Gilles Hejblum

Bordeaux School of Public Health, Burdeos, Aquitaine, France

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Publications (47)180.55 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Adverse drug events (ADEs) are defined as any injury from a medical intervention related to a drug including non-compliance. ADEs can even be responsible for intensive care unit (ICU) admissions.
    European Journal of Hospital Pharmacy 03/2015; 22(Suppl_1):A188-A188. DOI:10.1136/ejhpharm-2015-000639.461 · 0.47 Impact Factor
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    ABSTRACT: To describe epidemiology and outcome of critically ill homeless patients, as compared with those of nonhomeless patients. Homeless and nonhomeless admissions were matched on the basis of a 1:4 ratio, using a propensity score-based procedure involving age, sex, date, and main diagnosis at ICU admission. A 18-bed closed medical ICU of a French tertiary care university hospital. All consecutive admissions from July 2000 to December 2012. None. There were 421 homeless and 9,353 nonhomeless admissions. Considering homeless admissions, 50% patients had no health insurance, 56% had no financial resource, 91% were socially isolated, and 69% lived in street. In a multivariable analysis of homeless admissions including age, sex, and Simplified Acute Physiology Score II, living in street was significantly associated with hospital mortality (odds ratio = 2.94; 95% CI, 1.30-7.10; p = 0.012). As compared with nonhomeless, homeless admissions more frequently concerned men (89% vs 57%; p < 0.0001) and younger patients (49 yr [43-57] vs 62 yr [46-76]; p < 0.0001), whereas Simplified Acute Physiology Score II (37 [24-50] vs 37 [25-52]; p = 0.99) and distribution of the number of organ supports (p = 0.49) were similar. ICU mortality concerned 19.1% and 18% of matched homeless and nonhomeless admissions, respectively. The corresponding figures for hospital mortality were 20.8% and 20.6%. In multivariable analysis, homeless status was associated with neither ICU (odds ratio = 1.27 [0.92-1.73]; p = 0.14) nor hospital mortality (odds ratio = 1.07 [0.77-1.49]; p = 0.68), while it was independently associated with longer ICU (means ratio = 1.16 [1.01-1.34]; p = 0.035) and hospital (means ratio = 1.30 [1.12-1.49]; p = 0.0002) stay of survivors. Critically ill homeless patients benefit from the same level of care and have globally the same prognosis than housed patients but experience longer lengths of stay. Most precarious patients living in street have a higher mortality rate. The study perspective is not ICU centered but also concerns the global organization of healthcare since homeless patients are referred by numerous sources and discharged to different wards.
    Critical care medicine 03/2015; 43(6). DOI:10.1097/CCM.0000000000000944 · 6.15 Impact Factor
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    ABSTRACT: Adverse drug events (ADE) may lead to hospital admission, and in some cases admission to an ICU is mandatory. We conducted a systematic review dealing with the incidence of ADE requiring ICU admission in adult patients, the reference population being all ICU admissions. Medline, Embase and Web of Science databases were screened from January 1982 to July 2014, using appropriate key words. Only original articles in English reporting the incidence of ADE requiring ICU admission in adult patients among total ICU admissions were included. Article eligibility was assessed by two independent reviewers, a third being involved in cases of disagreement. All reported characteristics (type of ICU, characteristics of patients, incidence of ADE, severity and preventability, drugs involved, causality) in the selected articles were collected for the review. The quality of studies was independently assessed by two reviewers with a specific score that we developed. A meta-analysis was conducted. Inclusion criteria were fulfilled by 11 studies out of the 4,311 identified in the initial literature search. The median (interquartile) quality score was 0.61 (0.44; 0.69). The reported incidences of ADE requiring ICU admission in adult patients ranged from 0.37 to 27.4%, with an associated mortality rate ranging from 2 to 28.1% and a mean length of stay ranging from 2.3 to 6.4 days. Preventable events accounted for 17.5 to 85.7% of the events. Costs and mechanisms at the root of ADE were investigated in only two and five studies, respectively. The forest plot examining the incidence of ADE requiring ICU admission in adult patients was associated with high heterogeneity (I2 statistic >98%), and the shape of the corresponding funnel plot was asymmetric. Heterogeneity across studies concerned many features, including studied populations, events considered, causality assessment methods, definitions of preventability and severity. Despite the heterogeneity of the reports, our review indicates that ICU admission due to ADE is a significant issue that should deserve further interest. The review led us to propose a list of items devoted to the reporting of future studies on ADE requiring ICU admissions. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0643-5) contains supplementary material, which is available to authorized users.
