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Halfwerk FR, Wielens N, Hulskotte S, Brusse-Keizer M, Grandjean JG. A mobilization poster stimulates early in-hospital rehabilitation after cardiac surgery: a prospective sequential-group study. J Cardiothorac Surg 2023; 18:83. [PMID: 36895040 PMCID: PMC9999498 DOI: 10.1186/s13019-023-02173-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/28/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Patients infrequently mobilize at the surgical ward after cardiac surgery. Inactivity results in prolonged hospital stay, readmissions and increased cardiovascular mortality. Next, the course of in-hospital mobilization activities for patients is unclear. The aim was to evaluate early mobilization after heart surgery with a mobilization poster on the Activity Classification Guide for Inpatient Activities score from the American College for Sports Medicine (ACSM). Second, to develop a Thorax Centrum Twente (TCT) score to assess distinctive activities performed. METHODS A poster was developed for the Moving is Improving! study to stimulate hospital mobilization after heart surgery. In this sequential-group study at a cardiothoracic surgery ward, 32 patients were included in the usual care group and 209 patients in the poster mobilization group. Change of ACSM and TCT scores over time were both defined as primary endpoints. Secondary endpoints included length of stay and survival. A subgroup analysis for coronary artery bypass grafting (CABG) was performed. RESULTS ACSM score increased during hospital stay (p < 0.001). No significant increase of ACSM score was observed with a mobilization poster (p = 0.27), nor in the CABG subgroup (p = 0.15). The poster increased mobility to chair, toilet, corridor (all p < 0.01) and cycle ergometer (p = 0.02) as measured by the activity-specific TCT scores, without differences in length of stay or survival. CONCLUSIONS ACSM score measured day-to-day functional changes, without significant differences between the poster mobilization and usual care group. Actual activities measured with the TCT score did improve. The mobilization poster is now new standard care, and effects in other centers and other departments should be assessed. TRIAL REGISTRATION This study does not fall under the ICMJE trial definition and was not registered.
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Affiliation(s)
- Frank R Halfwerk
- Department of Cardio-Thoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, PO Box 50000, 7500 KA, Enschede, The Netherlands. .,Department of Biomechanical Engineering, TechMed Centre, University of Twente, PO Box 217, 7500 AE, Enschede, The Netherlands.
| | - Nicole Wielens
- Department of Cardio-Thoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, PO Box 50000, 7500 KA, Enschede, The Netherlands
| | - Stephanie Hulskotte
- Department of Cardio-Thoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, PO Box 50000, 7500 KA, Enschede, The Netherlands
| | | | - Jan G Grandjean
- Department of Cardio-Thoracic Surgery, Thorax Centrum Twente, Medisch Spectrum Twente, PO Box 50000, 7500 KA, Enschede, The Netherlands.,Department of Biomechanical Engineering, TechMed Centre, University of Twente, PO Box 217, 7500 AE, Enschede, The Netherlands
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Du M, Prats-Uribe A, Khalid S, Prieto-Alhambra D, Strauss VY. Random effects modelling versus logistic regression for the inclusion of cluster-level covariates in propensity score estimation: A Monte Carlo simulation and registry cohort analysis. Front Pharmacol 2023; 14:988605. [PMID: 37033623 PMCID: PMC10077146 DOI: 10.3389/fphar.2023.988605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
Purpose: Surgeon and hospital-related features, such as volume, can be associated with treatment choices and outcomes. Accounting for these covariates with propensity score (PS) analysis can be challenging due to the clustered nature of the data. We studied six different PS estimation strategies for clustered data using random effects modelling (REM) compared with logistic regression. Methods: Monte Carlo simulations were used to generate variable cluster-level confounding intensity [odds ratio (OR) = 1.01-2.5] and cluster size (20-1,000 patients per cluster). The following PS estimation strategies were compared: i) logistic regression omitting cluster-level confounders; ii) logistic regression including cluster-level confounders; iii) the same as ii) but including cross-level interactions; iv), v), and vi), similar to i), ii), and iii), respectively, but using REM instead of logistic regression. The same strategies were tested in a trial emulation of partial versus total knee replacement (TKR) surgery, where observational versus trial-based estimates were compared as a proxy for bias. Performance metrics included bias and mean square error (MSE). Results: In most simulated scenarios, logistic regression, including cluster-level confounders, led to the lowest bias and MSE, for example, with 50 clusters × 200 individuals and confounding intensity OR = 1.5, a relative bias of 10%, and MSE of 0.003 for (i) compared to 32% and 0.010 for (iv). The results from the trial emulation also gave similar trends. Conclusion: Logistic regression, including patient and surgeon-/hospital-level confounders, appears to be the preferred strategy for PS estimation.
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Affiliation(s)
- Mike Du
- Botnar Research Centre, Nuffield Orthopaedic Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Albert Prats-Uribe
- Botnar Research Centre, Nuffield Orthopaedic Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sara Khalid
- Botnar Research Centre, Nuffield Orthopaedic Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Daniel Prieto-Alhambra
- Botnar Research Centre, Nuffield Orthopaedic Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- *Correspondence: Daniel Prieto-Alhambra,
| | - Victoria Y. Strauss
- Botnar Research Centre, Nuffield Orthopaedic Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Boehringer-Ingelheim Pharma GmbH & Co., KG, Ingelheim, Germany
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Mohammadi T, Roshanaei G, Faradmal J, Sadeghifar M, Manafi B, Mahjub H. Improving service efficiency and throughput of cardiac surgery patients using Monte Carlo simulation: a queueing setting. Sci Rep 2022; 12:21217. [PMID: 36481779 DOI: 10.1038/s41598-022-25689-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
Bed occupancy rate (BOR) is important for healthcare policymakers. Studies showed the necessity of using simulation approach when encountering complex real-world problems to plan the optimal use of resources and improve the quality of services. So, the aim of the present study is to estimate average length of stay (LOS), BOR, bed blocking probability (BBP), and throughput of patients in a cardiac surgery department (CSD) using simulation models. We studied the behavior of a CSD as a complex queueing system at the Farshchian Hospital. In the queueing model, customers were patients and servers were beds in intensive care unit (ICU) and post-operative ward (POW). A computer program based on the Monte Carlo simulation, using Python software, was developed to evaluate the behavior of the system under different number of beds in ICU and POW. The queueing simulation study showed that, for a fixed number of beds in ICU, BOR in POW decreases as the number of beds in POW increases and LOS in ICU increases as the number of beds in POW decreases. Also, based on the available data, the throughput of patients in the CSD during 800 days was 1999 patients. Whereas, the simulation results showed that, 2839 patients can be operated in the same period. The results of the simulation study clearly demonstrated the behavior of the CSD; so, it must be mentioned, hospital administrators should design an efficient plan to increase BOR and throughput of patients in the future.
