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Chikwe J, Chen Q, Bowdish ME, Roach A, Emerson D, Gelijns A, Egorova N. Surgery and transcatheter intervention for degenerative mitral regurgitation in the United States. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00027-8. [PMID: 38237762 DOI: 10.1016/j.jtcvs.2024.01.014] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/21/2023] [Accepted: 01/08/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVES We evaluated practice trends and 3-year outcomes of transcatheter edge-to-edge repair (TEER) and surgical repair for degenerative mitral regurgitation in the United States. METHODS From the Centers for Medicare and Medicaid Services data (2012-2019), 53,117 mitral valve interventions (surgery or TEER) were performed for degenerative mitral regurgitation, identified by excluding rheumatic and congenital disease, endocarditis, myocardial infarction, cardiomyopathy, and concomitant or prior coronary revascularizations. Median follow-up was 2.9 years (interquartile range, 1.2-5.1 years). End points were 3-year survival, stroke, mitral reinterventions, and heart failure readmissions. RESULTS Volume of total annual mitral interventions did not significantly change (P = .18) between 2012 and 2019. However, surgical cases decreased by one-third, whereas TEER increased. Among 27,170 patients (52.5% men; mean age, 73.5 years) who underwent TEER (n = 7755) or surgical repair (n = 19,415), surgical patients were younger (71.8 vs 80.8 years; P < .001), with less comorbidity and frailty. In 4532 patient pairs matched for age, frailty, and comorbidity, 3-year survival after TEER was 65.9% (95% CI, 64.3%-67.6%) and 85.7% (95% CI, 84.5%-86.9%) after surgery (P < .001). Three years after TEER or surgery, stroke rates were 1.8% (95% CI, 1.5%-2.2%) and 2.0% (95% CI, 1.6%-2.4%) (P = .49); heart failure readmission rates were 17.8% (95% CI, 16.7%-18.9%) and 11.2% (95% CI, 10.3%-12.2%) (P < .001); and mitral reintervention rates were 6.1% (95% CI, 5.5%-6.9%) and 1.3% (95% CI, 1.0%-1.7%) (P < .001), respectively. CONCLUSIONS Among Medicare beneficiaries with degenerative mitral regurgitation, an increase in TEER utilization was associated with worse survival, increased heart failure readmissions, and more mitral reinterventions. Randomized trials are needed to better inform treatment choice.
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Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif.
| | - Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Amy Roach
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Annetine Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
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Bienstock S, Lin F, Blankstein R, Leipsic J, Cardoso R, Ahmadi A, Gelijns A, Patel K, Baldassarre LA, Hadley M, LaRocca G, Sanz J, Narula J, Chandrashekhar YS, Shaw LJ, Fuster V. Advances in Coronary Computed Tomographic Angiographic Imaging of Atherosclerosis for Risk Stratification and Preventive Care. JACC Cardiovasc Imaging 2023; 16:1099-1115. [PMID: 37178070 DOI: 10.1016/j.jcmg.2023.02.002] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 01/04/2023] [Accepted: 02/01/2023] [Indexed: 05/15/2023]
Abstract
The diagnostic evaluation of coronary artery disease is undergoing a dramatic transformation with a new focus on atherosclerotic plaque. This review details the evidence needed for effective risk stratification and targeted preventive care based on recent advances in automated measurement of atherosclerosis from coronary computed tomography angiography (CTA). To date, research findings support that automated stenosis measurement is reasonably accurate, but evidence on variability by location, artery size, or image quality is unknown. The evidence for quantification of atherosclerotic plaque is unfolding, with strong concordance reported between coronary CTA and intravascular ultrasound measurement of total plaque volume (r >0.90). Statistical variance is higher for smaller plaque volumes. Limited data are available on how technical or patient-specific factors result in measurement variability by compositional subgroups. Coronary artery dimensions vary by age, sex, heart size, coronary dominance, and race and ethnicity. Accordingly, quantification programs excluding smaller arteries affect accuracy for women, patients with diabetes, and other patient subsets. Evidence is unfolding that quantification of atherosclerotic plaque is useful to enhance risk prediction, yet more evidence is required to define high-risk patients across varied populations and to determine whether such information is incremental to risk factors or currently used coronary computed tomography techniques (eg, coronary artery calcium scoring or visual assessment of plaque burden or stenosis). In summary, there is promise for the utility of coronary CTA quantification of atherosclerosis, especially if it can lead to targeted and more intensive cardiovascular prevention, notably for those patients with nonobstructive coronary artery disease and high-risk plaque features. The new quantification techniques available to imagers must not only provide sufficient added value to improve patient care, but also add minimal and reasonable cost to alleviate the financial burden on our patients and the health care system.