    Critical care (London, England) 11/2014; 18(6):643. DOI:10.1186/s13054-014-0643-5
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    ABSTRACT: Objective Because it has no unique clinical, biologic, or histologic features, reactive hemophagocytic syndrome may be difficult to distinguish from other diseases such as severe sepsis or hematologic malignancies. This study was undertaken to develop and validate a diagnostic score for reactive hemophagocytic syndrome.MethodsA multicenter retrospective cohort of 312 patients who were judged by experts to have reactive hemophagocytic syndrome (n = 162), were judged by experts to not have reactive hemophagocytic syndrome (n = 104), or in whom the diagnosis of reactive hemophagocytic syndrome was undetermined (n = 46) was used to construct and validate the reactive hemophagocytic syndrome diagnostic score, called the HScore. Ten explanatory variables were evaluated for their association with the diagnosis of hemophagocytic syndrome, and logistic regression was used to calculate the weight of each criterion included in the score. Performance of the score was assessed using developmental and validation data sets.ResultsNine variables (3 clinical [i.e., known underlying immunosuppression, high temperature, organomegaly], 5 biologic [i.e., triglyceride, ferritin, serum glutamic oxaloacetic transaminase, and fibrinogen levels, cytopenia], and 1 cytologic [i.e., hemophagocytosis features on bone marrow aspirate]) were retained in the HScore. The possible number of points assigned to each variable ranged from 0-18 for known underlying immunosuppression to 0-64 for triglyceride level. The median HScore was 230 (interquartile range [IQR] 203-257) for patients with a positive diagnosis of reactive hemophagocytic syndrome and 125 (IQR 91-150) for patients with a negative diagnosis. The probability of having hemophagocytic syndrome ranged from <1% with an HScore of ≤90 to >99% with an HScore of ≥250.Conclusion The HScore can be used to estimate an individual's risk of having reactive hemophagocytic syndrome. This scoring system is freely available online (http://saintantoine.aphp.fr/score/).
    09/2014; 66(9). DOI:10.1002/art.38690
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    ABSTRACT: The diagnosis of the reactive form of hemophagocytic syndrome in adults remains particularly difficult since none of the clinical or laboratory manifestations are specific. We undertook a study in order to elicit which features constitute helpful criteria for a positive diagnosis. In this Delphi study, the features investigated in the questionnaire and the experts invited to participate in the survey were issued from a bibliographic search. The questionnaire was iteratively proposed to experts via a web-based application with a feedback of the results observed at the preceding Delphi round. Experts were asked to label each investigated criterion in one of the following categories: absolutely required, important, of minor interest, or not assessable in the routine practice environment. A positive consensus was a priori defined as at least 75% answers observed in the categories absolutely required and important. The questionnaire investigated 26 criteria and 24 experts originating from 13 countries participated in the second and final Delphi round. A positive consensus was reached for the nine following criteria: unilineage cytopenia, bicytopenia, pancytopenia, presence of hemophagocytosis pictures on a bone marrow aspirate or on a tissue biopsy, high ferritin level, fever, organomegaly, presence of a predisposing underlying disease, and high level of lactate dehydrogenase. A negative consensus was reached for 13 criteria, and an absence of consensus was observed for 4 criteria. The study constitutes the first initiative to date for defining international guidelines devoted to the positive diagnosis of the reactive form of hemophagocytic syndrome.
