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Double-blind, placebo-controlled, randomized trial of prophylactic metoprolol for reduction of hospital length of stay after heart surgery:: The β-blocker length of stay (BLOS) study

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AMERICAN HEART JOURNAL 2003年第2期145卷 226-232页

作者： Connolly, SJ Cybulsky, I Lamy, A Roberts, RS O'Brien, B Carroll, S Crystal, E Thorpe, KE Math, M Gent, M McMaster Univ Dept Med Hamilton ON L8S 4L8 Canada McMaster Univ Dept Surg & Clin Epidemiol Hamilton ON L8S 4L8 Canada McMaster Univ Dept Biostat Hamilton ON L8S 4L8 Canada

Background Atrial fibrillation (AF) is a common complication of heart surgery. Previous studies have shown that there is an association between postoperative AF and prolongation of hospital length of stay. No previous trials have been primarily directed at demonstrating that the use of drugs that prevent AF would shorten length of stay and reduce the costs of postoperative care. Methods A randomized, double-blind, placebo-controlled trial of metoprolol was performed in patients immediately after nonemergent heart surgery. Metoprolol was given orally at a dose of 100 mg per day after the patient's arrival in the intensive care unit until hospital discharge or 14 days, whichever was sooner. This dose was increased to 150 mg per day after the enrollment of 411 patients. The primary outcome measure of the study was hospital length of stay from admission to intensive care unit until hospital discharge. There were 1000 patients enrolled, evenly distributed to the metoprolol and placebo groups. Results There was a 20% reduction in the risk of AF developing with metoprolol, from 39% of patients to 31% of patients (P = .01). There was no effect of treatment on hospital length of stay, which was 152 +/- 61 hours for placebo and 155 +/- 90 hours for metoprolol (P = 0.79). The cost of postoperative care in the 2 treatment groups was similar. Conclusion Prophylactic metoprolol reduces the risk of AF after heart surgery. It does not reduce hospital length of stay. Although it is cost effective for the reduction of AF, it did not reduce the overall cost of care.

关键词：心房颤动/经济学心房颤动/预防和控制冠状动脉分流术成本及成本分析双盲法心脏瓣膜疾病/外科学住院时间美托洛尔/投药和剂量美托洛尔/经济学美托洛尔/治疗应用手术后并发症/经济学手术后并发症/预防和控制女(雌)性人类男(雄)性中年人

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Repaired coarctation: A "cost-effective" approach to identify complications in adults

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第4期35卷 997-1002页

作者： Therrien, J Thorne, SA Wright, A Kilner, PJ Somerville, J Univ London Imperial Coll Sci Technol & Med Jane Somerville Grown Up Congenital Heart Unit Royal Brompton & Harefield NHS Trust Natl Heart & Lung Inst London England Univ London Imperial Coll Sci Technol & Med Clin Trials & Evaluat Unit Royal Brompton & Harefield NHS Trust Natl Heart & Lung Inst London England Univ London Imperial Coll Sci Technol & Med Magnet Resonance Imaging Unit Royal Brompton & Harefield NHS Trust Natl Heart & Lung Inst London England

OBJECTIVES The study was done to determine the most "cost-effective" approach to follow adults after repair of coarctation of the aorta. BACKGROUND Recoarctation and/or aneurysm formation following surgical repair or angioplasty for coarctation of the aorta carry a significant morbidity and mortality. Various screening tests to detect such complications are used, but little is known of their sensitivities and specificities;as a consequence, the most "cost-effective" approach to follow such patients is undefined. METHODS Retrospective analysis was done on the sensitivity and specificity of symptomatology, physical examination, electrocardiogram, chest radiograph, exercise testing and transthoracic echocardiography to detect recoarctation and/or aneurysm formation in 84 adult patients following surgical repair or angioplasty of coarctation of the aorta, using magnetic resonance imaging (MRI) as the gold standard test. RESULTS Echocardiography had the highest sensitivity in detecting recoarctation (87%) and chest radiograph the highest sensitivity in detecting aneurysm formation (67%). Combined clinical visit and echocardiography had a high sensitivity for diagnosing recoarctation and/or aneurysm formation (97%), but performing a clinical visit and an MRT on every patient without any prior screening test emerged as the most "cost-effective" strategy. CONCLUSIONS The most "cost-effective" approach to diagnose complications at the site of repair in patients after surgical repair or balloon angioplasty of coarctation of the aorta appears to be the combination of clinical assessment and MRI scan on every patient. If MRT resources are scant, performing a clinical assessment plus a transthoracic echocardiography and an MRT on patients with positive results is an acceptable alternative. (C) 2000 by the American College of Cardiology.