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Schnelle C, Clark J, Mascord R, Jones MA. Is There a Doctors' Effect on Patients' Physical Health, Beyond the Intervention and All Known Factors? A Systematic Review. Ther Clin Risk Manag 2022; 18:721-737. [PMID: 35903086 PMCID: PMC9314759 DOI: 10.2147/tcrm.s372464] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/11/2022] [Indexed: 01/10/2023] Open
Abstract
Purpose Despite billions of doctor visits worldwide each year, little is known on whether doctors themselves affect patients’ physical health after accounting for intervention and confounders such as patients’ and doctors’ data, hospital effects, nor how strong that doctors’ effect is. Knowledge of surgeons’ and psychotherapists’ effects exists, but not for 102 other medical specialties notwithstanding the importance of such knowledge. Methods Eligibility Criteria: Randomized controlled trials (RCTs), case-control, and cohort studies including medical doctors except surgeons for any intervention, reporting the proportion of variance in patients’ outcomes owing to the doctors (random effects), or the fixed effects of grading doctors by outcomes, after multivariate adjustment. Exclusions: studies of <15 doctors or solely reporting doctors’ effects for known variables. Sources Medline, Embase, PsycINFO, inception to June 2020. Manual search for papers referring/referred to by resulting studies. Risk of Bias Using Newcastle–Ottawa scale. Results Despite all medical interventions bar surgery being eligible, only thirty cohort papers were found, covering 36,239 doctors, with 10 specialties, 21 interventions, 60 outcomes (17 unique). Studies reported doctors’ effects by grading doctors from best to worst, or by diversely calculating the doctor-attributed percentage of patients’ outcome variation, ie the intra-class correlation coefficient (ICC). Sixteen studies presented fixed effects, 18 random effects, and 3 another approach. No RCTs found. Thirteen studies reported exceptionally good and/or poor performers with confidence intervals wholly outside the average performance. ICC range 0 to 33%, mean 3.9%. Highly diverse reporting, meta-analysis therefore not applicable. Conclusion Doctors, on their own, can affect patients’ physical health for many interventions and outcomes. Effects range from negligible to substantial, even after accounting for all known variables. Many published cohorts may reveal valuable information by reanalyzing their data for doctors’ effects. Positive and negative doctor outliers appear regularly. Therefore, it can matter which doctor is chosen. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/uXjR7VOXTwQ
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Affiliation(s)
- Christoph Schnelle
- Institute of Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
| | - Justin Clark
- Institute of Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
| | - Rachel Mascord
- General Dentist, BMA House, Sydney, New South Wales, Australia
| | - Mark A Jones
- Institute of Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
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Schnelle C, Jones MA. The Doctors' Effect on Patients' Physical Health Outcomes Beyond the Intervention: A Methodological Review. Clin Epidemiol 2022; 14:851-870. [PMID: 35879943 PMCID: PMC9307914 DOI: 10.2147/clep.s357927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/22/2022] [Indexed: 01/02/2023] Open
Abstract
Background Previous research suggests that when a treatment is delivered, patients’ outcomes may vary systematically by medical practitioner. Objective To conduct a methodological review of studies reporting on the effect of doctors on patients’ physical health outcomes and to provide recommendations on how this effect could be measured and reported in a consistent and appropriate way. Methods The data source was 79 included studies and randomized controlled trials from a systematic review of doctors’ effects on patients’ physical health. We qualitatively assessed the studies and summarized how the doctors’ effect was measured and reported. Results The doctors’ effects on patients’ physical health outcomes were reported as fixed effects, identifying high and low outliers, or random effects, which estimate the variation in patient health outcomes due to the doctor after accounting for all available variables via the intra-class correlation coefficient. Multivariable multilevel regression is commonly used to adjust for patient risk, doctor experience and other demographics, and also to account for the clustering effect of hospitals in estimating both fixed and random effects. Conclusion This methodological review identified inconsistencies in how the doctor’s effect on patients’ physical health outcomes is measured and reported. For grading doctors from worst to best performances and estimating random effects, specific recommendations are given along with the specific data points to report. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/rvHjVIEPVhI
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Affiliation(s)
- Christoph Schnelle
- Institute of Evidence-Based Healthcare, Bond University, Robina, QLD, 4226, Australia
| | - Mark A Jones
- Institute of Evidence-Based Healthcare, Bond University, Robina, QLD, 4226, Australia
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Schnelle C, Clark J, Mascord R, Jones MA. Is There a Surgeons’ Effect on Patients’ Physical Health, Beyond the Intervention, That Requires Further Investigation? A Systematic Review. Ther Clin Risk Manag 2022; 18:467-490. [PMID: 35502434 PMCID: PMC9056050 DOI: 10.2147/tcrm.s357934] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/04/2022] [Indexed: 12/23/2022] Open
Abstract
