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Keekstra N, Biemond M, van Schaik J, Schepers A, Hamming JF, van der Vorst JR, Lindeman JHN. Toward Uniform Case Identification Criteria in Observational Studies on Peripheral Arterial Disease: A Scoping Review. Ann Vasc Surg 2024; 106:71-79. [PMID: 38615752 DOI: 10.1016/j.avsg.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The diagnosis of peripheral arterial disease (PAD) is commonly applied for symptoms related to atherosclerotic obstructions in the lower extremity, though its clinical manifestations range from an abnormal ankle-brachial index to critical limb ischemia. Subsequently, management and prognosis of PAD vary widely with the disease stage. A critical aspect is how this variation is addressed in administrative database-based studies that rely on diagnosis codes for case identification. The objective of this scoping review is to inventory the identification strategies used in studies on PAD that rely on administrative databases, to map the pros and cons of the International Classification of Diseases (ICD) codes applied, and to propose a first outline for a consensus framework for case identification in administrative databases. METHODS Registry-based reports published between 2010 and 2021 were identified through a systematic PubMed search. Studies were subcategorized on the basis of the expressed study focus: claudication, critical limb ischemia, or general peripheral arterial disease, and the ICD code(s) applied for case identification mapped. RESULTS Ninety studies were identified, of which 36 (40%) did not specify the grade of PAD studied. Forty-nine (54%) articles specified PAD grade studied. Five (6%) articles specified different PAD subgroups in methods and baseline demographics, but not in further analyses. Mapping of the ICD codes applied for case identification for studies that specified the PAD grade studied indicated a remarkable heterogeneity, overlap, and inconsistency. CONCLUSIONS A large proportion of registry-based studies on PAD fail to define the study focus. In addition, inconsistent strategies are used for PAD case identification in studies that report a focus. These findings challenge study validity and interfere with inter-study comparison. This scoping review provides a first initiative for a consensus framework for standardized case selection in administrative studies on PAD. It is anticipated that more uniform coding will improve study validity and facilitate inter-study comparisons.
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Affiliation(s)
- Niels Keekstra
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mathijs Biemond
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jan van Schaik
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Jan H N Lindeman
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.
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Rashid M, Stevens C, Wijeysundera HC, Curzen N, Khoo CW, Mohamed MO, Aktaa S, Wu J, Ludman P, Mamas MA. Rates of Elective Percutaneous Coronary Intervention in England and Wales: Impact of COURAGE and ORBITA Trials. J Am Heart Assoc 2022; 11:e025426. [DOI: 10.1161/jaha.122.025426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background
There are limited data about how COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) and ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) trials have impacted percutaneous coronary intervention (PCI) practices at regional or national level. We evaluated temporal trends in elective PCI rates for stable angina and, specifically, examined the impact of the COURAGE and ORBITA trials on PCI practices in England and Wales.
Methods and Results
We used national PCI data comprising >1.2 million patients undergoing PCI between January 2006 and December 2019. Patient demographics, procedural details, and clinical outcomes were analyzed, and temporal trends in PCI rates for stable angina were compared before and after the publication of the COURAGE and ORBITA trials. Of 1 245 802 PCI procedures, 430 248 (34.5%) were performed for stable angina. Over the study period, the number of elective PCI procedures per year (30 823 in 2006 to 34 103 in 2019) and per 100 000 population estimates (50.7 in 2006 to 58.4 in 2019) remained stable. The proportion of patients undergoing elective PCI without angina symptoms almost doubled from 5.1% to 9.7%. The incidence rate of elective PCI volume after the COURAGE trial, published in 2007, was not different from before the trial was published (incidence rate ratio, 1.06 [95% CI, 0.69–1.62]). It also remained stable after the publication of the ORBITA trial in 2017 (incidence rate ratio, 0.96 [95% CI, 0.74–1.23]).
Conclusions
In this nationwide analysis, rates of elective PCI for stable angina remained stable over 14 years. Publication of the COURAGE and ORBITA trials had no impact on elective PCI activity.
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Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Chris Stevens
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton & Department of Cardiology University Hospital NHS Trust Southampton UK
| | - Chee Wah Khoo
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Mohamed Osama Mohamed
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
| | - Suleman Aktaa
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine Leeds UK
| | - Jianhua Wu
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine Leeds UK
- School of Dentistry University of Leeds UK
| | - Peter F. Ludman
- Department of Cardiology Queen Elizabeth University Hospital Birmingham UK
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
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Zhang R, Liu G, Pan Y, Zhou M, Wang Y. Association between hospital volume, processes of care and outcomes after acute ischaemic stroke: a prospective observational study. BMJ Open 2022; 12:e060015. [PMID: 35680259 PMCID: PMC9185595 DOI: 10.1136/bmjopen-2021-060015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES There is uncertainty with respect to the hospital volume and clinical outcomes for patients with stroke. This study aimed to assess the association between hospital volume, processes of care and outcomes after ischaemic stroke. DESIGN A multicentre prospective cohort study. SETTING Two hundred and seventeen secondary or tertiary public hospitals from China. PARTICIPANTS A total of 17 550 patients within 7 days of acute ischaemic stroke were included. MAIN OUTCOME MEASURES The outcomes included all-cause mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. The patients were divided into four groups based on quartiles of the hospital volume. We compared the difference in the process of care across the groups and estimated the effects of hospital volume on mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. Restricted cubic splines were used to illustrate the association between hospital volume and clinical outcomes. RESULTS There were no significant differences in the process of care across the four groups. When adjusted for confounders, the effect of hospital volume on mortality, recurrent stroke and combined vascular events was not significant. However, compared with the highest quartile, the patients in the lowest quartile of hospital volume tend to have poor outcome at 1 year (OR=1.29, 95% CI 1.01 to 1.64, p=0.0393). The restricted cubic spline analyses suggested a non-linear relationship between hospital volume and 1-year combined vascular events and poor outcome at 3 months and 1 year. CONCLUSIONS We found no significant associations between hospital volume, processes of care at the hospital, and mortality, recurrent stroke, and combined vascular events in patients with ischaemic stroke. However, hospital volume may be associated with poor outcome at 1 year.
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Affiliation(s)
- Runhua Zhang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Maigeng Zhou
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
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4
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Blecha M, DeJong M, Carlson K. Risk Factors for Mortality within 5 Years of Carotid Endarterectomy for Asymptomatic Stenosis. J Vasc Surg 2022; 75:1945-1957. [DOI: 10.1016/j.jvs.2022.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/05/2022] [Indexed: 02/07/2023]
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Turki E, Almutairi OT, Modhi A, Mohammed B, Alturki AY. A bibliometric analysis on the most-cited publications on carotid endarterectomy throughout history. J Cerebrovasc Endovasc Neurosurg 2021; 23:314-326. [PMID: 34852422 PMCID: PMC8743826 DOI: 10.7461/jcen.2021.e2021.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Carotid endarterectomy (CEA) is the gold standard surgical procedure for managing carotid stenosis due to atherosclerosis and reducing the risk of ischemic stroke. This bibliometric analysis summarizes the most-cited articles on CEA and highlights the contributing articles to today’s evidence-based practice. Methods A title-specific search using the Scopus database was used to perform the search. Pertinent article-based, journal-based, and author-based parameters were obtained for review. Results A total of 6,824 articles were published between 1970 and 2020. The top 100 most-cited articles accumulated a total of 54,153 citations with an average citation count (CC) of 541, with only a 4.53% self-citation rate for all authors. The publication trends peaked between 1997 and 2010, in which two-third of the highly cited works were published. The most prolific categories with top citations are the clinical, indications, and management, in a descending order. There were 41 published Randomized Controlled Trials (RCT) in the most-cited list. Conclusions Citation analysis on carotid endarterectomy has witnessed a marked shift in the publication trends from studying the outcome and complications to comparing carotid stenting with endarterectomy. This analysis is a good introductory article to physicians interested in this topic, as it summarizes the highly impactful articles and enlists the most-cited RCT on CEA.
