Tennessee Valley Geriatric Research Education Clinical Center

Tennessee Ridge, TN, United States

Tennessee Valley Geriatric Research Education Clinical Center

Tennessee Ridge, TN, United States
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Patrick S.W.,Vanderbilt University | Patrick S.W.,Vanderbilt Center for Health Services Research | Dudley J.,Vanderbilt University | Martin P.R.,Vanderbilt University | And 10 more authors.
Pediatrics | Year: 2015

BACKGROUND AND OBJECTIVES: Although opioid pain relievers are commonly prescribed in pregnancy, their association with neonatal outcomes is poorly described. Our objectives were to identify neonatal complications associated with antenatal opioid pain reliever exposure and to establish predictors of neonatal abstinence syndrome (NAS). METHODS: We used prescription and administrative data linked to vital statistics for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. A random sample of NAS cases was validated by medical record review. The association of antenatal exposures with NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant characteristics. RESULTS: Of 112 029 pregnant women, 31 354 (28%) filled ≥1 opioid prescription. Women prescribed opioid pain relievers were more likely than those not prescribed opioids (P < .001) to have depression (5.3% vs 2.7%), anxiety disorder (4.3% vs 1.6%) and to smoke tobacco (41.8% vs 25.8%). Infants with NAS and opioid-exposed infants were more likely than unexposed infants to be born at a low birth weight (21.2% vs 11.8% vs 9.9%; P < .001). In a multivariable model, higher cumulative opioid exposure for short-acting preparations (P , .001), opioid type (P < .001), number of daily cigarettes smoked (P < .001), and selective serotonin reuptake inhibitor use (odds ratio: 2.08 [95% confidence interval: 1.67-2.60]) were associated with greater risk of developing NAS. CONCLUSIONS: Prescription opioid use in pregnancy is common and strongly associated with neonatal complications. Antenatal cumulative prescription opioid exposure, opioid type, tobacco use, and selective serotonin reuptake inhibitor use increase the risk of NAS. Copyright © 2015 by the American Academy of Pediatrics.


Morandi A.,Geriatric Research Group | Morandi A.,Vanderbilt University | Bellelli G.,Geriatric Research Group | Bellelli G.,University of Milan Bicocca | And 10 more authors.
Journal of the American Medical Directors Association | Year: 2013

Objectives: Rehospitalizations for elderly patients are an increasing health care burden. Nonetheless, we have limited information on unplanned rehospitalizations and the related risk factors in elderly patients admitted to in-hospital rehabilitation facilities after an acute hospitalization. Setting: In-hospital rehabilitation and aged care unit. Design: Retrospective cohort study. Participants: Elderly patients 65 years or older admitted to an in-hospital rehabilitation hospital after an acute hospitalization between January 2004 and June2011. Measurements: The rate of 30-day unplanned rehospitalization to hospitals was recorded. Risk factors for unplanned rehospitalization were evaluated at rehabilitation admission: age, comorbidity, serum albumin, number of drugs, decline in functional status, delirium, Mini Mental State Examination score, and length of stay in the acute hospital. A multivariable Cox proportional regression model was used to identify the effect of these risk factors for time to event within the 30-day follow-up. Results: Among 2735 patients, with a median age of 80 years (interquartile range 74-85), 98 (4%) were rehospitalized within 30 days. Independent predictors of 30-day unplanned rehospitalization were the use of 7 or more drugs (hazard ratio [HR], 3.94; 95% confidence interval, 1.62-9.54; P= .002) and a significant decline in functional status (56 points or more at the Barthel Index) compared with the month before hospital admission (HR 2.67, 95% CI: 1.35-5.27; P= .005). Additionally, a length of stay in the acute hospital of 13 days or more carried a twofold higher risk of rehospitalization (HR 2.67, 95% CI: 1.39-5.10); P= .003). Conclusions: The rate of unplanned rehospitalization was low in this study. Polypharmacy, a significant worsening of functional status compared with the month before acute hospital admission, and hospital length of stay are important risk factors. © 2013 American Medical Directors Association, Inc.