Objective To find and review published papers researching surgeons’ effects on patients’ physical health. Clinical outcomes of surgery patients with similar prognoses cannot be fully explained by surgeon skill or experience. Just as there are “hospital” and “psychotherapist” effects, there may be “surgeons” effects that persist after controlling for known variables like patient health and operation riskiness. Methods Cohort studies and randomized controlled trials (RCTs) of any surgical intervention, which, after multivariate adjustment, either showed proportion of variance in patients’ physical health outcomes due to surgeons (random effects) or graded surgeons from best to worst (fixed effects). Studies with <15 surgeons or only ascribing surgeons’ effects to known variables excluded. Medline, PubMed, Embase, and PsycINFO were used for search until June 2020. Manual search for papers referring/referred by resulting studies. Risk of bias assessed by Cochrane risk-of-bias tool and Newcastle–Ottawa Scale. Results Included studies: 52 cohort studies and three RCTs of 52,436+ surgeons covering 102 outcomes (33 unique). Studies either graded surgeons from best to worst or calculated the intra-class correlation coefficient (ICC), the percentage of patients’ variation due to surgeons, in diverse ways. Sixteen studies showed exceptionally good and/or bad performers with confidence intervals wholly above or below the average performance. ICCs ranged from 0 to 47%, median 4.0%. There are no well-established reporting standards; highly heterogeneous reporting, therefore no meta-analysis. Discussion Interpretation: There is a surgeons' effect on patients’ physical health for many types of surgeries and outcomes, ranging from small to substantial. Surgeons with exceptional patient outcomes appear regularly even after accounting for all known confounding variables. Many existing cohort studies and RCTs could be reanalyzed for surgeons’ effects especially after methodological reporting guidelines are published. Conclusion In terms of patient outcomes, it can matter which surgeon is chosen. Surgeons with exceptional patient outcomes are worth studying further. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/pL-eGyAGhSk
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Affiliation(s)
- Christoph Schnelle
- Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
- Correspondence: Christoph Schnelle, Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia, Email
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
| | - Rachel Mascord
- General Dentist, BMA House, Sydney, New South Wales, Australia
| | - Mark A Jones
- Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
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Sutton TS, McKay RG, Mather J, Takata E, Eschert J, Cox M, Douglas A, McLaughlin T, Loya D, Mennett R, Cech MG, Hinchey J, Walker A, Hammond J, Hashim S. Enhanced Recovery After Surgery is Associated with Improved Outcomes and Reduced Racial and Ethnic Disparities Following Isolated Coronary Artery Bypass Surgery: A Retrospective Analysis with Propensity Score Matching. J Cardiothorac Vasc Anesth 2022; 36:2418-2431. [DOI: 10.1053/j.jvca.2022.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 11/11/2022]
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Bouza E, de Alarcón A, Fariñas MC, Gálvez J, Goenaga MÁ, Gutiérrez-Díez F, Hortal J, Lasso J, Mestres CA, Miró JM, Navas E, Nieto M, Parra A, Pérez de la Sota E, Rodríguez-Abella H, Rodríguez-Créixems M, Rodríguez-Roda J, Sánchez Espín G, Sousa D, Velasco García de Sierra C, Muñoz P, Kestler M. Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections ( SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery ( SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases ( CIBERES). J Clin Med 2021; 10:5566. [PMID: 34884268 PMCID: PMC8658224 DOI: 10.3390/jcm10235566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 01/04/2023] Open
Abstract
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
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Affiliation(s)
- Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | | | - Juan Gálvez
- Virgen Macarena University Hospital, 41009 Seville, Spain;
| | | | - Francisco Gutiérrez-Díez
- Cardiovascular Surgery Department, Marques de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | - Javier Hortal
- Anesthesia and Intensive Care Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - José Lasso
- Plastic Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Carlos A. Mestres
- Department of Cardiac Surgery, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - José M. Miró
- Infectious Diseases Services, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Enrique Navas
- Infectious Diseases Department, Ramón y Cajal University Hospital, 28034 Madrid, Spain;
| | - Mercedes Nieto
- Cardiovascular Unit, Intensive Care Department, San Carlos Clinical Hospital, 28040 Madrid, Spain;
| | - Antonio Parra
- Department of Radiology, Marquez de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | | | - Hugo Rodríguez-Abella
- Cardiac Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Marta Rodríguez-Créixems
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | - Gemma Sánchez Espín
- Heart Clinical Management Unit, Virgen de la Victoria University Hospital, 29006 Malaga, Spain;
| | - Dolores Sousa
- Infectious Diseases Department, A Coruña Hospital Complex, 15006 A Coruña, Spain;
| | | | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | - Martha Kestler
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
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Kyle B, Zawadka M, Shanahan H, Cooper J, Rogers A, Hamarneh A, Sivaraman V, Anwar S, Smith A. Consensus Defined Diastolic Dysfunction and Cardiac Postoperative Morbidity Score: A Prospective Observational Study. J Clin Med 2021; 10:jcm10215198. [PMID: 34768718 PMCID: PMC8584550 DOI: 10.3390/jcm10215198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022] Open
Abstract
Diastolic dysfunction is associated with major adverse outcomes following cardiac surgery. We hypothesized that multisystem endpoints of morbidity would be higher in patients with diastolic dysfunction. A total of 142 patients undergoing cardiac surgical procedures with cardiopulmonary bypass were included in the study. Intraoperative assessments of diastolic function according to the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines using transesophageal echocardiography were performed. Cardiac Postoperative Morbidity Score (CPOMS) on days 3, 5, 8, and 15; length of stay in ICU and hospital; duration of intubation; incidence of new atrial fibrillation; 30-day major adverse cardiac and cerebrovascular events were recorded. Diastolic function was determinable in 96.7% of the dataset pre and poststernotomy assessment (n = 240). Diastolic dysfunction was present in 70.9% (n = 88) of measurements before sternotomy and 75% (n = 93) after sternal closure. Diastolic dysfunction at either stage was associated with greater CPOMS on D5 (p = 0.009) and D8 (p = 0.009), with CPOMS scores 1.24 (p = 0.01) higher than in patients with normal function. Diastolic dysfunction was also associated with longer durations of intubation (p = 0.001), ICU length of stay (p = 0.019), and new postoperative atrial fibrillation (p = 0.016, OR (95% CI) = 4.50 (1.22–25.17)). We were able to apply the updated ASE/EACVI guidelines and grade diastolic dysfunction in the majority of patients. Any grade of diastolic dysfunction was associated with greater all-cause morbidity, compared with patients with normal diastolic function.
