted with 38 stakeholders at nine hospitals (seven high-performers and two innovators). Hospitals were diverse regarding size, teaching status, PR program characteristics, and geographic location. Participants included PR medical directors, PR managers, respiratory therapists, inpatient and outpatient providers, and others. We found that high-performing hospitals were broadly focused on improving care for patients with COPD, and several had recently implemented new initiatives to reduce rehospitalizations after admission for COPD in response to the Centers for Medicare and Medicaid Services/Medicare's Hospital Readmission Reduction Program. Innovative and high-performing hospitals had systems in place to identify patients with COPD that enabled them to provide patient education and targeted discharge planning. Strategies took several forms, including the use of a COPD navigator or educator. In addition, we found that high-performing hospitals reported effective interprofessional and patient communication, had clinical champions or external change agents, and received support from hospital leadership. Specific strategies to promote PR included education of referring providers, education of patients to increase awareness of PR and its benefits, and direct assistance in overcoming barriers. Conclusions: Our findings suggest that successful efforts to increase participation in PR may be most effective when part of a larger strategy to improve outcomes for patients with COPD. Further research is necessary to test the generalizability of our findings.

Background: Early studies of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) suggested that physician leadership was an important driver of ACO success, but it is unknown whether the demographic and professional composition of current MSSP ACO governing boards is associated with ACOs' publicly reported outcomes., Objective: To investigate whether governing boards with higher physician participation and greater female involvement have better outcomes., Design: Cross-sectional observational study., Participants: All 2017 MSSP ACOs identified by the Center for Medicare and Medicaid Services ACO Public Use Files (PUF)., Main Measures: We collected governing board composition from ACO websites in 2019. Outcome metrics included risk-standardized readmission and unplanned admissions rates. We used descriptive statistics and linear regression models to examine the association between board composition and outcomes., Key Results: Of the 339 ACOs that still existed in 2019 and had available data, 77% had physician-majority boards and 11.5% had no women on their boards. Eighty-nine percent reported a Medicare beneficiary on their board, of which about one-third had a woman representative. The average number of members on MSSP ACO boards was 12, with a mean of 67% physicians and 24% women. Board composition varied minimally by ACO characteristics, such as geographic region, number of beneficiaries, or type of participants. Higher levels of physician participation in ACO governing boards were associated with lower all-cause unplanned admission rates for patients with heart failure (p = - 0.26, p < 0.001) and for patients with multiple chronic conditions (p = - 0.28, p = 0.001). The number of women on the board was not associated with any outcome differences., Conclusions: MSSP ACO governing boards were predominately male and physician-led. Physician involvement may be important for achieving quality goals, while lack of female involvement showcases an opportunity to diversify boards., (© 2021. Society of General Internal Medicine.)

Background: There is strong evidence that noninvasive ventilation (NIV) improves the outcomes of patients hospitalized with severe COPD exacerbation, and NIV is recommended as the first-line therapy for these patients. Yet, several studies have demonstrated substantial variation in NIV use across hospitals, leading to preventable morbidity and mortality. In addition, prior studies suggested that efforts to increase NIV use in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, our initial project aimed to compare two educational strategies: online education (OLE) and interprofessional education (IPE), which targets complex team-based care in NIV delivery. Due to the impact of the COVID-19 pandemic on recruitment and planned intervention, we had made several changes in the study design, statistical analysis, and implementation strategies delivery as outlined in the methods., Methods: We originally proposed a two-arm, pragmatic, cluster, randomized hybrid implementation-effectiveness trial comparing two education strategies to improve NIV uptake in patients with severe COPD exacerbation in 20 hospitals with a low baseline rate of NIV use. Due to logistical constrains and slow recruitment, we changed the study design to an opened cohort stepped-wedge design with three steps which will allow the institutions to enroll when they are ready to participate. Only the IPE strategy will be implemented, and the education will be provided in an online virtual format. Our primary outcome will be the hospital-level risk-standardized NIV proportion for the period post-IPE training, along with the change in rate from the period prior to training. Aim 1 will compare the change over time of NIV use among patients with COPD in the step-wedged design. Aim 2 will explore the mediators' role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and effectiveness. Finally, in Aim 3, through interviews with providers, we will assess the acceptability and feasibility of the educational training., Conclusion: The changes in study design will result in several limitation. Most importantly, the hospitals in the three cohorts are not randomized as they enroll based on their readiness. Second, the delivery of the IPE is virtual, and it is not known if remote education is conducive to team building. However, this study will be among the first to test the impact of IPE in the inpatient setting carefully and may generalize to other interventions directed to seriously ill patients., Trial Registration: ClinicalTrials.gov NCT04206735 . Registered on December 20, 2019., (© 2021. The Author(s).)

Rationale: Although clinical trials have found that pulmonary rehabilitation (PR) can reduce the risk of readmissions after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, less is known about PR's impact in routine clinical practice. Objectives: To evaluate the association between initiation of PR within 90 days of discharge and rehospitalization(s). Methods: We analyzed a retrospective cohort of Medicare beneficiaries (66 years of age or older) hospitalized for COPD in 2014 who survived at least 30 days after discharge. Measurements and Main Results: We used propensity score matching and estimated the risk of recurrent all-cause rehospitalizations at 1 year using a multistate model to account for the competing risk of death. Of 197,376 total patients hospitalized in 4,446 hospitals, 2,721 patients (1.5%) initiated PR within 90 days of discharge. Overall, 1,534 (56.4%) patients who initiated PR and 125,720 (64.6%) who did not were rehospitalized one or more times within 1 year of discharge. In the propensity-score-matched analysis, PR initiation was associated with a lower risk of readmission in the year after PR initiation (hazard ratio, 0.83; 95% confidence interval, 0.77-0.90). The mean cumulative number of rehospitalizations at 1 year was 0.95 for those who initiated PR within 90 days and 1.15 for those who did not ( P  < 0.001). Conclusions: After hospitalization for COPD, Medicare beneficiaries who initiated PR within 90 days of discharge experienced fewer rehospitalizations over 1 year. These results support findings from randomized controlled clinical trials and highlight the need to identify effective strategies to increase PR participation.

Rationale: Although <5% of children hospitalized with an asthma exacerbation have pneumonia that can be radiographically confirmed, at some hospitals, an asthma-pneumonia co-diagnosis is so common that the term "asthmonia" is used to describe the phenomenon. High rates of asthmonia diagnosis may incur unwarranted health care costs and contribute to unnecessary antibiotic prescribing. Objectives: To characterize hospital variation in rates of pediatric asthmonia diagnosis and analyze associations between hospitals' asthmonia diagnosis rates and clinical outcomes. Methods: We conducted a cross-sectional analysis of 274 hospitals contributing to the Premier Healthcare Database. Children and adolescents 2-17 years of age were included if they were hospitalized with an asthma exacerbation from 10/1/2015 to 6/30/2018. Asthmonia was defined as a discharge diagnosis of pneumonia in a patient with an asthma exacerbation. To compute hospital-level risk-standardized asthmonia rates, hierarchical generalized linear models with hospital random effects were estimated, adjusting for patient characteristics. The median odds ratio was calculated to quantify the effect of hospital-level clustering on asthmonia diagnosis. Hospitals were stratified into quartiles based on risk-standardized asthmonia diagnosis rates to identify associated hospital characteristics. Generalized linear models, adjusting for hospital characteristics, were developed to compute associations between hospital risk-standardized rates and clinical outcomes. Results: Of 24,606 asthma exacerbations, 19,402 (78.9%) were diagnosed with asthma alone and 5,204 (21.1%) received asthma-pneumonia co-diagnoses. The hospital median risk-adjusted asthmonia diagnosis rate was 20.9% (interquartile range, 16.2-27.2%; range, 8.4-55.9%). The median odds ratio was 1.75 (95% confidence interval, 1.63-1.86). Compared with hospitals in the lowest quartile of asthma-pneumonia co-diagnosis, those in the highest quartile were more likely to be smaller, nonteaching, rural hospitals with minimal subspecialty support (all P < 0.001). Hospitals with high rates of risk-standardized asthmonia diagnosis had greater antibiotic use, more prolonged lengths of stay, and higher costs, with no significant differences in risk of transfer or readmission. Conclusions: Marked variation exists in rates of asthmonia diagnosis, and the hospital of admission is one of the strongest predictors of diagnosis. Efforts to reduce rates of unwarranted asthmonia diagnosis are needed, particularly at small, rural, nonteaching hospitals with minimal pediatric specialty support.

