Miriam M Treggiari

Swedish Medical Center Seattle, Seattle, Washington, United States

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Publications (12)49.9 Total impact

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    ABSTRACT: IMPORTANCE Low-risk elective surgical procedures are common, but there are no clear guidelines for when preoperative consultations are required. Such consultations may therefore represent a substantial discretionary service. OBJECTIVE To assess temporal trends, explanatory factors, and geographic variation for preoperative consultation in Medicare beneficiaries undergoing cataract surgery, a common low-risk elective procedure. DESIGN, SETTING, AND PARTICIPANTS Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556 637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89 817 individuals who underwent surgery from 2005 to 2006. MAIN OUTCOMES AND MEASURES Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery. RESULTS The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75-84 years vs 66-74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04-1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65-0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49-1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05-1.15]), anesthesia provider (anesthesiologist vs non-medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10-1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI, 2.33-4.10]). The burden of comorbidity was associated with consultation, but the effect size was small (<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0-69%]), even after accounting for differences in patient-level, anesthesia provider-level, and facility-level characteristics. CONCLUSIONS AND RELEVANCE Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.
    JAMA Internal Medicine 12/2013; · 10.58 Impact Factor
  • Article: In reply.
    Anesthesiology 06/2013; 118(6):1482-3. · 5.16 Impact Factor
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    ABSTRACT: BACKGROUND:: Many patients scheduled for elective surgery are referred for a preoperative medical consultation. Only limited data are available on factors associated with preoperative consultations. The authors hypothesized that surgical specialty contributes to variation in referrals for preoperative consultations. METHODS:: This is a cohort study using data from Group Health Cooperative, an integrated healthcare system. The authors included 13,673 patients undergoing a variety of common procedures-primarily low-risk surgeries-representing six surgical specialties, in 2005-2006. The authors identified consultations by family physicians, general internists, pulmonologists, or cardiologists in the 42 days preceding surgery. Multivariable logistic regression was used to estimate the association between surgical specialty and consultation, adjusting for potential confounders including the revised cardiac risk index, age, gender, Deyo comorbidity index, number of prescription medications, and 11 medication classes. RESULTS:: The authors found that 3,063 (22%) of all patients had preoperative consultations, with significant variation by surgical specialty. Patients having ophthalmologic, orthopedic, or urologic surgery were more likely to have consultations compared with those having general surgery-adjusted odds ratios (95% CI) of 3.8 (3.3-4.2), 1.5 (1.3-1.7), and 2.3 (1.8-2.8), respectively. Preoperative consultations were more common in patients with lower revised cardiac risk scores. CONCLUSION:: There is substantial practice variation among surgical specialties with regard to the use of preoperative consultations in this integrated healthcare system. Given the large number of consultations provided for patients with low cardiac risk and for patients presenting for low-risk surgeries, their indications, the financial burden, and cost-effectiveness of consultations deserve further study.
    Anesthesiology 03/2013; · 5.16 Impact Factor
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    ABSTRACT: BACKGROUND: In critically ill patients, induction with etomidate is hypothesized to be associated with an increased risk of mortality; previous randomized studies suggest a modest trend toward an increased risk of death among etomidate recipients, however this relationship has not been measured with great statistical precision. We aimed to test whether etomidate is associated with risk of hospital mortality and other clinical outcomes in critically ill patients. METHODS: We conducted a retrospective cohort study, from 1/1/2001 to 12/31/2005, of 824 patients requiring mechanical ventilation, who underwent adrenal function testing in the intensive care units of two academic medical centers. The primary outcome was in-hospital mortality comparing patients given etomidate(n=452) to those given an alternative induction agent(n=372). The secondary outcome was diagnosis of critical illness-related corticosteroid insufficiency (CIRCI) following etomidate exposure. RESULTS: Overall mortality was 34.3%. After adjustment for age, gender and baseline illness severity, the relative risk (RR) of death among etomidate recipients was higher than that of patients given an alternative agent (RR=1.20;95%CI,0.99-1.45). Among patients whose adrenal function was assessed within the 48 hours following intubation, the adjusted risk of meeting criteria for CIRCI was 1.37 (95%CI,1.12-1.66) comparing etomidate recipients to patients given another induction agent. CONCLUSION: In this study of critically ill patients requiring endotracheal intubation, etomidate administration was associated with a trend toward a relative increase in mortality, similar to the collective results of smaller randomized trials conducted to date. If truly a small relative increased risk is present, though previous trials have been underpowered to detect it, in absolute terms the number of deaths associated with etomidate in this high-risk population would be considerable. Large, prospective controlled trials are needed to finalize the role of etomidate in critically ill patients.