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Affiliation(s)
- Elarjani Turki
- Department of Neurosurgery, Miami University, Miami, USA
| | - Othman T Almutairi
- Department of Adult Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Alhussinan Modhi
- Department of Adult Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Bafaquh Mohammed
- Department of Adult Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Y Alturki
- Department of Adult Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
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Itoga NK, Martinez-Singh K, Lee JT, John Harris E, Baker LC, Garcia-Toca M. Analysis of Medicare Payments and Patient Outcomes With Pre-Operative Imaging for Carotid Endarterectomy. Ann Vasc Surg 2021; 76:179-184. [PMID: 34153493 DOI: 10.1016/j.avsg.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/18/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in preoperative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease. METHODS We used a 20% Medicare sample from 2006 to 2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated preoperative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use. RESULTS A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8 ± 7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4 ± 1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5 ± 2.1 ultrasounds, 0.95 ± 0.86 neck CTs and 0.47 ± 0.7 MRIs per patient. The average payment for ultrasound was $140 ± 40, $282 ± 94 for CT and $410 ± 146 for MRI. The average inpatient reimbursements were $7,413 ± 4,215 for patients without CSI compared with $7,792 ± 3,921 for patients with CSI, P < 0.001. The average LOS during CEA admission was 2.5 ± 3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by postoperative day 2 compared with ultrasound alone (88.9% vs. 91.5%, respectively, P < 0.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups. CONCLUSIONS Our analysis found preoperative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources.
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Affiliation(s)
- Nathan K Itoga
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA; Department of Health Research and Policy, Stanford University, Stanford, CA; Department of Surgery, University of Hawaii, Honolulu, Hawaii.
| | | | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Edmund John Harris
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Laurence C Baker
- Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
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7
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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8
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Keyhani S, Cheng EM. Screening for Asymptomatic Carotid Artery Stenosis in Adult Patients: Unclear Benefit but Downstream Risks. JAMA Intern Med 2021; 181:585-587. [PMID: 33528498 DOI: 10.1001/jamainternmed.2021.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Salomeh Keyhani
- Department of Medicine, University of California, San Francisco.,San Francisco VA Medical Center, San Francisco, California
| | - Eric M Cheng
- Department of Neurology, University of California, Los Angeles.,VA Greater Los Angeles Healthcare System, Los Angeles, California
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9
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Keyhani S, Cheng EM, Hoggatt KJ, Austin PC, Madden E, Hebert PL, Halm EA, Naseri A, Johanning JM, Mowery D, Chapman WW, Bravata DM. Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis. JAMA Neurol 2021; 77:1110-1121. [PMID: 32478802 PMCID: PMC7265126 DOI: 10.1001/jamaneurol.2020.1427] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Carotid endarterectomy (CEA) among asymptomatic patients involves a trade-off between a higher short-term perioperative risk in exchange for a lower long-term risk of stroke. The clinical benefit observed in randomized clinical trials (RCTs) may not extend to real-world practice. Objective To examine whether early intervention (CEA) was superior to initial medical therapy in real-world practice in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis. Design, Setting, and Participants This comparative effectiveness study was conducted from August 28, 2018, to March 2, 2020, using the Corporate Data Warehouse, Suicide Data Repository, and other databases of the US Department of Veterans Affairs. Data analyzed were those of veterans of the US Armed Forces aged 65 years or older who received carotid imaging between January 1, 2005, and December 31, 2009. Patients without a carotid imaging report, those with carotid stenosis of less than 50% or hemodynamically insignificant stenosis, and those with a history of stroke or transient ischemic attack in the 6 months before index imaging were excluded. A cohort of patients who received initial medical therapy and a cohort of similar patients who received CEA were constructed and followed up for 5 years. The target trial method was used to compute weighted Kaplan-Meier curves and estimate the risk of fatal and nonfatal strokes in each cohort in the pragmatic sample across 5 years of follow-up. This analysis was repeated after restricting the sample to patients who met RCT inclusion criteria. Cumulative incidence functions for fatal and nonfatal strokes were estimated, accounting for nonstroke deaths as competing risks in both the pragmatic and RCT-like samples. Exposures Receipt of CEA vs initial medical therapy. Main Outcomes and Measures Fatal and nonfatal strokes. Results Of the total 5221 patients, 2712 (51.9%; mean [SD] age, 73.6 [6.0] years; 2678 men [98.8%]) received CEA and 2509 (48.1%; mean [SD] age, 73.6 [6.0] years; 2479 men [98.8%]) received initial medical therapy within 1 year after the index carotid imaging. The observed rate of stroke or death (perioperative complications) within 30 days in the CEA cohort was 2.5% (95% CI, 2.0%-3.1%). The 5-year risk of fatal and nonfatal strokes was lower among patients randomized to CEA compared with patients randomized to initial medical therapy (5.6% vs 7.8%; risk difference, -2.3%; 95% CI, -4.0% to -0.3%). In an analysis that incorporated the competing risk of death, the risk difference between the 2 cohorts was lower and not statistically significant (risk difference, -0.8%; 95% CI, -2.1% to 0.5%). Among patients who met RCT inclusion criteria, the 5-year risk of fatal and nonfatal strokes was 5.5% (95% CI, 4.5%-6.5%) among patients randomized to CEA and was 7.6% (95% CI, 5.7%-9.5%) among those randomized to initial medical therapy (risk difference, -2.1%; 95% CI, -4.4% to -0.2%). Accounting for competing risks resulted in a risk difference of -0.9% (95% CI, -2.9% to 0.7%) that was not statistically significant. Conclusions and Relevance This study found that the absolute reduction in the risk of fatal and nonfatal strokes associated with early CEA was less than half the risk difference in trials from 20 years ago and was no longer statistically significant when the competing risk of nonstroke deaths was accounted for in the analysis. Given the nonnegligible perioperative 30-day risks and the improvements in stroke prevention, medical therapy may be an acceptable therapeutic strategy.
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Affiliation(s)
- Salomeh Keyhani
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco.,San Francisco Veterans Affairs (VA) Medical Center, San Francisco, California
| | - Eric M Cheng
- Department of Neurology, UCLA (University of California Los Angeles), Los Angeles.,VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Katherine J Hoggatt
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco.,San Francisco Veterans Affairs (VA) Medical Center, San Francisco, California
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Erin Madden
- Northern California Institute of Research and Education, San Francisco
| | - Paul L Hebert
- University of Washington, Seattle.,Puget Sound VA, Seattle, Washington
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.,Department of Population, University of Texas Southwestern Medical Center, Dallas.,Department of Data Science, University of Texas Southwestern Medical Center, Dallas
| | - Ayman Naseri
- San Francisco Veterans Affairs (VA) Medical Center, San Francisco, California.,Department of Ophthalmology, University of California San Francisco, San Francisco
| | - Jason M Johanning
- Department of Surgery, University of Nebraska, Omaha.,Omaha VA Medical Center, Omaha, Nebraska
| | - Danielle Mowery
- Biomedical Informatics, University of Utah, Salt Lake City.,Salt Lake City VA Health Care System, Salt Lake City, Utah.,Now with Department of Biostatistics, Epidemiology, & Informatics, University of Pennsylvania, Philadelphia
| | | | - Dawn M Bravata
- Department of Medicine, Indiana University School of Medicine, Indianapolis.,Department of Neurology, Indiana University School of Medicine, Indianapolis.,Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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Burke JF, Morgenstern LB, Osborne NH, Hayward RA. Combined risk modelling approach to identify the optimal carotid revascularisation approach. Stroke Vasc Neurol 2021; 6:476-482. [PMID: 33685994 PMCID: PMC8485229 DOI: 10.1136/svn-2020-000558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/05/2021] [Accepted: 02/16/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) results in fewer perioperative strokes, but more myocardial infarctions (MI) than carotid artery stenting (CAS). We explored a combined modelling approach that stratifies patients by baseline stroke and MI. METHODS Baseline registry-based risk models for perioperative stroke and MI were identified via literature search. We then selected treatment risk models in the Carotid Revascularisation Stenting versus Endarterectomy (CREST) trial by serially adding covariates (baseline risk, treatment (CEA vs CAS), treatment-risk interaction and age-treatment interaction terms). Treatment risk models were externally validated using data from the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and carotid stenting registries and treatment models were recalibrated to the SVS-VQI population. Predicted net benefit was estimated by summing the predicted stroke and MI risk differences with CEA versus CAS. RESULTS Perioperative treatment models had moderate predictiveness (c-statistic 0.69 for stroke and 0.68 for MI) and reasonable calibration across the risk spectrum for both stroke and MI within CREST. On external validation in SVS-VQI, predictiveness was substantially reduced (c-statistic 0.61 for stroke and 0.54 for MI) and models substantially overpredicted risk.Most patients (86.7%) were predicted to have net benefit from CEA in CREST (97.0% of symptomatic patients vs 75% of asymptomatic patients). DISCUSSION A combined modelling approach that separates risk elements has potential to inform optimal treatment. However, our current approach is not ready for clinical application. These data support guidelines that suggest that CEA should be the preferred revascularisation modality in most patients with symptomatic carotid stenosis.
