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Ultra-fast track hospital discharge using conventional cardiac surgical techniques

ANNALS OF THORACIC SURGERY 1999年第2期67卷 363-369页

作者： Walji, S Peterson, RJ Neis, P DuBroff, R Gray, WA Benge, W SW Cardiol Associates Albuquerque NM USA

Background. Recent introduction of minimally invasive adult cardiac surgical techniques has emphasized the advantage of early hospital discharge. However, we chose an alternative approach to determine the safety, efficacy, and feasibility of ultra-fast track protocols while retaining both standard surgical exposure (median sternotomy) and conventional cardiac surgical techniques (hypothermia, cardiopulmonary bypass with cardiac arrest, and optimal myocardial protection). Methods. From September 1995 to January 1998, a total of 258 consecutive patients underwent cardiac procedures by a single surgeon. Acceleration of clinical pathways was used to initiate earlier discharges. Stringent postdischarge follow-up was implemented. Prospectively entered data were then analyzed retrospectively. Results. A variety of isolated as well as combined coronary and valve procedures were performed. Of the 258 patients ,perated on during this entire study period, a total of 144 patients (56%) were discharged within postoperative days 1 to 4 (ultra-fast track discharge). Over the past 12 months, this incidence increased to 70% (76 of 108 patients). Approximately 50% of these patients were operated on urgently or emergently. To date, there have been no deaths in this ultra-fast track group. There were eight brief readmissions, of which one was for rewiring of a noninfected sternal dehiscence, and the remaining were for cardiac diagnostic studies or a noncardiac problem altogether. Conclusions. Conventional cardiac operation can allow ultrafast hospital discharges while retaining the advantage of time-tested techniques and providing wider application without requiring new or additional training or equipment. (C) 1999 by The Society of Thoracic Surgeons.

关键词：心脏外科手术/统计学和数值数据冠状动脉分流术/统计学和数值数据心脏瓣膜假体植入/统计学和数值数据住院时间/统计学和数值数据新墨西哥病人出院/统计学和数值数据前瞻性研究回顾性研究治疗结果成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Evaluating the exposure and disease relationship with adjustment for different types of exposure misclassification: A regression approach

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STATISTICS IN MEDICINE 1999年第20期18卷 2795-2808页

作者： Kosinski, AS Flanders, WD Emory Univ Rollins Sch Publ Hlth Dept Biostat Atlanta GA 30322 USA Emory Univ Rollins Sch Publ Hlth Dept Epidemiol Atlanta GA 30322 USA

Misclassification of exposure can lead to biased results in the epidemiologic research. Available methods accounting for misclassification often require the use of a gold standard or assume non-differential misclassification of exposure. We present a regression approach which can detect and account for different types of misclassification when estimating the exposure and disease relationship. This approach uses two imperfect measures of a dichotomous exposure and does not require a gold standard. Standard statistical packages with a logistic regression module can be used for estimation of parameters through the EM algorithm process. Two examples are used to illustrate the methodology. Copyright (C) 1999 John Wiley & Sons, Ltd.

关键词：算法血管成形术气囊冠状动脉/统计学和数值数据冠状动脉分流术/统计学和数值数据冠心病/治疗运动试验/统计学和数值数据似然函数随机对照试验(主题) 回归分析体层摄影术发射型计算机单光子/统计学和数值数据女(雌)性人类男(雄)性

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The relationship between operator volume and outcomes after percutaneous coronary interventions in high volume hospitals in 1994-1996 - The northern New England experience

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第5期34卷 1471-1480页

作者： Malenka, DJ McGrath, PD Wennberg, DE Ryan, TJ Kellett, MA Shubrooks, SJ Bradley, WA Hettlemen, BD Robb, JF Hearne, MJ Silver, TM Watkins, MW O'Meara, JR VerLee, PN O'Rourke, DJ Dartmouth Coll Hitchcock Med Ctr Cardiol Sect Lebanon NH 03756 USA Dartmouth Coll Hitchcock Med Ctr Dartmouth Med Sch Ctr Evaluat & Clin Sci Hanover NH 03756 USA Maine Med Ctr Dept Med Div Hlth Serv Res Portland ME 04102 USA Maine Med Ctr Dept Med Div Cardiol Portland ME 04102 USA Catholic Med Ctr Manchester NH USA Beth Israel Deaconess Med Ctr Div Cardiol Boston MA USA Eastern Maine Med Ctr Div Cardiol Bangor ME USA Fletcher Allen Hlth Care Div Cardiol Burlington VT USA

