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The association of red cell distribution width at hospital discharge and out-of-hospital mortality following critical illness*.
Crit Care Med. 2014 Apr; 42(4):918-29.CC

Abstract

OBJECTIVES

Red cell distribution width is associated with mortality and bloodstream infection risk in the critically ill. In hospitalized patients with critical illness, it is not known if red cell distribution width can predict subsequent risk of all-cause mortality following hospital discharge. We hypothesized that an increase in red cell distribution width at hospital discharge in patients who survived to discharge following critical care would be associated with increased postdischarge mortality.

DESIGN

Two-center observational cohort study

SETTING

: All medical and surgical ICUs at the Brigham and Women's Hospital and Massachusetts General Hospital.

PATIENTS

We studied 43,212 patients, who were 18 years old or older and received critical care between 1997 and 2007 and survived hospitalization.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The exposure of interest was red cell distribution width within 24 hours of hospital discharge and categorized a priori in quintiles as less than or equal to 13.3%, 13.3-14.0%, 14.0-14.7%, 14.7-15.8%, and more than 15.8%. The primary outcome was all-cause mortality in the 30 days following hospital discharge. Secondary outcomes included 90-day and 365-day mortality following hospital discharge. Mortality was determined using the U.S. Social Security Administration Death Master File, and 365-day follow-up was present in all cohort patients. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both red cell distribution width and mortality. Adjustment included age, race, gender, Deyo-Charlson Index, patient type (medical vs surgical), sepsis, and number of organs with acute failure. In patients who received critical care and survived hospitalization, the discharge red cell distribution width was a robust predictor of all-cause mortality and remained so following multivariable adjustment. Patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 2.86 (95% CI, 2.25-3.62), 4.57 (95% CI, 3.66-5.72), and 8.80 (95% CI, 7.15-10.83), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Following multivariable adjustment, patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 1.63 (95% CI, 1.27-2.07), 2.36 (95% CI, 1.87-2.97), and 4.18 (95% CI, 3.36-5.20), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Similar significant robust associations post multivariable adjustments are seen with death by days 90 and 365 postdischarge. Estimating the receiver-operating characteristic area under the curve shows that discharge red cell distribution width has moderate discriminative power for mortality 30 days following hospital discharge (area under the curve = 0.70; SE 0.006; 95% CI, 0.69-0.71; p < 0.0001).

CONCLUSION

In patients treated with critical care who survive hospitalization, an elevated red cell distribution width at the time of discharge is a robust predictor of subsequent all-cause patient mortality. Increased discharge red cell distribution width likely reflects the presence of proinflammatory state, oxidative stress, arterial underfilling, or a combination, thereof which may explain the observed impact on patient survival following discharge. Elevated red cell distribution width at hospital discharge may identify ICU survivors who are at risk for adverse outcomes following hospital discharge.

Authors+Show Affiliations

1Department of Medicine, Brigham and Women's Hospital, Boston, MA. 2The Nathan E. Hellman Memorial Laboratory, Renal Division, Brigham and Women's Hospital, Boston, MA. 3Department of Nursing, Brigham and Women's Hospital, Boston, MA. 4Pulmonary Division, Massachusetts General Hospital, Boston, MA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