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Affiliation(s)
- James Francis Burke
- Neurology, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Lewis B Morgenstern
- Neurology, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Nicholas H Osborne
- Vascular Surgery, Univerity of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Rodney A Hayward
- Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
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11
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Tremblay A, Chee AC, Dhaliwal I, Dumoulin E, Gillson A, MacEachern PR, Mitchell M, Schieman C, Stollery D, Li P, Fortin M, Tyan CC, Vakil E, Hergott C. Protocol for the Stather Canadian Outcomes Registry for Chest ProcedurEs (SCOPE). BMJ Open Respir Res 2021; 8:8/1/e000834. [PMID: 33509788 PMCID: PMC7845675 DOI: 10.1136/bmjresp-2020-000834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/11/2021] [Accepted: 01/16/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction The Stather Canadian Outcomes registry for chest ProcedurEs (SCOPE registry) is a Canadian multicentre registry of chest procedures. Methods and analysis The SCOPE registry is designed as a multicentre prospective database of specific bronchoscopic or other pulmonary procedures. Each procedure of interest will be associated with a registry module, and data capture designed to evaluate effectiveness of procedures on relevant patient outcomes. Participating physicians will be asked to enter data for all procedures performed in a given module. The anonymised dataset will be housed in a web-based electronic secure database. Specific modules included will be based on participating physician suggestions, capacity and consensus of the steering committee and relevance of hypotheses/research potential. Ethics and dissemination The central registry is under approval from the Conjoint Health Research Ethics Board at the University of Calgary. We aim for registry data to lead to publication of manuscripts in international medical journals as the primary mode of dissemination. Data may also be used by local investigators for personal and/or institutional quality control purposes as well as to inform health policies. Data requests from non-participating investigators for use under ethics approved research protocols can be considered.
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Affiliation(s)
- Alain Tremblay
- Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alex C Chee
- Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Ashley Gillson
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Michael Mitchell
- Medicine, University of Western Ontario, London, Ontario, Canada
| | - Colin Schieman
- Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Pen Li
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Marc Fortin
- Respiratory Medicine, Universite Laval, Quebec, Québec, Canada
| | - Chung C Tyan
- Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Erik Vakil
- Medicine, University of Calgary, Calgary, Alberta, Canada
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12
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Carotid Artery Stenting in Asymptomatic Carotid Artery Stenosis: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 75:648-656. [PMID: 32057380 DOI: 10.1016/j.jacc.2019.11.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/19/2019] [Indexed: 01/22/2023]
Abstract
The advance of therapies to reduce the stroke impact of asymptomatic carotid artery stenosis has proved difficult over the last decade. Disagreement concerning the underlying randomized control trials has limited entry into the care arena of endovascular therapies. Recently, advances in percutaneous therapies for carotid artery disease have been reported and provide a substantial database supporting the further incorporation of endovascular-based therapies in patients who need revascularization and meet selection criteria. With a second randomized control trial now published, it is time for a re-evaluation of endovascular therapy as a component of carotid artery care. This review describes the advances in the field in the last 5 years, clarifying the current position of these therapies in the care of the patient with asymptomatic carotid artery disease.
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Secemsky EA, Ferro EG, Rao SV, Kirtane A, Tamez H, Zakroysky P, Wojdyla D, Bradley SM, Cohen DJ, Yeh RW. Association of Physician Variation in Use of Manual Aspiration Thrombectomy With Outcomes Following Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction: The National Cardiovascular Data Registry CathPCI Registry. JAMA Cardiol 2020; 4:110-118. [PMID: 30624549 DOI: 10.1001/jamacardio.2018.4472] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Following negative randomized clinical trials, US guidelines downgraded support for routine manual aspiration thrombectomy (AT) during primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). However, some PCI operators continue to endorse a clinical benefit with AT use despite the lack of supportive data. Objective To examine temporal trends and comparative outcomes of AT use during pPCI for STEMI. Design, Setting, and Participants Retrospective cohort study of the National Cardiovascular Data Registry (NCDR) CathPCI Registry from July 1, 2009, to June 30, 2016, to assess temporal trends and in-hospital outcomes associated with AT use. To evaluate outcomes through 180 days, a subanalysis was conducted among Centers for Medicare and Medicaid Services-linked patients from July 1, 2009, through December 31, 2014. The comparative effectiveness analysis was performed using instrumental variable analyses to account for treatment selection bias. The instrumental variable was operator's preference to use AT during pPCI. Data were analyzed between February 1, 2017, and April 1, 2018. Exposures Aspiration thrombectomy use during pPCI for STEMI. Main Outcomes and Measures Primary outcomes included in-hospital stroke and death. Secondary outcomes included heart failure, stroke, all-cause rehospitalization, and death through 180 days of follow-up. Results Among all pPCIs performed (683 584), the mean (SD) age of patients was 61.7 (12.8) years, 489 257 were male (71.6%), and 596 384 were white (87.2%). Among patients undergoing pPCI, AT use increased from 2009 through 2011, with peak use of 13.8%. This was followed by a decline of more than 9%, reaching 4.7% by mid-2016. Overall, AT was used in 10.8% of pPCIs (lowest operator group median, 0%; highest operator group median, 33.8%). After instrumental variable analysis, AT use was associated with no difference in in-hospital death (adjusted absolute risk difference, -0.18%; 95% CI, -0.53% to 0.16%; P = .29) and a small increase in in-hospital stroke (adjusted RD, 0.14%; 95% CI, 0.01%-0.30%; P = .03). Among Centers for Medicare and Medicaid Services-linked patients, AT use was not associated with differences in death, heart failure, stroke, or rehospitalization at 180 days. Conclusions and Relevance In this large, nationwide analysis, AT use during STEMI pPCI declined by more than 50% since 2011, with use as of mid-2016 at less than 5%. Selective AT use was associated with a small excess risk of in-hospital stroke and no difference in other outcomes through 180 days of follow-up.
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Affiliation(s)
- Eric A Secemsky
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Sunil V Rao
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Ajay Kirtane
- Center for Interventional Vascular Therapy, Division of Cardiology, Department of Medicine, Columbia University, New York, New York.,Associate Editor
| | - Hector Tamez
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Pearl Zakroysky
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Steven M Bradley
- Center for Healthcare Delivery Innovation, Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - David J Cohen
- St Luke's Mid America Heart Institute, University of Missouri, Kansas City
| | - Robert W Yeh
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Large Databases Used for Outcomes Research. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Elías FR, Medina G, Sánchez M, Rios CS, Belmont GDLC, Danés LG. Carotid endarterectomy 20-year experience in a low-volume center. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_24_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Scalia P, O'Malley AJ, Durand MA, Goodney PP, Elwyn G. Presenting time-based risks of stroke and death for Patients facing carotid stenosis treatment options: Patients prefer pie charts over icon arrays. PATIENT EDUCATION AND COUNSELING 2019; 102:1939-1944. [PMID: 31101429 DOI: 10.1016/j.pec.2019.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/14/2019] [Accepted: 05/04/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To user-test graphical display formats (icon arrays, pie, bar, and line charts) to identify preferred formats and metrics ('probability of death or stroke' or 'proportion of time lived without death or stroke') in order to display time-dependent risks of stroke or death for three carotid stenosis treatments: endarterectomy (surgery), stenting, and medical therapy. METHODS Iterative cycles of semi-structured interviews with patients recruited from a Vascular Clinic. RESULTS A total of 27 patients (mean age = 68; range: 50-85) were interviewed over four cycles. Patients strongly preferred the pie chart over icon arrays, and over bar or line graphs. The preference was based on patient recognition of the time-based increase in risk for stroke or death for treatment options. Patients preferred data presented as probabilities instead of the proportion of time lived. We did not assess patients' understanding. CONCLUSION Patients preferred the pie chart formats and reported better realization that risks increase with time for each option and that tradeoffs exist when surgery has a higher short-term risk than medical therapy. PRACTICE IMPLICATIONS There remains debate on how best to convey time-dependent risk information to patients, especially where low literacy and numeracy might exist.
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Affiliation(s)
- Peter Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, One Medical Center Drive, Lebanon, NH, 03756, USA; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Williamson Translational Building, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Philip P Goodney
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, One Medical Center Drive, Lebanon, NH, 03756, USA.