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Affiliation(s)
- Solomon Bienstock
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Fay Lin
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathon Leipsic
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Rhanderson Cardoso
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amir Ahmadi
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Annetine Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Krishna Patel
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lauren A Baldassarre
- Department of Cardiovascular Medicine and Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael Hadley
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gina LaRocca
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Javier Sanz
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jagat Narula
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Leslee J Shaw
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Valentin Fuster
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Chikwe J, O'Gara P, Gelijns A. Reply: Reconsider the MitraClip for High-Risk Patients. J Am Coll Cardiol 2021; 78:e295. [PMID: 34857102 DOI: 10.1016/j.jacc.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/05/2021] [Indexed: 10/19/2022]
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Chikwe J, O'Gara P, Fremes S, Sundt TM, Habib RH, Gammie J, Gaudino M, Badhwar V, Gillinov M, Acker M, Rowe G, Gill G, Goldstone AB, Schwann T, Gelijns A, Trento A, Mack M, Adams DH. Mitral Surgery After Transcatheter Edge-to-Edge Repair: Society of Thoracic Surgeons Database Analysis. J Am Coll Cardiol 2021; 78:1-9. [PMID: 33945832 DOI: 10.1016/j.jacc.2021.04.062] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Transcatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative outcomes are ill defined. OBJECTIVES This study evaluated national outcomes of mitral surgery after TEER. METHODS The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality. RESULTS In the study cohort of 463 patients, the median age was 76 years (interquartile range [IQR]: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI]: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio [OR]: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease. CONCLUSIONS This study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures.
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Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai, Los Angeles, California, USA.
| | - Patrick O'Gara
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stephen Fremes
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois, USA
| | - James Gammie
- Division of Cardiac Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Mario Gaudino
- Division of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Acker
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Georgina Rowe
- Department of Cardiac Surgery, Cedars-Sinai, Los Angeles, California, USA
| | - George Gill
- Department of Cardiac Surgery, Cedars-Sinai, Los Angeles, California, USA
| | - Andrew B Goldstone
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas Schwann
- Division of Cardiac Surgery, Baystate Health, Springfield, Massachusetts, USA
| | - Annetine Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alfredo Trento
- Department of Cardiac Surgery, Cedars-Sinai, Los Angeles, California, USA
| | | | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Giustino G, Overbey J, Taylor D, Ailawadi G, Kirkwood K, DeRose J, Gillinov MA, Dagenais F, Mayer ML, Moskowitz A, Bagiella E, Miller M, Grayburn P, Smith PK, Gelijns A, O'Gara P, Acker M, Lala A, Hung J. Sex-Based Differences in Outcomes After Mitral Valve Surgery for Severe Ischemic Mitral Regurgitation: From the Cardiothoracic Surgical Trials Network. JACC Heart Fail 2020; 7:481-490. [PMID: 31146872 DOI: 10.1016/j.jchf.2019.03.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/17/2019] [Accepted: 03/05/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVES This study investigated sex-based differences in outcomes after mitral valve (MV) surgery for severe ischemic mitral regurgitation (SIMR). BACKGROUND Whether differences in outcomes exist between men and women after surgery for SIMR remains unknown. METHODS Patients enrolled in a randomized trial comparing MV replacement versus MV repair for SIMR were included and followed for 2 years. Endpoints for this analysis included all-cause mortality, major adverse cardiovascular and cerebrovascular events (MACCE) (defined as the composite of death, stroke, hospitalization for heart failure, worsening New York Heart Association functional class or MV re-operation), quality of life (QOL), functional status, and percentage of change in left ventricular end-systolic volume index (LVESVI) from baseline through 2 years. RESULTS Of 251 patients enrolled in the trial, 96 (38.2%) were women. Compared with men, women had smaller LV volumes and effective regurgitant orifice areas (EROA) but greater EROA/left ventricular (LV) end-diastolic volume ratios. At 2 years, women had higher rates of all-cause mortality (27.1% vs. 17.4%, respectively; adjusted hazard ratio [adjHR]: 1.85; 95% confidence interval [CI]: 1.05 to 3.26; p = 0.03) and of MACCE (49.0% vs. 38.1%, respectively; adjHR: 1.58; 95% CI: 1.06 to 2.37; p = 0.02). Women also reported worse QOL and functional status at 2 years. There were no significant differences in the percentage of change over 2 years in LVESVI between women and men (adjβ: -10.4; 95% CI: -23.4 to 2.6; p = 0.12). CONCLUSIONS Women with SIMR displayed different echocardiographic features and experienced higher mortality and worse QOL after MV surgery than men. There were no significant differences in the degree of reverse LV remodeling between sexes. (Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation [Severe Ischemic Mitral Regurgitation]; NCT00807040).