关键词：主动脉瘤胸/诊断主动脉瘤胸/经济学主动脉瘤胸/外科学主动脉缩窄/诊断主动脉缩窄/经济学主动脉缩窄/外科学费用效益分析超声心动描记术/经济学随访研究磁共振成像/经济学手术后并发症/诊断手术后并发症/经济学手术后并发症/外科学试验预期值复发再手术青少年成年人女(雌)性人类男(雄)性中年人

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Potential clinical benefits and cost savings of universal leucocyte-depletion of blood components

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TRANSFUSION SCIENCE 1998年第4期19卷 343-346页

作者： Murphy, MF Natl Blood Serv Oxford England John Radcliffe Hosp Dept Haematol Oxford OX3 9DU England

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A cost-Effectiveness comparison of surgical treatments for mitral valve disease

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International Journal of Technology Assessment in Health Care 1988年第3期4卷 447-461页

作者： Papageorge, Basil N. Schweitzer, Stuart O. University of California Los Angeles United States

This study compares the cost-effectiveness of mitral valve reconstruction and replacement. Published clinical data were used to determine the effectiveness of each procedure. Both direct and indirect costs were calculated. The findings indicate that reconstruction has lower costs per year of life extended than replacement due to better outcomes. Changing outcome probabilities and discount rates did not alter these results. Cost savings in excess of 40% may be achieved by early reconstruction for suitable patients. These results suggest that the prevailing practice of delaying surgery until replacement is needed should be reconsidered, especially for patients who could benefit from reconstruction. © 1988, Cambridge University Press. All rights reserved.

关键词：费用效益分析评价研究心脏瓣膜疾病/外科学心脏瓣膜人工/经济学二尖瓣/外科学手术后并发症/经济学社会经济因素技术评估生物医学/经济学美国生命价值人类

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Effect of risk factors on the costs of coronary surgery

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第11期85卷 1338-+页

作者： Robicsek, F Carolinas Heart Inst Dept Thorac & Cardiovasc Surg Carolinas Med Ctr Charlotte NC USA

In the era of modern coronary surgery, with appropriate institutional support, cardiac surgeons are expected to provide an uneventful perioperative course for low-risk patients (i.e., low morbidity and mortality, short hospital stay, ergo proper low hospital costs). In a high-risk patient population, however, only surgical excellence can cope with the inherent difficulty of keeping complication rates minimal, hospital stays short. and costs low.

关键词：冠状动脉分流术/经济学冠心病/经济学冠心病/病因学冠心病/外科学成本及成本分析健康状况指标医院费用/统计学和数值数据手术后并发症/经济学手术后并发症/病因学人类

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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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A cost-utility analysis of preoperative total parenteral nutrition

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International Journal of Technology Assessment in Health Care 1989年第2期5卷 183-194页

作者： Goel, Vivek Detsky, Allan S. University of Toronto Canada

It has been suggested that preoperative total parenteral nutrition may be used to reduce the risk of nutrition-associated postoperative complications in high-risk patients. These patients can be identified based on their nutritional status. The efficiency of this intervention is assessed using the technique of cost-utility analysis. Data from multiple sources is integrated to perform the economic assessment. The cost-utility ratios for treating several malnourished patients with localized upper gastrointestinal cancer are below %40,000. These cost-utility ratios compare favorably with published results of other programs. The ratios increase considerably if patients who are better nourished (at lower risk of postoperative complication) receive the intervention. The analysis is very sensitive to the efficacy of the intervention. © 1989, Cambridge University Press. All rights reserved.

关键词：费用效益分析/方法经济学模型理论营养障碍/病因学营养障碍/预防和控制安大略胃肠外营养全/经济学手术后并发症/经济学手术前护理/经济学生活质量危险因素美国生命价值人类

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Reperfusion injury significantly impacts clinical outcome after pulmonary transplantation

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ANNALS OF THORACIC SURGERY 2000年第6期69卷 1681-1685页

作者： King, RC Binns, OAR Rodriguez, F Kanithanon, RC Daniel, TM Spotnitz, WD Tribble, CG Kron, IL Univ Virginia Hlth Sci Ctr Dept Surg Div Thorac & Cardiovasc Surg Charlottesville VA 22908 USA

Background. Reperfusion injury after pulmonary transplantation can contribute significantly to postoperative pulmonary dysfunction. We hypothesized that posttransplantation reperfusion injury would result in an increase in both in-hospital mortality and morbidity. We also hypothesized that the incidence of reperfusion injury would be dependent upon the cause of recipient lung disease and the interval of donor allograft ischemia. Methods. We performed a retrospective study of all lung transplant recipients at our institution from June 1990 until June 1998. One hundred patients received 120 organs during this time period. We compared two groups of patients in this study: those experiencing a significant reperfusion injury (22%) and those who did not (78%). Results. In-hospital mortality was significantly greater in patients experiencing reperfusion injury (40.9% Versus 11.7%, p < 0.02). Posttransplantation reperfusion injury also resulted in prolonged ventilation (393.5 Versus 56.8 hours, p < 0.001) and an increased length of stay in both the intensive care unit (22.2 versus 10.5 days, p < 0.01) and in the hospital (48.8 versus 25.6 days, p < 0.03). The incidence of reperfusion injury could not be attributed to length of donor organ ischemia (221.5 versus 252.9 minutes, p < 0.20). The clinical impact of reperfusion injury was significantly greater in patients undergoing transplantation for preexisting pulmonary hypertension (6/14) than those with chronic obstructive pulmonary disease or emphysema alone (6/54) (42.9% versus 11.1%, p < 0.012). Conclusions. Clinically significant pulmonary reperfusion injury increased in-hospital mortality and morbidity resulting in prolonged ventilation, length of stay in the intensive care unit, and cost of hospitalization. The incidence of reperfusion injury was not dependent upon the duration of donor organ ischemia but increased with the presence of preoperative pulmonary hypertension. These findings suggest that recipient pathophys