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Affiliation(s)
- Bonnie Kyle
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
| | - Mateusz Zawadka
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
- NIHR Biomedical Research Centre, William Harvey Research Institute, Barts, Queen Mary University of London, London E1 4NS, UK;
- 2 Department of Anesthesiology and Intensive Care, Medical University of Warsaw, 02-091 Warsaw, Poland
- Polish National Agency for Academic Exchange, 00-635 Warsaw, Poland
- Correspondence: ; Tel.: +48-5992-002
| | - Hilary Shanahan
- Department of Anaesthesia and Critical Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB2 0AY, UK;
| | - Jackie Cooper
- NIHR Biomedical Research Centre, William Harvey Research Institute, Barts, Queen Mary University of London, London E1 4NS, UK;
| | - Andrew Rogers
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
| | - Ashraf Hamarneh
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
| | - Vivek Sivaraman
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
| | - Sibtain Anwar
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
- NIHR Biomedical Research Centre, William Harvey Research Institute, Barts, Queen Mary University of London, London E1 4NS, UK;
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Andrew Smith
- Perioperative Medicine, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, UK; (B.K.); (A.R.); (A.H.); (S.A.); (A.S.)
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Cromhout PF, Thygesen LC, Moons P, Nashef S, Damgaard S, Berg SK. Social and emotional factors as predictors of poor outcomes following cardiac surgery. Interact Cardiovasc Thorac Surg 2021; 34:193-200. [PMID: 34606597 PMCID: PMC8766216 DOI: 10.1093/icvts/ivab261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/21/2021] [Accepted: 08/13/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Existing risk prediction models in cardiac surgery stratify individuals based on their predicted risk, including only medical and physiological factors. However, the complex nature of risk assessment and the lack of parameters representing non-medical aspects of patients’ lives point towards the need for a broader paradigm in cardiac surgery. Objectives were to evaluate the predictive value of emotional and social factors on 4 outcomes; death within 90 days, prolonged stay in intensive care (≥72 h), prolonged hospital admission (≥10 days) and readmission within 90 days following cardiac surgery, as a supplement to traditional risk assessment by European System for Cardiac Operative Risk Evaluation (EuroSCORE). METHODS The study included adults undergoing cardiac surgery in Denmark 2014–2017 including information on register-based socio-economic factors, and, in a nested subsample, self-reported symptoms of anxiety and depression. Logistic regression analyses were conducted, adjusted for EuroSCORE, of variables reflecting social and emotional factors. RESULTS Amongst 7874 included patients, lower educational level (odds ratio 1.33; 95% confidence interval 1.17–1.51) and living alone (1.25; 1.14–1.38) were associated with prolonged hospital admission after adjustment for EuroSCORE. Lower educational level was also associated with prolonged intensive care unit stay (1.27; 1.00–1.63). Having a high income was associated with decreased odds of prolonged hospital admission (0.78; 0.70–0.87). No associations or predictive value for symptoms of anxiety or depression were found on any outcomes. CONCLUSIONS Social disparity is predictive of poor outcomes following cardiac surgery. Symptoms of anxiety and depression are frequent especially amongst patients with a high-risk profile according to EuroSCORE. Subj collection 105, 123
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Affiliation(s)
| | - Lau Caspar Thygesen
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Philip Moons
- Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium.,Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Samer Nashef
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Sune Damgaard
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Selina Kikkenborg Berg
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
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11
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Seddigh S, Lethbridge L, Theriault P, Matwin S, Dunbar MJ. Association between surgical wait time and hospital length of stay in primary total knee and hip arthroplasty. Bone Jt Open 2021; 2:679-684. [PMID: 34409843 PMCID: PMC8384439 DOI: 10.1302/2633-1462.28.bjo-2021-0033.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS In countries with social healthcare systems, such as Canada, patients may experience long wait times and a decline in their health status prior to their operation. The aim of this study is to explore the association between long preoperative wait times (WT) and acute hospital length of stay (LoS) for primary arthroplasty of the knee and hip. METHODS The study population was obtained from the provincial Patient Access Registry Nova Scotia (PARNS) and the Canadian national hospital Discharge Access Database (DAD). We included primary total knee and hip arthroplasties (TKA, THA) between 2011 and 2017. Patients waiting longer than the recommended 180 days Canadian national standard were compared to patients waiting equal or less than the standard WT. The primary outcome measure was acute LoS postoperatively. Secondarily, patient demographics, comorbidities, and perioperative parameters were correlated with LoS with multivariate regression. RESULTS A total of 11,833 TKAs and 6,627 THAs were included in the study. Mean WT for TKA was 348 days (1 to 3,605) with mean LoS of 3.6 days (1 to 98). Mean WT for THA was 267 days (1 to 2,015) with mean LoS of 4.0 days (1 to 143). There was a significant increase in mean LoS for TKA waiting longer than 180 days (2.5% (SE 1.1); p = 0.028). There was no significant association for THA. Age, sex, surgical year, admittance from home, rural residence, household income, hospital facility, the need for blood transfusion, and comorbidities were all found to influence LoS. CONCLUSION Surgical WT longer than 180 days resulted in increased acute LoS for primary TKA. Meeting a shorter WT target may be cost-saving in a social healthcare system by having shorter LoS. Cite this article: Bone Jt Open 2021;2(8):679-684.
