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Principal Investigator: George L Anesi
Organization: UNIVERSITY OF PENNSYLVANIA
Fiscal Year: 2024
Award: $718,366
Funding agency: National Heart Lung and Blood Institute
PROJECT SUMMARY
Decisions to admit patients with acute respiratory failure (ARF) and sepsis (the most common and lethal cause
of the acute respiratory distress syndrome) to intensive care units (ICUs) are highly variable across the US.
And, yet, these triage decisions have a substantial impact on patient outcomes. In our prior work, we used
detailed electronic health record (EHR) data from 9.2 million hospitalizations and found that decisions to admit
ARF patients to wards were associated with a 3.8% absolute increase in mortality. In contrast, choices to admit
sepsis patients to ICUs resulted in considerably longer length of stay and a 5.1% absolute increase in death.
The nationwide impact of such discretionary triage would be exponentially greater. Our findings highlight
tremendous opportunities to improve ARF and sepsis outcomes by identifying the patient subgroups and
processes of care that most strongly contribute to the benefits and harms of ICU- versus ward-based care.
This application proposes to update our ARF and sepsis cohort such that it includes all admissions from 2013
through 2022 across 29 hospitals in the Kaiser Permanente Northern California and University of Pennsylvania
health systems, and incorporate more than 100 more data fields per patient. This curation of highly granular
EHR data will enable us to identify the: (1) distinct patient subgroups and phenotypes among those meeting
the syndromic criteria of `ARF' and `sepsis;' and the (2) processes of care and (3) inpatient complications that
causally explain the observed associations of ICU vs. ward triage with patient outcomes. Our multidisciplinary
team will apply diverse expertise in instrumental variable regression, mediation analyses, machine learning,
complex EHR data, and probabilistic phenotyping to complete three aims that promote our long-term goal of
improving care, and hence outcomes, for patients with ARF and sepsis regardless of where they are treated.
Several methodological innovations will enable us to achieve these goals, and, in turn, to not only surmount
key limitations of prior studies that sought to determine which acutely ill patients benefit from ICU admission,
but identify the mechanisms underlying such triage effects. These data will also allow us to quantify the impact
of COVID-19 on ICU and ward triage patterns, care processes, and outcomes among ARF and sepsis patients,
thereby modernizing our results and enabling their applicability to pandemic eras.
Completing the aims of this study will improve public health by identifying ways in which emergency
departments, ICUs, and wards can improve outcomes for the more than 4 million Americans hospitalized each
year with ARF and/or sepsis. Such results will enable development and testing of personalized triage
algorithms, and guide optimal care for patients without always requiring ICU admission, thereby improving
patient outcomes, reducing health care costs, and preserving ICU capacity for patients who truly need it.
Terms: <ARDS><Accident and Emergency department><Accounting><Acute><Acute Renal Failure with Renal Papillary Necrosis><Acute Respiratory Distress><Acute Respiratory Distress Syndrome><Acute respiratory failure><Admission><Admission activity><Adult ARDS><Adult RDS><Adult Respiratory Distress Syndrome><Affect><Algorithms><American><Antibiotic Agents><Antibiotic Drugs><Antibiotics><COPD><COVID crisis><COVID epidemic><COVID pandemic><COVID-19><COVID-19 affected><COVID-19 consequence><COVID-19 crisis><COVID-19 effect><COVID-19 epidemic><COVID-19 era><COVID-19 global health crisis><COVID-19 global pandemic><COVID-19 health crisis><COVID-19 impact><COVID-19 impacted><COVID-19 pandemic><COVID-19 period><COVID-19 public health crisis><COVID-19 years><CV-19><California><Caring><Cessation of life><Chronic Obstruction Pulmonary Disease><Chronic Obstructive Lung Disease><Chronic Obstructive Pulmonary Disease><Classification><Clinical><Collaborations><Complex><Complication><Consultations><Coronavirus Infectious Disease 2019><Da Nang Lung><Data><Data Set><Death><Delirium><Development><Diagnostic><Electronic Health Record><Elements><Emergency Department><Emergency room><Goals><Guidelines><Health Care Costs><Health Costs><Health system><Healthcare Costs><Heart failure><Heterogeneity><Hospital Admission><Hospitalization><Hospitals><Hour><Iatrogenesis><Infection><Inpatients><Intensive Care Units><Knowledge><Length of Stay><Life><Liquid substance><Location><Machine Learning><Measures><Mediation><Mediator><Methodology><Methods><Miscellaneous Antibiotic><Modeling><Negotiating><Negotiation><Number of Days in Hospital><Outcome><Palliative Care><Palliative Therapy><Palliative Treatment><Patient Admission><Patient Care><Patient Care Delivery><Patient outcome><Patient-Centered Outcomes><Patient-Focused Outcomes><Patients><Pattern><Pennsylvania><Phenotype><Population Heterogeneity><Probability><Process><Public Health><Recommendation><Resistance><SARS-CoV-2 epidemic><SARS-CoV-2 global health crisis><SARS-CoV-2 global pandemic><SARS-CoV-2 pandemic><SARS-coronavirus-2 epidemic><SARS-coronavirus-2 pandemic><Sepsis><Severe Acute Respiratory Syndrome CoV 2 epidemic><Severe Acute Respiratory Syndrome CoV 2 pandemic><Severe acute respiratory syndrome coronavirus 2 epidemic><Severe acute respiratory syndrome coronavirus 2 pandemic><Shock Lung><Steroid Compound><Steroids><Stiff lung><Subgroup><Syndrome><Systematics><Testing><Triage><Universities><Update><Urinary tract infection><Urinary tract infectious disease><Work><acute care><acute kidney injury><blood infection><bloodstream infection><cardiac failure><care for patients><care of patients><caring for patients><chronic obstructive pulmonary disorder><cohort><comfort care><consultation><coronavirus disease 2019><coronavirus disease 2019 consequence><coronavirus disease 2019 crisis><coronavirus disease 2019 effect><coronavirus disease 2019 epidemic><coronavirus disease 2019 global health crisis><coronavirus disease 2019 global pandemic><coronavirus disease 2019 health crisis><coronavirus disease 2019 impact><coronavirus disease 2019 pandemic><coronavirus disease 2019 public health crisis><coronavirus disease crisis><coronavirus disease epidemic><coronavirus disease pandemic><coronavirus disease-19><coronavirus disease-19 global pandemic><coronavirus disease-19 impact><coronavirus disease-19 pandemic><coronavirus infectious disease-19><current pandemic><death risk><delirious><developmental><diverse populations><electronic health care record><electronic health medical record><electronic health plan record><electronic health registry><electronic medical health record><end of life care><experience><fluid><future pandemic><heterogeneous population><high risk><hospital days><hospital length of stay><hospital stay><iatrogenic><iatrogenically><iatrogenicity><improved><improved outcome><indexing><innovate><innovation><innovative><insight><liquid><machine based learning><meeting><meetings><mortality><mortality risk><multidisciplinary><next pandemic><novel><pandemic><pandemic disease><patient oriented outcomes><patient subclass><patient subcluster><patient subgroups><patient subpopulations><patient subsets><patient subtypes><population diversity><present pandemic><preservation><resistant><sepsis patients><septic patients><severe acute respiratory syndrome coronavirus 2 global health crisis><severe acute respiratory syndrome coronavirus 2 global pandemic><treatment pattern><unsupervised learning><unsupervised machine learning><urinary infection><ward><wet lung>