    Respiratory care 08/2012; · 2.03 Impact Factor
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    ABSTRACT: INTRODUCTION: Protocols for the delivery of analgesia, sedation and delirium care of the critically ill, mechanically ventilated patient have been shown to improve outcomes but are not uniformly used. The extent to which elements of analgesia, sedation and delirium guidelines are incorporated into order sets at hospitals across a geographic area is not known. We hypothesized that both greater hospital volume and membership in a hospital network are associated with greater adherence of order sets to sedation guidelines. METHODS: Sedation order sets from all nonfederal hospitals without pediatric designation in Washington State that provided ongoing care to mechanically ventilated patients were collected and their content systematically abstracted. Hospital data were collected from Washington State sources and interviews with ICU leadership in each hospital. An expert-validated score of order set quality was created based on the 2002 four-society guidelines. Clustered multivariable linear regression was used to assess the relationship between hospital characteristics and the order set quality score. RESULTS: Fifty-one Washington State hospitals met the inclusion criteria and all provided order sets. Based on expert consensus, 21 elements were included in the analgesia, sedation and delirium order set quality score. Each element was equally weighted and contributed one point to the score. Hospital order set quality scores ranged from 0 to 19 (median = 8, interquartile range 6 to 14). In multivariable analysis, a greater number of acute care days (P = 0.01) and membership in a larger hospital network (P = 0.01) were independently associated with a greater quality score. CONCLUSIONS: Hospital volume and membership in a larger hospital network were independently associated with a higher quality score for ICU analgesia, sedation and delirium order sets. Further research is needed to determine whether greater order-set quality is associated with improved outcomes in the critically ill. The development of critical care networks might be one strategy to improve order set quality scores.
    Critical care (London, England) 06/2012; 16(3):R106. · 4.72 Impact Factor
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    ABSTRACT: Intensivists may be primarily responsible for airway management in non-operating room locations. Little is known of airway management training provided during fellowship.Our primary aim was to describe the current state of airway education in internal medicine-based critical care fellowship programs. Between February 1 and April 30, 2011, program directors of all 3-year combined pulmonary/critical care and 2-year multidisciplinary critical care medicine programs in the United States were invited to complete an online survey. Contact information was obtained via FRIEDA Online (https://freida.ama-assn.org). Non-responders were sent automated reminders, were contacted by e-mail, or by telephone. The overall response proportion was 66% (111/168 programs). Sixty-four (58%) programs reported a designated airway rotation, chiefly occurring for 1 month during the first year of training. Thirty-five programs (32%)reported having a director of airway education and 78 (70%) reported incorporating simulation based airway education. Nearly all programs (95%) reported provision of supervised airway experience during fellowship. Commonly used airway management devices, including video laryngoscopes,intubating stylets, supraglottic airway devices, and fiberoptic bronchoscopes, were reportedly available to trainees. However, 73% reported < 10 uses of a supraglottic airway device, 60% < 25 uses of intubating stylets, 73% < 30 uses of a video laryngoscope, and 65% reported < 10 flexible fiberoptic intubations. Estimates of the required number of procedures to ensure competence varied widely. The majority of programs have a formal airway management program incorporating a variety of intubation techniques. Overall experience varies widely, however.
    Respiratory care 01/2012; 57(7):1084-8. · 2.03 Impact Factor