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Affiliation(s)
- Shahriar Seddigh
- Department of Orthopaedic Surgery, Nova Scotia Health Authority, Halifax, Canada
| | - Lynn Lethbridge
- Department of Surgery, Dalhousie University, Halifax, Canada
| | - Patrick Theriault
- Department of Orthopaedic Surgery, Nova Scotia Health Authority, Halifax, Canada
| | - Stan Matwin
- Faculty of Computer Science, Dalhousie University, Halifax, Canada
| | - Michael J. Dunbar
- Division of Orthopaedic Surgery, Nova Scotia Health Authority, Halifax, Canada
- School of Biomedical Engineering, Dalhousie University, Halifax, Canada
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12
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Edgar K, Roberts I, Sharples L. Including random centre effects in design, analysis and presentation of multi-centre trials. Trials 2021; 22:357. [PMID: 34022937 PMCID: PMC8140487 DOI: 10.1186/s13063-021-05266-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 04/13/2021] [Indexed: 01/03/2023] Open
Abstract
Background In large multicentre trials in diverse settings, there is uncertainty about the need to adjust for centre variation in design and analysis. A key distinction is the difference between variation in outcome (independent of treatment) and variation in treatment effect. Through re-analysis of the CRASH-2 trial (2010), this study clarifies when and how to use multi-level models for multicentre studies with binary outcomes. Methods CRASH-2 randomised 20,127 trauma patients across 271 centres and 40 countries to either single-dose tranexamic acid or identical placebo, with all-cause death at 4 weeks the primary outcome. The trial data had a hierarchical structure, with patients nested in hospitals which in turn are nested within countries. Reanalysis of CRASH-2 trial data assessed treatment effect and both patient and centre level baseline covariates as fixed effects in logistic regression models. Random effects were included to assess where there was variation between countries, and between centres within countries, both in underlying risk of death and in treatment effect. Results In CRASH-2, there was significant variation between countries and between centres in death at 4 weeks, but absolutely no differences between countries or centres in the effect of treatment. Average treatment effect was not altered after accounting for centre and country variation in this study. Conclusions It is important to distinguish between underlying variation in outcomes and variation in treatment effects; the former is common but the latter is not. Stratifying randomisation by centre overcomes many statistical problems and including random intercepts in analysis may increase power and decrease bias in mean and standard error estimates. Trial registration Current Controlled Trials ISRCTN86750102, ClinicalTrials.gov NCT00375258, and South African Clinical Trial Register DOH-27-0607-1919 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05266-w.
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Affiliation(s)
- Kate Edgar
- Department of Medical Statistics, LSHTM, Keppel Street, London, WC1E 7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, LSHTM, Keppel Street, London, WC1E 7HT, UK
| | - Linda Sharples
- Department of Medical Statistics, LSHTM, Keppel Street, London, WC1E 7HT, UK.
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13
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Zarrizi M, Paryad E, Khanghah AG, Leili EK, Faghani H. Predictors of Length of Stay in Intensive Care Unit after Coronary Artery Bypass Grafting: Development a Risk Scoring System. Braz J Cardiovasc Surg 2021; 36:57-63. [PMID: 33594861 PMCID: PMC7918390 DOI: 10.21470/1678-9741-2019-0405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Introduction To determine predictors of length of stay (LOS) in the intensive care unit (ICU) after coronary artery bypass grafting (CABG) and to develop a risk scoring system were the objectives of this study. Methods In this retrospective study, 1202 patients' medical records after CABG were evaluated by a research-made checklist. Tarone-Ware test was used to determine the predictors of patients' LOS in the ICU. Cox regression model was used to determine the risk factors and risk ratios associated with ICU LOS. Results The mean ICU LOS after CABG was 55.27±17.33 hours. Cox regression model showed that having more than two chest tubes (95% confidence interval [CI] 1.005-1.287, Relative Risk [RR]=1.138), occurrence of atelectasis (95% CI 1.000-3.007, RR=1.734), and occurrence of atrial fibrillation after CABG (95% CI 1.428-2.424, RR=1.861) were risk factors associated with longer ICU LOS. The discrimination power of this set of predictors was demonstrated with an area under the receiver operating characteristic curve and it was 0.69. A simple risk scoring system was developed based on three identified predictors that can raise ICU LOS. Conclusion The simple risk scoring system developed based on three identified predictors can help to plan more accurately a patient's LOS in hospital for CABG and can be useful in managing human and financial resources.
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Affiliation(s)
- Maryam Zarrizi
- Critical Care Nursing, Dr. Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Ezzat Paryad
- Department of Nursing (Medical-surgical), GI Cancer Screening and Prevention Research Center (GCSPRC), School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | - Atefeh Ghanbari Khanghah
- Department of Nursing (Medical-surgical), Social Determinants of Health Research Center (SDHRC), School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | - Ehsan Kazemnezhad Leili
- Department of Biostatistics, Social Determinants of Health Research Center (SDHRC), Guilan University of Medical Sciences, Rasht, Iran
| | - Hamed Faghani
- Critical Care Nursing, Dr. Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran
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14
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Li D, Zhou X, Li M. Arterial duct stent versus surgical shunt for patients with duct-dependent pulmonary circulation: a meta-analysis. BMC Cardiovasc Disord 2021; 21:9. [PMID: 33407150 PMCID: PMC7789398 DOI: 10.1186/s12872-020-01817-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 12/08/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Both systemic-pulmonary shunt and arterial duct stent could be the palliation of duct-dependent pulmonary circulation. We aimed to compare the safety and efficacy of the two approaches. METHODS The PubMed, EMBASE, and Cochrane Library databases were searched through December 2019 for studies comparing stent implantation and surgical shunt in duct-dependent pulmonary circulation. The baseline characteristics included ventricle physiology and cardiac anomaly. The main outcomes were hospital stay and total mortality. Additional outcomes included procedural complications, intensive care unit (ICU) stay, pulmonary artery growth at follow-up, and other indexes. A random- or fixed-effects model was used to summarize the estimates of the mean difference (MD)/risk ratio (RR) with 95% confidence intervals (CIs). RESULTS In total, 757 patients with duct-dependent pulmonary circulation from six studies were included. Pooled estimates of hospital stay (MD, - 4.83; 95% CI - 7.92 to - 1.74; p < 0.05), total mortality (RR 0.44; 95% CI 0.28-0.70; p < 0.05), complications (RR 0.49; 95% CI 0.30-0.81; p < 0.05) and ICU stay (MD, - 4.00; 95% CI - 5.96 to - 2.04; p < 0.05) favored the stent group. Significant differences were found in the proportions of patients with a single ventricle (RR 0.82; 95% CI 0.68-0.98; p < 0.05) or a double ventricle (RR 1.23; 95% CI 1.07-1.41; p < 0.05) between the stent and shunt groups. Additionally, pulmonary artery growth showed no significant differences between the two groups. CONCLUSION Arterial duct stent appears to have not inferior outcomes of procedural complications, mortality, hospital and ICU stay, and pulmonary artery growth in selected patients compared with a surgical shunt. TRIAL REGISTRATION CRD42019147672.