关键词：用力呼气量/生理学医院费用医院死亡率住院时间/经济学肺/血液供给肺移植/经济学肺移植/生理学氧/血液手术后并发症/经济学手术后并发症/死亡率手术后并发症/病理生理学再灌注损伤/经济学再灌注损伤/死亡率再灌注损伤/病理生理学回顾性研究女(雌)性人类男(雄)性中年人

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Assessment of pulmonary complications after lung resection

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ANNALS OF THORACIC SURGERY 1999年第5期67卷 1444-1447页

作者： Wang, J Olak, J Ultmann, RE Ferguson, MK Univ Chicago Dept Surg Thorac Surg Sect Chicago IL 60637 USA

Background. We assessed the utility of maximum oxygen consumption during exercise (MVO2) and diffusing capacity for carbon monoxide (DLCO) in the prediction of postoperative pulmonary complications, and the effect of such complications on postoperative length of hospital stay and the cost of hospitalization. Methods. Candidates for lung resection were prospectively studied by preoperative measurement of DLCO (expressed as a percentage of predicted [DLCO%]) and MVO2. Postoperative pulmonary complications, duration of postoperative hospitalization, and the cost of hospitalization were assessed. Results. Forty patients had lung resection with no operative mortality. The postoperative length of hospitalization was longer for the 13 patients who developed pulmonary complications compared with the 27 patients who did not (7.7 +/- 0.8 vs 5.0 +/- 0.4 days, respectively;p = 0.007), and the cost of hospitalization in the former group was higher ($11,530 +/- $1,959 vs $6,578 +/- $406, respectively;p = 0.031). Diffusing capacity was higher in patients without than in patients with pulmonary complications (DLCO% 90.1 +/- 5.0 vs 65.3 +/- 5.9;p = 0.0034). The mean MVO2 did not differ between the groups (17.8 +/- 0.9 vs 16.3 +/- 1.2). DLCO% predicted pulmonary complications (p = 0.006). Conclusions. DLCO% predicts the likelihood of pulmonary complications after major lung resection, which are associated with increased length of hospital stay and cost. (Ann Thorac Surg 1499;67:1444-7) (C) 1999 by The Society of Thoracic Surgeons.

关键词：癌非小细胞肺/外科学运动试验住院时间/经济学肺肿瘤/外科学氧耗量肺切除术肺炎/经济学肺炎/病因学手术后并发症/经济学前瞻性研究呼吸功能试验肺量测定法美国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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Who should follow up lung cancer patients after operation?

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ANNALS OF THORACIC SURGERY 2000年第6期69卷 1696-1700页

作者： Gilbert, S Reid, KR Lam, MY Petsikas, D Queens Univ Div Cardiothorac Surg Dept Surg Kingston ON K7L 2V6 Canada Queens Univ Dept Epidemiol & Community Hlth Kingston ON K7L 2V6 Canada

Background. It is unclear whether follow-up by a thoracic surgeon after lung cancer resection alters survival. Methods. The charts of 245 early stage (less than or equal to IIB) nonsmall cell lung cancer patients, diagnosed between 1988 and 1995, were reviewed. Follow-up data were complete to January 1, 1997 in 96.3% (236 of 245) of cases. Results. Ninety of the 111 recurrences were detected before discharge from the thoracic clinic. Despite clinic follow-up, 66.7% (60 of 90) were identified by the family physician, and only 28.9% (26 of 90) by the surgeon. The remaining 4.4% (4 of 90) were detected by other physicians. Ninety-six percent (25 of 26) surgeon-detected recurrences had suspicious clinical or chest radiographic findings, compared with 92% for family physician-detected recurrences (55 of 60;not significant). The cost per recurrence detected by surgeons was Can $4,367. A. 75% cost savings could ensure if patients were followed up by their family physician. There was no 5-year survival benefit for patients whose recurrence was detected by the surgeon. Conclusions. Long-term follow-up after limited-stage non-small cell lung cancer resection could possibly be performed by a family physician alone without compromising overall survival, and with significant cost savings. (C) 2000 by The Society of Thoracic Surgeons.

关键词：出院后医疗/经济学费用效益分析家庭医学随访研究医院费用肺肿瘤/经济学肺肿瘤/死亡率肺肿瘤/外科学肿瘤复发局部/经济学肿瘤复发局部/死亡率安大略病人医疗小组/经济学手术后并发症/经济学手术后并发症/死亡率存活率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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