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    ABSTRACT: Ventricular late potentials (LP) recording with signal-averaged electrocar- diogram allow identifying patients at risk of sudden death and ventricular tachycardia. Cardiac surgery with cardiopulmonary bypass (CPB) could predispose to the development of myocardial ischemia related to imperfect cardioplegia. To the best of our knowledge, no study investigated the protection of cardioplegia and CPB regarding the occurrence of LP in patients without previous myocardial infarction and undergoing cardiac surgery. In 61 elective patients scheduled for cardiac surgery involving CPB, signal-averaged electrocar- diogram was performed the day before and 24-48 h after the surgery. The electrodes were positioned according to Frank's orthogonal derivations. Twenty five patients were excluded because of poor quality signals, leaving 36 patients (age, 64 ± 14) available for the analyses. An abnormal signal-averaged electrocardiogram was considered when ≥2 of the recorded indexes were present. McNemar's tests were performed on the dichotomized values to investigate differences in pre-post scores. The mean CPB duration was of 110 ± 57 min. Patients scheduled for cardiac surgery do not exhibited LP after CPB (no significant difference in pre-post CPB scores, P = NS). The probability of a patient with a negative score transitioning to a positive score was 0.23 (P = NS). The present study in cardiac surgical patients suggests that cardioplegia associated to CPB has no significant impact on the occurrence of LP, irrespective of surgery performed.
    International Journal of Clinical Monitoring and Computing 09/2011; 25(4):269-74.
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    ABSTRACT: Subarachnoid hemorrhage (SAH) is an acute cerebrovascular event which can have devastating effects on the central nervous system as well as a profound impact on several other organs. SAH patients are routinely admitted to an intensive care unit and are cared for by a multidisciplinary team. A lack of high quality data has led to numerous approaches to management and limited guidance on choosing among them. Existing guidelines emphasize risk factors, prevention, natural history, and prevention of rebleeding, but provide limited discussion of the complex critical care issues involved in the care of SAH patients. The Neurocritical Care Society organized an international, multidisciplinary consensus conference on the critical care management of SAH to address this need. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. A jury of four experienced neurointensivists was selected for their experience in clinical investigations and development of practice guidelines. Recommendations were developed based on literature review using the GRADE system, discussion integrating the literature with the collective experience of the participants and critical review by an impartial jury. Recommendations were developed using the GRADE system. Emphasis was placed on the principle that recommendations should be based not only on the quality of the data but also tradeoffs and translation into practice. Strong consideration was given to providing guidance and recommendations for all issues faced in the daily management of SAH patients, even in the absence of high quality data.
    Neurocritical Care 07/2011; 15(2):211-40. · 3.04 Impact Factor
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    ABSTRACT: Conivaptan is an arginine-vasopressin-receptor antagonist approved for the treatment of hyponatremia. We hypothesized that administration of conivaptan to normonatremic patients with traumatic brain injury (TBI) is safe and could reduce intracranial pressure (ICP). Open-label, randomized, controlled trial enrolling 10 subjects within 24 h of severe TBI to receive a single 20 mg dose of conivaptan (n = 5) or usual care (n = 5). The primary endpoint was the evaluation of the safety profile defined by serum sodium increases averaging >1 mEq/h when measured every 4 h and any adverse events. Secondary endpoints were 48-h serum sodium, sodium load, change in ICP, and urine output. Ten patients were included in the intention-to-treat analysis. Three patients (2 conivaptan, 1 usual care group) experienced brief sodium increases averaging >1 mEq/h, with no patients achieving Na >160 mEq/l. There were no drug-related serious adverse events. At 48 h, the mean sodium was 142 ± 6 mEq/l (conivaptan) and 144 ± 10 mEq/l (usual care, P = 0.71). 48-h sodium load was 819 ± 724 mEq in the conivaptan and 1,137 ± 1,165 mEq in the usual care group (P = 0.62). At 4 h, serum sodium was higher (P = 0.02) and ICP was lower (P = 0.046) in the conivaptan compared with usual care group. 24-h but not 48-h urine output was different between the two groups (P < 0.01 and P = 0.20, respectively). These data suggest that a single dose conivaptan is safe in non-hyponatremic patients with severe TBI and may reduce ICP. Further studies are needed to establish the effect of conivaptan on clinically relevant endpoints, and its role in the management of intracranial hypertension.
    Neurocritical Care 03/2011; 14(3):354-60. · 3.04 Impact Factor
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    ABSTRACT: The second-generation air-Q intubating laryngeal airway is a newer commercially available supraglottic airway device. In this retrospective review, we describe our initial clinical experience of 70 insertions. The ease and number of insertion attempts, airway leak pressure, device positioning, duration of use, success of fibreoptic-aided intubation and oropharyngeal morbidity were recorded. The intubating laryngeal airway was successfully inserted in all 770 patients and functioned adequately as a primary airway in all 57 patients in which it was used. The median airway leak pressure was 25 and 30 cmH2O for the single-use and reusable devices (P = 0.001), respectively. Fibreoptic-aided intubation using the intubating laryngeal airway as a conduit was successful in 12/13 (92%) cases. One in four (26%) patients complained of mild sore throat postoperatively before discharge. In our series, the intubating laryngeal airway performed adequately as a primary airway during anaesthesia with respect to ease of insertion, adequacy of airway maintenance, and as a conduit for intubation in both anticipated and unanticipated difficult airways. Further investigation is warranted regarding the role of the intubating laryngeal airway as a conduit for both blind and fibreoptic-aided intubation. In addition, the incidence of postoperative throat complaints deserves further scrutiny.