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MESH Headings
- Blalock-Taussig Procedure/adverse effects
- Blalock-Taussig Procedure/mortality
- Cardiac Catheterization/adverse effects
- Cardiac Catheterization/instrumentation
- Cardiac Catheterization/mortality
- Child
- Child, Preschool
- Ductus Arteriosus, Patent/diagnostic imaging
- Ductus Arteriosus, Patent/mortality
- Ductus Arteriosus, Patent/physiopathology
- Ductus Arteriosus, Patent/therapy
- Female
- Heart Defects, Congenital/diagnostic imaging
- Heart Defects, Congenital/mortality
- Heart Defects, Congenital/physiopathology
- Heart Defects, Congenital/therapy
- Hemodynamics
- Humans
- Infant
- Infant, Newborn
- Length of Stay
- Male
- Palliative Care
- Pulmonary Artery/abnormalities
- Pulmonary Artery/diagnostic imaging
- Pulmonary Artery/growth & development
- Pulmonary Artery/surgery
- Pulmonary Circulation
- Recovery of Function
- Stents
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Dongxu Li
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
| | - Xu Zhou
- Evidence-Based Medicine Research Center, Jiangxi University of Traditional Chinese Medicine, Nanchang, People's Republic of China
| | - Mengsi Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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15
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Hauguel-Moreau M, Naudin C, N’Guyen L, Squara P, Rosencher J, Makowski S, Beverelli F. Smart bracelet to assess physical activity after cardiac surgery: A prospective study. PLoS One 2020; 15:e0241368. [PMID: 33259484 PMCID: PMC7707519 DOI: 10.1371/journal.pone.0241368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/30/2020] [Indexed: 11/18/2022] Open
Abstract
Objectives Little is known about the physical activity of patients after cardiac surgery. This study was designed to assess this activity using a connected bracelet. Methods In this prospective, monocentric study, patients scheduled for cardiac surgery were offered to wear an electronic bracelet. The main objective was to measure the physical activity recovery. Secondary objectives were the predictors of the correct use of the monitoring system, of the physical recovery and, if any, the relationship between physical activity and out-of-hospital morbidity. Results One hundred patients were included. Most patients (86%) were interested in participating in the study. The compliance to the device and to the study protocol was good (94%). At discharge, the mean number of daily steps was 1454 ± 145 steps, increasing quite homogeneously, reaching 5801±1151 steps at Day 60. The best fit regression curve gave a maximum number of steps at 5897±119 (r2 = 0.97). The 85% level of activity was achieved at Day 30±3. No predictor of noncompliance was found. At discharge, age was independently associated with a lower number of daily steps (p <0.001). At Day 60, age, peripheral arterial disease and cardio-pulmonary bypass duration were independently associated with a lower number of daily steps (p = 0.039, p = 0.041 and p = 0.033, respectively). Conclusions After cardiac surgery, wearing a smart bracelet recording daily steps is simple, well tolerated and suitable for measuring physical activity. Standard patients achieved around 6000 daily steps 2 months after discharge. 85% of this activity is reached in the first month. Clinical trial registry number NCT03113565
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Affiliation(s)
| | - Cécile Naudin
- Research Department, CMC Ambroise Paré, Neuilly sur Seine, France
| | - Lee N’Guyen
- Research Department, CMC Ambroise Paré, Neuilly sur Seine, France
- Critical Care Department, CMC Ambroise Paré, Neuilly sur Seine, France
| | - Pierre Squara
- Research Department, CMC Ambroise Paré, Neuilly sur Seine, France
- Critical Care Department, CMC Ambroise Paré, Neuilly sur Seine, France
- * E-mail:
| | - Julien Rosencher
- Cardiology Department, CMC Ambroise Paré, Neuilly sur Seine, France
| | - Serge Makowski
- Cardiology Department, CMC Ambroise Paré, Neuilly sur Seine, France
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16
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Cromhout PF, Thygesen LC, Moons P, Nashef S, Damgaard S, Christensen AV, Rasmussen TB, Borregaard B, Thrysoee L, Thorup CB, Mols RE, Juel K, Berg SK. Supplementing prediction by EuroSCORE with social and patient-reported measures among patients undergoing cardiac surgery. J Card Surg 2020; 36:509-521. [PMID: 33283356 DOI: 10.1111/jocs.15227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/28/2020] [Accepted: 11/19/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The risk of poor outcomes is traditionally attributed to biological and physiological processes in cardiac surgery. However, evidence exists that other factors, such as emotional, behavioral, social, and functional, are predictive of poor outcomes. Objectives were to evaluate the predictive value of several emotional, social, functional, and behavioral factors on four outcomes: death within 90 days, prolonged stay in intensive care, prolonged hospital admission, and readmission within 90 days following cardiac surgery. METHODS This prospective study included adults undergoing cardiac surgery 2013-2014, including information on register-based socioeconomic factors and self-reported health in a nested subsample. Logistic regression analyses to determine the association and incremental value of each candidate predictor variable were conducted. Multiple regression analyses were used to determine the incremental value of each candidate predictor variable, as well as discrimination and calibration based on the area under the curve (AUC) and Brier score. RESULTS Of 3217 patients, 3% died, 9% had prolonged intensive care stay, 51% had prolonged hospital admission, and 39% were readmitted to hospital. Patients living alone (odds ratio, 1.19; 95% confidence interval, 1.02-1.38), with lower educational levels (1.27; 1.04-1.54) and low health-related quality of life (1.43; 1.02-2.01) had prolonged hospital admission. Analyses revealed living alone as predictive of prolonged intensive care unit (ICU) stay (Brier, 0.08; AUC, 0.68), death (0.03; 0.71), and prolonged hospital admission (0.24; 0.62). CONCLUSION Living alone was found to supplement EuroSCORE in predicting death, prolonged hospital admission, and prolonged ICU stay following cardiac surgery. Low educational level and impaired health-related quality of life were, furthermore, predictive of prolonged hospital admission.
