Kinzelman-Vesely, Elissa A.

Abstract Background Geographic cohorting (GCh) is a popular model of care that localizes physician teams to a single hospital unit. Objectives We conducted a scoping review identifying the aims, implementation strategies, study methods, and measured outcomes of GCh. Methods We searched the medical literature analysis and retrieval system online, Embase, and Scopus databases. Eligible citations included English language reports of interventions including GCh in adult patients. Included studies were screened for their aim, GCh implementation strategy, study method, and outcomes measured. Results Of 1863 identified citations, 30 met inclusion criteria, representing 27 interventions. Implementation aims varied from specific goals measured by a single metric to multiple outcomes intended to capture wide‐ranging effects of GCh. A majority of studies ( n = 13, 48.1%) used a pre‐post cohort design. GCh was implemented in one of four ways: (1) as a stand‐alone intervention, (2) bundled with accountable care unit elements, (3) bundled with care components that did not include all ACU elements, (4) GCh bundled with ACU elements and additional components (“enhanced” ACU). The measured outcomes sorted to eight different categories: patient outcomes, patient safety, patient experience, work flow, workload, clinician experience, communication/team work, and cost. Conclusions The current literature on GCh describes implementation as both a stand‐alone intervention and bundled with other care elements. Current research has not delineated whether the degree to which GCh is implemented matters, nor what impact it has as part of a bundled care intervention. Future work would benefit from a prospective design that clarifies these questions, facilitating care models tailored to the needs of the practice ecosystem.

Objective Specific sedative hypnotic agents, administered to facilitate endotracheal intubation (ETI) in critically ill adults, may lead to adverse outcomes such as peri-intubation cardiovascular collapse. However, little is known from systematic investigations of the impact these individual agents have on cardiovascular function or other clinical outcomes. Data sources MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, Scopus and Web of science databases. Study selection We conducted a systematic search for randomized and non-randomized studies that evaluated adult (≥18 years) critically ill patients who were sedated to facilitate ETI with ketamine, propofol, ketamine/propofol, etomidate, or a benzodiazepine and who had data on peri-intubation hemodynamics and at least one other outcome involving acute kidney injury, delirium, opioid use, intubation difficulty, sequential organ failure assessment, length of stay, or mortality. Eighty-five studies were identified for eligibility assessment with 23 included in the analysis. Data extraction Two reviewers independently screened articles, extracted data from selected articles, and assessed risk of bias using ROBINS-I for observational studies and revised Cochrane Risk of Bias tool for randomized controlled trials. Data synthesis Acute cardiovascular dysfunction (peri-intubation hemodynamic instability and/or cardiac arrest) was similar between etomidate and ketamine with more events seen when propofol versus non-propofol sedation was administered. However, exploratory meta-analysis demonstrated no difference between etomidate and ketamine (OR 1.05 [95%CI 0.60-1.84]) or between etomidate and propofol (OR 0.91 [95%CI 0.33-2.46]). Compared to ketamine, etomidate demonstrated lower survival to hospital discharge in the included studies in exploratory meta-analysis OR 0.76 (95%CI 0.62-0.92). Limited data existed for other outcomes with no discernible differences between sedative agents. Conclusions Acute cardiovascular dysfunction was more common when propofol, as compared to non-propofol sedation, was administered, although not statistically significant in exploratory meta-analysis. In addition, etomidate conferred lower survival to hospital discharge versus non-etomidate sedation, which was confirmed in exploratory meta-analysis of etomidate versus ketamine.

The impact of bariatric surgery (BS) on kidney transplantation (KT) outcomes in patients with obesity remains controversial. We systematically searched MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials for studies reporting outcomes of KT recipients that underwent prior BS. Common/random effects meta-analyses were performed to obtain summary ratios of the postoperative outcomes. Eighteen eligible studies involving 315 patients were identified. Sleeve gastrectomy was the most common BS type (65.7%) followed by Roux-en-Y gastric bypass (27.6%) and gastric banding (4.4%). Across studies that provided the data, the %excess weight loss from BS to KT was 62.79% (95% confidence interval [CI], 52.01-73.56; range, 46.2%-80.3%). The rates of delayed graft function and acute rejection were 16% (95% CI, 7%-28%) and 16% (95% CI, 11%-23%) in 14 and 11 studies that provided this data, respectively. The rates of wound, urinary, and vascular complications following KT were 5% (95% CI, 0%-13%),19% (95% CI, 2%-42%), and 2% (95% CI, 0%-5%), in 12, 9, and 11 studies that provided this data, respectively. Follow-up time after KT was reported in 11 studies (61.1%) and ranged from 16 mo to >5 y. Graft loss was reported in 14 studies with an average of 3% (95% CI, 1%-6%). Four studies that included a comparator group of patients with obesity who did not undergo BS before KT showed comparable outcomes between the groups. We conclude that currently there is a paucity of robust evidence to suggest that pretransplant BS has a major effect on post-KT outcomes. High-quality studies are needed to fully evaluate the impact of BS on KT outcomes.