    PLoS ONE 04/2014; 9(4):e94024. DOI:10.1371/journal.pone.0094024 · 3.53 Impact Factor
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    ABSTRACT: Assessing the accuracy of influenza epidemic periods determined by statistical models is important to improve the performance of algorithms used in real-time syndromic surveillance systems. This is a difficult problem to address in the absence of a reliable gold standard. The objective of this study is to establish an expert-based determination of the start and the end of influenza epidemics in France. A three-round international web-based Delphi survey was proposed to 288 eligible influenza experts. Fifty-seven (20%) experts completed the three-rounds of the study. The experts were invited to indicate the starting and the ending week of influenza epidemics, on 32 time-series graphs of influenza seasons drawn using data from the French Sentinelles Network (Influenza-like illness incidence rates) and virological data from the WHO-FluNet. Twenty-six of 32 time-series graphs proposed corresponded to each of the French influenza seasons observed between 1985 and 2011. Six influenza seasons were proposed twice at each round to measure variation among expert responses. We obtained consensual results for 88% (23/26) of the epidemic periods. In two or three rounds (depending on the season) answers gathered around modes, and the internal control demonstrated a good reproducibility of the answers. Virological data did not appear to have a significant impact on the answers or the level of consensus, except for a season with a major mismatch between virological and incidence data timings. Thanks to this international web-based Delphi survey, we obtained reproducible, stable and consensual results for the majority of the French influenza epidemic curves analysed. The detailed curves together with the estimates from the Delphi study could be a helpful tool for assessing the performance of statistical outbreak detection methods, in order to optimize them.
    BMC Medical Informatics and Decision Making 12/2013; 13(1):138. DOI:10.1186/1472-6947-13-138 · 1.50 Impact Factor
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    ABSTRACT: Background: Should an emerging infectious disease outbreak or an environmental disaster occur, the collection of epidemiological data must start as soon as possible after the event's onset. Questionnaires are usually built de novo for each event, resulting in substantially delayed epidemiological responses that are detrimental to the understanding and control of the event considered. Moreover, the public health and/or academic institution databases constructed with responses to different questionnaires are usually difficult to merge, impairing necessary collaborations. We aimed to show that e-commerce concepts and software tools can be readily adapted to enable rapid collection of data after an infectious disease outbreak or environmental disaster. Here, the 'customers' are the epidemiologists, who fill their shopping 'baskets' with standardised questions. Methods: For each epidemiological field, a catalogue of questions is constituted by identifying the relevant variables based on a review of the published literature on similar circumstances. Each question is tagged with information on its source papers. Epidemiologists can then tailor their own questionnaires by choosing appropriate questions from this catalogue. The software immediately provides them with ready-to-use forms and online questionnaires. All databases constituted by the different EpiBasket users are interoperable, because the corresponding questionnaires are derived from the same corpus of questions. Results: A proof-of-concept prototype was developed for Knowledge, Attitudes and Practice (KAP) surveys, which is one of the fields of the epidemiological investigation frequently explored during, or after, an outbreak or environmental disaster. The catalogue of questions was initiated from a review of the KAP studies conducted during or after the 2003 severe acute respiratory syndrome epidemic. Conclusion: Rapid collection of standardised data after an outbreak or environmental disaster can be facilitated by transposing the e-commerce paradigm to epidemiology, taking advantage of the powerful software tools already available.