Page V.J.,Watford General Hospital | Page V.J.,Imperial College London | Ely E.W.,Vanderbilt University | Ely E.W.,Tennessee Valley Geriatric Research Education Clinical Center | And 9 more authors.
The Lancet Respiratory Medicine | Year: 2013

Background: Delirium is frequently diagnosed in critically ill patients and is associated with poor clinical outcomes. Haloperidol is the most commonly used drug for delirium despite little evidence of its effectiveness. The aim of this study was to establish whether early treatment with haloperidol would decrease the time that survivors of critical illness spent in delirium or coma. Methods: We did this double-blind, placebo-controlled randomised trial in a general adult intensive care unit (ICU). Critically ill patients (≥18 years) needing mechanical ventilation within 72 h of admission were enrolled. Patients were randomised (by an independent nurse, in 1:1 ratio, with permuted block size of four and six, using a centralised, secure web-based randomisation service) to receive haloperidol 2·5 mg or 0·9% saline placebo intravenously every 8 h, irrespective of coma or delirium status. Study drug was discontinued on ICU discharge, once delirium-free and coma-free for 2 consecutive days, or after a maximum of 14 days of treatment, whichever came first. Delirium was assessed using the confusion assessment method for the ICU (CAM-ICU). The primary outcome was delirium-free and coma-free days, defined as the number of days in the first 14 days after randomisation during which the patient was alive without delirium and not in coma from any cause. Patients who died within the 14 day study period were recorded as having 0 days free of delirium and coma. ICU clinical and research staff and patients were masked to treatment throughout the study. Analyses were by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Registry, number ISRCTN83567338. Findings: 142 patients were randomised, 141 were included in the final analysis (71 haloperidol, 70 placebo). Patients in the haloperidol group spent about the same number of days alive, without delirium, and without coma as did patients in the placebo group (median 5 days [IQR 0-10] vs 6 days [0-11] days; p=0·53). The most common adverse events were oversedation (11 patients in the haloperidol group vs six in the placebo group) and QTc prolongation (seven patients in the haloperidol group vs six in the placebo group). No patient had a serious adverse event related to the study drug. Interpretation: These results do not support the hypothesis that haloperidol modifies duration of delirium in critically ill patients. Although haloperidol can be used safely in this population of patients, pending the results of trials in progress, the use of intravenous haloperidol should be reserved for short-term management of acute agitation. Funding: National Institute for Health Research. © 2013 Elsevier Ltd.


Janz D.R.,Vanderbilt University | Abel T.W.,Vanderbilt University | Jackson J.C.,Vanderbilt University | Gunther M.L.,Vanderbilt Center for Health Services Research | And 2 more authors.
Journal of Critical Care | Year: 2010

Purpose: Delirium affects 50% to 80% of intensive care unit (ICU) patients and is associated with increased risk of mortality. Given the paucity of data reporting the neuropathologic findings in ICU patients experiencing delirium, the purpose of this pilot, hypothesis-generating study was to evaluate brain autopsies in ICU patients who suffered from delirium to explore possible neuroanatomical correlates. Materials and Methods: Using delirium databases at Vanderbilt University, we identified patients who had delirium in the ICU and subsequently died and received a brain autopsy during the same hospitalization. Brain autopsy reports were collected retrospectively on all 7 patients who met these criteria. Results: Patients' mean age was 55 (SD ± 8.4) years, and median number of days spent with delirium was 7 (±5 interquartile range). In 6 (86%) of 7 patients, pathologic lesions normally attributed to hypoxia or ischemia were noted in the hippocampus, pons, and striatum. Hippocampal lesions represented the most common neuropathologic site of injury, present in 5 (71%) of 7 patients. Conclusions: Hypoxic ischemic injury in multiple locations of the brain was a common finding. The biological plausibility of hippocampal lesions as a contributor to long-term cognitive impairment warrants postmortem investigation on a larger scale with comparison to patients not experiencing ICU delirium. © 2010 Elsevier Inc.


Khan B.A.,Indiana University | Khan B.A.,Regenstrief Institute Inc. | Guzman O.,Westchester Medical Center | Campbell N.L.,Regenstrief Institute Inc. | And 14 more authors.
Chest | Year: 2012

