Friday, October 17, 2008

MagCitrate #2:Prognosis in ESRD & CHF, More

This is the hat tip to Dr. Bob Arnold iteration of the Magnesium Citrate posts as these are all articles suggested to us by him.

Critical Care Medicine has a paper looking at prognosis in end stage renal disease patients admitted to an ICU. This is a nation-wide Swedish study which used registry data to look at short and long-term mortality in patients with pre-existing ESRD who were admitted to ICUs and received renal replacement therapy there (it's a little tough to tell from the article but I think not all of the patients were receiving dialysis prior to admission to the ICU although they all had advanced renal failure prior to admission).

They found certain comorbidities increased the odds ratio of short and long term mortality (e.g. heart failure, etc.) but the more useful data for palliative care people is likely the straight-forward mortality data. Unfortunately the mortality data they present is weirdly incomplete (at least to meet my needs) and doesn't have stuff like simple in-hospital mortality etc. presented numerically. However, there is quite the Kaplan-Meier curve which gives some data reinforcing the idea that critical illness in ESRD patients is a highly mortal event and marker for a poor prognosis. All of these numbers are me eye-balling a KM curve but immediate mortality (presumably in-hospital) was about 20%, 50% mortality in the entire cohort was reached around ~7 months, and the 1 year survival for the cohort was 40%.

Next is one from American Heart Journal looking at a prognostic model to predict early mortality after a hospitalization for heart failure. The data come from a large study of a quality improvement bundle designed to improve outcomes in a hospitalized CHF cohort involving nearly 50,000 patients in over 200 US hospitals (OPTIMIZE-HF study: see here for example). The current analysis involves looking at patients who were discharged alive but had early (within 90 days re-hospitalization or death) and developing a prognostic model to predict who were likely to have those outcomes. Gross early mortality was 8.6% for the entire cohort (still thousands of patients) and early re-hospitalization was about 30%. They were able to create a relatively simple point-system involving age, weight, systolic blood pressure, and serum sodium and creatinine concentrations which predicted risk of 90 day mortality with decent accuracy in a validation analysis.

What I actually found most interesting about reading the article was its conclusion which talked about how this can be used to identify patients who are at high risk of mortality and therefore should be considered for more aggressive management and follow-up. I don't argue that point per se but it was fascinating for me to read those sentences realizing Gosh that never crossed my mind: I was thinking of course that these tools are useful for identifying patients who urgently need to have palliative care-type interventions (whether or not they're seen by a palliative care specialist): discussion of prognosis, goals, hopes/fears for future, advance care planning, symptom and psych-spiritual assessment, etc.

You get the feeling in how the last paragraph is written that CHF is not something that people 'should' die from, that if we just somehow stepped-up the medical care/interventions/monitoring we'd be able to forestall death, and that in fact these early deaths were preventable as opposed to being from a progressive illness that, despite the great and evolving disease-modifying interventions we have - is still a terminal one with morbidity and mortality surpassing many cancers for its most severe forms.

Chest has published 'practical guidelines' for running ICU family conferences. It's a good one for the teaching file and is notable - besides being accurate, readable, and helpful for trainees - that it frames the guidelines as evidence-based ones (which they are insofar as they are in fact based on the best available research). What's pleasing about this is that there is a sufficient evidence base to actually base guidelines on and, along the lines of my post about the Coping with Cancer study, there is a growing amount of data that good communication makes major differences in our patients and families lives and is not just some nice idea.

Chest also has a review on anxiety and depression in COPD: epidemiology, evaluation, how they are way undertreated, how to treat, policy and research recommendations, etc.

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