Background: Pediatric health care quality in the United States varies, but the reasons for variation are not fully understood. Differences in pediatric practices' organizational characteristics, such as organizational structures, strategies employed to improve quality, and other contextual factors, may contribute to the variation observed., Purpose: To assess the relationship between organizational characteristics and performance on clinical quality (CQ) and patient experience (PE) measures in primary care pediatric practices in Massachusetts., Methodology: A 60-item questionnaire that assessed the presence of selected organizational characteristics was sent to 172 pediatric practice managers in Massachusetts between December 2017 and February 2018. The associations between select organizational characteristics and publicly available CQ and PE scores were analyzed using analysis of variance; open-ended survey questions were analyzed using qualitative content analysis., Results: Eighty-six practices (50.0%) responded; 80 (46.5%) were included in the primary analysis. Having a quality champion ( p = .03), offering co-located specialty services (e.g., behavioral health; p = .04), being a privately owned practice ( p = .04), believing that patients and families feel respected ( p = .03), and having a lower percentage of patients (10%-25%) covered by public health insurance ( p = .04) were associated with higher CQ scores. Higher PE scores were associated with private practice ownership ( p = .0006). Qualitative analysis suggested organizational culture and external factors, such as health care finance, may affect quality., Conclusions: Both modifiable organizational practices and factors external to a practice may affect quality of care. Addressing differences in practice performance may not be reducible to implementation of changes in single organizational characteristics., Practice Implications: Pediatric practices seeking to improve quality of care may wish to adopt the strategies that were associated with higher performance on quality measures, but additional studies are needed to better understand the mechanisms behind these associations and how they relate to each other., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Antibiotic resistance represents a worldwide public health threat. Characterising prescribing patterns for conditions for which antibiotics have no role can inform antimicrobial stewardship efforts. Asthma is among the most common non-infectious diseases in children and results in 100 000 hospitalisations annually in the USA. We sought to identify the rate of antibiotic prescribing in children hospitalised for asthma exacerbations, and to characterise patient and hospital factors associated with receipt of antibiotics., Methods: Children and adolescents aged 2-17 years admitted to hospital between 1 October 2015 and 30 June 2018 with an asthma exacerbation were identified from the Premier Alliance Database. After excluding hospitalisations for which antibiotics appeared to have been justified, we assessed receipt and duration of antibiotic treatments during the hospital stay. We developed a hierarchical logistic regression model to identify patient and hospital factors associated with antibiotic treatment. For each hospital with at least 10 asthma cases we computed the percentage of cases receiving antibiotic treatment., Results: 23 129 hospital stays met inclusion criteria; in 3329 (14%) of these, antibiotics were prescribed without clear indication. Hospital prescribing rates varied widely (range 0%-95%), with 25% of hospitals prescribing antibiotics at a rate of 27.5% or more. Patient factors most strongly associated with receipt of antibiotics included the presence of a complex chronic condition (OR: 2.4, 95% CI 2.1 to 2.9; p<0.0001) and admission to the intensive care unit compared with a general medical-surgical bed (OR: 1.6, 95% CI 1.5 to 1.9; p<0.0001). Hospitalisation at general hospitals with minimum paediatric specialty support conferred a nearly threefold higher odds of antibiotic treatment (OR: 2.9, 95% CI 1.5 to 5.6; p<0.0001)., Conclusions: These findings illustrate an opportunity to reduce unnecessary exposure to antibiotics in children hospitalised with asthma, particularly in general hospitals where three-quarters of children in the USA receive their hospital-based care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: While guidelines recommend outpatient management of patients with low-risk pulmonary embolism (PE), little is known about the disposition of patients with PE diagnosed in United States emergency departments (EDs). We sought to determine disposition practices and subsequent health care utilization in patients with acute PE in U.S. EDs., Methods: This was a retrospective cohort study of adult ED patients with a new diagnosis of acute PE treated at 740 U.S. acute care hospitals from July 1, 2016, through June 30, 2018. The primary outcome was the initial disposition following an ED visit for acute PE. Additional measures included hospital cost and 30-day revisit rate to the ED., Results: A total of 61,070 cases were included in the overall cohort, of which 4.1% of new cases of PE were discharged from the ED. The median hospital-specific proportion of patients discharged was 3.1% (interquartile range = 0.8%-6.8%). The median odds ratio, representing the importance of the hospital in initial disposition decisions, was 2.21 (95% confidence interval = 2.05 to 2.37), which was greater than any patient-level factor with the exception of concurrent ED diagnosis of hypoxemia/respiratory failure, shock, or hypotension. Within 30 days of discharge, 17.9% of discharged cases had an ED return visit to the ED only and 10.3% of patients were hospitalized. Of the 30-day ED return visits in patients initially managed as outpatients, 1.3% had a bleeding-associated diagnosis., Conclusion: Despite guidelines promoting outpatient management, few patients are currently discharged home in the United States; however, practice varies widely across hospitals. Return visit rates were high but most did not result in hospitalization., (© 2020 by the Society for Academic Emergency Medicine.)

Objective: To develop and validate a clinical risk prediction score for noninvasive ventilation (NIV) failure defined as intubation after a trial of NIV in non-surgical patients., Design: Retrospective cohort study of a multihospital electronic health record database., Patients: Non-surgical adult patients receiving NIV as the first method of ventilation within two days of hospitalization., Measurement: Primary outcome was intubation after a trial of NIV. We used a non-random split of the cohort based on year of admission for model development and validation. We included subjects admitted in years 2010-2014 to develop a risk prediction model and built a parsimonious risk scoring model using multivariable logistic regression. We validated the model in the cohort of subjects hospitalized in 2015 and 2016., Main Results: Of all the 47,749 patients started on NIV, 11.7% were intubated. Compared with NIV success, those who were intubated had worse mortality (25.2% vs. 8.9%). Strongest independent predictors for intubation were organ failure, principal diagnosis group (substance abuse/psychosis, neurological conditions, pneumonia, and sepsis), use of invasive ventilation in the prior year, low body mass index, and tachypnea. The c-statistic was 0.81, 0.80 and 0.81 respectively, in the derivation, validation and full cohorts. We constructed three risk categories of the scoring system built on the full cohort; the median and interquartile range of risk of intubation was: 2.3% [1.9%-2.8%] for low risk group; 9.3% [6.3%-13.5%] for intermediate risk category; and 35.7% [31.0%-45.8%] for high risk category., Conclusions: In patients started on NIV, we found that in addition to factors known to be associated with intubation, neurological, substance abuse, or psychiatric diagnoses were highly predictive for intubation. The prognostic score that we have developed may provide quantitative guidance for decision-making in patients who are started on NIV.

Rationale: Patients undergoing cardiac surgery often require vasopressor or inotropic ("vasoactive") medications, but patterns of postoperative use are not well described. Objectives: This study aimed to describe vasoactive medication administration throughout hospitalization for cardiac surgery, to identify patient- and hospital-level factors associated with postoperative use, and to quantify variation in treatment patterns among hospitals. Methods: Retrospective study using the Premier Healthcare Database. The cohort included adult patients who underwent coronary artery bypass grafting or open valve repair or replacement (or in combination) from January 1, 2016, to June 30, 2018. Primary outcome was receipt of vasoactive medication(s) on the first postoperative day (POD1). We identified patient- and hospital-level factors associated with receipt of vasoactive medications using multilevel mixed-effects logistic regression modeling. We calculated adjusted median odds ratios to determine the extent to which receipt of vasoactive medications on POD1 was determined by each hospital, then calculated quotients of Akaike Information Criteria to compare the relative contributions of patient and hospital characteristics and individual hospitals with observed variation. Results: Among 104,963 adults in 294 hospitals, 95,992 (92.2%) received vasoactive medication(s) during hospitalization; 30,851 (29.7%) received treatment on POD1, most commonly norepinephrine ( n  = 11,427, 37.0%). A median of 29.0% (range, 0.0-94.4%) of patients in each hospital received vasoactive drug(s) on POD1. After adjustment, hospital of admission was associated with twofold increased odds of receipt of any vasoactive medication on POD1 (adjusted median odds ratio, 2.07; 95% confidence interval, 1.93-2.21). Admitting hospital contributed more to observed variation in POD1 vasoactive medication use than patient or hospital characteristics (quotients of Akaike Information Criteria 0.58, 0.44, and <0.001, respectively). Conclusions: Nearly all cardiac surgical patients receive vasoactive medications during hospitalization; however, only one-third receive treatment on POD1, with significant variability by institution. Further research is needed to understand the causes of variability across hospitals and whether these differences are associated with outcomes.

