Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York.
JAMA Netw Open. 2018 Aug 3;1(4):e181119. doi: 10.1001/jamanetworkopen.2018.1119.
Guidelines from December 2011 recommended against obtaining daily chest radiographs (CXRs) for patients requiring mechanical ventilation (MV). Daily CXR use for patients receiving MV in US hospitals is unknown and, if high, may represent an opportunity to reduce low-value care and unnecessary radiation.
To determine frequency of daily CXR use for US patients receiving MV, assess variability across hospitals, and evaluate whether use has decreased over time.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of hospitalized adults (aged ≥18 years) receiving MV for 3 days or longer. Mechanical ventilation was defined by having an International Classification of Diseases, Ninth Revision, Clinical Modification code of 96.7x and an MV charge on more than 1 hospital day. Hospital discharges in the Premier Perspectives database were examined from July 1, 2008, to December 31, 2014. Data analysis was conducted from July 28, 2017, to December 13, 2017.
Hospital discharge date (quarter of the year) and hospital in which patients received MV.
The outcome was daily CXR use (up to 7 days) during MV. We used standard statistics to describe CXR use, multilevel multivariable regression modeling with adjusted median odds ratio (OR) to evaluate variability by hospital, and multivariable piecewise regression (breakpoint: fourth quarter of 2011) with adjusted OR to evaluate time trends and response to guideline recommendations.
The primary cohort included 512 518 patients receiving MV (mean [SD] age, 63.0 [16.1] years; 46% female) in 416 hospitals, of whom 321 093 (63%) received daily CXRs. Wide variability was seen across hospitals; hospitals performed daily CXRs on a median of 66% of patients (interquartile range, 50%-77%; full range, 12%-97%). The adjusted median OR was 2.43 (95% CI, 2.29-2.59), suggesting the same patient had 2.43-fold higher odds of receiving a daily CXR if admitted to a higher- vs lower-use hospital; the odds of receiving daily CXRs were unchanged through quarter 3 of 2011 (adjusted OR, 1.00; 95% CI, 0.99-1.01), after which there was a 3% relative reduction in the odds of daily CXR use per quarter (adjusted OR, 0.97; 95% CI, 0.96-0.98).
Three-fifths of US patients receiving MV also received daily CXRs from 2008 to 2014, although use declined slowly after new guidelines were published. The hospital at which a patient received care was associated with the odds of daily CXR receipt.
2011 年 12 月的指南建议对需要机械通气（MV）的患者避免每天进行胸部 X 光检查（CXR）。美国医院中接受 MV 的患者每日 CXR 使用情况尚不清楚，如果使用率较高，可能代表有机会减少低价值的护理和不必要的辐射。
确定美国接受 MV 的患者每日 CXR 使用的频率，评估医院之间的差异，并评估其随时间的变化。
设计、地点和参与者：这是一项对接受 MV 治疗至少 3 天的住院成人（年龄≥18 岁）的回顾性队列研究。MV 通过国际疾病分类第 9 版临床修订版 96.7x 代码和超过 1 天的 MV 费用来定义。对 Premier Perspectives 数据库中的医院出院数据进行了检查，时间范围为 2008 年 7 月 1 日至 2014 年 12 月 31 日。数据分析于 2017 年 7 月 28 日至 2017 年 12 月 13 日进行。
出院日期（一年中的季度）和患者接受 MV 的医院。
结果是 MV 期间每天进行 CXR（最多 7 天）。我们使用标准统计数据来描述 CXR 的使用情况，使用调整后的中位数优势比（OR）进行多水平多变量回归建模，以评估医院之间的差异，并使用多变量分段回归（断点：2011 年第四季度）和调整后的 OR 来评估时间趋势和对指南建议的反应。
主要队列包括 416 家医院的 512518 名接受 MV（平均[标准差]年龄 63.0[16.1]岁；46%为女性）的患者，其中 321093 名（63%）接受了每日 CXR。医院之间存在很大差异；中位数为 66%（四分位距，50%-77%；全范围，12%-97%）的患者进行了每日 CXR。调整后的中位数 OR 为 2.43（95%置信区间，2.29-2.59），这表明同一患者如果入住使用率较高的医院，接受每日 CXR 的几率要高出 2.43 倍；2011 年第 3 季度之前，接受每日 CXR 的几率没有变化（调整后的 OR，1.00；95%置信区间，0.99-1.01），此后，每季度接受每日 CXR 的几率相对降低 3%（调整后的 OR，0.97；95%置信区间，0.96-0.98）。
2008 年至 2014 年间，接受 MV 的五分之三的美国患者也接受了每日 CXR，但在新指南发布后，使用率缓慢下降。患者接受治疗的医院与接受每日 CXR 的几率有关。
