Michael Herscher, MD, MA

 

Clinical question: How accurate are doctors and nurses at predicting survival and functional outcomes in critically ill patients?

Background: Doctors have been shown to have moderate accuracy at predicting in-hospital mortality in critically ill patients; however, little is known about their ability to predict longer-term outcomes.

Study design: Prospective cohort study.

Setting: Five medical and surgical ICUs in three hospitals in Philadelphia.

Synopsis: Physicians and nurses predicted survival and functional outcomes for critically ill patients requiring mechanical ventilation or vasopressors. Outcomes predicted were in-hospital and 6-month mortality and ability to return to original residence, toilet independently, ambulate stairs, remember most things, think clearly, and solve problems.

Six-month follow-up was completed for 299 patients. Accuracy was highest when either physicians or nurses expressed confidence in their predictions; doctors confident in their predications of 6-month survival had a positive likelihood ratio of 33.00 (95% CI, 8.34-130.63). Both doctors and nurses least accurately predicted cognitive function (positive LR, 2.36; 95% CI, 1.36-4.12; negative LR, 0.75; 95% CI, 0.61-0.92 for doctors, positive LR, 1.50; 95% CI, 0.86-2.60; negative LR, 0.88; 95% CI, 0.73-1.06 for nurses), while doctors most accurately predicated 6-month mortality (positive LR, 5.91; 95% CI, 3.74-9.32; negative LR, 0.41; 95% CI, 0.33-0.52) and nurses most accurately predicted in-hospital mortality (positive LR, 4.71; 95% CI, 2.94-7.56; negative LR, 0.6; 95% CI,0.49-0.75).

Bottom line: Doctors and nurses were better at predicting mortality than they were at predicting cognition, and their predicted outcomes were most accurate when they expressed a high degree of confidence in the predictions.

Citation: Detsky ME, Harhay MO, Bayard DF, et al. Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after an ICU admission. JAMA. 2017;317(21):2187-95.

Dr. Herscher is assistant professor, division of hospital medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: How accurate are doctors and nurses at predicting survival and functional outcomes in critically ill patients?

Background: Doctors have been shown to have moderate accuracy at predicting in-hospital mortality in critically ill patients; however, little is known about their ability to predict longer-term outcomes.

Study design: Prospective cohort study.

Setting: Five medical and surgical ICUs in three hospitals in Philadelphia.

Synopsis: Physicians and nurses predicted survival and functional outcomes for critically ill patients requiring mechanical ventilation or vasopressors. Outcomes predicted were in-hospital and 6-month mortality and ability to return to original residence, toilet independently, ambulate stairs, remember most things, think clearly, and solve problems.

Six-month follow-up was completed for 299 patients. Accuracy was highest when either physicians or nurses expressed confidence in their predictions; doctors confident in their predications of 6-month survival had a positive likelihood ratio of 33.00 (95% CI, 8.34-130.63). Both doctors and nurses least accurately predicted cognitive function (positive LR, 2.36; 95% CI, 1.36-4.12; negative LR, 0.75; 95% CI, 0.61-0.92 for doctors, positive LR, 1.50; 95% CI, 0.86-2.60; negative LR, 0.88; 95% CI, 0.73-1.06 for nurses), while doctors most accurately predicated 6-month mortality (positive LR, 5.91; 95% CI, 3.74-9.32; negative LR, 0.41; 95% CI, 0.33-0.52) and nurses most accurately predicted in-hospital mortality (positive LR, 4.71; 95% CI, 2.94-7.56; negative LR, 0.6; 95% CI,0.49-0.75).

Bottom line: Doctors and nurses were better at predicting mortality than they were at predicting cognition, and their predicted outcomes were most accurate when they expressed a high degree of confidence in the predictions.

Citation: Detsky ME, Harhay MO, Bayard DF, et al. Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after an ICU admission. JAMA. 2017;317(21):2187-95.

Dr. Herscher is assistant professor, division of hospital medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: How accurate are doctors and nurses at predicting survival and functional outcomes in critically ill patients?

Background: Doctors have been shown to have moderate accuracy at predicting in-hospital mortality in critically ill patients; however, little is known about their ability to predict longer-term outcomes.

Study design: Prospective cohort study.

Setting: Five medical and surgical ICUs in three hospitals in Philadelphia.

Synopsis: Physicians and nurses predicted survival and functional outcomes for critically ill patients requiring mechanical ventilation or vasopressors. Outcomes predicted were in-hospital and 6-month mortality and ability to return to original residence, toilet independently, ambulate stairs, remember most things, think clearly, and solve problems.

Six-month follow-up was completed for 299 patients. Accuracy was highest when either physicians or nurses expressed confidence in their predictions; doctors confident in their predications of 6-month survival had a positive likelihood ratio of 33.00 (95% CI, 8.34-130.63). Both doctors and nurses least accurately predicted cognitive function (positive LR, 2.36; 95% CI, 1.36-4.12; negative LR, 0.75; 95% CI, 0.61-0.92 for doctors, positive LR, 1.50; 95% CI, 0.86-2.60; negative LR, 0.88; 95% CI, 0.73-1.06 for nurses), while doctors most accurately predicated 6-month mortality (positive LR, 5.91; 95% CI, 3.74-9.32; negative LR, 0.41; 95% CI, 0.33-0.52) and nurses most accurately predicted in-hospital mortality (positive LR, 4.71; 95% CI, 2.94-7.56; negative LR, 0.6; 95% CI,0.49-0.75).