OBJECTIVES The purpose of this study was to examine the relationship between annual operator volume and outcomes of percutaneous coronary interventions (PCIs) using contemporaneous data. BACKGROUND The 1997 American College of Cardiology (ACC)/American Heart Association task force based their recommendation that interventionists perform greater than or equal to 75 procedures per year to maintain competency in PCI on data collected largely in the early 1990s. The practice of interventional cardiology has since changed with the availability of new devices and drugs. METHODS Data were collected from 1994 through 1996 on 15,080 PCIs performed during 14,498 hospitalizations by 47 interventional cardiologists practicing at the five high volume (>600 procedures per hospital per year) hospitals in northern New England and one Massachusetts-based institution that support these procedures. Operators were categorized into terciles based on their annualized volume of procedures. Multivariate regression analysis was used to control for case-mix. In-hospital outcomes included death, emergency coronary artery bypass graft surgery (eCABG), non-emergency CABG (non-eCABG), myocardial infarction (MI), death and clinical success (greater than or equal to 1 attempted lesion dilated to <50% residual stenosis and no death, CABG or MI). RESULTS Average annual procedure rates varied across terciles from low = 68, middle = 115 and high = 209. After adjusting for case-mix, clinical success rates were comparable across terciles (low, middle and high terciles: 90.9%, 88.8% and 90.7%, p(trend) = 0.237), as were all the adverse outcomes including death (low-risk patients = 0.45%, 0.41%, 0.71%, p(trend) = 0.086;high-risk patients = 5.68%, 5.99%, 7.23%, p(trend) = 0.324), eCABG (1.74%, 2.05%, 1.75%, p(trend) = 0.733) and MI (2.57%, 1.90%, 1.86%, p(trend) = 0.065). CONCLUSIONS Using current data, there is no significant relationship between operator Volumes averaging greater than or equal to 68 per

关键词：血管成形术气囊冠状动脉/统计学和数值数据临床工作能力冠状动脉分流术/统计学和数值数据冠心病/治疗 Logistic模型新英格兰卫生保健质量支架/统计学和数值数据治疗结果人类

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Coronary surgery, ethnic origin, and value in health care

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EUROPEAN HEART JOURNAL 1999年第15期20卷 1066-1067页

作者： Weintraub, WS Emory Univ Sch Publ Hlth Atlanta GA 30322 USA

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Thrombolysis with saruplase versus streptokinase in acute myocardial infarction:: Five-year results of the PRIMI Trial

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AMERICAN HEART JOURNAL 1999年第3期138卷 518-524页

作者： Spiecker, M Windeler, J Vermeer, F Michels, R Seabra-Gomes, R vom Dahl, J Kerber, S Verheugt, FWA Westerhof, PW Bär, FW Nixdorff, U Barth, H Hopkins, GR von Fisenne, MJM Meyer, J Johannes Gutenberg Univ Mainz Dept Cardiol D-6500 Mainz Germany Heidelberg Univ Dept Med Stat Heidelberg Germany Univ Hosp Dept Cardiol Maastricht Netherlands Catharina Hosp Dept Cardiol Eindhoven Netherlands Hosp Santa Cruz Dept Cardiol Lisbon Portugal Univ Aachen Dept Cardiol D-5100 Aachen Germany Grunenthal GmbH Aachen Germany Univ Munster Dept Cardiol D-4400 Munster Germany Univ Nijmegen Dept Cardiol Nijmegen Netherlands Univ Utrecht Hosp Dept Cardiol Utrecht Netherlands