24448196

Citation

Purtle, Steven W., et al. "The Association of Red Cell Distribution Width at Hospital Discharge and Out-of-hospital Mortality Following Critical Illness*." Critical Care Medicine, vol. 42, no. 4, 2014, pp. 918-29.
Purtle SW, Moromizato T, McKane CK, et al. The association of red cell distribution width at hospital discharge and out-of-hospital mortality following critical illness*. Crit Care Med. 2014;42(4):918-29.
Purtle, S. W., Moromizato, T., McKane, C. K., Gibbons, F. K., & Christopher, K. B. (2014). The association of red cell distribution width at hospital discharge and out-of-hospital mortality following critical illness*. Critical Care Medicine, 42(4), 918-29. https://doi.org/10.1097/CCM.0000000000000118
Purtle SW, et al. The Association of Red Cell Distribution Width at Hospital Discharge and Out-of-hospital Mortality Following Critical Illness*. Crit Care Med. 2014;42(4):918-29. PubMed PMID: 24448196.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The association of red cell distribution width at hospital discharge and out-of-hospital mortality following critical illness*. AU - Purtle,Steven W, AU - Moromizato,Takuhiro, AU - McKane,Caitlin K, AU - Gibbons,Fiona K, AU - Christopher,Kenneth B, PY - 2014/1/23/entrez PY - 2014/1/23/pubmed PY - 2014/5/13/medline SP - 918 EP - 29 JF - Critical care medicine JO - Crit Care Med VL - 42 IS - 4 N2 - OBJECTIVES: Red cell distribution width is associated with mortality and bloodstream infection risk in the critically ill. In hospitalized patients with critical illness, it is not known if red cell distribution width can predict subsequent risk of all-cause mortality following hospital discharge. We hypothesized that an increase in red cell distribution width at hospital discharge in patients who survived to discharge following critical care would be associated with increased postdischarge mortality. DESIGN: Two-center observational cohort study SETTING: : All medical and surgical ICUs at the Brigham and Women's Hospital and Massachusetts General Hospital. PATIENTS: We studied 43,212 patients, who were 18 years old or older and received critical care between 1997 and 2007 and survived hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The exposure of interest was red cell distribution width within 24 hours of hospital discharge and categorized a priori in quintiles as less than or equal to 13.3%, 13.3-14.0%, 14.0-14.7%, 14.7-15.8%, and more than 15.8%. The primary outcome was all-cause mortality in the 30 days following hospital discharge. Secondary outcomes included 90-day and 365-day mortality following hospital discharge. Mortality was determined using the U.S. Social Security Administration Death Master File, and 365-day follow-up was present in all cohort patients. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both red cell distribution width and mortality. Adjustment included age, race, gender, Deyo-Charlson Index, patient type (medical vs surgical), sepsis, and number of organs with acute failure. In patients who received critical care and survived hospitalization, the discharge red cell distribution width was a robust predictor of all-cause mortality and remained so following multivariable adjustment. Patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 2.86 (95% CI, 2.25-3.62), 4.57 (95% CI, 3.66-5.72), and 8.80 (95% CI, 7.15-10.83), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Following multivariable adjustment, patients with a discharge red cell distribution width of 14.0-14.7%, 14.7-15.8%, and more than 15.8% have an odds ratio for mortality in the 30 days following hospital discharge of 1.63 (95% CI, 1.27-2.07), 2.36 (95% CI, 1.87-2.97), and 4.18 (95% CI, 3.36-5.20), respectively, all relative to patients with a discharge red cell distribution width less than or equal to 13.3%. Similar significant robust associations post multivariable adjustments are seen with death by days 90 and 365 postdischarge. Estimating the receiver-operating characteristic area under the curve shows that discharge red cell distribution width has moderate discriminative power for mortality 30 days following hospital discharge (area under the curve = 0.70; SE 0.006; 95% CI, 0.69-0.71; p < 0.0001). CONCLUSION: In patients treated with critical care who survive hospitalization, an elevated red cell distribution width at the time of discharge is a robust predictor of subsequent all-cause patient mortality. Increased discharge red cell distribution width likely reflects the presence of proinflammatory state, oxidative stress, arterial underfilling, or a combination, thereof which may explain the observed impact on patient survival following discharge. Elevated red cell distribution width at hospital discharge may identify ICU survivors who are at risk for adverse outcomes following hospital discharge. SN - 1530-0293 UR - https://www.unboundmedicine.com/medline/citation/24448196/The_association_of_red_cell_distribution_width_at_hospital_discharge_and_out_of_hospital_mortality_following_critical_illness__ L2 - https://dx.doi.org/10.1097/CCM.0000000000000118 DB - PRIME DP - Unbound Medicine ER -