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Abstract
OBJECTIVE To quantify the extent to which payments for laparoscopic and open colectomy are influenced by a surgeon's experience with laparoscopy. BACKGROUND Numerous studies suggest that healthcare costs for laparoscopic colectomy are lower than open surgery. None have assessed the importance of surgeon experience on the relative financial benefits of laparoscopy. METHODS We conducted a study of 182,852 national Medicare beneficiaries undergoing laparoscopic or open colectomy between 2010 and 2012. Using instrumental variable methods to account for selection bias, we compared Medicare payments for laparoscopic and open colectomy. We stratified our analysis by surgeons' annual experience with laparoscopic colectomy to determine the influence of provider experience on payments. RESULTS In the fully adjusted analysis, average episode payments per patient were $2640 [95% confidence interval (CI) -$4091 to -$1189] lower with the laparoscopic approach versus open. Surgeons in the highest quartile of laparoscopic experience demonstrated an average payment savings of $5456 per patient (CI -$7918 to -$2994) in their laparoscopic versus open cases. Among surgeons in the lowest quartile of laparoscopic experience, there was, however, no difference between laparoscopic and open cases (difference: $954, 95% CI -$731 to $2639). Differences in payments were explained by differences in complications rates. Both groups had similar rates of complications for open procedures (least experience, 21%, most experience, 21%; P = 0.45), but differed significantly on rates of complications for laparoscopic cases (least experience, 28%, most experience, 15%; P < 0.01). CONCLUSIONS This population-based study demonstrates that differences in payments between laparoscopic and open colectomy are influenced by surgeon experience. The laparoscopic approach does not reduce payments for patients whose surgeons have limited experience with the procedure.
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Boissel JP, Cogny F, Marko N, Boissel FH. From Clinical Trial Efficacy to Real-Life Effectiveness: Why Conventional Metrics do not Work. Drugs Real World Outcomes 2019; 6:125-132. [PMID: 31359347 PMCID: PMC6702507 DOI: 10.1007/s40801-019-0159-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Randomised, double-blind, clinical trial methodology minimises bias in the measurement of treatment efficacy. However, most phase III trials in non-orphan diseases do not include individuals from the population to whom efficacy findings will be applied in the real world. Thus, a translation process must be used to infer effectiveness for these populations. Current conventional translation processes are not formalised and do not have a clear theoretical or practical base. There is a growing need for accurate translation, both for public health considerations and for supporting the shift towards personalised medicine. Objective Our objective was to assess the results of translation of efficacy data to population efficacy from two simulated clinical trials for two drugs in three populations, using conventional methods. Methods We simulated three populations, two drugs with different efficacies and two trials with different sampling protocols. Results With few exceptions, current translation methods do not result in accurate population effectiveness predictions. The reason for this failure is the non-linearity of the translation method. One of the consequences of this inaccuracy is that pharmacoeconomic and postmarketing surveillance studies based on direct use of clinical trial efficacy metrics are flawed. Conclusion There is a clear need to develop and validate functional and relevant translation approaches for the translation of clinical trial efficacy to the real-world setting. Electronic supplementary material The online version of this article (10.1007/s40801-019-0159-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Nicholas Marko
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, TX, USA
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Kallmayer MA, Salvermoser M, Knappich C, Trenner M, Karlas A, Wein F, Eckstein HH, Kuehnl A. Quality appraisal of systematic reviews, and meta-analysis of the hospital/surgeon-linked volume-outcome relationship of carotid revascularization procedures. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:354-363. [DOI: 10.23736/s0021-9509.19.10943-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Affiliation(s)
- Amir A. Ghaferi
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- Surgical Innovation Editor, JAMA Surgery
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Fairfield KM, Black AW, Lucas FL, Siewers AE, Cohen MC, Healey CT, Briggs AC, Han PKJ, Wennberg JE. Behavioral Risk Factors and Regional Variation in Cardiovascular Health Care and Death. Am J Prev Med 2018; 54:376-384. [PMID: 29338952 DOI: 10.1016/j.amepre.2017.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 10/17/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Reducing the burden of death from cardiovascular disease includes risk factor reduction and medical interventions. METHODS This was an observational analysis at the hospital service area (HSA) level, to examine regional variation and relationships between behavioral risks, health services utilization, and cardiovascular disease mortality (the outcome of interest). HSA-level prevalence of cardiovascular disease behavioral risks (smoking, poor diet, physical inactivity) were calculated from the Behavioral Risk Factor Surveillance System; HSA-level rates of stress tests, diagnostic cardiac catheterization, and revascularization from a statewide multi-payer claims data set from Maine in 2013 (with 606,260 patients aged ≥35 years), and deaths from state death certificate data. Analyses were done in 2016. RESULTS There were marked differences across 32 Maine HSAs in behavioral risks: smoking (12.4%-28.6%); poor diet (43.6%-73.0%); and physical inactivity (16.4%-37.9%). After adjustment for behavioral risks, rates of utilization varied by HSA: stress tests (28.2-62.4 per 1,000 person-years, coefficient of variation=17.5); diagnostic cardiac catheterization (10.0-19.8 per 1,000 person-years, coefficient of variation=17.3); and revascularization (4.6-6.2 per 1,000 person-years; coefficient of variation=9.1). Strong HSA-level associations between behavioral risk factors and cardiovascular disease mortality were observed: smoking (R2=0.52); poor diet (R2=0.38); and physical inactivity (R2=0.35), and no association between revascularization and cardiovascular disease mortality after adjustment for behavioral risk factors (R2=0.02). HSA-level behavioral risk factors were also strongly associated with all-cause mortality: smoking (R2=0.57); poor diet (R2=0.49); and physical inactivity (R2=0.46). CONCLUSIONS There is substantial regional variation in behavioral risks and cardiac utilization. Behavioral risk factors are associated with cardiovascular disease mortality regionally, whereas revascularization is not. Efforts to reduce cardiovascular disease mortality in populations should focus on prevention efforts targeting modifiable risk factors.
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Affiliation(s)
- Kathleen M Fairfield
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine.
| | - Adam W Black
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine
| | - Andrea E Siewers
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine
| | - Mylan C Cohen
- Maine Medical Partners-MaineHealth Cardiology and Maine Medical Center, Portland, Maine
| | | | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine
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International patient registry on acupuncture therapy for premature ovarian insufficiency: Challenges and opportunities. WORLD JOURNAL OF ACUPUNCTURE-MOXIBUSTION 2018. [DOI: 10.1016/j.wjam.2018.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Lansdale N, Al-Khafaji N, Green P, Kenny SE. Population-level surgical outcomes for infantile hypertrophic pyloric stenosis. J Pediatr Surg 2018; 53:540-544. [PMID: 28576429 DOI: 10.1016/j.jpedsurg.2017.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/12/2017] [Accepted: 05/14/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Determine national outcomes for pyloromyotomy; how these are affected by: (i) surgical approach (open/laparoscopic), or (ii) centre type/volume and establish potential benchmarks of quality. METHODS Hospital Episode Statistics data were analysed for admissions 2002-2011. Data presented as median (IQR). RESULTS 9686 infants underwent pyloromyotomy (83% male). Surgery was performed in 22 specialist (SpCen) and 39 nonspecialist centres (NonSpCen). The proportion treated in SpCen increased linearly by 0.4%/year (r=0.76, p=0.01). Annual case volume in SpCen vs. NonSpCen was 40 (24-53) vs. 1 (0-3). Time to surgery was shorter in SpCen (1day [1, 2] vs. 2 [1-3]), but total stay equal (4days [3-6]). 137 (1.4%) had complications requiring reoperation (wound problem 0.6%; repeat pyloromyotomy 0.5% and perforation, bleeding or obstruction 0.2%): pooled rates were similar between SpCen and NonSpCen (1.4% vs. 1.6%, p=0.52). Three NonSpCen had >5% reoperations (within 99.8% C.I. as small denominators). There was no relationship between reoperation and centre volume. Laparoscopic pyloromyotomy had increased risk of repeat pyloromyotomy (OR 2.28 [1.14-4.57], p=0.029). CONCLUSIONS Pyloric stenosis surgery shifted from centres local to patients, but outcomes were unaffected by centre type/volume. Modest reported benefits of laparoscopy appear offset by increased reoperations. Quality benchmarks could be set for reoperation <4%. TYPE OF STUDY Treatment Study. LEVEL OF EVIDENCE Level III.