    Emerging Health Threats Journal 10/2013; 6:19748. DOI:10.3402/ehtj.v6i0.19748
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    B Guidet, G Hejblum, G Joynt
    European Journal of Intensive Care Medicine 08/2013; 39(11). DOI:10.1007/s00134-013-3063-0 · 5.54 Impact Factor
  • Revue des Maladies Respiratoires 01/2012; 29:A19. DOI:10.1016/j.rmr.2011.10.013 · 0.49 Impact Factor
  • K. Atsou, G. Hejblum, C. Chouaid
    Value in Health 11/2011; 14(7). DOI:10.1016/j.jval.2011.08.1433 · 2.89 Impact Factor
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    Kokuvi Atsou, Christos Chouaid, Gilles Hejblum
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    ABSTRACT: The medico-economic impact of smoking cessation considering a smoking patient with chronic obstructive pulmonary disease (COPD) is poorly documented. Here, considering a COPD smoking patient, the specific burden of continuous smoking was estimated, as well as the effectiveness and the cost-effectiveness of smoking cessation. A multi-state Markov model adopting society's perspective was developed. Simulated cohorts of English COPD patients who are active smokers (all severity stages combined or patients with the same initial severity stage) were compared to identical cohorts of patients who quit smoking at cohort initialization. Life expectancy, quality adjusted life-years (QALY), disease-related costs, and incremental cost-effectiveness ratio (ICER: £/QALY) were estimated, considering smoking cessation programs with various possible scenarios of success rates and costs. Sensitivity analyses included the variation of model key parameters. At the horizon of a smoking COPD patient's remaining lifetime, smoking cessation at cohort intitialization, relapses being allowed as observed in practice, would result in gains (mean) of 1.27 life-years and 0.68 QALY, and induce savings of -1824 £/patient in the disease-related costs. The corresponding ICER was -2686 £/QALY. Smoking cessation resulted in 0.72, 0.69, 0.64 and 0.42 QALY respectively gained per mild, moderate, severe, and very severe COPD patient, but was nevertheless cost-effective for mild to severe COPD patients in most scenarios, even when hypothesizing expensive smoking cessation intervention programmes associated with low success rates. Considering a ten-year time horizon, the burden of continuous smoking in English COPD patients was estimated to cost a total of 1657 M£ while 452516 QALY would be simultaneously lost. The study results are a useful support for the setting of smoking cessation programmes specifically targeted to COPD patients.
    PLoS ONE 09/2011; 6(9):e24870. DOI:10.1371/journal.pone.0024870 · 3.53 Impact Factor
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    ABSTRACT: Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU.
    03/2011; 1(1):4. DOI:10.1186/2110-5820-1-4
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    ABSTRACT: Mathematical modeling in epidemiology (MME) is being used increasingly. However, there are many uncertainties in terms of definitions, uses and quality features of MME. To delineate the current status of these models, a 10-item questionnaire on MME was devised. Proposed via an anonymous internet-based survey, the questionnaire was completed by 189 scientists who had published in the domain of MME. A small minority (18%) of respondents claimed to have in mind a concise definition of MME. Some techniques were identified by the researchers as characterizing MME (e.g. Markov models), while others-at the same level of sophistication in terms of mathematics-were not (e.g. Cox regression). The researchers' opinions were also contrasted about the potential applications of MME, perceived as highly relevant for providing insight into complex mechanisms and less relevant for identifying causal factors. The quality criteria were those of good science and were not related to the size and the nature of the public health problems addressed. This study shows that perceptions on the nature, uses and quality criteria of MME are contrasted, even among the very community of published authors in this domain. Nevertheless, MME is an emerging discipline in epidemiology and this study underlines that it is associated with specific areas of application and methods. The development of this discipline is likely to deserve a framework providing recommendations and guidance at various steps of the studies, from design to report.