Bottom line: Doctors and nurses were better at predicting mortality than they were at predicting cognition, and their predicted outcomes were most accurate when they expressed a high degree of confidence in the predictions.

Citation: Detsky ME, Harhay MO, Bayard DF, et al. Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after an ICU admission. JAMA. 2017;317(21):2187-95.

Dr. Herscher is assistant professor, division of hospital medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: How often are incidentally found pulmonary nodules and instructions for follow-up included in the discharge summary?

Background: Lung nodules are frequent incidental findings on imaging, but it is unclear whether patients are subsequently receiving the recommended follow-up.

Study design: Retrospective cohort study.

Setting: Single academic medical center in the United States.

Synopsis: The authors identified 7,173 patients who had undergone abdominal CT scans during their admission and reviewed charts of 402 patients who had incidentally found pulmonary nodules identified on the scans. For each of the patients, discharge summaries were evaluated to determine whether they made reference to the nodules and whether follow-up instructions were included. Of the 208 patients noted to have nodules requiring follow-up, only 48 (23%) had discharge summaries that mentioned the nodules. Factors associated with including the nodules in the discharge summary were the radiologist recommending further surveillance, radiologist including the nodule in the summary heading of the report, and being on a medical as opposed to a surgical service. The authors concluded that systems-based approaches to incidentally found lung nodules are needed to ensure adequate follow-up.

Bottom line: Incidentally found lung nodules are often not included in discharge documentation and therefore may not receive the recommended follow-up.

Citation: Bates R, Plooster C, Croghan I, et al. Incidental pulmonary nodules reported on CT abdominal imaging: Frequency and factors affecting inclusion in the hospital discharge summary. J Hosp Med. 2017;6:454-7.

Dr. Herscher is assistant professor, division of hospital medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: How often are incidentally found pulmonary nodules and instructions for follow-up included in the discharge summary?

Background: Lung nodules are frequent incidental findings on imaging, but it is unclear whether patients are subsequently receiving the recommended follow-up.

Study design: Retrospective cohort study.

Setting: Single academic medical center in the United States.

Synopsis: The authors identified 7,173 patients who had undergone abdominal CT scans during their admission and reviewed charts of 402 patients who had incidentally found pulmonary nodules identified on the scans. For each of the patients, discharge summaries were evaluated to determine whether they made reference to the nodules and whether follow-up instructions were included. Of the 208 patients noted to have nodules requiring follow-up, only 48 (23%) had discharge summaries that mentioned the nodules. Factors associated with including the nodules in the discharge summary were the radiologist recommending further surveillance, radiologist including the nodule in the summary heading of the report, and being on a medical as opposed to a surgical service. The authors concluded that systems-based approaches to incidentally found lung nodules are needed to ensure adequate follow-up.

Bottom line: Incidentally found lung nodules are often not included in discharge documentation and therefore may not receive the recommended follow-up.

Citation: Bates R, Plooster C, Croghan I, et al. Incidental pulmonary nodules reported on CT abdominal imaging: Frequency and factors affecting inclusion in the hospital discharge summary. J Hosp Med. 2017;6:454-7.

Dr. Herscher is assistant professor, division of hospital medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: How often are incidentally found pulmonary nodules and instructions for follow-up included in the discharge summary?

Background: Lung nodules are frequent incidental findings on imaging, but it is unclear whether patients are subsequently receiving the recommended follow-up.

Study design: Retrospective cohort study.

Setting: Single academic medical center in the United States.

Synopsis: The authors identified 7,173 patients who had undergone abdominal CT scans during their admission and reviewed charts of 402 patients who had incidentally found pulmonary nodules identified on the scans. For each of the patients, discharge summaries were evaluated to determine whether they made reference to the nodules and whether follow-up instructions were included. Of the 208 patients noted to have nodules requiring follow-up, only 48 (23%) had discharge summaries that mentioned the nodules. Factors associated with including the nodules in the discharge summary were the radiologist recommending further surveillance, radiologist including the nodule in the summary heading of the report, and being on a medical as opposed to a surgical service. The authors concluded that systems-based approaches to incidentally found lung nodules are needed to ensure adequate follow-up.

Bottom line: Incidentally found lung nodules are often not included in discharge documentation and therefore may not receive the recommended follow-up.

Citation: Bates R, Plooster C, Croghan I, et al. Incidental pulmonary nodules reported on CT abdominal imaging: Frequency and factors affecting inclusion in the hospital discharge summary. J Hosp Med. 2017;6:454-7.

Dr. Herscher is assistant professor, division of hospital medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: Is there a benefit to home noninvasive ventilation (NIV) following a hospital admission for chronic obstructive pulmonary disease (COPD) exacerbation?