Objective: Prior studies indicate that inadequate and excessive gestational weight gain (GWG) are associated with poor maternal and infant outcomes, and that stress and anxiety may contribute to GWG. However, these studies often failed to use validated measures of stress and anxiety, measured only total GWG, and were limited to largely non-Hispanic White populations. We explored the association between stress and anxiety and GWG., Methods: We used data from 1,308 participants in Proyecto Buena Salud, a prospective cohort of predominantly Puerto Rican women 18-40 years of age (2006-2012). We measured stress with the Perceived Stress Scale and anxiety with the State-Trait Anxiety Scale, and abstracted GWG from medical records., Results: The average GWG was 31.0 ± 16.1 pounds. More than one-half of participants (51.8%) exceeded Institute of Medicine guidelines for GWG. After adjusting for age and pre-pregnancy body mass index, women in the highest quartiles of stress and anxiety in early pregnancy had approximately 4 lbs lower GWG (β = -3.89; SE = 1.54; p = .012 and β = -4.37; SE = 1.54; p = .005, respectively) as compared with those in the lowest quartiles. Similarly, women in the highest quartiles of mid/late pregnancy stress and anxiety had lower GWG (β = -3.84 lbs; SE = 1.39; p = .006, and β = -3.51 lbs; SE = 1.38; p = .011, respectively) and a lower rate of GWG in the second and third trimesters (β = -0.117 lbs/week; SE = 0.044; p = .008 and β = -0.116 lbs/week; SE = 0.043; p = .007, respectively), compared with those in the lowest quartiles., Conclusions: High stress and anxiety were associated with lower GWG. Interventions to decrease stress and anxiety during pregnancy should include counseling on maintaining healthy GWG., (Copyright © 2020 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Importance: Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge., Objective: To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival., Design, Setting, and Patients: This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015., Exposures: Initiation of pulmonary rehabilitation within 90 days of hospital discharge., Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality., Results: Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], -6.7% [95% CI, -7.9% to -5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, -4.6% [95% CI, -5.9% to -3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD, -11.1% [95% CI, -13.2% to -8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01)., Conclusions and Relevance: Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.

Background: There are concerns that starting nicotine replacement therapy (NRT) in the immediate perioperative period may negatively impact wound healing. We investigated the association of NRT with postoperative outcomes among smokers hospitalized for a surgical procedure., Methods: This was a retrospective study in 552 hospitals of active smokers hospitalized between January 1, 2015 and December 31, 2016 for a major surgical procedure (Medicare Severity Diagnosis-Related Group expected length of stay, ≥ 2 days). We analyzed the association of receipt of NRT within 2 days of admission with a composite outcome of inpatient complications and with other outcomes. We developed a propensity score for receipt of NRT and examined differences in outcomes in a propensity-matched cohort., Results: Of 147,506 active smokers, 25,651 (17.4%) were prescribed NRT within 2 days of admission. Patients treated with NRT were younger; less likely to be black or Hispanic; more likely to have Medicaid; and more likely to have a diagnosis of alcohol or other substance use disorder, or COPD, compared with those who were not treated. In the propensity-matched analysis, there was no association between receipt of NRT and in-hospital complications (OR, 0.99; 95% CI, 0.93-1.05), mortality (OR, 0.84; 95% CI, 0.68-1.04), all-cause 30-day readmissions (OR, 1.02; 95% CI, 0.97-1.07), or 30-day readmission for wound complications (OR, 0.96; 95% CI, 0.86-1.07)., Conclusions: This is the first large observational study of surgical patients to demonstrate that perioperative NRT is not associated with adverse outcomes after surgery. These results strengthen the evidence that NRT should be prescribed routinely in the perioperative period., (Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Guidelines recommend pulmonary rehabilitation (PR) after hospitalization for an exacerbation of COPD, but few patients enroll in PR. We explored whether density of PR programs explained regional variation and racial disparities in receipt of PR., Methods: We used Centers for Medicare & Medicaid Services data from 223,832 Medicare beneficiaries hospitalized for COPD during 2012 who were eligible for PR postdischarge. We used Hospital-Referral Regions (HRR) as the unit of analysis. For each HRR, we calculated the density of PR programs as a measure of program access and estimated risk-standardized rates of PR within 6 months of discharge overall, and for non-Hispanic, white, and black beneficiaries. We used linear regression to examine the relationship between access to PR and HRR PR rates. We tested for racial disparity in PR rates among non-Hispanic white and black beneficiaries living in the same HRRs., Results: Across 306 HRRs, the median number of PR programs per 1,000 Medicare beneficiaries was 0.06 (interquartile range [IQR], 0.04-0.10). Risk-standardized rates of PR ranged from 0.53% to 6.67% (median, 1.93%). Density of PR programs was positively associated with PR rates overall and among non-Hispanic white beneficiaries (P < .001), but this relationship was not observed among black beneficiaries. Rates were higher among non-Hispanic white beneficiaries (median, 2.08%; IQR, 1.54%-2.87%) compared with black beneficiaries (median, 1.19%; IQR, 1.15%-1.20%)., Conclusions: Greater PR program density was associated with higher rates of PR for non-Hispanic white but not black beneficiaries. Further research is needed to identify reasons for this discrepancy and strategies to increase receipt of PR for black patients., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: Performance on pediatric quality measures varies across primary care practices. Health care quality is associated with organizational factors, but their effect is understudied in pediatric care. This study aimed to develop hypotheses regarding the relationship between organizational factors and composite scores on pediatric quality measures., Methods: Using a positive deviance approach, semistructured interviews were conducted with pediatricians and staff (N = 35) at 10 purposively selected high-performing pediatric primary care practices in Massachusetts between September and December 2016. Practices were sampled to achieve diversity in geographic location, size, and organizational structure. Interviews aimed to identify organizational strategies (eg, care processes) and contextual factors (eg, teamwork) that may be associated with performance on quality measures. Interviews were audiotaped, transcribed, and analyzed using qualitative content analytic methods., Results: We identified 4 major themes (MTs): MT1, Practice Culture; MT2, Practice Structures and Quality Improvement Tools; MT3, Attitudes and Beliefs Related to Measuring Care Quality; and MT4, Perceived Barriers to Achieving High Performance on Quality Measures. MT1 subthemes included contextual factors such as teamwork, leadership, and feeling respected as an employee. MT2 subthemes included fixed characteristics such as practice size and strategies such as the use of an electronic medical record. MT3 and MT4 subthemes linked these constructs to factors external to the practices., Conclusions: This study suggested that elements of organizational culture may play as important a role in the quality of care delivered as specific quality improvement strategies. Interventions to further test this relationship may aid practices seeking to improve the care they deliver., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Opioids are a leading cause of adverse drug events in the hospital. Guidelines recommend that physicians assess the risks of opioids and discuss them with patients when considering opioid use. There are no studies examining patient- and prescribing-related risk factors for opioid-related adverse drug events (ORADEs) in hospitalized medical patients., Objective: To identify independent risk factors for severe ORADEs in hospitalized medical patients., Design: Retrospective cohort study., Patients: Medical patients hospitalized at US, non-federal, and acute care facilities, with at least one pharmacy charge for an opioid during hospitalization. We excluded patients with metastatic malignancy, hospice, or palliative care billing codes., Main Measures: We used Cox proportional hazards modeling to identify risk factors for severe ORADEs, defined by a pharmacy charge for naloxone. Candidate risk factors were chosen a priori, based on clinical grounds and prior literature., Key Results: Among 731,208 hospitalizations (median age 60, 56.5% female), a severe ORADE occurred in 2727 (0.4%). Independent risk factors included patient characteristics (advanced age, female gender), comorbidities (congestive heart failure, opioid abuse/dependence, non-opioid drug abuse/dependence, psychosis, depression, obstructive sleep apnea), organ failures on admission (respiratory failure, shock/hypotension, renal failure, hepatic failure, acidosis, and neurologic failure), medication co-administrations (antipsychotics and short-acting benzodiazepines), and characteristics of the opioid prescriptions themselves (total dose for the day, parenteral route of administration, and receipt of multiple types of opioids in a day). Although a risk prediction model derived from these factors performed well on stratified k-fold cross-validation (average c-statistics 0.68-0.71), the low incidence of the outcome limited the positive predictive value of the risk score., Conclusions: In this national cohort of medical patients, we identified several risk factors for ORADEs that can be used to inform physician decision-making, conversations with patients about risk, and development and targeting of harm reduction strategies for at-risk populations.

