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• W4242794927 abstract "The publication of aggregated summaries of clinical information that allows an overall view of the current practice of critical care is made possible by the generosity of the institutions who agreed to share their deidentified data and by the efforts of the Phillips eICU Research Institute, which collected, deidentified, and stored the data for this study. One main aim of our presentation of “Five Year Trends of Critical Care Practice and Outcomes,”1Lilly C.M. Swami S. Liu X. Riker R.R. Badawi O. Five-year trends of critical care practice and outcomes.Chest. 2017; 152: 723-735Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar including its extensive online-only detailed tabulations of its supporting data, was to foster the contemplation, discussion, use, speculation, and interpretation that leads to the development and testing of the novel hypotheses that are necessary for the advancement of the science of critical care medicine. We are delighted that Ukken et al were intrigued with the trend toward lower hospital mortality, changes in end-of-life care, and other facets of our report. The authors agree with many of the observations of Ukken et al and also note many connections that may account for the observed changes of critical care practice. The paucity of speculation regarding these connections in our discussion section is not intended to discourage, but rather to encourage, our readers to use the summary data to formulate and investigate their own hypotheses and leverage this study in the background sections of the reports of their own investigations. We are grateful to Ukken et al for the opportunity to provide more context regarding how the data were collected and aggregated, because a better understanding enlightens and enables interpretation. We also have several observations regarding its prespecified study design (ie, formulated a priori). Like most high-quality studies, our study of trends of practice used predefined inclusion and exclusion criteria to select cases. We acknowledge that one could deviate from convention by calculating a “missing data” statistic at the level of the ICU by considering excluded cases as missing. However, a standard measure of calculating missing data frequency for included cases indicates that only approximately 0.1% of the intended cohort was discarded due to missing mortality data. The fact that only a small fraction of included case data was missing led us to believe that using imputation could not materially impact the analytical results. We agree with Ukken et al that multilevel analyses can be a useful analytical approach, particularly when modeling at the level of the patient. Because our stated aim was to provide benchmarking data to those responsible for ICU-level outcomes, the prespecified models of our analytical plan model were at the level of the ICU rather than the patient. As our analyses aimed to evaluate how the experiences of ICUs had changed over the study period, multilevel modeling with clusters higher than the level of the ICU were deemed to be outside the scope of this project. Ukken et al astutely and correctly identified heterogeneity of sample size for some data elements as a concerning feature of this data set. Before we finalized the analytical plan, we identified the predominant source of this variability as being due to differences in documentation strategies over time at individual study sites that led to some non-main-study outcome data elements being available for only some study years. During the study period, many institutions adopted new electronic health record keeping that changed the way that data were captured at the bedside or how it interfaced with the study database. Inspection of the source data from each ICU for each year allowed us to include data from all years in which valid data were captured for our prespecified analyses. Although this analysis was performed a priori, concern regarding the possibility that this issue might have affected our results caused us to perform post hoc sensitivity analyses that included data from only those ICUs that reliably charted records for all 5 years, comparing it with the results of the analyses that included all the valid data. The alternative methods of analyses did not produce results that were materially different. We are in an exciting era in which more and larger data sets are becoming available. The authors have provided summaries and analyses of a large well-curated critical care data set and provided these additional analytical and methodological insights to remove barriers that could otherwise hamper the generation of knowledge from this valuable resource. Five-Year Trends of Critical Care Practice and OutcomesCHESTVol. 152Issue 4PreviewLongitudinal analyses of large, detailed adult critical care datasets provide insights into practice trends and generate useful outcome and process benchmarks. Full-Text PDF Effects of Advanced Care Planning on Reduced Mortality, Implications of Blood Transfusion Use by ICU sites, and Further Statistical ConsiderationsCHESTVol. 153Issue 1PreviewWe read with interest the study by Lilly et al1 identifying temporal trends of critical care practice and outcomes using nationally representative eICU Research Institute data. Full-Text PDF" @default.
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• W4242794927 doi "https://doi.org/10.1016/j.chest.2017.10.018" @default.
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