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Affiliation(s)
- Pernille F Cromhout
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lau C Thygesen
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven-University of Leuven, Leuven, Belgium.,Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Samer Nashef
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
| | - Sune Damgaard
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne V Christensen
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Trine B Rasmussen
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
| | - Britt Borregaard
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Lars Thrysoee
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Charlotte B Thorup
- Department of Cardiology, Cardiac Surgery & Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Rikke E Mols
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Knud Juel
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Selina K Berg
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
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Abstract
As mortality is now low for many cardiac surgical procedures, there has been an increasing focus on patient centered outcomes such as recovery and quality of life. The Enhanced Recovery After Surgery (ERAS) cardiac society recently published the first set of guidelines for cardiac surgery which will be useful as a starting point to help translate this philosophy for the benefit of those undergoing cardiac surgery. At the same time there are many advances in other areas such as mechanical circulation, diagnostics and quality metrics. We intend here to present a balanced and evidenced based review of selected aspects of current practice, encompassing both UK and international perioperative care with a focus on recent advances. For the convenience of the reader we will adopt the conventional perioperative preoperative, intraoperative and postoperative phases of care. The focus of cardiac surgical practice needs to evolve from mortality to recovery. Those specialists who work in cardiac anaesthesia and critical care are well placed to contribute to these changes. Accompanying this work is the development of technologies to improve recognition of and intervention to prevent early organ dysfunction. Measuring, benchmarking and publishing quality outcomes from cardiac surgical centres is likely to improve services and benefit our patients.
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Affiliation(s)
| | | | | | - Nick Fletcher
- St Georges University Hospitals, London, UK.,Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, UK
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18
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Pisano A, Torella M, Yavorovskiy A, Landoni G. The Impact of Anesthetic Regimen on Outcomes in Adult Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:711-729. [PMID: 32434720 DOI: 10.1053/j.jvca.2020.03.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/18/2020] [Accepted: 03/29/2020] [Indexed: 11/11/2022]
Abstract
Despite improvements in surgical techniques and perioperative care, cardiac surgery still is burdened by relatively high mortality and frequent major postoperative complications, including myocardial dysfunction, pulmonary complications, neurologic injury, and acute kidney injury. Although the surgeon's skills and volume and patient- and procedure-related risk factors play a major role in the success of cardiac surgery, there is growing evidence that also optimizing perioperative care may improve outcomes significantly. The present review focuses on the aspects of perioperative care that are strictly related to the anesthesia regimen, with special reference to volatile anesthetics and neuraxial anesthesia, whose effect on outcome in adult cardiac surgery has been investigated extensively.
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Affiliation(s)
- Antonio Pisano
- Department of Critical Care, Cardiac Anesthesia and Intensive Care Unit, AORN Dei Colli, Monaldi Hospital, Naples, Italy
| | - Michele Torella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, First Moscow State Medical University, Moscow, Russia
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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19
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Cromhout PF, Berg SK, Moons P, Damgaard S, Nashef S, Thygesen LC. Updating EuroSCORE by including emotional, behavioural, social and functional factors to the risk assessment of patients undergoing cardiac surgery: a study protocol. BMJ Open 2019; 9:e026745. [PMID: 31272975 PMCID: PMC6615815 DOI: 10.1136/bmjopen-2018-026745] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Conventional risk assessment in cardiac surgery focus on medical and physiological factors and have been developed to predict mortality. Other relevant risk factors associated with increased risk of poor outcomes are not included. Adding non-medical variables as potential prognostic factors to risk assessments direct attention away from specific diagnoses towards a more holistic view of the patients and their predicament. The aim of this paper is to describe the method and analysis plan for the development and validation of a prognostic screening tool as a supplement to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) to predict mortality, readmissions and prolonged length of admission in patients within 90 days after cardiac surgery, as individual outcomes. METHODS AND ANALYSIS The development of a prognostic screening tool with inclusion of emotional, behavioural, social and functional factors complementing risk assessment by EuroSCORE will adopt the methods recommended by the PROGnosis RESearch Strategy Group and report using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis statement. In the development stage, we will use data derived from three datasets comprising 1143, 3347 and 982 patients for a prospective cohort study of patients undergoing cardiac surgery, respectively. We will construct logistic regression models to predict mortality, prolonged length of admission and 90-day readmissions. In the validation stage, we will use data from a separate sample of 333 patients planned to undergo cardiac surgery to assess the performance of the developed prognostic model. We will produce validation plots showing the overall performance, area under the curve statistic for discrimination and the calibration slope and intercept. ETHICS AND DISSEMINATION The study will follow the requirements from the Ethical Committee System ensuring voluntary participation in accordance with the Helsinki declarations. Data will be filed in accordance with the requirements of the Danish Data Protection Agency.
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Affiliation(s)
| | - Selina Kikkenborg Berg
- Heart Centre, Rigshospitalet, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Philip Moons
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Institute of Health and Care Sciences, University of Gothenborg, Gothenborg, Sweden
| | - Sune Damgaard
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Samer Nashef
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Lau Caspar Thygesen
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Sivaganesan A, Asher AL, Bydon M, Khan I, Kerezoudis P, Foley KT, Nian H, Harrell FE Jr, Archer KR, Devin CJ. A Strategy for Risk-adjusted Ranking of Surgeons and Practices Based on Patient-reported Outcomes After Elective Lumbar Surgery. Spine (Phila Pa 1976) 2019; 44:670-7. [PMID: 30312268 DOI: 10.1097/BRS.0000000000002894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study retrospectively analyzes prospectively collected data. OBJECTIVE The primary aim of this study is to present a scheme for patient-reported outcome (PRO)-based, risk-adjusted rankings of spine surgeons and sites that perform elective lumbar surgery, using the Quality and Outcomes Database (QOD). SUMMARY OF BACKGROUND DATA There is currently no means of determining which spine surgeons or centers are positive or negative outliers with respect to PROs for elective lumbar surgery. This is a critical gap as we move toward a value-based model of health care in which providers assume more accountability for the effectiveness of their treatments. METHODS Random effects regression models were fit for the following outcomes, with QOD site as a fixed effect but surgeon ID as a random effect: Oswestry Disability Index, EQ-5D, back pain and leg pain, and satisfaction. Hierarchical Bayesian models were also fit for each outcome, with QOD site as a random effect and surgeon as a nested random effect. RESULTS Our study cohort consists of 8834 patients who underwent surgery by 124 QOD surgeons, for the degenerative lumbar diseases. Nonoverlapping Bayesian credible intervals demonstrate that the variance attributed to QOD site was greater than the nested variance attributed to surgeon ID for the included PROs. CONCLUSION This study presents a novel strategy for the risk-adjusted, PRO-based ranking of spine surgeons and practices. This can help identify positive and negative outliers, thereby forming the basis for large-scale quality improvement. Assuming adequate coverage of baseline risk adjustment, the choice of surgeon matters when considering PROs after lumbar surgery; however, the choice of site appears to matter more. LEVEL OF EVIDENCE 3.