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Papoyan SA, Shchegolev AA, Gromov DG, Krasnikov AP, Mutaev MM, Radchenko AN, Sazonov MY, Syromyatnikov DD. Carotid artery stenting of advanced age patients. ACTA ACUST UNITED AC 2018. [DOI: 10.17116/kardio20181105166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Vinogradov RA, Pykhteev VS, Martirosova KI, Lashevich KA. [Perioperative complications prognosis in carotid endarterectomy]. Khirurgiia (Mosk) 2018:82-85. [PMID: 29376964 DOI: 10.17116/hirurgia2018182-85] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- R A Vinogradov
- Research Institute - Ochapovsky Regional Clinical Hospital # 1, Krasnodar, Russia; Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
| | - V S Pykhteev
- Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
| | - K I Martirosova
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - K A Lashevich
- Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
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Chu QD, Zhou M, Peddi P, Medeiros KL, Zibari GB, Shokouh-Amiri H, Wu XC. Influence of facility type on survival outcomes after pancreatectomy for pancreatic adenocarcinoma. HPB (Oxford) 2017; 19:1046-1057. [PMID: 28967535 DOI: 10.1016/j.hpb.2017.04.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/04/2017] [Accepted: 04/29/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Although a volume-outcome relationship has been well established for pancreatectomy, little is known about differences in mortality by facility type. The objective of this study is to evaluate the impact of facility type on short-term and long-term survival outcomes for patients with pancreatic adenocarcinoma who underwent pancreatectomy and identify determinants of overall survival (OS). METHODS A cohort of 33,382 patients with Stage I-III pancreatic adenocarcinoma diagnosed between 1998 and 2011 were evaluated from the National Cancer Data Base. Clinicopathological, sociodemographic and treatment variables were compared among three facility types where patients received resection: (i) community cancer program (CCP), (ii) comprehensive community cancer program (CCCP), and (iii) academic research program (ARP). 5-year OS was calculated using the Kaplan-Meier method. RESULTS Despite ARP having significantly higher percentage of poorly differentiated tumors, higher T-stage tumors, more positive lymph nodes, and greater circle distance compared to the other facilities, it had the highest 5-yr OS. The 5-yr OS for CCP, CCCP, and ARP was 11.2%, 13.2%, and 16.6%, respectively (P < 0.0001) and the median survival time (months) was 12.4, 15.6 and 19.1, respectively. CONCLUSION Patients receiving pancreatic resection at an ARP yielded a higher 5-year OS compared to CCP or CCCP.
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Affiliation(s)
- Quyen D Chu
- Department of Surgery, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA; The Feist-Weiller Cancer Center, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Meijiao Zhou
- Louisiana Tumor Registry & Epidemiology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA; School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Prakash Peddi
- Department of Medicine, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA; The Feist-Weiller Cancer Center, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA.
| | - Kaelen L Medeiros
- Louisiana Tumor Registry & Epidemiology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA; School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Gazi B Zibari
- Department of Surgery, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA; John C McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, LA, USA
| | - Hosein Shokouh-Amiri
- Department of Surgery, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA; John C McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, LA, USA
| | - Xiao-Cheng Wu
- Louisiana Tumor Registry & Epidemiology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, USA; School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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Mao J, Goodney P, Cronenwett J, Sedrakyan A. Association of Very Low-Volume Practice With Vascular Surgery Outcomes in New York. JAMA Surg 2017; 152:759-766. [PMID: 28514469 DOI: 10.1001/jamasurg.2017.1100] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Little research has focused on very low-volume surgery, especially in the context of decreasing vascular surgery volume with the adoption of endovascular procedures. Objective To investigate the existence and outcomes of open abdominal aortic aneurysm repair (OAR) and carotid endarterectomy (CEA) performed by very low-volume surgeons in New York. Design, Settings, and Participants This cohort study examined inpatient data of patients undergoing elective OAR or CEA from 2000 to 2014 from all New York hospitals. Exposures Surgeons who performed 1 or less designated procedure per year on average were considered very low volume, as opposed to higher-volume surgeons. Main Outcomes and Measures Temporal trends of the existence of very low-volume practice were evaluated. Hierarchical logistic regression was used to compare in-hospital outcomes and health care resource use between patients treated by very low-volume surgeons and higher-volume surgeons for both OAR and CEA, adjusting for patient, surgeon, and hospital characteristics. Results There were 8781 OAR procedures and 68 896 CEA procedures included in the study. The mean (SD) patient age was 71.7 (8.4) years for OAR and 71.5 (9.1) years for CEA. A total of 614 surgeons performed OAR and 1071 performed CEA in New York during the study period. Of these, 318 (51.8%) and 512 (47.8%), respectively, were very low-volume surgeons. Very low-volume surgeons were less likely to be vascular surgeons. The number and proportion of very low-volume surgeons decreased over years. Compared with patients treated by higher-volume surgeons, those treated by very low-volume surgeons were more likely to have higher in-hospital mortality (odds ratio [OR], 2.09; 95% CI, 1.41-3.08) following OAR and higher risks of postoperative myocardial infarction (OR, 1.83; 95% CI, 1.03-3.26) and stroke (OR, 1.78; 95% CI, 1.21-2.62) following CEA. Patients treated by very low-volume surgeons also had greater health care resource use following both surgeries, including prolonged length of stay (OR, 1.37; 95% CI, 1.11-1.70) following OAR as well as higher charges (OR, 1.28; 95% CI, 1.01-1.62) and increased 30-day readmission (OR, 1.30; 95% CI 1.04-1.62) following CEA. Conclusions and Relevance The OAR and CEA procedures performed by very low-volume surgeons resulted in worse postoperative outcomes and greater lengths of stay. Although the percentage of very low-volume surgeons declined from 2000 to 2014, it remains concerning, given ready access to higher-volume surgeons. Future research is needed to understand the existence of this practice pattern in other surgical fields. Efforts to eliminate this practice pattern are warranted to ensure high-quality care for all patients.
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Affiliation(s)
- Jialin Mao
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jack Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
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Caliskan E, Cox JL, Holmes DR, Meier B, Lakkireddy DR, Falk V, Salzberg SP, Emmert MY. Interventional and surgical occlusion of the left atrial appendage. Nat Rev Cardiol 2017; 14:727-743. [DOI: 10.1038/nrcardio.2017.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
The creation of any patient database requires substantial planning. In the case of thoracic outlet syndrome, which is a rare disease, the Society for Vascular Surgery has defined reporting standards to serve as an outline for the creation of a patient registry. Prior to undertaking this task, it is critical that designers understand the basics of registry planning and a priori establish plans for data collection and analysis.
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Affiliation(s)
- Misty D Humphries
- Division of Vascular and Endovascular Surgery, University of California Davis Health, 4860 Y Street, Suite 3400, Sacramento, CA 95817, USA.
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Safian RD. Asymptomatic Carotid Artery Stenosis: Revascularization. Prog Cardiovasc Dis 2017; 59:591-600. [PMID: 28478115 DOI: 10.1016/j.pcad.2017.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 04/30/2017] [Indexed: 11/29/2022]
Abstract
In patients with carotid stenosis, the most common cause of stroke is atheroembolization, and the risk is strongly related to stenosis severity and symptomatic status (stroke or transient ischemic attack within 6months). Carotid revascularization by carotid endarterectomy (CEA) or carotid artery stenting (CAS) results in plaque "passivation" by lumen enlargement, plaque removal, or plaque coverage with subsequent endothelialization. While there is considerable circumstantial evidence linking a decrease in the risk of stroke to the use of "optimal medical therapy (OMT)", the components of OMT have not been defined, and such therapy has not been rigorously evaluated in any randomized clinical trial (RCT) compared with revascularization. Studies of other vascular patients suggest that statins decrease the risk of stroke by anti-inflammatory effects, rather than cholesterol reduction. The Carotid Revascularization Endarterectomy versus Stent Trial (CREST-2) is currently randomizing standard-risk patients with asymptomatic severe carotid stenosis to OMT alone versus OMT plus CEA or CAS, but results are not expected until 2020. In the meantime, data from several "landmark" trials of CEA versus aspirin demonstrated 45-65% reduction in the 5-year risk of stroke after CEA. Several RCTs demonstrate superiority of CAS over CEA in high-risk patients (those at high-risk for CEA), and equivalence of CAS and CEA in standard-risk patients (those at acceptable risk for CEA). Compared with CEA, CAS is associated with significantly less periprocedural myocardial infarction, cranial nerve injury, and neurological injury (cranial nerve injury plus stroke); higher risk of minor stroke; and similar risk of long-term stroke. Features that increase the risk of CAS include complex aortic arch and carotid anatomy, and features that increase the risk of CEA include severe underlying cardiopulmonary disease and hostile neck anatomy; age>80years, especially those with baseline cognitive impairment, are at higher risk for stroke after CEA and CAS.
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Affiliation(s)
- Robert D Safian
- Center for Innovation and Research in Cardiovascular Diseases, Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI.