    PLoS ONE 01/2011; 6(1):e16531. DOI:10.1371/journal.pone.0016531 · 3.53 Impact Factor
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    Kokuvi Atsou, Christos Chouaid, Gilles Hejblum
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    ABSTRACT: Chronic obstructive pulmonary disease (COPD) is predicted to become a major cause of death worldwide. Studies on the variability in the estimates of key epidemiological parameters of COPD may contribute to better assessment of the burden of this disease and to helpful guidance for future research and public policies. In the present study, we examined differences in the main epidemiological characteristics of COPD derived from studies across countries of the European Union, focusing on prevalence, severity, frequency of exacerbations and mortality, as well as on differences between the studies' methods. This systematic review was based on a search for the relevant literature in the Science Citation Index database via the Web of Science and on COPD mortality rates issued from national statistics. Analysis was finally based on 65 articles and Eurostat COPD mortality data for 21 European countries. Epidemiological characteristics of COPD varied widely from country to country. For example, prevalence estimates ranged between 2.1% and 26.1%, depending on the country, the age group and the methods used. Likewise, COPD mortality rates ranged from 7.2 to 36.1 per 10(5) inhabitants. The methods used to estimate these epidemiological parameters were highly variable in terms of the definition of COPD, severity scales, methods of investigation and target populations. Nevertheless, to a large extent, several recent international guidelines or research initiatives, such as GOLD, BOLD or PLATINO, have boosted a substantial standardization of methodology in data collection and have resulted in the availability of more comparable epidemiological estimates across countries. On the basis of such standardization, severity estimates as well as prevalence estimates present much less variation across countries. The contribution of these recent guidelines and initiatives is outlined, as are the problems remaining in arriving at more accurate COPD epidemiological estimates across European countries. The accuracy of COPD epidemiological parameters is important for guiding decision making with regard to preventive measures, interventions and patient management in various health care systems. Therefore, the recent initiatives for standardizing data collection should be enhanced to result in COPD epidemiological estimates of improved quality. Moreover, establishing international guidelines for reporting research on COPD may also constitute a major contribution.
    BMC Medicine 01/2011; 9:7. DOI:10.1186/1741-7015-9-7 · 7.28 Impact Factor
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    Gilles Hejblum, Bertrand Guidet
    Radiology 09/2010; 256(3):1013-4. DOI:10.1148/radiol.100997 · 6.21 Impact Factor
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    ABSTRACT: Few data are available on prescriber adherence to tuberculosis (TB) treatment guidelines. In particular, excessively long treatment carries a risk of avoidable adverse effects and represents a waste of healthcare resources. We examined factors potentially associated with excessively long treatment. We reviewed the medical records of patients diagnosed with TB in 2004 in the eastern Paris region. Sociodemographic and clinical factors associated with excessively long treatment were identified by logistic regression analyses. Based on contemporary guidelines, excessively long treatment was defined as more than 6 months of a four-drug regimen for thoracic TB with full sensitive strains, and more than 12 months for patients with extrathoracic TB. Analyses concerned 478 patients with a median age of 36.0 +/- 13.5 years, of whom 48% were living in precarious conditions (i.e. poor living conditions and/or no health insurance), 80% were born abroad, and 17% were HIV-seropositive. TB was restricted to the chest in 279 patients (isolated pulmonary, pleuropulmonary, and isolated pleural TB in 245, 13, and 21 patients, respectively), exclusively extrathoracic in 115 patients, and mixed in the remaining 84 patients. Treatment was prescribed by a chest specialist in 211 cases (44.1%) and 295 patients (61.7%) were managed in a single institution. The treatment duration complied with contemporary guidelines in 316 cases (66.1%) and was excessively long in 162 cases (33.9%). The median duration of excessively long treatment was 313 days (IQR: 272-412). In multivariate analysis, isolated thoracic TB, previous TB, HIV infection, a prescriber other than a chest specialist, and management in more than one healthcare center during treatment were independently associated with excessively lengthy treatment. One-third of TB patients received excessively long treatment, reflecting inadequate awareness of management guidelines or unwillingness to implement them.