Background Short-term safety and efficacy of thrombolysis with saruplase in acute myocardial infarction have been shown in several trials. To assess long-term outcome of patients treated with saruplase or streptokinase for myocardial infarction, a 5-year follow-up of patients included in the Pro-Urokinase in Myocardial Infarction Trial was performed. Methods and Results Follow-vp data are available from 8 centers on 255 (92.4%) of 276 included patients. The 5-year mortality rate was comparable with 20.8% of patients in the saruplase group and 16.9% in the streptokinase group (odds ratio 1.29, 95% confidence interval 0.69 to 2.42). In both groups, a considerable number of fatal cardiovascular events occurred more than 1 year after study inclusion. Rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting were comparable in both groups. Reinfarction within 5 years occurred in 19.0% of patients in the saruplase group and tended to be less frequent at 10.8% after streptokinase treatment (odds ratio 1.94, 95% confidence interval 0.98 to 3.84). In both groups, the majority of reinfarctions took place more than 3 months after study inclusion. The 5-year stroke rate was 3.6% and 7.2% in the saruplase and streptokinase groups, respectively (odds ratio 0.49, 95% confidence interval 0.16 to 1.47). Subjective symptoms of heart failure and angina pectoris were comparable in both groups. Conclusions Our data are consistent with a similar long-term outcome for patients treated with saruplase or streptokinase. Despite the low-risk profile of the patient cohort, there were considerable adverse event rates over a 5-year period.

关键词：脑血管障碍/流行病学队列研究冠状动脉分流术/统计学和数值数据纤维蛋白溶解药/治疗应用随访研究心肌梗死/药物疗法重组蛋白质类/治疗应用复发链激酶/治疗应用存活率分析血栓溶解疗法尿纤溶酶原激活物/治疗应用女(雌)性人类男(雄)性中年人

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Prognostic importance of lower extremity arterial disease in patients undergoing coronary revascularization in the Bypass Angioplasty Revascularization Investigation (BARI)

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第3期34卷 716-721页

作者： Burek, KA Sutton-Tyrrell, K Brooks, MM Naydeck, B Keller, N Sellers, MA Roubin, G Jandová, R Rihal, CS Univ Pittsburgh Pittsburgh PA 15261 USA Univ Michigan Hlth Syst Ann Arbor MI USA NYU Med Ctr New York NY 10016 USA Duke Univ Med Ctr Durham NC USA Univ Alabama Birmingham Birmingham AL USA Inst Clin & Expt Med Prague Czech Republic Mayo Clin Rochester MN USA

OBJECTIVES The purpose of this study was to evaluate the prevalence and prognostic importance of lower extremity arterial disease (LEAD) in patients with multivessel coronary artery disease. BACKGROUND The presence of clinically evident LEAD increases the risk of death in patients with known coronary artery disease. Because studies have lacked noninvasive measures of subclinical LEAD, the true prognostic importance of lower extremity atherosclerosis in this population has probably been underestimated. METHODS Ankle blood pressures were measured in 405 consecutive patients with angiographically documented multivessel coronary disease from seven Bypass Angioplasty Revascularization Investigation (BARI) sites and a parallel study site within 3 years of enrollment. Lower extremity arterial disease was defined as an ankle/arm systolic blood pressure ratio of 0.90 or less. RESULTS Among patients studied, 69 (17%) had LEAD. These patients were more likely to be current smokers, treated for diabetes, older and present with unstable angina compared with patients without LEAD. Among patients who underwent coronary arterial bypass grafting, major complications occurred in 2.8% of those without LEAD compared with 20.7% of those with LEAD (p = 0.002). Five-year mortality rates were similar for symptomatic LEAD (14%) and asymptomatic LEAD (14%). Patients without LEAD had a 3% mortality. After adjusting for baseline differences, the relative risk of death was 4.9 times greater for patients with LEAD compared with those without (95% confidence interval [CI]: 1.8, 13.4, p < 0.01). CONCLUSIONS Patients with LEAD have a significantly higher risk of death than patients without LEAD, regardless of the presence of symptoms. An abnormal ankle/arm index is a strong predictor of mortality and can be used to further stratify risk among patients with multivessel coronary artery disease. (J Am Coll Cardiol 1999;34:716-21) (C) 1999 by the American College of Cardiology.