Background: COPD is the fourth leading cause of death in the US, and COPD exacerbations result in approximately 700,000 hospitalizations annually. Patients with acute respiratory failure due to severe COPD exacerbation are treated with invasive (IMV) or noninvasive mechanical ventilation (NIV). Although IMV reverses hypercapnia/hypoxia, it causes significant morbidity and mortality. There is strong evidence that patients treated with NIV have better outcomes, and NIV is recommended as first line therapy in these patients. Yet, several studies have demonstrated substantial variation in the use of NIV across hospitals, leading to preventable morbidity and mortality. Through a series of mixed-methods studies, we have found that successful implementation of NIV requires physicians, respiratory therapists (RTs), and nurses to communicate and collaborate effectively, suggesting that efforts to increase the use of NIV in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, we propose to compare two educational strategies: online education (OLE) and interprofessional education (IPE) which targets complex team-based care in NIV delivery., Methods and Design: Twenty hospitals with low baseline rates of NIV use will be randomized to either the OLE or IPE study arm. The primary outcome of the trial is change in the hospital rate of NIV use among patients with COPD requiring ventilatory support. In aim 1, we will compare the uptake change over time of NIV use among patients with COPD in hospitals enrolled in the two arms. In aim 2, we will explore mediators' role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and implementation effectiveness. Finally, in aim 3, through interviews with providers, we will assess acceptability and feasibility of the educational training., Discussions: This study will be among the first to carefully test the impact of IPE in the inpatient setting. This work promises to change practice by offering approaches to facilitate greater uptake of NIV and may generalize to other interventions directed to seriously-ill patients., Trial Registration: Name of registry: ClinicalTrials.govTrial registration number: NCT04206735Date of Registration: December 20, 2019., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Importance: Little is known about the timing of urologic interventions in patients with renal colic discharged from the emergency department. Understanding patients' likelihood of a subsequent urologic intervention could inform decision-making in this population., Objectives: To examine the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention., Design, Setting, and Participants: This retrospective cohort study used the Massachusetts All Payers Claims Database to identify patients 18 to 64 years of age who were seen in a Massachusetts emergency department for renal colic from January 1, 2011, to October 31, 2014, Patients were identified via International Classification of Diseases, Ninth Revision codes, and all medical care was linked, enabling identification of subsequent health care use. Data analysis was performed from January 1, 2017, to December 31, 2018., Main Outcomes and Measures: The main outcome was receipt of urologic procedure within 60 days. Secondary outcomes included rates of return emergency department visit and urologic and primary care follow-up., Results: A total of 66 218 unique index visits by 55 314 patients (mean [SD] age, 42.6 [12.4] years; 33 590 [50.7%] female; 25 411 [38.4%] Medicaid insured) were included in the study. A total of 5851 patients (8.8%) had visits resulting in admission at the index encounter, and 1774 (2.7%) had visits resulting in a urologic procedure during that admission. Of the 60 367 patient visits resulting in discharge from the emergency department, 3018 (5.0%) led to a urologic procedure within 7 days, 4407 (7.3%) within 14 days, 5916 (9.8%) within 28 days, and 7667 (12.7%) within 60 days. A total of 3226 visits (5.3%) led to a subsequent emergency department visit within 7 days and 6792 (11.3%) within 60 days. For the entire cohort (admitted and discharged patients), 39 189 (59.2%) had contact with a urologist or primary care practitioner within 60 days. Having Medicaid-only insurance was associated with lower rates of urologic procedures (odds ratio, 0.70; 95% CI, 0.66-0.74) and urologic follow-up (5.6% vs 8.8%; P < .001) and higher rates of primary care follow-up (59.2% vs 47.2%; P < .001) compared with patients with all other insurance types., Conclusions and Relevance: In this cohort study, most adult patients younger than 65 years who were discharged from the emergency department with a diagnosis of renal colic did not undergo a procedure or see a urologist within 60 days. This finding has implications for both the emergency department and outpatient treatment of these patients.

Background: In patients hospitalized with heart failure (HF) exacerbations, physicians routinely supplement potassium to maintain levels ≥4.0 mEq/L. The evidence basis for this practice is relatively weak. We aimed to evaluate the association between serum potassium levels and outcomes in patients hospitalized with HF., Methods: We identified patients admitted with acute HF exacerbations to hospitals that contributed to an electronic health record-derived dataset. In a subset of patients with normal admission serum potassium (3.5-5.0 mEq/L), we averaged serum potassium values during a 72-hour exposure window and categorized as follows: <4.0 mEq/L (low normal), 4.0-4.5 mEq/L (medium normal), and >4.5 mEq/L (high normal). We created multivariable models examining associations between these categories and outcomes., Results: We included 4,995 patients: 2,080 (41.6%), 2,326 (46.6%), and 589 (11.8%) in the <4.0, 4.0-4.5, and >4.5 mEq/L cohorts, respectively. After adjustment for demographics, comorbidities, and presenting severity, we observed no difference in outcomes between the low and medium normal groups. Compared to patients with levels <4.0 mEq/L, patients with a potassium level of >4.5 mEq/L had a longer length of stay (median of 0.6 days; 95% CI = 0.1 to 1.0) but did not have statistically significant increases in mortality (OR [odds ratio] = 1.51; 95% CI = 0.97 to 2.36) or transfers to the intensive care unit (OR = 1.78; 95% CI = 0.98 to 3.26)., Conclusions: Inpatients with heart failure who had mean serum potassium levels of <4.0 showed similar outcomes to those with mean serum potassium values of 4.0-4.5. Compared with mean serum potassium level of <4.0, mean serum levels of >4.5 may be associated with increased risk of poor outcomes.

Importance: Guidelines recommend that patients with acute myocardial infarction (AMI) undergo echocardiography for assessment of cardiac structure and ejection fraction, but little is known about the association between echocardiography as used in routine clinical management of AMI and patient outcomes., Objective: To examine the association between risk-standardized hospital rates of transthoracic echocardiography and outcomes., Design, Setting, and Participants: This retrospective cohort study of data from 397 US hospitals that contributed to the Premier Healthcare Informatics inpatient database from January 1, 2014, to December 31, 2014, used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify 98 999 hospital admissions for patients with AMI. Data were analyzed between October 2017 and January 2019., Exposures: Rates of transthoracic echocardiography., Main Outcomes and Measures: Inpatient mortality, length of stay, total inpatient costs, and 3-month readmission rate., Results: Among the 397 hospitals with more than 25 admissions for AMI in 2014, a total of 98 999 hospital admissions for AMI were identified for analysis (38.2% women; mean [SD] age, 66.5 [13.6] years), of which 69 652 (70.4%) had at least 1 transthoracic echocardiogram performed. The median (IQR) hospital risk-standardized rate of echocardiography was 72.5% (62.6%-79.1%). In models that adjusted for hospital and patient characteristics, no difference was found in inpatient mortality (odds ratio [OR], 1.02; 95% CI, 0.88-1.19) or 3-month readmission (OR, 1.01; 95% CI, 0.93-1.10) between the highest and lowest quartiles of echocardiography use (median risk-standardized echocardiography use rates of 83% vs 54%, respectively). However, hospitals with the highest rates of echocardiography had modestly longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41; P = .01) and higher mean costs ($3164; 95% CI, $1843-$4485; P < .001) per admission compared with hospitals in the lowest quartile of use. Multiple sensitivity analyses yielded similar results., Conclusions and Relevance: In patients with AMI, hospitals in the quartile with the highest rates of echocardiography showed greater hospital costs and length of stay but few differences in clinical outcomes compared with hospitals in the quartile with the lowest rates of echocardiography. These findings suggest that more selective use of echocardiography might be used without adversely affecting clinical outcomes, particularly in hospitals with high rates of echocardiography use.