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Conroy EJ, Rosala-Hallas A, Blazeby JM, Burnside G, Cook JA, Gamble C. Randomized trials involving surgery did not routinely report considerations of learning and clustering effects. J Clin Epidemiol 2019; 107:27-35. [DOI: 10.1016/j.jclinepi.2018.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/11/2018] [Accepted: 11/05/2018] [Indexed: 10/27/2022]
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Milojevic M, Pisano A, Sousa-Uva M, Landoni G. Perioperative Medication Management in Adult Cardiac Surgery: The 2017 European Association for Cardio-Thoracic Surgery Guidelines. J Cardiothorac Vasc Anesth 2019; 33:304-306. [PMID: 30385193 DOI: 10.1053/j.jvca.2018.09.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Indexed: 12/15/2022]
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23
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Lu Z, Chang W, Meng S, Xue M, Xie J, Xu J, Qiu H, Yang Y, Guo F. The Effect of High-Flow Nasal Oxygen Therapy on Postoperative Pulmonary Complications and Hospital Length of Stay in Postoperative Patients: A Systematic Review and Meta-Analysis. J Intensive Care Med 2018; 35:1129-1140. [PMID: 30587060 DOI: 10.1177/0885066618817718] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the effect of high-flow nasal cannula oxygen (HFNO) therapy on hospital length of stay (LOS) and postoperative pulmonary complications (PPCs) in adult postoperative patients. DATA SOURCES PubMed, Embase, the Cochrane Library, Web of Science of Studies, China National Knowledge Index, and Wan Fang databases were searched until July 2018. STUDY SELECTION Randomized controlled trials (RCTs) comparing HFNO with conventional oxygen therapy or noninvasive mechanical ventilation in adult postoperative patients were included. The primary outcomes were hospital LOS and PPCs; short-term mortality (defined as intensive care unit, hospital, or 28-day mortality) and intubation rate were the secondary outcomes. DATA EXTRACTION Demographic variables, high-flow oxygen therapy application, effects, and side effects were retrieved. Data were analyzed by the methods recommended by the Cochrane Collaboration. The strength of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation. Random errors were evaluated with trial sequential analysis. DATA SYNTHESIS Fourteen studies (2568 patients) met the inclusion criteria and were included. Compared to the control group, the pooled effect showed that HFNO was significantly associated with a shorter hospital stay (mean difference: -0.81; 95% confidence interval [CI]: -1.34 to -0.29, P = .002), but not mortality (risk ratio [RR]: 1.0, 95% CI: 0.63 to 1.59, P = 1.0). Weak evidence of a reduction in reintubation rate (RR: 0.76, 95% CI: 0.57-1.01, P = .06) and PPC rate (RR: 0.89, 95% CI: 0.75-1.06, P = .18) with HFNO versus control group was recorded. CONCLUSIONS The available RCTs suggest that, among the adult postoperative patients, HFNO therapy compared to the control group significantly reduces hospital LOS.
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Affiliation(s)
- Zhonghua Lu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Wei Chang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Shanshan Meng
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Ming Xue
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jianfeng Xie
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jingyuan Xu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Fengmei Guo
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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Papachristofi O, Klein AA, Mackay J, Nashef S, Fletcher NS, Sharples LD. Does the "Weekend Effect" for Postoperative Mortality Stand Up to Scrutiny? Association for Cardiothoracic Anesthesia and Critical Care Cohort Study of 110,728 Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2018; 32:2178-2186. [PMID: 29753669 DOI: 10.1053/j.jvca.2018.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Ongoing debate focuses on whether patients admitted to the hospital on weekends have higher mortality than those admitted on weekdays. Whether this apparent "weekend effect" reflects differing patient risk, care quality differences, or inadequate adjustment for risk during analysis remains unclear. This study aimed to examine the existence of a "weekend effect" for risk-adjusted in-hospital mortality after cardiac surgery. DESIGN Retrospective analysis of prospectively collected cardiac registry data. SETTING Ten UK specialist cardiac centers. PARTICIPANTS A total of 110,728 cases, undertaken by 127 consultant surgeons and 190 consultant anesthetists between April 2002 and March 2012. INTERVENTIONS Major risk-stratified cardiac surgical operations. MEASUREMENTS AND MAIN RESULTS Crude in-hospital mortality rate was 3.1%. Multilevel multivariable models were employed to estimate the effect of operative day on in-hospital mortality, adjusting for center, surgeon, anesthetist, patient risk, and procedure priority. Weekend elective cases had significantly lower mortality risk compared to Monday elective cases (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42, 0.96) following risk adjustment by the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and procedure priority; differences between weekend and Monday for urgent and emergency/salvage cases were not significant (OR 1.12, 95% CI 0.73, 1.72, and 1.07, 95% CI 0.79, 1.45 respectively). Considering only the logistic EuroSCORE but not procedure priority yielded 29% higher odds of death for weekend cases compared to Monday operations (OR 1.29, 95% CI 1.08, 1.54). CONCLUSIONS This study suggests that undergoing cardiac surgery during the weekend does not affect negatively patient survival, and highlights the importance of comprehensive risk adjustment to avoid detecting spurious "weekend effects."
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Affiliation(s)
- Olympia Papachristofi
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK.
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - John Mackay
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Samer Nashef
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Nick S Fletcher
- Department of Anaesthesia and Intensive Care, St George's Hospital, London, UK
| | - Linda D Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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