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Intensive care unit (ICU)-acquired bacteraemia and ICU mortality and discharge : addressing time-varying confounding using appropriate methodology

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Abstract
Background: Studies often ignore time-varying confounding or may use inappropriate methodology to adjust for time-varying confounding. Aim: To estimate the effect of intensive care unit (ICU)-acquired bacteraemia on ICU mortality and discharge using appropriate methodology. Methods: Marginal structural models with inverse probability weighting were used to estimate the ICU mortality and discharge associated with ICU-acquired bacteraemia among patients who stayed more than two days at the general ICU of a London teaching hospital and remained bacteraemia-free during those first two days. For comparison, the same associations were evaluated with (i) a conventional Cox model, adjusting only for baseline confounders and (ii) a Cox model adjusting for baseline and time-varying confounders. Findings: Using the marginal structural model with inverse probability weighting, bacteraemia was associated with an increase in ICU mortality (cause-specific hazard ratio (CSHR): 1.29; 95% confidence interval (CI): 1.02-1.63)and a decrease in discharge (CSHR: 0.52; 95% CI: 0.45-0.60). By 60 days, among patients still in the ICU after two days and without prior bacteraemia, 8.0% of ICU deaths could be prevented by preventing all ICU-acquired bacteraemia cases. The conventional Cox model adjusting for time-varying confounders gave substantially different results [for ICU mortality, CSHR: 1.08 (95% CI: 0.88-1.32); for discharge, CSHR: 0.68 (95% CI: 0.60-0.77)]. Conclusion: In this study, even after adjusting for the timing of acquiring bacteraemia and time-varying confounding using inverse probability weighting for marginal structural
Keywords
Burden, Intensive care units, Bacteraemia, Inverse probability weighting, Bias, BLOOD-STREAM INFECTIONS, MARGINAL STRUCTURAL MODELS, ATTRIBUTABLE MORTALITY, NOSOCOMIAL INFECTIONS, MULTISTATE MODELS, RISK-FACTORS, EPIDEMIOLOGY, POPULATION

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Chicago
Pouwels, KB, Stijn Vansteelandt, R Batra, JD Edgeworth, T Smieszek, and JV Robotham. 2018. “Intensive Care Unit (ICU)-acquired Bacteraemia and ICU Mortality and Discharge : Addressing Time-varying Confounding Using Appropriate Methodology.” Journal of Hospital Infection 99 (1): 42–47.
APA
Pouwels, K., Vansteelandt, S., Batra, R., Edgeworth, J., Smieszek, T., & Robotham, J. (2018). Intensive care unit (ICU)-acquired bacteraemia and ICU mortality and discharge : addressing time-varying confounding using appropriate methodology. JOURNAL OF HOSPITAL INFECTION, 99(1), 42–47.
Vancouver
1.
Pouwels K, Vansteelandt S, Batra R, Edgeworth J, Smieszek T, Robotham J. Intensive care unit (ICU)-acquired bacteraemia and ICU mortality and discharge : addressing time-varying confounding using appropriate methodology. JOURNAL OF HOSPITAL INFECTION. 2018;99(1):42–7.
MLA
Pouwels, KB, Stijn Vansteelandt, R Batra, et al. “Intensive Care Unit (ICU)-acquired Bacteraemia and ICU Mortality and Discharge : Addressing Time-varying Confounding Using Appropriate Methodology.” JOURNAL OF HOSPITAL INFECTION 99.1 (2018): 42–47. Print.
@article{8559877,
  abstract     = {Background: Studies often ignore time-varying confounding or may use inappropriate methodology to adjust for time-varying confounding. 
Aim: To estimate the effect of intensive care unit (ICU)-acquired bacteraemia on ICU mortality and discharge using appropriate methodology. 
Methods: Marginal structural models with inverse probability weighting were used to estimate the ICU mortality and discharge associated with ICU-acquired bacteraemia among patients who stayed more than two days at the general ICU of a London teaching hospital and remained bacteraemia-free during those first two days. For comparison, the same associations were evaluated with (i) a conventional Cox model, adjusting only for baseline confounders and (ii) a Cox model adjusting for baseline and time-varying confounders. 
Findings: Using the marginal structural model with inverse probability weighting, bacteraemia was associated with an increase in ICU mortality (cause-specific hazard ratio (CSHR): 1.29; 95\% confidence interval (CI): 1.02-1.63)and a decrease in discharge (CSHR: 0.52; 95\% CI: 0.45-0.60). By 60 days, among patients still in the ICU after two days and without prior bacteraemia, 8.0\% of ICU deaths could be prevented by preventing all ICU-acquired bacteraemia cases. The conventional Cox model adjusting for time-varying confounders gave substantially different results [for ICU mortality, CSHR: 1.08 (95\% CI: 0.88-1.32); for discharge, CSHR: 0.68 (95\% CI: 0.60-0.77)]. 
Conclusion: In this study, even after adjusting for the timing of acquiring bacteraemia and time-varying confounding using inverse probability weighting for marginal structural},
  author       = {Pouwels, KB and Vansteelandt, Stijn and Batra, R and Edgeworth, JD and Smieszek, T and Robotham, JV},
  issn         = {0195-6701},
  journal      = {JOURNAL OF HOSPITAL INFECTION},
  keyword      = {Burden,Intensive care units,Bacteraemia,Inverse probability weighting,Bias,BLOOD-STREAM INFECTIONS,MARGINAL STRUCTURAL MODELS,ATTRIBUTABLE MORTALITY,NOSOCOMIAL INFECTIONS,MULTISTATE MODELS,RISK-FACTORS,EPIDEMIOLOGY,POPULATION},
  language     = {eng},
  number       = {1},
  pages        = {42--47},
  title        = {Intensive care unit (ICU)-acquired bacteraemia and ICU mortality and discharge : addressing time-varying confounding using appropriate methodology},
  url          = {http://dx.doi.org/10.1016/j.jhin.2017.11.011},
  volume       = {99},
  year         = {2018},
}

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