Background In randomized controlled trials, perioperative administration of amiodarone has been shown to reduce the incidence of postoperative atrial arrhythmias and length of stay (LOS) among patients undergoing coronary bypass surgery. However, little is known about the use or effectiveness of perioperative amiodarone in routine clinical practice. Methods and Results We studied patients ≥18 years old without a previous history of atrial or ventricular arrhythmias who underwent elective coronary bypass surgery between 2013 and 2014 within a network of 235 US hospitals. Perioperative amiodarone was defined as receipt of amiodarone either on the day of or the day preceding surgery. We used covariate-adjusted modeling and instrumental variable methods to examine the association between receipt of amiodarone and the development of atrial arrhythmias, in-hospital mortality, readmission, LOS, and cost. Of 12 758 patients, 2195 (17.2%) received perioperative amiodarone, 3330 (26.1%) developed atrial arrhythmias postoperatively, and the average LOS was 6.4 days (±2.6 days). Instrumental variable analysis showed that receipt of perioperative amiodarone was associated with lower risk of atrial arrhythmias (risk difference -11 percentage points, 95% CI -19 to -4 percentage points; P=0.002) and a shorter LOS (-0.7 day, 95% CI -1.39 to -0.01 days; P=0.048). There was no association between receipt of perioperative amiodarone and in-hospital mortality, cost, or readmission. Conclusions Among patients undergoing coronary bypass surgery without previous arrhythmias, perioperative amiodarone is associated with a lower risk of atrial arrhythmias and shorter LOS. These findings are consistent with previous randomized trials and lend support to current guideline recommendations.

Aim: Publicly reported quality data theoretically enable parents to choose higher-performing paediatric practices. However, little is known about how parents decide where to seek paediatric care. We explored the relationship between geographic factors, care quality and choice of practice to see if the decision-making process could be described in terms of a 'gravity model' of spatial data., Methods: In the context of a randomised controlled trial, we used a geographic information system to calculate flow volume between practice locations and participants' homes, to locate subjects within a census tract, to determine distances between points and to perform exploratory mapping. Generalised linear modelling was then used to determine whether the data fit a gravity model, which is a spatial model that evaluates factors impacting travel from one set of locations to another., Results: A total of 662 women and 52 paediatric practices were included in the analysis. Proximity of a practice to home was the most important factor in choosing a practice (Z = -15.01, P < 0.001). Practice size was important to a lesser extent, with larger practices more likely to be chosen (Z = 8.96, P < 0.001). A practice's performance on quality measures was associated with choice only for women who had received an intervention to increase use of quality data (Z = 2.51, P < 0.05)., Conclusions: The gravity model and the concept of flow can help explain the choice of paediatric practice in a predominantly low-income, racially ethnic minority (non-White) urban population. This has important ramifications for the potential impact of publicly reported quality data., (© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Importance: Although professional society guidelines discourage use of empirical antibiotics in the treatment of asthma exacerbation, high antibiotic prescribing rates have been recorded in the United States and elsewhere., Objective: To determine the association of antibiotic treatment with outcomes among patients hospitalized for asthma and treated with corticosteroids., Design, Setting, and Participants: Retrospective cohort study of data of 19 811 adults hospitalized for asthma exacerbation and treated with systemic corticosteroids in 542 US acute care hospitals from January 1, 2015, through December 31, 2016., Exposures: Early antibiotic treatment, defined as an treatment with an antibiotic initiated during the first 2 days of hospitalization and prescribed for a minimum of 2 days., Main Outcomes and Measures: The primary outcome measure was hospital length of stay. Other measures were treatment failure (initiation of mechanical ventilation, transfer to the intensive care unit after hospital day 2, in-hospital mortality, or readmission for asthma) within 30 days of discharge, hospital costs, and antibiotic-related diarrhea. Multivariable adjustment, propensity score matching, propensity weighting, and instrumental variable analysis were used to assess the association of antibiotic treatment with outcomes., Results: Of the 19 811 patients, the median (interquartile range [IQR]) age was 46 (34-59) years, 14 389 (72.6%) were women, 8771 (44.3%) were white, and Medicare was the primary form of health insurance for 5120 (25.8%). Antibiotics were prescribed for 8788 patients (44.4%). Compared with patients not treated with antibiotics, treated patients were older (median [IQR] age, 48 [36-61] vs 45 [32-57] years), more likely to be white (48.6% vs 40.9%) and smokers (6.6% vs 5.3%), and had a higher number of comorbidities (eg, congestive heart failure, 6.2% vs 5.8%). Those treated with antibiotics had a significantly longer hospital stay (median [IQR], 4 [3-5] vs 3 [2-4] days) and a similar rate of treatment failure (5.4% vs 5.8%). In propensity score-matched analysis, receipt of antibiotics was associated with a 29% longer hospital stay (length of stay ratio, 1.29; 95% CI, 1.27-1.31) and higher cost of hospitalization (median [IQR] cost, $4776 [$3219-$7373] vs $3641 [$2346-$5942]) but with no difference in the risk of treatment failure (propensity score-matched OR, 0.95; 95% CI, 0.82-1.11). Multivariable adjustment, propensity score weighting, and instrumental variable analysis as well as several sensitivity analyses yielded similar results., Conclusions and Relevance: Antibiotic therapy may be associated with a longer hospital length of stay, higher hospital cost, and similar risk of treatment failure. These results highlight the need to reduce inappropriate antibiotic prescribing among patients hospitalized for asthma.

Rationale: Current guidelines recommend pulmonary rehabilitation (PR) after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, but little is known about its adoption or factors associated with participation., Objectives: To evaluate receipt of PR after a hospitalization for COPD exacerbation among Medicare beneficiaries and identify individual- and hospital-level predictors of PR receipt and adherence., Methods: We identified individuals hospitalized for COPD during 2012 and recorded receipt, timing, and number of PR visits. We used generalized estimating equation models to identify factors associated with initiation of PR within 6 months of discharge and examined factors associated with number of PR sessions completed., Results: Of 223,832 individuals hospitalized for COPD, 4,225 (1.9%) received PR within 6 months of their index hospitalization, and 6,111 (2.7%) did so within 12 months. Median time from discharge until first PR session was 95 days (interquartile range, 44-190 d), and median number of sessions completed was 16 (interquartile range, 6-25). The strongest factor associated with initiating PR within 6 months was prior home oxygen use (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.39-1.59). Individuals aged 75-84 years and those aged 85 years and older (respectively, OR, 0.70; 95% CI, 0.66-0.75; and OR, 0.25; 95% CI 0.22-0.28), those living over 10 miles from a PR facility (OR, 0.42; 95% CI, 0.39-0.46), and those with lower socioeconomic status (OR, 0.42; 95% CI, 0.38-0.46) were less likely to receive PR., Conclusions: Two years after Medicare began providing coverage for PR, participation rates after hospitalization were extremely low. This highlights the need for strategies to increase participation.

