In the Literature
Setting: N/A.
Synopsis: Three randomized-controlled trials eligible for this review included 2,299 critically ill adults with acute lung injury, as defined by the American-European Consensus Conference. The meta-analysis compared higher and lower PEEP levels with a mean difference of at least 3 cm H2O, incorporated a target tidal volume of less than 8 mL/kg of predicted body weight in both ventilation strategies, and provided patient follow-up until death or for at least 20 days.
This review demonstrated no statistically significant difference in hospital mortality between the groups. However, in patients with ARDS, higher levels of PEEP were associated with a relative reduction in mortality of 10%. This is supported by a recent cohort study in patients with acute lung injury or ARDS, which showed that the effect of PEEP on lung recruitment was associated with the proportion of potentially recruitable lung, as determined by computed tomography.
Since patients with ARDS have more pulmonary edema than those with acute lung injury without ARDS, the former have greater recruitability, and thus might benefit more from higher levels of PEEP.
Bottom line: Higher levels of PEEP might be associated with lower hospital mortality in patients with ARDS, but such a benefit is unlikely in patients with less severe lung injuries, and could actually be harmful.
Citation: Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA. 2010;303(9):865-873. TH
PEDIATRIC HM LITERATURE
By Mark Shen, MD
High-Performing State Healthcare Systems Have Higher Children’s Hospital Readmission Rates
Clinical question: What is the relationship between a hospital’s readmission rate and performance of the surrounding healthcare system?
Background: Hospital readmission rates might be influenced by factors related to the specific patient and hospital care, as well as such external factors as the performance of the surrounding healthcare system. Traditionally, readmission rates are thought to most accurately reflect the quality of hospital care; however, the relative contributions of patient, hospital, and external factors to hospital readmission rates have not been delineated.
Study design: Multilevel cohort study.
Setting: Thirty-nine children’s hospitals in 24 states.
Synopsis: The Pediatric Health Information System (PHIS) administrative database was sampled for the 2005 calendar year to review discharges from 39 participating children’s hospitals. Patients 2 to 18 years were included, and out of a total of 198,422 patients, 32,196 were readmitted within 365 days of discharge.
The Commonwealth Fund’s 2008 State Variations in Child Health System Performance ranking was used to define the state-level health system performance. Higher readmission rates correlated with higher-ranked state child health systems after adjustment for patient-level characteristics.
This surprising result calls into question the often-assumed link between hospital readmission rates and poor systems of care. However, despite the strength of its large sample size, this study’s macro-level view of the healthcare system might be too crude to truly define the external factors that play a role in readmission. State-level healthcare rankings might not accurately reflect the healthcare ecosystem surrounding each children’s hospital, and children’s hospitals do not care for the majority of children in the U.S.
Bottom line: Children’s hospital readmissions correlate with higher state child health system performance.
Citation: Feudtner C, Pati S, Goodman DM, et al. State-level child health system performance and the likelihood of readmission to children’s hospitals. J Pediatr. 2010;157(1):98-102.