    BMC Public Health 08/2010; 10:495. DOI:10.1186/1471-2458-10-495 · 2.32 Impact Factor
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    ABSTRACT: Outbreaks of emerging infectious diseases, especially those of a global nature, require rapid epidemiological analysis and information dissemination. The final products of those activities usually comprise internal memoranda and briefs within public health authorities and original research published in peer-reviewed journals. Using the 2003 severe acute respiratory syndrome (SARS) epidemic as an example, we conducted a comprehensive time-stratified review of the published literature to describe the different types of epidemiological outputs. We identified and analyzed all published articles on the epidemiology of the SARS outbreak in Hong Kong or Toronto. The analysis was stratified by study design, research domain, data collection, and analytical technique. We compared the SARS-case and matched-control non-SARS articles published according to the timeline of submission, acceptance, and publication. The impact factors of the publishing journals were examined according to the time of publication of SARS articles, and the numbers of citations received by SARS-case and matched-control articles submitted during and after the epidemic were compared. Descriptive, analytical, theoretical, and experimental epidemiology concerned, respectively, 54%, 30%, 11%, and 6% of the studies. Only 22% of the studies were submitted, 8% accepted, and 7% published during the epidemic. The submission-to-acceptance and acceptance-to-publication intervals of the SARS articles submitted during the epidemic period were significantly shorter than the corresponding intervals of matched-control non-SARS articles published in the same journal issues (p<0.001 and p<0.01, respectively). The differences of median submission-to-acceptance intervals and median acceptance-to-publication intervals between SARS articles and their corresponding control articles were 106.5 d (95% confidence interval [CI] 55.0-140.1) and 63.5 d (95% CI 18.0-94.1), respectively. The median numbers of citations of the SARS articles submitted during the epidemic and over the 2 y thereafter were 17 (interquartile range [IQR] 8.0-52.0) and 8 (IQR 3.2-21.8), respectively, significantly higher than the median numbers of control article citations (15, IQR 8.5-16.5, p<0.05, and 7, IQR 3.0-12.0, p<0.01, respectively). A majority of the epidemiological articles on SARS were submitted after the epidemic had ended, although the corresponding studies had relevance to public health authorities during the epidemic. To minimize the lag between research and the exigency of public health practice in the future, researchers should consider adopting common, predefined protocols and ready-to-use instruments to improve timeliness, and thus, relevance, in addition to standardizing comparability across studies. To facilitate information dissemination, journal managers should reengineer their fast-track channels, which should be adapted to the purpose of an emerging outbreak, taking into account the requirement of high standards of quality for scientific journals and competition with other online resources.
    PLoS Medicine 05/2010; 7(5):e1000272. DOI:10.1371/journal.pmed.1000272 · 14.00 Impact Factor
  • BMJ quality & safety 04/2010; 19(Suppl 1):A6-A7. DOI:10.1136/qshc.2010.041608.5 · 3.28 Impact Factor
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    ABSTRACT: Les radiographies de thorax (RT) constituent l’examen d’imagerie le plus fréquemment prescrit chez les patients de réanimation. Les variations de leurs indications et modalités de prescription (systématique ou à la demande), d’un service à un autre, reflètent l’hétérogénéité des pratiques, non conforme aux recommandations actuelles. Celles-ci plaident en effet pour des RT quotidiennes, notamment pour les patients ventilés et/ou souffrant de pathologies cardiopulmonaires aiguës, tandis que les études de recherche de consensus montrent que les RT sont en réalité plus prescrites selon le contexte clinicobiologique des patients que selon des recommandations générales. L’étude « Radio en réanimation: RARE », récemment publiée, a montré qu’une stratégie de prescription à la demande plutôt que systématique permettait une diminution moyenne d’un tiers du nombre de RT effectuées chez les patients ventilés, sans altération du pronostic. En outre, des indications plus ciblées, associées à l’emploi d’alternatives diagnostiques efficaces, notamment échographiques, devraient permettre de réduire le nombre de RT pratiquées en réanimation, l’irradiation des patients, les délais diagnostiques et les coûts. L’ensemble des données actuellement