Background: Delirium evaluation in patients in the ICU requires the use of an arousal/sedation assessment tool prior to assessing consciousness. The Richmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS) are well-validated arousal/sedation tools. We sought to assess the concordance of RASS and SAS assessments in determining eligibility of patients in the ICU for delirium screening using the confusion assessment method for the ICU(CAM-ICU). Methods: We performed a prospective cohort study in the adult medical, surgical, and progressive (step-down) ICUs of a tertiary care, university-affiliated, urban hospital in Indianapolis, Indiana. The cohort included 975 admissions to the ICU between January and October 2009. Results: The outcome measures of interest were the correlation and agreement between RASS and SAS measurements. In 2,469 RASS and SAS paired screens, the rank correlation using the Spearman correlation coefficient was 0.91, and the agreement between the two screening tools for assessing CAM-ICU eligibility as estimated by the k coefficient was 0.93. Analysis showed that 70.1% of screens were eligible for CAM-ICU assessment using RASS(7.1% sedated [RASS -3 to -1]; 62.6% calm [0]; and 0.4% restless, agitated [+1 to +3]), compared with 72.1% using SAS(5% sedated [SAS 3]; 66.5% calm [4]; and 0.6% anxious, agitated [5, 6]). In the mechanically ventilated subgroup, RASS identified 19.1% CAM-ICU eligible patients compared with 24.6% by SAS. The correlation coefficient in this subgroup was 0.70 and the agreement was 0.81. Conclusion: Both SAS and RASS led to similar rates of delirium assessment using the CAM-ICU. © 2012 American College of Chest Physicians.


Denny J.C.,Vanderbilt University | Choma N.N.,Vanderbilt University | Choma N.N.,Tennessee Valley Geriatric Research Education Clinical Center | Peterson J.F.,Vanderbilt University | And 5 more authors.
Medical Decision Making | Year: 2012

Background. Difficulty identifying patients in need of colorectal cancer (CRC) screening contributes to low screening rates. Objective. To use Electronic Health Record (EHR) data to identify patients with prior CRC testing. Design. A clinical natural language processing (NLP) system was modified to identify 4 CRC tests (colonoscopy, flexible sigmoidoscopy, fecal occult blood testing, and double contrast barium enema) within electronic clinical documentation. Text phrases in clinical notes referencing CRC tests were interpreted by the system to determine whether testing was planned or completed and to estimate the date of completed tests. Setting. Large academic medical center. Patients. 200 patients ≥ 50 years old who had completed ≥ 2 non-acute primary care visits within a 1-year period. Measures. Recall and precision of the NLP system, billing records, and human chart review were compared to a reference standard of human review of all available information sources. Results. For identification of all CRC tests, recall and precision were as follows: NLP system (recall 93%, precision 94%), chart review (74%, 98%), and billing records review (44%, 83%). Recall and precision for identification of patients in need of screening were: NLP system (recall 95%, precision 88%), chart review (99%, 82%), and billing records (99%, 67%). Limitations. Small sample size and requirement for a robust EHR. Conclusions. Applying NLP to EHR records detected more CRC tests than either manual chart review or billing records review alone. NLP had better precision but marginally lower recall to identify patients who were due for CRC screening than billing record review.


Khan B.A.,Indiana University | Khan B.A.,Regenstrief Institute | Fadel W.F.,Indiana University | Tricker J.L.,Wishard Health Services | And 12 more authors.
Critical Care Medicine | Year: 2014

Objectives: Mechanically ventilated critically ill patients receive significant amounts of sedatives and analgesics that increase their risk of developing coma and delirium. We evaluated the impact of a "Wake-up and Breathe Protocol" at our local ICU on sedation and delirium. Design: A pre/post implementation study design. Setting: A 22-bed mixed surgical and medical ICU. Patients: Seven hundred two consecutive mechanically ventilated ICU patients from June 2010 to January 2013. Interventions: Implementation of daily paired spontaneous awakening trials (daily sedation vacation plus spontaneous breathing trials) as a quality improvement project. Measurements and Main Results: After implementation of our program, there was an increase in the mean Richmond Agitation Sedation Scale scores on weekdays of 0.88 (p < 0.0001) and an increase in the mean Richmond Agitation Sedation Scale scores on weekends of 1.21 (p < 0.0001). After adjusting for age, race, gender, severity of illness, primary diagnosis, and ICU, the incidence and prevalence of delirium did not change post implementation of the protocol (incidence: 23% pre vs 19.6% post; p = 0.40; prevalence: 66.7% pre vs 55.3% post; p = 0.06). The combined prevalence of delirium/coma decreased from 90.8% pre protocol implementation to 85% postimplementation (odds ratio, 0.505; 95% CI, 0.299-0.853; p = 0.01). Conclusions: Implementing a "Wake Up and Breathe Program" resulted in reduced sedation among critically ill mechanically ventilated patients but did not change the incidence or prevalence of delirium. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.


