Confounding by Indication in Clinical Research

Kyriacou, Demetrios N.; Lewis, Roger J.

doi:10.1001/jama.2016.16435

Cited by 343 publications

(276 citation statements)

References 9 publications

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“…As such, confounding by indication could have influenced the results. 36 In the data registry, data on unsuccessful intubation attempts are not available. Limited published data are available on unsuccessful intubation in the global in-hospital setting.…”

Section: Discussionmentioning

confidence: 99%

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

Andersen

Granfeldt

Callaway

et al. 2017

JAMA

166

129

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IMPORTANCETracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting.OBJECTIVE To determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge. DESIGN, SETTING, AND PARTICIPANTSObservational cohort study of adult patients who had an in-hospital cardiac arrest from January 2000 through December 2014 included in the Get With The Guidelines-Resuscitation registry, a US-based multicenter registry of in-hospital cardiac arrest. Patients who had an invasive airway in place at the time of cardiac arrest were excluded. Patients intubated at any given minute (from 0-15 minutes) were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics. EXPOSURE Tracheal intubation during cardiac arrest. MAIN OUTCOMES AND MEASURESThe primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and a good functional outcome. A cerebral performance category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability) was considered a good functional outcome. RESULTSThe propensity-matched cohort was selected from 108 079 adult patients at 668 hospitals. The median age was 69 years (interquartile range, 58-79 years), 45 073 patients (42%) were female, and 24 256 patients (22.4%) survived to hospital discharge. Of 71 615 patients (66.3%) who were intubated within the first 15 minutes, 43 314 (60.5%) were matched to a patient not intubated in the same minute. Survival was lower among patients who were intubated compared with those not intubated: 7052 of 43 314 (16.3%) vs 8407 of 43 314 (19.4%), respectively (risk ratio [RR] = 0.84; 95% CI, 0.81-0.87; P < .001). The proportion of patients with ROSC was lower among intubated patients than those not intubated: 25 022 of 43 311 (57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97; 95% CI, 0.96-0.99; P < .001). Good functional outcome was also lower among intubated patients than those not intubated: 4439 of 41 868 (10.6%) vs 5672 of 41 733 (13.6%), respectively (RR = 0.78; 95% CI, 0.75-0.81; P < .001). Although differences existed in prespecified subgroup analyses, intubation was not associated with improved outcomes in any subgroup.CONCLUSIONS AND RELEVANCE Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

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Section: Discussionmentioning

confidence: 99%

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

Andersen

Granfeldt

Callaway

et al. 2017

JAMA

166

129

View full text Add to dashboard Cite

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“…31,32 In these analyses, the test scores from all patients during medicated periods were compared with those during non-medicated periods (referred to as 'between-patient comparison'; Online Supplement).…”

Section: Discussionmentioning

confidence: 99%

Association Between Medication Use and Performance on Higher Education Entrance Tests in Individuals With Attention-Deficit/Hyperactivity Disorder

Sjölander

Cederlöf

et al. 2017

JAMA Psychiatry

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Association between medication use and performance on higher education entrance tests in individuals with Abstract IMPORTANCEIndividuals with attention-deficit/hyperactivity disorder (ADHD) are at greater risk for academic problems. Pharmacologic treatment is effective in reducing core symptoms of ADHD, but it is unclear whether it helps to improve academic outcomes. OBJECTIVETo investigate the association of the use of ADHD medication and the performance of higher education entrance test in individuals with ADHD. DESIGN, SETTING, AND PARTICIPANTSThis cohort study followed 61,640 individuals with a diagnosis of ADHD from January 01, 2006 to December 31, 2013. Using Swedish national registers, we extracted records of their pharmacological treatment along with data from the Sweden Scholastic Aptitude Test. Using a within-patient design, we compared test scores when patients were taking medication for ADHD with scores when they were not. EXPOSURESPeriods with and without ADHD medications. MAIN OUTCOMES AND MEASURESScores from the higher education entrance examination. RESULTS Within

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“…Since this relationship was likely to be confounded by indication [10], whereby patient’s severity of illness may have influenced decisions about MV, we adjusted our outcomes for several potential important covariates in a multivariate analysis using a large patient cohort.…”

Section: Introductionmentioning

confidence: 99%

Endotracheal Intubation and In-Hospital Mortality after Intracerebral Hemorrhage

et al. 2018

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Background: Many patients with acute intracerebral hemorrhages (ICHs) undergo endotracheal intubation with subsequent mechanical ventilation (MV) for “airway protection” with the intent to prevent aspiration, pneumonias, and its related mortality. Conversely, these procedures may independently promote pneumonia, laryngeal trauma, dysphagia, and adversely affect patient outcomes. The net benefit of intubation and MV in this patient cohort has not been systematically investigated. Methods: We conducted a large single-center observational cohort study to examine the independent association between endotracheal intubation and MV, hospital-acquired pneumonia (HAP), and in-hospital mortality (HM) in patients with ICH. All consecutive patients admitted with a primary diagnosis of a spontaneous ICH to a tertiary care hospital in Boston, Massachusetts, from June 2000 through January 2014, who were ≥18 years of age and hospitalized for ≥2 days were eligible for inclusion. Patients with pneumonia on admission, or those having brain or lung neoplasms were excluded. Our exposure of interest was endotracheal intubation and MV during hospitalization; our primary outcomes were incidence of HAP and HM, ascertained using International Classification of Diseases-9 and administrative discharge disposition codes, respectively, in patients who underwent endotracheal intubation and MV versus those who did not. Multivariable logistic regression was used to control for confounders. Results: Of the 2,386 hospital admissions screened, 1,384 patients fulfilled study criteria and were included in the final analysis. A total of 507 (36.6%) patients were intubated. Overall 133 (26.23%) patients in the intubated group developed HAP versus 41 (4.67%) patients in the non-intubated group (p < 0.0001); 195 (38.5%) intubated patients died during hospitalization compared to 48 (5.5%) non-intubated patients (p < 0.0001). After confounder adjustments, OR for HAP and HM, were 4.23 (95% CI 2.48–7.22; p < 0.0001) and 4.32 (95% CI 2.5–7.49; p < 0.0001) with c-statistics of 0.79 and 0.89, in the intubated versus non-intubated patients, respectively. Conclusion: In this large hospital-based cohort of patients presenting with an acute spontaneous ICH, endotracheal intubation and MV were associated with increased odds of HAP and HM. These findings urge further examination of the practice of intubation in prospective studies.

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Confounding by Indication in Clinical Research

Cited by 343 publications

References 9 publications

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

Association Between Medication Use and Performance on Higher Education Entrance Tests in Individuals With Attention-Deficit/Hyperactivity Disorder

Endotracheal Intubation and In-Hospital Mortality after Intracerebral Hemorrhage

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