Background: Inpatient cardiac rehabilitation (ICR) programs provide important services to hospitalized patients by delivering risk factor education, daily ambulation, and facilitation of referral to outpatient cardiac rehabilitation. However, little is known about ICR utilization or practice patterns., Methods: We examined the use of ICR, between January 2007 and June 2011, in a geographically and structurally diverse sample of US hospitals (Premier, Inc)., Results: Among 458 hospitals, there were 1 343 537 admissions with a qualifying diagnosis for outpatient cardiac rehabilitation. Formal ICR was available at 223 (49%) of these hospitals. Overall, patient utilization of ICR was low (21.2%) and varied by indication. Utilization was highest in those undergoing cardiac surgery (43.3%) and lowest in patients with medically managed myocardial infarction (15.6%) or heart failure (10.6%). A larger bed count, the presence of cardiac interventional services, and Midwest location were associated with increased likelihood of a hospital having an ICR program. In multivariable hierarchical analysis adjusting for known hospital characteristics among hospitals that provided ICR, multiple patient factors were associated with a lower likelihood of ICR utilization, including older age, more comorbidities, female sex, and Medicare insurance, but unspecified hospital characteristics explained the vast majority of the variability., Conclusions: We found substantial variation in the delivery of ICR across US hospitals and by patient condition. Overall, only a minority of eligible patients ever received ICR and fewer than half of hospitals treating cardiac patients provided formal ICR services. This substantial gap in the secondary prevention of heart disease warrants further investigation and intervention.

Background Little is known about the safety of nicotine replacement therapy ( NRT ) in smokers hospitalized with coronary heart disease. Methods and Results We examined the short-term safety of NRT use among smokers hospitalized for coronary heart disease in a geographically and structurally diverse sample of US hospitals in the year 2014. We compared smokers who started NRT in the first 2 days of hospitalization with smokers without any exposure to NRT and adjusted for baseline differences through propensity score matching. Outcomes included inpatient mortality, hospital length of stay, and 1-month readmission. From 270 hospitals, we included 27 459 smokers (mean age, 58 years; 69% men; 56.9% in intensive care unit), of whom 4885 (17.8%) received NRT (97.2% used the nicotine patch, at a median dose of 21 mg/d for 3 days). After propensity matching, covariates were well balanced within each patient group. Among patients with myocardial infarction, compared with patients who did not receive NRT , those who received NRT showed no difference in mortality (2.1% versus 2.3%; P=0.98), mean length of stay (4.4±3.5 versus 4.3±3.3 days; P=0.60), or 1-month readmission (15.8% versus 14.6%; P=0.31). Results were similar for patients undergoing percutaneous coronary intervention or coronary artery bypass surgery. Conclusions Among smokers hospitalized for treatment of coronary heart disease, use of NRT was not associated with any differences in short-term outcomes. Given the known beneficial effects of NRT in treating nicotine withdrawal, reducing cravings, and promoting smoking cessation after discharge, our findings suggest that NRT is a safe and reasonable treatment option.

Background: Invasive mechanical ventilation (IMV), dialysis for acute kidney failure, and other critical care therapies (CCTs) are associated with a high risk for complications in patients with metastatic cancer. Inpatient palliative care (IPC) can assist in assessing patients' preferences for life-prolonging treatment at the end of life. This study investigated the use pattern of IPC, outcomes (in-hospital mortality, length of stay [LOS], discharge destination, and cost of care), and predictors of IPC use in patients with metastatic cancer who received CCTs. We hypothesized that IPC services are underused in this cohort. Methods: In this retrospective cohort study, we used the 2010 California State Inpatient Databases to identify adults with metastatic cancer who received CCTs that are common and reliably coded (IMV, tracheostomy, percutaneous endoscopic gastrostomy tube, dialysis for acute kidney failure, and total parenteral nutrition). We determined IPC use in all patients, in those who received IMV, and across 4 cancer subtypes (lung, breast, colorectal, and genitourinary). Outcomes were assessed based on IPC use. Multivariable analyses were used to investigate factors associated with IPC use. Results: We identified 5,862 hospitalizations, 19.8% of which used IPC services. IPC use varied across cancer subtypes (lung, 28.3%; breast, 22.4%; colorectal, 12.8%; genitourinary, 16.1%; P <.01). Patients who received and did not receive IPC services had high in-hospital mortality rates (63.9% and 29.8%, respectively), and costs of care and LOS were lower in survivors who received IPC compared with those who did not. Predictors of IPC use were lung cancer (vs colorectal or genitourinary cancer), higher comorbidity score, do-not-resuscitate status on admission or within 24 hours of admission, infections (vs cancer-related diagnoses), and higher hospital bed count. Conclusions: Use of IPC was low in the cohort who received CCTs with poor outcomes, although data on outpatient palliative care services is lacking. Predictors of IPC use may be used to identify patients who may benefit from these services., (Copyright © 2018 by the National Comprehensive Cancer Network.)

Objectives: One quarter of pediatric hospitalizations begin as direct admissions, defined as hospitalization without receiving care in the hospital's emergency department (ED). Direct admission rates are highly variable across hospitals, yet previous studies have not examined reasons for this variation. We aimed to determine the relationships between hospital and community factors and pediatric direct admission rates, and to evaluate the degree to which these characteristics explain variation in risk-adjusted direct admission rates., Methods: We conducted a cross-sectional study of the Healthcare Cost and Utilization Project's Kids Inpatient Database, American Hospital Association Database, and Area Health Resource File, including children <18 years of age who were admitted for a medical hospitalization in states contributing data to all data sets. Using hierarchical generalized linear modeling, we generated risk-adjusted direct admission rates and used generalized linear models to assess the association of hospital and community characteristics with these risk-adjusted rates., Results: We included 211,458 children discharged from 933 hospitals and 26 states; 20.2% were admitted directly. One-fifth of the variance in risk-adjusted direct admission rates was attributed to observed hospital and community factors. The greatest proportion of this explained variance was related to ED volume (37%), volume of pediatric hospitalizations (27%), and size of the pediatrician workforce (12%)., Conclusions: Direct admission rates were associated with several hospital and community characteristics, but the majority of variation in hospitals' direct admission rates was not explained by these factors. These findings suggest opportunities for diverse hospital types to develop the infrastructure and communication systems necessary to support pediatric direct admissions., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Comparing heart failure (HF) outcomes across hospitals requires adequate risk adjustment. We aimed to develop and validate a model that can be used to compare quality of HF care across hospitals., Methods and Results: We included patients with HF aged ≥18 years admitted to one of 433 hospitals that participated in the Premier Inc Data Warehouse. This model (Premier) contained patient demographics, comorbidities, and acute conditions present on admission, derived from administrative and billing records. In a separate data set derived from electronic health records, we validated the Premier model by comparing hospital risk-standardized mortality rates calculated with the Premier model to those calculated with a validated clinical model containing laboratory data (LAPS [Laboratory-Based Acute Physiology Score]). Among the 200 832 admissions in the Premier Inc Data Warehouse, inpatient mortality was 4.0%. The model showed acceptable discrimination in the warehouse data (C statistic 0.75; 95% confidence interval, 0.74-0.76). In the validation data set, both the Premier model and the LAPS models showed acceptable discrimination (C statistic: Premier: 0.76 [95% confidence interval, 0.74-0.77]; LAPS: 0.78 [95% confidence interval, 0.76-0.80]). Risk-standardized mortality rates for both models ranged from 2% to 7%. A linear regression equation describing the association between Premier- and LAPS-specific mortality rates revealed a regression line with a slope of 0.71 (SE: 0.07). The correlation coefficient of the standardized mortality rates from the 2 models was 0.82., Conclusions: Compared with a validated model derived from clinical data, an HF mortality model derived from administrative data showed highly correlated risk-standardized mortality rate estimates, suggesting it could be used to identify high- and low-performing hospitals for HF care., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Purpose: To compare the outcomes of patients hospitalized with pneumonia treated with noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV)., Materials and Methods: Using the HealthFacts multihospital electronic medical record database, we included patients hospitalized with a diagnosis of pneumonia and treated with NIV or IMV. We developed a propensity model for receipt of initial NIV and assessed the outcomes in a propensity-matched cohort, and in a covariate adjusted and propensity score weighted models., Results: Among 3971 ventilated patients, 1109 (27.9%) were initially treated with NIV. Patients treated with NIV were older, had lower acuity of illness score, and were more likely to have congestive heart failure and chronic pulmonary disease. Mortality was 15.8%, 29.8% and 25.9.0% among patients treated with initial NIV, initial IMV and among those with NIV failure. In the propensity matched analysis, the risk of death was lower in patients treated with NIV (relative risk: 0.71, 95% CI: 0.59-0.85). Subgroup analysis showed that NIV was beneficial among patients with cardiopulmonary comorbidities (relative risk 0.59, 95% CI: 0.47-0.75) but not in those without (relative risk 0.96, 95% CI: 0.74-0.1.25)NIV failure was significantly (p=0.002) more common in patients without cardiopulmonary conditions (21.3%) compared to those with these conditions (13.8%)., Conclusions: Initial NIV was associated with better survival among the subgroup of patients hospitalized with pneumonia who had COPD or heart failure. Patients who failed NIV had high in-hospital mortality, emphasizing the importance of careful patient selection monitoring when managing severe pneumonia with NIV., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: This study aimed to evaluate the association between prepregnancy body mass index (BMI), gestational weight gain (GWG), and cesarean delivery in Hispanics., Methods: We examined these associations among 1,215 participants in Proyecto Buena Salud, a prospective cohort of Hispanic women studied from 2006 to 2011. Prepregnancy BMI, GWG, and the mode of delivery were abstracted from medical records., Results: A quarter of the participants entered pregnancy with obesity, 23% delivered via cesarean, and 52% exceeded the Institute of Medicine guidelines for GWG. After adjusting for age, women with obesity had 2.03 times the odds of cesarean delivery compared with women with normal BMI (95% confidence interval [CI]: 1.46-2.82); findings remained significant after adjusting for GWG. Women with excessive total GWG had 1.49 times the odds of cesarean delivery (95% CI: 1.06-2.10) compared with women who gained within guidelines. An excessive rate of third trimester GWG (standard deviation [SD] change in GWG per week) increased the odds of cesarean delivery (odds ratio = 1.66; 95% CI: 1.05-2.62), while an excessive rate of first and third trimester GWG was not associated with increased odds., Conclusions: Obesity prior to pregnancy was associated with increased odds of cesarean delivery among Hispanics. Excessive GWG across pregnancy and an excessive rate of third trimester GWG were also associated with increased odds., (© 2017 The Obesity Society.)