    Anaesthesia and intensive care 01/2011; 39(1):40-5. · 1.40 Impact Factor
  • Miriam Treggiari
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    ABSTRACT: Thesis (Ph. D.)--University of Washington, 2007. Background. Sedation is administered to virtually all mechanically ventilated patients admitted to an intensive care unit (ICU). The results of observational studies suggest that memory of an ICU stay may protect patients from subsequent adverse mental health outcomes. We hypothesized that a strategy of light ICU sedation would have favorable effects on subsequent patient mental health compared to deep sedation.Methods. In patients requiring mechanical ventilation, a single center trial of targeted sedation was conducted. Patients were randomized to receive either light sedation (patient awake and cooperative -- Ramsay scale 1-2 [R1-2]) or deep sedation (patient asleep, awakening upon physical stimulation -- Ramsay scale 3-4 [R3-4]). Self reported measures of anxiety, depression, and symptoms of post-traumatic stress disorder (PTSD) were collected at ICU discharge and four weeks after hospital discharge using the Hospital Anxiety and Depression Scale, the PTSD-Symptom Checklist, and the Civilian Mississippi Scale. Other endpoints included length of ICU stay and duration of mechanical ventilation.Results. 137 patients were assigned to either the R1-2 (n=69) or the R3-4 (n=68) group. Seven patients withdrew consent and one patient was randomized in error, leaving 129 patients (n=65, R1-2; n=64 R3-4) available for the analysis. The cumulative dose of benzodiazepines used for sedation was substantially different between the two groups. ICU mortality was 13% in each group. Depression was more frequent in the R 3-4 group at ICU discharge (19%) compared with the R1-2 group (5%; P=.02), but there were no differences in the prevalence of anxiety, depression or PTSD symptoms between the two groups at the four-week follow-up. Patients assigned to the deep sedation group experienced more trouble remembering the event (37% R3-4, 14% R1-2; P=.02). Patients in the R 1-2 group had a higher number of ICU free days and more ventilator free days. There were no differences in the incidence of organ dysfunction or of adverse events.Conclusions. These data suggest that a strategy of light sedation affords benefits with regard to reduction of ICU stay and duration of ventilation without negatively affecting subsequent patient mental health or patient safety (ClinicalTrials.gov Identifier: NCT00221520).
    Critical care medicine 01/2010; 38(1):349-350. · 6.37 Impact Factor
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    ABSTRACT: : To investigate if light sedation favorably affects subsequent patient mental health compared with deep sedation. Symptoms of posttraumatic stress disorder are common in patients after they have undergone prolonged mechanical ventilation and are associated with sedation depth. : Randomized, open-label, controlled trial. : Single tertiary care center. : Adult patients requiring mechanical ventilation. : Patients were randomized to receive either light (patient awake and cooperative) or deep sedation (patient asleep, awakening upon physical stimulation). : Self-reported measures of posttraumatic stress disorder, anxiety, and depression were collected at intensive care unit discharge and 4 wks later. The primary outcomes were symptoms of posttraumatic stress disorder, anxiety, and depression 4 wks after intensive care unit discharge.A total of 137 patients were assigned to either the light (n = 69) or the deep sedation (n = 68) group. Seven patients withdrew consent and one patient was randomized in error, leaving 129 patients (n = 65 in light sedation and n = 64 in deep sedation) available for analysis. At the 4-wk follow-up, patients in the deep sedation group tended to have more posttraumatic stress disorder symptoms (p = .07); the deep sedation group had more trouble remembering the event (37% vs. 14%; p = .02) and more disturbing memories of the intensive care unit (18% vs. 4%; p = .05). Patients in the light sedation group had an average one day less being ventilated and 1.5 fewer days in the intensive care unit. There were no differences between the two groups in the occurrence of anxiety and depression, and also no difference in mortality or in the incidence of adverse events. : These data suggest that a strategy of light sedation affords benefits with regard to reduction of intensive care unit stay and duration of ventilation without negatively affecting subsequent patient mental health or patient safety.
    Critical care medicine 08/2009; 37(9):2527-34. · 6.37 Impact Factor

Publication Stats

172 Citations
49.90 Total Impact Points

Institutions

  • 2012
    • Swedish Medical Center Seattle
      Seattle, Washington, United States
  • 2011
    • University of Wisconsin, Madison
      • Department of Anesthesiology
      Madison, MS, United States
    • University of Colorado
      • Department of Medicine
      Denver, CO, United States
  • 2009–2011
    • University of Washington Seattle
      • Department of Anesthesiology and Pain Medicine
      Seattle, Washington, United States