disponibles doit suggérer aux sociétés savantes d’actualiser leurs recommandations concernant les modalités de prescription des RT en réanimation. Chest-X-rays (CXR) are the most frequent imagebased explorations performed in intensive care units (ICUs). Indications and prescription modalities (whether routine or on demand prescription strategies) may substantially differ from an ICU to another. The observed heterogeneity reflects a substantial distance between clinical practice and official recommendations. Current guidelines recommend CXRs on a daily basis especially for patients receiving mechanical ventilation and/or suffering from acute cardio-pulmonary failure, whereas practice-based studies report that CXR prescriptions are mainly based on the clinical context. The recently published RARE study shows, with a reliable methodology, that prescribing CXR on demand rather than as a daily routine allows to reduce CXR prescription by 32% in patients receiving mechanical ventilation, with a better diagnostic and therapeutic efficiency and without any impairment of prognosis. Therefore, precise targeted prescription together with the use of reliable diagnostic alternatives (such as ultrasound) should result in a decrease in the number of CXRs performed in the ICU, in patients’ global irradiation, in diagnostic delays, and in costs. Considering current available data, guidelines for CXR prescriptions in the ICU should be updated. Mots clésRéanimation–Radiographie de thorax–Stratégie de prescription–Radiographie KeywordsIntensive care unit (ICU)–Chest-X-ray–Strategy of prescription–Routine–On demand
    Réanimation 01/2010; 20(1):31-40. DOI:10.1007/s13546-010-0001-9
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    ABSTRACT: Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, some units use an on-demand strategy, in which chest radiographs are done only if warranted by the patient's clinical status. By comparison between routine and on-demand strategies, we aimed to establish which strategy was more efficient and effective for optimum patient care. In a cluster-randomised, open-label crossover study, we randomly assigned 21 intensive care units at 18 hospitals in France to use a routine or an on-demand strategy for prescription of chest radiographs during the first of two treatment periods. Units used the alternative strategy in the second period. Each treatment period lasted for the time taken for enrolment and study of 20 consecutive patients per intensive care unit; patients were monitored until discharge from the unit or for up to 30 days' mechanical ventilation, whichever was first. Units enrolled 967 patients, but 118 were excluded because they had been receiving mechanical ventilation for less than 2 days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00893672. 11 intensive care units were randomly allocated to use a routine strategy to order chest radiographs in the first treatment period, and 10 units to use an on-demand strategy. Overall, 424 patients had 4607 routine chest radiographs (mean per patient-day of mechanical ventilation 1.09, 95% CI 1.05-1.14), and 425 had 3148 on-demand chest radiographs (mean 0.75, 0.67-0.83), which corresponded to a reduction of 32% (95% CI 25-38) with the on-demand strategy (p<0.0001). Our results strongly support adoption of an on-demand strategy in preference to a routine strategy to decrease use of chest radiographs in mechanically ventilated patients without a reduction in patients' quality of care or safety. Assistance Publique-Hôpitaux de Paris (Direction Régionale de la Recherche Clinique Ile de France).
    The Lancet 11/2009; 374(9702):1687-93. DOI:10.1016/S0140-6736(09)61459-8 · 45.22 Impact Factor

Publication Stats

711 Citations
180.55 Total Impact Points

Institutions

  • 2014
    • Bordeaux School of Public Health
      Burdeos, Aquitaine, France
  • 2009–2014
    • Polytech Paris-UPMC
      Lutetia Parisorum, Île-de-France, France
    • Hôpital Saint-Antoine (Hôpitaux Universitaires Est Parisien)
      • Service des Maladies Infectieuses et Tropicales
      Paris, Ile-de-France, France
  • 2008–2013
    • Pierre and Marie Curie University - Paris 6
      • Faculté de médecine Pierre et Marie Curie
      Lutetia Parisorum, Île-de-France, France
  • 2007–2013
    • Unité Inserm U1077
      Caen, Lower Normandy, France
  • 1993–2011
    • French Institute of Health and Medical Research
      Lutetia Parisorum, Île-de-France, France
  • 2001
    • Hôpital La Pitié Salpêtrière (Groupe Hospitalier "La Pitié Salpêtrière - Charles Foix")
      Lutetia Parisorum, Île-de-France, France
  • 1999
    • Hôpital Ambroise Paré – Hôpitaux universitaires Paris Ile-de-France Ouest
      Billancourt, Île-de-France, France