关键词：血管成形术气囊冠状动脉/统计学和数值数据动脉闭塞性疾病/并发症动脉闭塞性疾病/诊断动脉闭塞性疾病/流行病学冠状动脉分流术/统计学和数值数据冠心病/诊断冠心病/死亡率冠心病/治疗小腿/血液供给患病率预后危险因素女(雌)性人类男(雄)性中年人

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Comparing physician-specific two-year patient outcomes after coronary angiography - Methodologic issues and results

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第5期33卷 1278-1285页

作者： Ellis, SG Miller, D Keys, TF Brown, K Ellert, R Howell, G Lincoff, AM Topol, EJ Cleveland Clin Fdn Dept Cardiol Cleveland OH 44195 USA Cleveland Clin Fdn Dept Epidemiol & Biostat Cleveland OH 44195 USA Cleveland Clin Fdn Off Qual Management Cleveland OH 44195 USA Ischemia Res & Educ Fdn San Francisco CA USA

OBJECTIVES We sought to evaluate methodologies to compare physician-related long-term patient outcomes appropriately. BACKGROUND Evaluation of physicians on the basis of short-term patient outcome is becoming widely practiced. These analyses fail to consider the importance of long-term outcome, and methods appropriate to such an analysis are poorly defined. METHODS All patients undergoing coronary angiography between 1992 and 1994 who received all of their cardiac care at our institution were followed for 27 +/- 13 months (mean +/- SD). Patients (n = 754) were cared for by one or more of 17 staff physicians. Risk-adjusted models were developed for four candidate clinical end points and cost. Physicians were then evaluated for each outcome measure. RESULTS Of the clinical end points, death could be modeled most accurately (c-statistic = 0.83), The c-statistics for other end points ranged from 0.63 to 0.70. Physicians with outcomes statistically different (p < 0.05) from other physicians were identified more commonly than would be expected from the play of chance (p = 0.005). However, improvement in the c-statistics by the addition of physician identifiers was very modest. Physician's evaluations by the four measures of clinical outcome were variably correlated (r = .00 to .85). Graphic display of clinical and cost results for each physician did identify certain physicians who might be judged to provide more cost-effective care than others. CONCLUSIONS Although comparisons of groups of physicians on the basis of long-term patient outcomes may have merit, individual physician-to-physician comparisons will be more difficult, owing to 1) multiple physicians contributing care to individual patients;2) the poor predictive capacity of models other than that for survival;and 3) the modest apparent impact of differences in physician providers on long-term patient outcome. With these caveats in mind, modeling to compare patient outcomes of individual physicians with homogeneou

关键词：血管成形术气囊冠状动脉/经济学血管成形术气囊冠状动脉/死亡率血管成形术气囊冠状动脉/统计学和数值数据冠状血管造影术/经济学冠状血管造影术/死亡率冠状血管造影术/统计学和数值数据冠状动脉分流术/经济学冠状动脉分流术/死亡率冠状动脉分流术/统计学和数值数据冠心病重症监护病房/统计学和数值数据冠心病/诊断显像冠心病/经济学冠心病/治疗成本及成本分析无病生存随访研究结果评价(卫生保健)/经济学结果可重复性回顾性研究存活率老年人人类中年人

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Coronary artery stent outcomes in a Medicare population: Less emergency bypass surgery and lower mortality rates in patients with stents

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AMERICAN HEART JOURNAL 1999年第3期138卷 437-440页

作者： Ritchie, JL Maynard, C Every, NR Chapko, MK Univ Washington Div Cardiol Dept Med Seattle WA 98195 USA Univ Washington Dept Hlth Serv Seattle WA 98195 USA Dept Vet Affairs Dept Med & Hlth Serv Res & Dev Seattle WA USA

Background Randomized trials of coronary stents versus conventional balloon angioplasty have demonstrated improved short- and long-term outcomes for selected patients receiving stents. The purpose of this study was to compare outcomes in patients receiving stents with those undergoing conventional balloon angioplasty in everyday clinical practice. Methods and Results This study uses information from the Medicare Provider Analysis and Review Files for fiscal years 1994 and 1996, the first year the coronary stent code was used. For patients 65 years of age and older, 165,657 cases in 1994 and 201,869 in 1996, including 74,836 cases with stent placement, were identified. Outcomes included hospital deaths, use of same admission coronary artery bypass surgery, and either or both. Analyses were performed separately for those with and those without a principal diagnosis of acute myocardial. Hospital mortality rates were simliar in bath years, but the use of same-admiision coronary artery bypass surgery was lower in 1996. In that year, for both patients with and those without acute myocordial infarction, hospital death and the use of same-admission coronary artery bypass surgery were lower in the stent group. Additionally, results in the stent group were generally better at high-volume (>200 cases per year) institutions, as was the case for the prestent, 1994 results. Conclusions This studs documents improved short-term outcomes in older patients who undergo coronary stent placement, Stenting did not eliminate the finding of improved outcomes at high-volume centers.