Rationale: Randomized trials suggest that assessment of serum procalcitonin (PCT) levels can be used to safely limit antibiotic use among patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD)., Objectives: To determine the impact of PCT testing on antibiotic treatment of patients hospitalized for exacerbations of COPD in routine practice., Methods: We conducted a series of cross-sectional and longitudinal multivariable analyses using data from 2009 to 2011 and 2013 to 2014 from a sample of 505 U.S. hospitals., Results: Of 203,177 patients hospitalized for COPD exacerbation in 2013 to 2014, nearly 9 out of 10 were treated with antibiotics. Hospital PCT testing rates ranged from 0 to 83%. In cross-sectional analysis, there was a weak negative association between the rate of PCT testing and risk-adjusted rates of antibiotic initiation (Spearman correlation, -0.12; P = 0.005); each 10-point increase in the percentage of patients undergoing PCT testing was associated with a 0.7% decline in risk-adjusted antibiotic use (P = 0.001). There was no association between hospital rates of PCT testing and duration of antibiotic treatment. In a longitudinal analysis, comparing treatment patterns in 2009 to 2011 and 2013 to 2014, we did not observe a significant difference in the change in antibiotic treatment rates or duration of therapy between hospitals that had adopted PCT testing compared with those that had not., Conclusions: As currently implemented, PCT testing appears to have had little impact on decisions to initiate antibiotic therapy or on duration of treatment for COPD exacerbations. Implementation research is necessary to translate the promising outcomes from PCT testing observed in randomized trials into clinical practice.

Background: Pediatric practices' scores on healthcare quality measures are increasingly available to the public. However, patients from low-income and racial/ethnic minority populations rarely use these data. We sought to understand potential barriers to using quality data by assessing what factors mattered to women when choosing a pediatric practice., Methods: As part of a randomized trial to overcome barriers to using quality data, we recruited women from a prenatal clinic serving an underserved population. Women reported how much 12 factors mattered when they chose a pediatric practice (5-point Likert scale), what other factors mattered to them, and which factors mattered the most. We assessed whether factor importance varied with selected participant characteristics and qualitatively analyzed the "other" factors named., Results: Participants' (n = 367) median age was 23 years, and they were largely Hispanic (60.4%), white (21.2%), or black (16.9%). Insurance acceptance "mattered a lot" to the highest percentage of women (93.2%), while online information about what other parents think of a practice "mattered a lot" to the fewest (7.4%). Major themes from our qualitative analysis of "other" factors that mattered included physicians' interpersonal skills and pediatrician-specific traits. Factors related to access "mattered the most" to the majority of women., Conclusions: Pediatrician characteristics and factors related to access to care may be more important to low-income and racial/ethnic minority women than more commonly reported quality metrics. Aligning both the content and delivery of publicly reported quality data with women's interests may increase use of pediatric quality data., Clinical Trial Registration: Clinicaltrials.gov NCT01784575.

Rationale: Noninvasive ventilation (NIV) is a cornerstone of treatment for patients with severe exacerbations of chronic obstructive pulmonary disease (COPD), where it has been shown to reduce the need for intubation, hospital length of stay, and mortality. Despite high-quality evidence and strong recommendations in clinical guidelines, use of NIV varies widely across hospitals., Objectives: To identify approaches used by hospitals that have been successful in implementing NIV to treat patients with severe exacerbations of COPD., Methods: Adopting a positive deviance approach, in-depth interviews were conducted with key stakeholders from a sample of high-performing hospitals selected from a large and representative network of 386 U.S. hospitals. High performers were defined as hospitals in which a high proportion of patients with COPD requiring mechanical ventilation were treated with NIV, and that also achieved low risk-adjusted mortality for all patients with COPD. Interviews were audio-recorded and transcribed verbatim. Themes and subthemes were identified through iterative readings of the transcripts and discussion until the team agreed that all important themes and subthemes had been identified. All transcripts were coded by three or four researchers. Differences in coding were discussed to negotiate consensus, resulting in a single agreed-on set of coded transcripts., Results: Interviews were conducted with 32 participants from seven hospitals. Hospitals were diverse regarding size, teaching status, and geographic location. Participants included respiratory therapists (n = 15), physicians (n = 10), and nurses (n = 7). The qualitative analyses revealed three interrelated domains that characterized effective NIV use: processes, structural elements, and contextual factors. Several themes comprised each domain. Key processes included timely identification of appropriate patients, early initiation of NIV, frequent reassessment of patients, and attention to patient comfort. Necessary structural elements included adequate equipment, sufficient numbers of qualified respiratory therapists, and flexibility in staffing. Important contextual factors included provider buy-in, respiratory therapist autonomy, interdisciplinary teamwork, and staff education. Hospital leaders, policies, and protocols were identified as playing a supporting role in promoting essential elements., Conclusions: We identified factors, such as respiratory therapist autonomy, that facilitated essential processes (e.g., timely initiation) of NIV use at high-performing hospitals. These findings may be useful to hospitals seeking to optimize their use of NIV among patients with COPD.