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Deery SE, Schermerhorn ML. Open versus endovascular abdominal aortic aneurysm repair in Medicare beneficiaries. Surgery 2017; 162:721-731. [PMID: 28343694 DOI: 10.1016/j.surg.2017.01.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 01/12/2017] [Accepted: 01/28/2017] [Indexed: 11/25/2022]
Abstract
Abdominal aortic aneurysms are relatively common and often life-threatening, with especially high mortality after aneurysm rupture. The introduction of endovascular aneurysm repair, a minimally invasive alternative to traditional open repair, led to decreased mortality and morbidity in randomized controlled trials, but these trials were conducted in highly selected patients and providers and were underpowered to detect differences in rare adverse events throughout follow-up. With observational studies of Medicare beneficiaries, we demonstrate that the randomized trial results are generalizable to the majority of patients undergoing abdominal aortic aneurysm repair in the United States. Additionally, with a larger cohort, comparative analyses evaluating rare, previously unstudied late outcomes such as laparotomy-related complications, late reinterventions, mortality with reinterventions, and late rupture could be conducted. Furthermore, trends in management over time and relationships between surgeon and hospital volume and outcomes can be studied. The goal of this review was to summarize the existing literature regarding abdominal aortic aneurysms among Medicare beneficiaries and to evaluate the benefits and limitations of administrative claims data in comparative effectiveness research.
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Knyazev OV, Parfenov AI, Kagramanova AV, Ruchkina IN, Shcherbakov PL, Shakhpazyan NK, Noskova KK, Ivkina TI, Khomeriki SG. [Long-term infliximab therapy for ulcerative colitis in real clinical practice]. TERAPEVT ARKH 2017; 88:46-52. [PMID: 27636927 DOI: 10.17116/terarkh201688846-52] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM to retrospectively evaluate the efficiency of long-term infliximab (INF) therapy in patients with refractory ulcerative colitis (UC). SUBJECTS AND METHODS The investigation enrolled 48 patients with refractory UC who had taken IFL in 2008 to 2014. Steroid-dependent or steroid-refractory UC was established in 40 (83.3%) patients; 8 (16.7%) were noted to be refractory to therapy with azathioprine or 6-mercaptopurine. Cytomegalovirus DNA was identified in the biopsy specimens of the large intestinal mucosa (LIM) from 7 patients. One patient received antiviral therapy. Induction therapy with IFL was in its administration in a dose of 5 mg/kg at 0, 2, and 6 weeks, then maintenance therapy was continued every 8 weeks. RESULTS After an IFL induction cycle, 3 (6.3%) patients were unresponsive to therapy and were excluded from the investigation. At present, 25 (55.5%) of the 45 patients who have responded to the therapy continue to take IFL 5 mg/kg every 8 weeks and are in clinical remission; 4 (8.8%) patients receive intensified IFL therapy. Initially 23 patients received combined therapy with IFL + an immunosuppressive drug; 22 had IFL monotherapy. Escape from the effect of the performed therapy was observed in 5 (11.1%) patients, which required its intensification. The intensified therapy resulted in sustained remission in 4 (8.8%) patients; colectomy was carried out in one (2.2%) case. Secondary loss of response to IFL, its intolerance, development of severe infectious complications, which did not allow for further maintenance therapy with IFL, were seen in 11 (24.4%) patients; 5 (11.1%) stopped the therapy because they had been excluded from the additional drug subsidy list. Maintenance therapy with IFL proved successful during 64 months in 29 (64.4%) of the 45 patients and during 64 months if its intensity, when the occasion required, was enhanced. CONCLUSION The long-term use of IFL in UC confirmed its high efficacy in achieving clinical response, in inducing a clinical remission and its capacity to heal LIM, and in sustaining remission.
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Affiliation(s)
- O V Knyazev
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - A I Parfenov
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - A V Kagramanova
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - I N Ruchkina
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - P L Shcherbakov
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | | | - K K Noskova
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - T I Ivkina
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
| | - S G Khomeriki
- Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow, Russia
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Chaudhry SA, Afzal MR, Kassab A, Hussain SI, Qureshi AI. A New Risk Index for Predicting Outcomes among Patients Undergoing Carotid Endarterectomy in Large Administrative Data Sets. J Stroke Cerebrovasc Dis 2016; 25:1978-83. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/28/2015] [Accepted: 01/16/2016] [Indexed: 11/16/2022] Open
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Bates ER, Babb JD, Casey DE, Cates CU, Duckwiler GR, Feldman TE, Gray WA, Ouriel K, Peterson ED, Rosenfield K, Rundback JH, Safian RD, Sloan MA, White CJ. ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert Consensus Document on Carotid Stenting. Vasc Med 2016; 12:35-83. [PMID: 17451093 DOI: 10.1177/1358863x06076103] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abbott AL, Bladin CF, Levi CR, Chambers BR. What Should We Do with Asymptomatic Carotid Stenosis? Int J Stroke 2016; 2:27-39. [DOI: 10.1111/j.1747-4949.2007.00096.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.
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Affiliation(s)
- Anne L. Abbott
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
| | - Christopher F. Bladin
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
| | - Christopher R. Levi
- Department of Neuroscience, John Hunter Hospital, Lookout Road, Lambton Heights, Newcastle, NSW, 2035, Australia
| | - Brian R. Chambers
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
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McCarthy FH, Groeneveld PW, Kobrin D, McDermott KM, Wirtalla C, Desai ND. Effect of Clinical Trial Experience on Transcatheter Aortic Valve Replacement Outcomes. Circ Cardiovasc Interv 2016; 8:e002234. [PMID: 26286740 DOI: 10.1161/circinterventions.114.002234] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) was approved by the Food and Drug Administration (FDA) in November 2011 after a collaborative technology development process involving professional medical societies, the medical device industry, and the FDA. After FDA approval, TAVR was adopted by numerous hospitals that had not participated in TAVR clinical trials. It is uncertain if outcomes at these hospitals were comparable with those at clinical trial hospitals. METHODS AND RESULTS All patients with Medicare physician claims for TAVR between January 1, 2011, and November 30, 2012, were identified, and postoperative mortality was assessed using Medicare enrollment data. Risk-adjusted mortality was calculated via a multivariable model that adjusted for demographics and comorbidities. We identified 5009 patients who underwent TAVR, with 3617 TAVRs performed at 68 hospitals that had participated in clinical trials and 1392 TAVRs performed at 140 nontrial hospitals. The preoperative characteristics of patients at trial versus nontrial hospitals were similar. There were no significant differences in risk-adjusted 30-day mortality (5.9% versus 5.6%, odds ratio, 0.88; 95% confidence interval, 0.66-1.15; P=0.34) or 180-day mortality (16.5% versus 15.8%, odds ratio, 0.99; 95% confidence interval, 0.75-1.3; P=0.94). CONCLUSIONS Patients undergoing TAVR at nontrial hospitals had comparable clinical outcomes to patients undergoing TAVR at clinical trial hospitals. This finding contrasts with several other cardiovascular devices and procedures for which higher mortality was observed at hospitals that did not participate in clinical trials. The unique policy and regulatory environment governing TAVR adoption by hospitals may have contributed to better outcomes during the technology diffusion process.
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Affiliation(s)
- Fenton H McCarthy
- From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G)
| | - Peter W Groeneveld
- From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G)
| | - Dale Kobrin
- From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G)
| | - Katherine M McDermott
- From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G)
| | - Christopher Wirtalla
- From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G)
| | - Nimesh D Desai
- From the Leonard Davis Institute of Health Economics (F.H.M., P.W.G., N.D.D.), Division of Cardiovascular Surgery, Perelman School of Medicine (F.H.M., D.K., K.M.M., N.D.D.), and Department of Medicine, Perelman School of Medicine (P.W.G, C.W.), University of Pennsylvania, Philadelphia; and Philadelphia Veterans Affairs Medical Center's Center for Health Equity Research and Promotion, PA (P.W.G).