关键词：血管成形术经腔经皮冠状动脉心血管外科手术/标准心血管外科手术/统计学和数值数据冠状动脉分流术/统计学和数值数据冠心病/死亡率冠心病/外科学 Medicare/统计学和数值数据结果评价(卫生保健) 回顾性研究支架美国老年人老年人 80以上女(雌)性人类男(雄)性

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Identifying pre- and postoperative predictors of cost and length of stay for coronary artery bypass surgery

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American Journal of Medical Quality 1999年第6期14卷 248-254页

作者： Ghali, William A. Hall, Ruth E. Ash, Arlene S. Moskowitz, Mark A. Health Care Research Unit Section of General Internal Medicine Boston Medical Center Boston MA United States Faculty of Medicine University of Calgary Calgary Alta. Canada Inst. for Clin. Evaluative Sciences University of Toronto Toronto Ont. Canada Faculty of Medicine University of Calgary Calgary Alta. T2N 4N1 3330 Hospital Drive NW Canada

Prior studies of resource use for coronary artery bypass graft (CABG) surgery have either focused on a limited number of hospitals or have used charges instead of costs. We used a large statewide database (n = 6791) to study predictors of cost and length of stay (LOS) for CABG surgery. We used linear regression to sequentially model (a) specific procedures performed, (b) preoperative patient characteristics, and (c) postoperative events to determine the relative impact of these 3 factors on resource use. We then used the resulting models to calculate adjusted mean hospital costs and LOS. These 3 factors were all significantly associated with resource use. Postoperative events were the greatest determinant of costs, while preoperative characteristics were the greatest determinant of LOS. Despite risk adjustment for these factors, resource use differed significantly across 12 hospitals (mean cost range, $22,200 to $41,900;mean LOS range, 11 to 18 days), suggesting that some institutions may need to reduce their resource use.

关键词：方差分析规范/经济学规范/利用冠状动脉分流术/经济学冠状动脉分流术/统计学和数值数据卫生资源/经济学卫生资源/统计学和数值数据卫生资源/利用医院费用/统计学和数值数据住院时间/经济学住院时间/统计学和数值数据线性模型马萨诸塞/流行病学手术后并发症/经济学手术后并发症/流行病学预后疾病严重程度指数治疗结果老年人女(雌)性人类男(雄)性中年人

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Long-term outcome following case management after coronary artery bypass surgery

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JOURNAL OF CARDIAC SURGERY 1998年第2期13卷 123-128页

作者： Walters, J Schwartz, CF Monaghan, H Watts, J Shlafer, GJ Deeb, GM Bolling, SF Univ Michigan Med Ctr Thorac Surg Sect Ann Arbor MI USA

Patient outcome following coronary artery bypass grafting (CABG) has come under increasing governmental, social, and economic scrutiny. To insure quality patient outcome after CABG, many new policies and programs have been instituted. One of these, case management, was developed as a tool for identification and quantification of patient clinical sequences and resource utilization. This present study examines the influence of case management on length of stay and patient outcome following CABG. One hundred forty randomized, retrospectively analyzed CABG patients from 1990, prior to case management, were compared against 140 age-and case-matched randomly controlled CABG patients from 1994 after case management was in place. Patients' demographics were similar. The outcome data showed that intensive care unit (ICU) use and total length of stay were significantly decreased. Furthermore, resource utilization as monitored by chest X-ray, electrocardiography, and laboratory testing were decreased as well. Finally, mortality was decreased despite an increase in risk-adjusted acuity of the patients. There appeared to be no effect of gender or age on the benefit derived from case management. These data demonstrate that the influence of case management is beneficial for resource utilization and patient outcome following CABG and that these types of patient care policy advancements should be encouraged.

关键词：病例管理冠状动脉分流术/死亡率冠状动脉分流术/统计学和数值数据费用控制临床路径卫生资源/利用重症监护病房/利用住院时间/统计学和数值数据密执安结果评价(卫生保健) 随机分配治疗结果老年人女(雌)性人类男(雄)性中年人

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