Background: Preventing hospital readmission following a COPD exacerbation is a priority; however, the role of NIV in this situation remains uncertain.

Study design: Multicenter, randomized controlled trial.

Setting: 13 medical centers in the United Kingdom.

Synopsis: Investigators randomized 116 patients with COPD and persistent hypercapnia (paCO₂ less than 53) 2-4 weeks following a COPD exacerbation to either home oxygen therapy with NIV or to home oxygen therapy alone. The study’s primary endpoint was a composite of time to readmission or death within 12 months. They found that the median time to this endpoint was significantly longer in the intervention group (1.4 vs. 4.3 months; 95% CI, 0.31-0.77; P = .002) and that the absolute risk reduction was 17.0% (80.4% vs. 63.4%; 95% CI, 0.1%-34.0%). The differences were driven by readmissions, as the mortality rate did not differ significantly between groups, although the study was not powered to evaluate this. Of note, the median NIV settings were 24/4, which constitutes a “high-pressure strategy” which may account for the benefits seen in this study that have been absent in some other trials.

Bottom line: NIV reduced readmissions in patients with COPD and persistent hypercapnia several weeks following an acute exacerbation.

Citation: Murphy PB, Rehal S, Arbane G, et al. Effect of home noninvasive ventilation with oxygen therapy vs. oxygen therapy alone on hospital readmission or death after an acute COPD exacerbation, a randomized clinical trial. JAMA. 2017;317(21):2177-86.

Dr. Herscher is assistant professor, division of hospital medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: Is there a benefit to home noninvasive ventilation (NIV) following a hospital admission for chronic obstructive pulmonary disease (COPD) exacerbation?

Background: Preventing hospital readmission following a COPD exacerbation is a priority; however, the role of NIV in this situation remains uncertain.

Study design: Multicenter, randomized controlled trial.

Setting: 13 medical centers in the United Kingdom.

Synopsis: Investigators randomized 116 patients with COPD and persistent hypercapnia (paCO₂ less than 53) 2-4 weeks following a COPD exacerbation to either home oxygen therapy with NIV or to home oxygen therapy alone. The study’s primary endpoint was a composite of time to readmission or death within 12 months. They found that the median time to this endpoint was significantly longer in the intervention group (1.4 vs. 4.3 months; 95% CI, 0.31-0.77; P = .002) and that the absolute risk reduction was 17.0% (80.4% vs. 63.4%; 95% CI, 0.1%-34.0%). The differences were driven by readmissions, as the mortality rate did not differ significantly between groups, although the study was not powered to evaluate this. Of note, the median NIV settings were 24/4, which constitutes a “high-pressure strategy” which may account for the benefits seen in this study that have been absent in some other trials.

Bottom line: NIV reduced readmissions in patients with COPD and persistent hypercapnia several weeks following an acute exacerbation.

Citation: Murphy PB, Rehal S, Arbane G, et al. Effect of home noninvasive ventilation with oxygen therapy vs. oxygen therapy alone on hospital readmission or death after an acute COPD exacerbation, a randomized clinical trial. JAMA. 2017;317(21):2177-86.

Dr. Herscher is assistant professor, division of hospital medicine, Icahn School of Medicine of the Mount Sinai Health System.

 

Clinical question: Is there a benefit to home noninvasive ventilation (NIV) following a hospital admission for chronic obstructive pulmonary disease (COPD) exacerbation?

Background: Preventing hospital readmission following a COPD exacerbation is a priority; however, the role of NIV in this situation remains uncertain.

Study design: Multicenter, randomized controlled trial.

Setting: 13 medical centers in the United Kingdom.

Synopsis: Investigators randomized 116 patients with COPD and persistent hypercapnia (paCO₂ less than 53) 2-4 weeks following a COPD exacerbation to either home oxygen therapy with NIV or to home oxygen therapy alone. The study’s primary endpoint was a composite of time to readmission or death within 12 months. They found that the median time to this endpoint was significantly longer in the intervention group (1.4 vs. 4.3 months; 95% CI, 0.31-0.77; P = .002) and that the absolute risk reduction was 17.0% (80.4% vs. 63.4%; 95% CI, 0.1%-34.0%). The differences were driven by readmissions, as the mortality rate did not differ significantly between groups, although the study was not powered to evaluate this. Of note, the median NIV settings were 24/4, which constitutes a “high-pressure strategy” which may account for the benefits seen in this study that have been absent in some other trials.

Bottom line: NIV reduced readmissions in patients with COPD and persistent hypercapnia several weeks following an acute exacerbation.

Citation: Murphy PB, Rehal S, Arbane G, et al. Effect of home noninvasive ventilation with oxygen therapy vs. oxygen therapy alone on hospital readmission or death after an acute COPD exacerbation, a randomized clinical trial. JAMA. 2017;317(21):2177-86.

Dr. Herscher is assistant professor, division of hospital medicine, Icahn School of Medicine of the Mount Sinai Health System.