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Abstract
OBJECTIVES To evaluate whether insurance is an unrecognized factor that plays a role in determining whether a patient receives surgery. METHODS A retrospective cross-sectional analysis was performed using the Healthcare Cost and Utilization Project data for Florida in the year 2010. Discharge level data from emergency departments and ambulatory surgery settings were used to identify clavicle fractures by International Classification of Diseases 9 codes 81,000, 81,002, and 81,003. Internal fixation was identified using the Current Procedural Terminology code 23,515. Clavicle fractures that did not result in a Current Procedural Terminology code of 23,515 were assumed to have been managed nonoperatively. Multivariate logistic regression, allowing for intragroup correlation among surgeons, was used to determine the influence of payer source on treatment modality adjusting for race, age, number of chronic conditions, and sex. RESULTS In total, there were 7858 clavicle fractures that met criteria for inclusion. Observations were removed from the analysis if there was missing personal demographic data or if the ability to track patients from the emergency department to follow-up care was not possible. Therefore, the final sample consisted of 5185 clavicle fractures of which 233 received internal fixation (4.5%). The odds of a patient with private insurance receiving internal fixation was 7.58 times [95% confidence interval (CI) = (4.04 to -14.21), P < 0.001] greater than a self-pay patient, all else being held constant. Patients defined by "other" sources of coverage, a group that includes worker's compensation, CHAMPUS (military), CHAMPVA (veterans), or other government insurance other than Medicare and Medicaid were also associated with an increased likelihood of receiving internal fixation by a factor of 6.80 (95% CI = 3.15, 14.64, P < 0.001) relative to self-pay patients, all else being held constant. The likelihood of patients with Medicare or Medicaid receiving internal fixation did not differ statistically from self-pay patients. CONCLUSIONS Patients with any form of insurance, when compared with the self-pay, Medicare, and Medicaid populations, had a higher likelihood of operative intervention in Florida in 2010. This may represent an unintended trend in treatment. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Jalbert JJ, Nguyen LL, Gerhard-Herman MD, Kumamaru H, Chen CY, Williams LA, Liu J, Rothman AT, Jaff MR, Seeger JD, Benenati JF, Schneider PA, Aronow HD, Johnston JA, Brott TG, Tsai TT, White CJ, Setoguchi S. Comparative Effectiveness of Carotid Artery Stenting Versus Carotid Endarterectomy Among Medicare Beneficiaries. Circ Cardiovasc Qual Outcomes 2016; 9:275-85. [DOI: 10.1161/circoutcomes.115.002336] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/21/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Jessica J. Jalbert
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Louis L. Nguyen
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Marie D. Gerhard-Herman
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Hiraku Kumamaru
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Chih-Ying Chen
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Lauren A. Williams
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Jun Liu
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Andrew T. Rothman
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Michael R. Jaff
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - John D. Seeger
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - James F. Benenati
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Peter A. Schneider
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Herbert D. Aronow
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Joseph A. Johnston
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Thomas G. Brott
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Thomas T. Tsai
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Christopher J. White
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
| | - Soko Setoguchi
- From the Division of Pharmacoepidemiology and Pharmacoeconomics (J.J.J., H.K., C.-Y.C., L.A.W., J.L., A.T.R., J.D.S.), Vascular and Endovascular Surgery (L.L.N.), and Cardiovascular Medicine (M.D.G.-H.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; LASER Analytica, New York, NY (J.J.J.); Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA (H.K.); Department of Cardiology, Division of Cardiovascular Medicine, Massachusetts
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Masoudi FA. The evolution of left atrial appendage occlusion: EWOLUTION and the WATCHMAN in practice. Eur Heart J 2016; 37:2475-7. [DOI: 10.1093/eurheartj/ehw041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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McCarthy FH, McDermott KM, Spragan D, Hoedt A, Kini V, Atluri P, Gaffey A, Szeto WY, Acker MA, Desai ND. Unconventional Volume-Outcome Associations in Adult Extracorporeal Membrane Oxygenation in the United States. Ann Thorac Surg 2016; 102:489-95. [PMID: 27130248 DOI: 10.1016/j.athoracsur.2016.02.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/21/2016] [Accepted: 02/01/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND The aim of this study was to evaluate institutional volume-outcome relationships in extracorporeal membrane oxygenation (ECMO) with subanalyses of ECMO in patients with a primary diagnosis of respiratory failure. METHODS All institutions with adult ECMO discharges in the Nationwide Inpatient Sample from 2002 to 2011 were evaluated. International Classification of Diseases (ninth revision) codes were used to identify ECMO-treated patients, indications, and concurrent procedures. Patients who were treated with ECMO after cardiotomy were excluded. Annual institutional and national volume of ECMO hospitalizations varied widely, hence the number of ECMO cases performed at an institution was calculated for each year independently. Institutions were grouped into high-, medium-, and low-volume terciles by year. Statistical analysis included hierarchical, multivariable logistic regression. RESULTS The in-hospital mortality rates for ECMO admissions at low-, medium-, and high-volume ECMO centers were 48% (n = 467), 60% (n = 285), and 57% (n = 445), respectively (p = 0.001). In post hoc pairwise comparisons, patients in low-volume hospitals were more likely to survive to discharge compared with patients in medium-volume (p = 0.001) and high-volume (p = 0.005) hospitals. There was no significant difference in survival between medium-volume and high-volume hospitals (p = 0.81). In a subanalysis of patients with respiratory failure, low-volume ECMO centers maintained the lowest rates of in-hospital mortality (47%), versus 61% in medium-volume institutions (p = 0.045) and 56% in high-volume institutions (p = 0.15). Multivariable logistical regression produced similar results in the entire study sample and in patients with respiratory failure. CONCLUSIONS ECMO outcomes in the Nationwide Inpatient Sample do not follow a traditional volume-outcome relationship, and these results suggest that, in properly selected patients, ECMO can be performed with acceptable results in U.S. centers that do not perform a high volume of ECMO.
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Affiliation(s)
- Fenton H McCarthy
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
| | - Katherine M McDermott
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Danielle Spragan
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Ashley Hoedt
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Vinay Kini
- Division of Cardiovascular Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Ann Gaffey
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael A Acker
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Luebke T, Brunkwall J. Meta- analysis and meta-regression analysis of the associations between sex and the operative outcomes of carotid endarterectomy. BMC Cardiovasc Disord 2015; 15:32. [PMID: 25956903 PMCID: PMC4432947 DOI: 10.1186/s12872-015-0029-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/21/2015] [Indexed: 12/26/2022] Open
Abstract
Background Subgroup analyses from randomized controlled trials (RCT) of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis suggest less benefit in women compared to men, due partly to higher age-independent peri-operative risk. However, a meta-analysis of case series and databases focussing on CEA-related gender differences has never been investigated. Methods A systematic review of all available publications (including case series, databases and RCTs) reporting data on the association between sex and procedural risk of stroke and/or death following CEA from 1980 to 2015 was investigated. Pooled Peto odds ratios of the procedural risk of stroke and/or death were obtained by Mantel-Haenszel random-effects meta-analysis. The I2 statistic was used as a measure of heterogeneity. Potential publication bias was assessed with the Egger test and represented graphically with Begg funnel plots of the natural log of the OR versus its standard error. Additional sensitivity analyses were undertaken to evaluate the potential effect of key assumptions and study-level factors on the overall results. Meta-regression models were formed to explore potential heterogeneity as a result of potential risk factors or confounders on outcomes. A tria sequential analysis (TSA) was performed with the aim to maintain an over- all 5 % risk of type I error, being the standard in most meta- analyses and systematic reviews. Results 58 articles reported combined stroke and mortality rates within 30 days of treatment. In the unselected overall meta-analysis, the incidence of stroke and death in the male and female groups differed significantly (Peto OR, 1,162; 95 % CI, 1.067-1.266; P = .001), revealing a worse outcome for female patients. Moderate heterogeneity among the studies was identified (I2 = 36 %), and the possibility of publication bias was low (P = .03). In sensitivity analyses the meta-analysis of case series with gender aspects as a secondary outcome showed a significantly increased risk for 30-day stroke and death in women compared to men (Peto OR, 1.390; 95 % CI, 1.148-1.684; P = .001), In contrast, meta-analysis of databases (Peto OR, 1.025; 95 % CI, 0.958-1.097; P = .474) and case series with gender related outcomes as a primary aim (Peto OR, 1.202; 95 % CI, 0.925-1.561; P = .168) demonstrated no increase in operative risk of stroke and death in women compared to men. Conclusions Metanalyses of case series and databases dealing with CEA reveal inconsistent results regarding gender differences related to CEA-procedure and should not be transferred into clinical practice.