Roumie C.L.,Tennessee Valley Geriatric Research Education Clinical Center | Roumie C.L.,Vanderbilt University | Liu X.,Tennessee Valley Geriatric Research Education Clinical Center | Liu X.,Vanderbilt University | And 8 more authors.
Pharmacoepidemiology and Drug Safety | Year: 2012

Purpose: To determine if incident oral antidiabetic drug (OAD) use was associated with 12-month systolic blood pressure (BP) and if this was mediated through body mass index (BMI) changes. Methods: A retrospective cohort of veterans with hypertension who initiated metformin (n=2057) or sulfonylurea (n=1494) between 1 January 2000 and 31 December 2007 in the Veterans Administration Mid-South Network was assembled. Patients were included if they had complete covariates, including 12-month BP and BMI, and persisted on therapy for 12months. Linear regression was conducted to investigate the effect of OADs on 12-month systolic BP adjusting for demographics, glycated hemoglobin, creatinine, BMI, health care utilization, and comorbidities, including cardiovascular disease (CVD). A second analysis examined if these effects were mediated by BMI change. The secondary outcome was the proportion of patients who had a controlled BP (≤140/90mmHg) at 12months adjusted for baseline BP and covariates. Results: Patients were white (82%) males (97%) with median age of 64years (interquartile range [IQR] 57, 72), and 27% had history of CVD. Sulfonylurea users had a 1.33mmHg (0.16, 2.50, p=0.03) higher 12-month systolic BP than metformin users. The median change in BMI from OAD initiation to 12months was -0.76 (IQR -1.78, 0.07) and 0.21 (IQR -0.57, 1.03) among metformin and sulfonylurea users, respectively. In a model adjusting for BMI change, the difference in 12-month systolic BP between sulfonylurea and metformin users became insignificant (0.23 (-1.00, 1.45), p=0.72), while one BMI unit change was associated with an increase in 12-month systolic BP of 1.07mmHg (0.74, 1.40, p<0.0001). At 12months, 68.3% of metformin patients had controlled BP versus 64.2% of sulfonylurea patients (p=0.01). Conclusions: Compared with metformin, sulfonylurea initiation was associated with increased systolic BP at 12months, which appears to be mediated by the differential effects of these drugs on BMI. © 2012 John Wiley & Sons, Ltd.


Denny J.C.,Vanderbilt University | Peterson J.F.,Vanderbilt University | Peterson J.F.,Tennessee Valley Geriatric Research Education Clinical Center | Choma N.N.,Vanderbilt University | And 5 more authors.
Journal of the American Medical Informatics Association | Year: 2010

Colorectal cancer (CRC) screening rates are low despite confirmed benefits. The authors investigated the use of natural language processing (NLP) to identify previous colonoscopy screening in electronic records from a random sample of 200 patients at least 50 years old. The authors developed algorithms to recognize temporal expressions and 'status indicators', such as 'patient refused', or 'test scheduled'. The new methods were added to the existing KnowledgeMap concept identifier system, and the resulting system was used to parse electronic medical records (EMR) to detect completed colonoscopies. Using as the 'gold standard' expert physicians' manual review of EMR notes, the system identified timing references with a recall of 0.91 and precision of 0.95, colonoscopy status indicators with a recall of 0.82 and precision of 0.95, and references to actually completed colonoscopies with recall of 0.93 and precision of 0.95. The system was superior to using colonoscopy billing codes alone. Health services researchers and clinicians may find NLP a useful adjunct to traditional methods to detect CRC screening status. Further investigations must validate extension of NLP approaches for other types of CRC screening applications.


PubMed | Tennessee Valley Geriatric Research Education Clinical Center and Vanderbilt University
Type: Journal Article | Journal: Journal of comparative effectiveness research | Year: 2015

Evaluate performance of analytical strategies commonly used to adjust for baseline differences in continuous outcome variables for comparative effectiveness studies.Data simulations resembling a comparison of HbA1c values after initiation of antidiabetic treatments adjusting for baseline HbA1c. We evaluated change scores, analyses of covariance including linear, nonlinear with/without robust variance estimations, before and after optimal matching. We also evaluated the impact of measurement error.With increasing HbA1c baseline differences between groups, bias in effect estimates and suboptimal CI coverage probabilities increased in all approaches. These issues were further compounded by measurement error. Matching on baseline HbA1c, substantially mitigated these issues.In comparative studies with continuous outcomes, matching on baseline values of the outcome variable improves analytical performance.

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