Background: The American Thoracic Society and Infectious Diseases Society of America guidelines for management of healthcare-associated pneumonia (HCAP), first published in 2005, have been controversial regarding the selection of empiric broad-spectrum antibiotics, whether the criteria for HCAP predicts the likelihood of infection with multidrug resistant organisms, and whether HCAP patients have improved outcomes when treated with empiric broad-spectrum antibiotics., Methods: A retrospective cohort study at 488 US hospitals from July 2007 to November 2011. Patients who met criteria for HCAP were included. Guideline-concordant antibiotics were assessed based on guideline recommendations. We assessed changes in hospital rates of concordant antibiotic use over time and their correlation with outcomes., Results: Among 149,963 patients with HCAP, 19.6% received fully guideline-concordant antibiotics, 21.7% received partially concordant antibiotics, and 58.9% received discordant antibiotics. Guideline concordance increased over time. Rates of fully or partially concordant antibiotics varied across hospitals (median 36.4%; interquartile range 25.8%-49.1%). Among patients who received discordant antibiotics, 81.5% were treated according to community-acquired pneumonia (CAP) guidelines. On average, the rate of guideline concordance increased by 2.2% per 6-month interval, while hospital level rates of mortality, excess length of stay, and progression to respiratory failure did not change., Conclusions: In this large, nationally representative cohort, only 1 in 5 patients with risk factors for HCAP received treatment that was fully in accordance with guidelines, and many received CAP therapy instead. At the hospital level, increases in the use of concordant antibiotics were not associated with declines in mortality, excess length of stay, or progression to respiratory failure., (© 2017 Society of Hospital Medicine)

Objectives: Symptomatic ureterolithiasis (renal colic) is a common Emergency Department (ED) complaint. Variation in practice surrounding the diagnosis and management of suspected renal colic could have substantial implications for both quality and cost of care as well as patient radiation burden. Previous literature has suggested that CT scanning has increased with no improvements in outcome, owing at least partially to the spontaneous passage of kidney stones in the majority of patients. Concerns about the rising medical radiation burden in the US necessitate scrutiny of current practices and viable alternatives. Our objective was to use data from a diverse sample of US EDs to examine rates of and variation in the use of CT scanning, admission, and inpatient procedures for patients with renal colic and analyze the influence of patient and hospital factors on the diagnostic testing and treatment patterns for patients with suspected renal colic., Methods: We conducted a retrospective cohort study of adult patients who received a diagnosis of renal colic via a visit to an ED at 444 US hospitals participating in the Premier Healthcare Alliance database from 2009-2011. We modeled use of CT, admission, and inpatient urologic intervention as functions of both patient characteristics and hospital characteristics., Results: Over the 2-year period, 307,612 patient visits met inclusion criteria. Among these patients, 254,211 (82.6%) had an abdominal CT scan, with 91.5% being non-contrast ("renal protocol") CT scans. Nineteen percent of visits (58,266) resulted in admission or transfer, and 9.8% of visits (30,239) resulted in a urologic procedure as part of the index visit. On multivariable analysis male patients, Hispanic patients, uninsured patients, and privately insured patients were more likely to have a CT scan performed. Older patients and those covered by Medicare were more likely to be admitted, and once admitted, white patients and privately insured patients were more likely to have a urologic intervention. Only hospital region was associated with variation in CT rates, and this variation was minimal. Region and size of the hospital were associated with admission rates, and hospitals with more practicing urologists had higher intervention rates., Conclusions: In this dataset, the majority of patients did not require admission or immediate intervention. Despite this, the large majority received CT scans, in a cohort representing 15-20% of all US ED visits. The CT rate was minimally variable at the hospital level, but the admission rates varied 2-fold, suggesting that hospital-level factors affect patient management. The high rate of CT usage coupled with the low rate of immediate intervention suggests that further research is warranted to identify patients who are at low risk for an immediate intervention, and could potentially be managed with ultrasound alone, expectant management, or delayed CT., Competing Interests: The authors have declared that no competing interests exist.

Objective: To determine the relationship between hospital noninvasive ventilation caseload and outcomes among patients with an acute chronic obstructive pulmonary disease exacerbation., Design: Cross-sectional study of 13,893 patients with chronic obstructive pulmonary disease treated with noninvasive ventilation., Setting: A total of 243 U.S. hospitals participating in the Premier Inpatient Database., Patients: A total of 13,893 patients admitted between July 2009 and June 2011., Interventions: None., Measurements and Main Results: Annual hospital volume of noninvasive ventilation was analyzed as a continuous variable, as well as after grouping it in four categories. The median hospital annual volume of noninvasive ventilation use was 627 and varied from 234 admissions in quartile 1 to 1,529 admissions in quartile 4. Noninvasive ventilation failure occurred in 15.2%, and in-hospital mortality was 6.5%. After adjusting for patient characteristics, relative to low-volume hospitals, high-volume hospitals did not have lower noninvasive ventilation failure (odds ratio quartile 4 vs quartile 1, 1.05; 95% CI, 0.65-1.68) or in-hospital mortality (odds ratio quartile 4 vs quartile 1, 0.88; 95% CI, 0.69-1.12). In a hierarchical multivariable analysis with adjustment for patient characteristics where volume was assessed as a continuous variable, hospital volume was not related to outcomes, including noninvasive ventilation failure (p = 0.87), in-hospital mortality (p = 0.88), 30-day readmission for chronic obstructive pulmonary disease (p = 0.83), or hospital length of stay (p = 0.12)., Conclusions: The results of this large retrospective cohort study suggest that hospitals with higher noninvasive ventilation volume do not achieve better outcomes of patients with chronic obstructive pulmonary disease exacerbation treated with noninvasive ventilation; even hospitals with low noninvasive ventilation volume are able to successfully implement this intervention.

Background: Racial/ethnic minority patients are often underrepresented in clinical trials. Efforts to address barriers to participation may improve representation, thus enhancing our understanding of how research findings apply to more diverse populations., Methods: The IDEAS (Information, Description, Education, Assistance, and Support) for a Healthy Baby study was a randomized controlled trial (RCT) of an intervention to reduce barriers to using publicly reported quality data for low-income, racial/ethnic minority women. We used strategies grounded in a health equity framework to address barriers to recruitment and retention in three domains: preparation, process, and patient-centeredness. "Preparation" included teaching study staff about health inequities, role-playing skills to develop rapport and trust, and partnering with clinic staff. "Processes" included use of electronic registration systems to pre-screen potential candidates and determine when eligible participants were in clinic and an electronic database to track patients through the study. Use of a flexible protocol, stipends, and consideration of literacy levels promoted "patient-centeredness.", Results: We anticipated needing to recruit 800 women over 18 months to achieve a completion goal of 650. Using the recruitment and retention strategies outlined above, we recruited 746 women in 15 months, achieving higher recruitment (87.1 %) and retention rates (97.3 %) than we had anticipated., Discussion: These successful recruitment and retention strategies used for a large RCT promoted inclusivity and accessibility. Researchers seeking to recruit racial and ethnic minority pregnant women in similar settings may find the preparation, process, and patient-centered strategies used in this study applicable for their own studies., Trial Registration: ClinicalTrials.gov NCT01784575 , 1R21HS021864-01., Competing Interests: Sarah Goff declares that she has no conflict of interest. Yara Youssef declares that she has no conflict of interest. Kathleen Mazor declares that she has no conflict of interest. Penelope Pekow declares that she has no conflict of interest. Katharine White consults for Actavis. Peter Lindenauer declares that he has no conflict of interest. The authors have no conflicts to disclose. The study involved human subjects. Approval was obtained from the Baystate Medical Center Institutional Review Board and participants completed informed written consent.

Study Objectives: To examine the relationship of early initiation of noninvasive ventilation (NIV) with postoperative outcomes in patients with obstructive sleep apnea (OSA) undergoing bariatric surgery., Methods: We included 5,266 patients with OSA undergoing bariatric surgeries at 161 hospitals in the United States. We defined early postoperative NIV as NIV used on the day of or the day after surgery; this could include prophylactic NIV or NIV used for early signs of respiratory deterioration. We developed a hierarchical model to identify factors associated with early use of NIV. Then, in a propensity matched cohort, we assessed the association between NIV use and outcomes., Results: Overall, 996 patients (18.9%) were treated with early postoperative NIV. Predictors of NIV initiation were: male sex (odds ratio: 1.34, 95% confidence interval 1.14-1.59), older age, chronic obstructive pulmonary disease (COPD; odds ratio 1.39, confidence interval: 1.17-1.64), gastric bypass surgery, short-acting narcotics intravenous on the day of surgery and admission to a hospital with high rate of OSA diagnosis. In a propensity matched analysis, we found no significant association between early initiation of NIV and receipt of invasive mechanical ventilation (IMV) (early NIV 4.5% vs. no NIV 3.8% p = 0.46), cardiovascular complications or mortality. Results were consistent in several sensitivity analyses., Conclusions: In this large observational study of patients with OSA undergoing bariatric surgery, early postoperative NIV use was not associated with better outcomes including less intubation and mortality. Properly designed controlled trials will be necessary to provide more definitive answers to this important clinical question., (© 2016 American Academy of Sleep Medicine)