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Affiliation(s)
- Thomas Luebke
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
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Hawkins BM, Kennedy KF, Aronow HD, Nguyen LL, White CJ, Rosenfield K, Normand SLT, Spertus JA, Yeh RW. Hospital Variation in Carotid Stenting Outcomes. JACC Cardiovasc Interv 2015; 8:858-863. [DOI: 10.1016/j.jcin.2015.01.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 01/14/2015] [Accepted: 01/28/2015] [Indexed: 11/16/2022]
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Watanabe M, Chaudhry SA, Adil MM, Alqadri S, Majidi S, Semaan E, Qureshi AI. The effect of atrial fibrillation on outcomes in patients undergoing carotid endarterectomy or stent placement in general practice. J Vasc Surg 2015; 61:927-32. [DOI: 10.1016/j.jvs.2014.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 11/02/2014] [Indexed: 11/25/2022]
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Kumamaru H, Jalbert JJ, Nguyen LL, Gerhard-Herman MD, Williams LA, Chen CY, Seeger JD, Liu J, Franklin JM, Setoguchi S. Surgeon case volume and 30-day mortality after carotid endarterectomy among contemporary medicare beneficiaries: before and after national coverage determination for carotid artery stenting. Stroke 2015; 46:1288-94. [PMID: 25791713 DOI: 10.1161/strokeaha.114.006276] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 02/20/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE After the 2005 National Coverage Determination to reimburse carotid artery stenting (CAS) for Medicare beneficiaries, the number of CAS procedures increased and carotid endarterectomy (CEA) decreased. We evaluated trends in surgeons' past-year CEA case-volume and 30-day mortality after CEA, and their association before and after the National Coverage Determination. METHODS In a retrospective cohort study of patients undergoing CEA (2001-2008) and CAS (2005-2008) using Medicare data, we described yearly trends of CEA and CAS rates, patient characteristics, and 30-day mortality after CEA. We used logistic regression adjusting for patient- and surgeon-level factors to assess the effect of surgeon case volume on 30-day mortality after CEA. RESULTS We identified 454 717 CEA and 27 943 CAS patients. Patients undergoing CEA in recent years were older and had more comorbidities than earlier years. CEA rates per 10 000 beneficiaries declined from 18.1 in 2002 to 12.7 in 2008, whereas median surgeon past-year case-volume declined from 27 to 21. The CAS rates peaked at 2.3 per 10 000 beneficiaries in 2006 but declined to 1.8 in 2008, resulting in declining overall revascularization procedure rates during 2005 to 2008. Thirty day post-CEA mortality was 1.40% (95% confidence interval, 1.34-1.47) in 2001 to 2002 and 1.17% (1.10-1.24) in 2007 to 2008. Surgeon's past-year case-volume of <10 was associated with higher 30-day mortality consistently during 2001 to 2008. CONCLUSIONS The rate of CEA procedures decreased substantially during 2001 to 2008, as did surgeon past-year case-volume. The postprocedural mortality in Medicare beneficiaries was high compared with trial patients but somewhat improved over time. Those operated by lower past-year case-volume surgeons had increased mortality.
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Affiliation(s)
- Hiraku Kumamaru
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.)
| | - Jessica J Jalbert
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.)
| | - Louis L Nguyen
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.)
| | - Marie D Gerhard-Herman
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.)
| | - Lauren A Williams
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.)
| | - Chih-Ying Chen
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.)
| | - John D Seeger
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.)
| | - Jun Liu
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.)
| | - Jessica M Franklin
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.)
| | - Soko Setoguchi
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (H.K., J.J.J., L.A.W., C.-Y. C., J.D.S., J.L., J.M.F.), Department of Vascular and Endovascular Surgery (L.L.N.), and Department of Cardiovascular Medicine (M.D.G.-H.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard School of Public Health, Boston, MA (H.K.); Laser Analytica, New York, NY (J.J.J.); and Duke Clinical Research Institute, Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (S.S.).
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Reistetter TA, Kuo YF, Karmarkar AM, Eschbach K, Teppala S, Freeman JL, Ottenbacher KJ. Geographic and facility variation in inpatient stroke rehabilitation: multilevel analysis of functional status. Arch Phys Med Rehabil 2015; 96:1248-54. [PMID: 25747551 DOI: 10.1016/j.apmr.2015.02.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 02/18/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke. DESIGN Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions. SETTING Inpatient rehabilitation units and facilities. PARTICIPANTS Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility-Patient Assessment Instrument. RESULTS Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level. CONCLUSIONS Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.
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Affiliation(s)
- Timothy A Reistetter
- Department of Occupational Therapy, University of Texas Medical Branch, Galveston, TX.
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Amol M Karmarkar
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Karl Eschbach
- Internal Medicine-Division of Geriatrics, University of Texas Medical Branch, Galveston, TX
| | - Srinivas Teppala
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Jean L Freeman
- Internal Medicine-Division of Geriatrics, University of Texas Medical Branch, Galveston, TX
| | - Kenneth J Ottenbacher
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
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Abstract
Stroke is the third leading cause of death in developed nations. Up to 88% of strokes are ischemic in nature. Extracranial carotid artery atherosclerotic disease is the third leading cause of ischemic stroke in the general population and the second most common nontraumatic cause among adults younger than 45 years. This article provides comprehensive, evidence-based recommendations for the management of extracranial atherosclerotic disease, including imaging for screening and diagnosis, medical management, and interventional management.
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Affiliation(s)
- Yinn Cher Ooi
- Department of Neurosurgery, University of California, Los Angeles
| | - Nestor R. Gonzalez
- Department of Neurosurgery and Radiology, University of California, Los Angeles, 100 UCLA Med Plaza Suite# 219, Los Angeles, CA 90095, +1(310)825-5154
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Okawa M, Ogata T, Abe H, Fukuda K, Higashi T, Inoue T. Do Octogenarians Still Have a High Risk of Adverse Outcomes after Carotid Endarterectomy in the Era of a Super-aged Society? A Single-center Study in Japan. J Stroke Cerebrovasc Dis 2015; 24:370-3. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 11/26/2022] Open
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Abstract
For a variety of neurosurgical conditions, increasing surgeon and hospital volumes correlate with improved outcomes, such as mortality, complication rates, length of stay, hospital charges, and discharge disposition. Neurosurgeons can improve patient outcomes at the population level by changing practice and referral patterns to regionalize care for select conditions at high-volume specialty treatment centers. Individual practitioners should be aware of where they fall on the volume spectrum and understand the implications of their practice and referral habits on their patients.
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Bennett KM, Scarborough JE, Shortell CK. Predictors of 30-day postoperative stroke or death after carotid endarterectomy using the 2012 carotid endarterectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg 2014; 61:103-11. [PMID: 25065581 DOI: 10.1016/j.jvs.2014.05.100] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 05/31/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study used a recently released procedure-targeted multicenter data source to determine independent predictors of postoperative stroke or death in patients undergoing carotid endarterectomy (CEA) for carotid artery stenosis. METHODS The 2012 CEA-targeted American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was used for this study. Patient, disease, and procedure characteristics of patients undergoing CEA were assessed. Multivariate logistic regression analysis was used to determine independent risk factors for 30-day postoperative stroke/death or other major complications. RESULTS The analysis included 3845 patients undergoing CEA (58.1% with asymptomatic and 41.9% with symptomatic carotid disease). The overall 30-day postoperative stroke/death rate was 3.0% (1.9% in asymptomatic patients, 4.6% in symptomatic patients). The variables that maintained an independent association with postoperative stroke/death after adjustment for other known patient-related and procedure-related factors were age ≥80 years, active smoking, contralateral internal carotid artery stenosis of 80% to 99%, emergency procedure status, preoperative stroke, presence of one or more ACS NSQIP-defined high-risk characteristics (including any or all of New York Heart Association class III/IV congestive heart failure, left ventricular ejection fraction <30%, recent unstable angina, or recent myocardial infarction), and operative time ≥150 minutes. CONCLUSIONS After adjustment for a comprehensive array of patient-related and procedure-related variables of particular import to patients with carotid artery stenosis, we have identified several factors that are independently associated with early stroke or death after CEA. These factors are generally related to the comorbid condition of CEA patients and to specific characteristics of their carotid disease, and not to technical features of the CEA procedure. Knowledge of these factors will assist surgeons in selecting appropriate patients for this procedure.
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Affiliation(s)
- Kyla M Bennett
- Department of Surgery, Duke University Medical Center, Durham, NC
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Abstract
Objectives: Procedures and new medical devices are typically introduced into healthcare systems with limited evidence, when they might be ineffective or unsafe. Systematic data collection (“registers”) can provide valuable “real world” evidence, but difficulties in funding registers are a major obstacle. A good economic case for the value of registers would therefore be useful.Methods: (i) Literature search on specific purposes of registers. (ii) Surveys (a) of senior clinicians involved with registers, seeking examples of beneficial outcomes, and (b) of administrators, regarding costs of running registers. (iii) A scoping exercise for possible methods to value (financially) the outputs of registers.Results: Four main categories of beneficial outcomes from registers were identified. These were—safety and quality assurance; training and quality improvement; complementing trial evidence and reducing uncertainty; and supporting trial research. Explicit examples of all these are presented, together with information about the costs of registers. Combining these with the scoping exercise we present suggestions for a methodology of assessing the value of registers across each of the categories.Conclusions: This study is unique in addressing methods for determining the financial value of registers, based on the amount they cost versus the financial benefits which may result from the evidence generated. Developing the suggested methods could support the case for funding new registers, by showing that their use can benefit healthcare systems through more efficient use of resources, so justifying their costs.
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