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Affiliation(s)
- Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jessica Overbey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Doris Taylor
- Department of Regenerative Medicine Research, Texas Heart Institute, Houston, Texas
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Katherine Kirkwood
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph DeRose
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Marc A Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - François Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mary-Lou Mayer
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Alan Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marissa Miller
- National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland
| | - Paul Grayburn
- Division of Cardiology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - Peter K Smith
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Annetine Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Patrick O'Gara
- Division of Cardiology, Brigham and Women's' Hospital, Boston, Massachusetts
| | - Michael Acker
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Anuradha Lala
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
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Woo YJ, Yau TM, Pan S, Borow K, Milano C, Taylor D, Chang H, Lala A, Acker M, Selzman C, Kern J, Hung J, O'Gara PT, Rose E, Itescu S, Taddei-Peters W, Miller M, Marks ME, Bagiella E, Gelijns A, Moskowitz A, Mancini D, Pagani F. MESENCHYMAL PRECURSOR CELLS IN LVAD RECIPIENTS: DOES HF ETIOLOGY MAKE A DIFFERENCE? J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31293-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lala A(A, Kirkwood K, Iribarne A, Moskowitz A, Overbey J, Charles EJ, Goldstein DJ, O’Gara PT, Puskas J, Bagiella E, Taddei-Peters W, O'sullivan K, Miller M, Laurin C, Giustino G, Yerokun B, Gillinov A, Gelijns A, Acker M, Stevenson L. IMPROVEMENT IN PATIENT CENTERED OUTCOMES FOLLOWING MITRAL VALVE SURGERY FOR SEVERE ISCHEMIC MITRAL REGURGITATION. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32795-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bertrand PB, Raymond SS, Smith PK, Thourani V, Ailawadi G, Bagiella E, Voisine P, Zeng X, Nagata Y, Levine RA, Gelijns A, Miller M, Moskowitz A, Taddei-Peters W, Moquete E, O’Gara PT, Alexander JH, Gammie JS, Yerokun B, DeRose J, Overbey J, Hung J. EFFECT OF LONGITUDINAL STRAIN ON CLINICAL AND ECHOCARDIOGRAPHIC OUTCOMES AFTER CARDIAC SURGERY FOR MODERATE ISCHEMIC MITRAL REGURGITATION. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32757-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Lala A, Rowland J, Gelijns A, Bagiella E, Moskowitz A, Ferket B, Pinney S, Miller M, Pagani F, Mancini D. Does Indication for LVAD at Time of Implant Matter in Younger Patients? J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Giustino G, Overbey J, Taylor D, Ailawadi G, Kirkwood K, Gillinov A, Dagenais F, Mayer ML, Gelijns A, Moskowitz A, Bagiella E, Miller M, Smith P, O'Gara P, Acker M, Lala-Trindade A(A, Hung J. SEX-BASED DIFFERENCES IN OUTCOMES AFTER MITRAL VALVE SURGERY FOR SEVERE ISCHEMIC MITRAL REGURGITATION: FROM THE CARDIOTHORACIC SURGICAL TRIALS NETWORK. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32557-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Moskowitz G, Hong K, Giustino G, Gillinov A, DeRose J, Ailawadi G, Iribarne A, Moskowitz A, Gelijns A, Egorova N. INCIDENCE AND RISK FACTORS FOR IMPLANTATION OF A CARDIAC ELECTRONIC DEVICE FOLLOWING MITRAL OR AORTIC VALVE SURGERY. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30993-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Giustino G, Alsaleh D, Gaudino M, Egorova N, Bakaeen F, Gillinov A, Moskowitz A, Voisine P, Puskas J, Alexander J, Smith P, Gelijns A, Fremes S. TRENDS AND FACTORS ASSOCIATED WITH USE OF MULTIPLE ARTERIAL GRAFTS FOR MULTIVESSEL CORONARY ARTERY BYPASS GRAFT SURGERY: A STATE-WIDE ANALYSIS OF 68,357 PROCEDURES. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30850-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Lala-Trindade A(A, Rowland J, Ferket B, Miller M, Pagani F, Bagiella E, Moskowitz A, Pinney S, Gelijns A, Mancini D. LISTING OLDER PATIENTS FOR TRANSPLANT OR OFFERING LVAD DESTINATION THERAPY? J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31625-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Gillinov AM, Shi W, Rosen A, O'Gara P, Welsh S, Bagiella E, Neill A, Williams D, Gelijns A, DAlessandro D, Horvath K, Moskowitz A, Mayer ML, Keim-Malpass J, Gupta L, Greco G. COSTS OF POSTOPERATIVE HYPERGLYCEMIA IN CARDIAC SURGERY PATIENTS. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)61863-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Vouyouka AG, Egorova NN, Sosunov EA, Moskowitz AJ, Gelijns A, Marin M, Faries PL. Analysis of Florida and New York state hospital discharges suggests that carotid stenting in symptomatic women is associated with significant increase in mortality and perioperative morbidity compared with carotid endarterectomy. J Vasc Surg 2012; 56:334-42. [PMID: 22583852 DOI: 10.1016/j.jvs.2012.01.066] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 01/23/2012] [Accepted: 01/31/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Although large randomized studies have established the efficacy and safety of carotid endarterectomy (CEA) and, recently, carotid artery stenting (CAS), the under-representation of women in these trials leaves the comparison of risks to benefits of performing these procedures on women an open question. To address this issue, we reviewed the hospital outcomes and delineated patient characteristics predicting outcome in women undergoing carotid interventions using New York and Florida statewide hospital discharge databases. METHODS We analyzed in-hospital mortality, postoperative stroke, cardiac postoperative complications, and combined postoperative stoke and mortality in 20,613 CEA or CAS hospitalizations for the years 2007 to 2009. Univariate and multiple logistic regression analyses of variables were performed. RESULTS CEA was performed in 16,576 asymptomatic and 1744 symptomatic women and CAS in 1943 asymptomatic and 350 symptomatic women. Compared with CAS, CEA rates, in asymptomatic vs symptomatic, were significantly lower for in-hospital mortality (0.3% vs 0.8% and 0.4% vs 3.4%), stroke (1.5% vs 2.6% and 3.5% vs 9.4%), and combined stroke/mortality (1.7% vs 3.1% and 3.8% vs 10.9%). In cohorts matched by propensity scores, the same trend favoring CEA remained significant in symptomatic women. There was no difference in cardiac complication rates among asymptomatic women, but among symptomatic woman cardiac complications were more frequent after CAS (10.6% vs 6.5%; P = .0077). Among symptomatic women, the presence of renal disease, coronary artery disease, or age ≥80 years increased the risk of CAS over CEA threefold for the composite end point of stroke or death. For asymptomatic women only in those with coronary artery disease or diabetes, there was a statistical difference in the composite mortality/stroke rates favoring CEA (1.9% vs 3.3% and 1.7% vs 3.4%, respectively). After adjusting for relevant clinical and demographic risk factors and hospital annual volume, for CAS vs CEA, the risk of the composite end point of stroke or mortality was 1.7-fold higher in symptomatic and 3.4-fold higher in asymptomatic patients. Medicaid insurance, symptomatic patient, history of cancer, and presence of heart failure on admission were among other strong predictors of composite stroke/mortality outcome. CONCLUSIONS Databases reflecting real-world practice performance and management of carotid disease in women suggest that CEA compared with CAS has overall better perioperative outcomes in women. Importantly, CAS is associated with significantly higher morbidity in certain clinical settings and this should be taken into account when choosing a revascularization procedure.
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Affiliation(s)
- Ageliki G Vouyouka
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Medical School, New York, NY 10029, USA.
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Egorova N, Vaishnava P, Basso Lipani M, Ricks D, Colgan C, Bernstein S, Nash I, Gelijns A, Moskowitz A, Kalman J. Abstract 89: Validating The Identification Of Patients At High Risk For Readmission By Examining Hospitalization History. Circ Cardiovasc Qual Outcomes 2012. [DOI: 10.1161/circoutcomes.5.suppl_1.a89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES:
To identify patients at high risk of readmission by validating a simple predictive tool based solely on hospitalization history.
BACKGROUND:
There is a federal mandate to reduce preventable readmissions. Predicting hospital readmission risk is of great interest to identify which patients would benefit most from transition interventions. Current models perform poorly. Mount Sinai Hospital (MSH) has implemented the Preventable Admissions Care Team (PACT), which has achieved significant results for patients not targeted by other transitional programs. PACT, a social worker-led transitional program, decreased 30-day readmission rate from 30% to 12%, ED visits by 63%, and achieved a 90% primary care show rate at 7-10-days post-discharge. Patients are identified for PACT solely by readmission history: one readmission in 30 days or 2 in 6 months, prior to the index hospitalization. Thus, our objective here was to determine the concordance of predictions based on hospitalization history with a more formal risk model based on factors that characterize patients through demographics and comorbidities.
METHODS:
Using logistic regression, we developed a risk prediction model for readmission within 30-days. The model, which used patient demographics and co-morbidities (alcohol abuse, AMI, afib, breast cancer, CKD, COPD, CVA, depression, hip fracture, or osteoporosis), was developed in a cohort of Medicare FFS beneficiaries with a high proportion of cardiovascular disease, hospitalized at MSH. The higher the risk score, the higher risk of readmission. Scores of 0-2 had a 7% risk of readmission; scores of 3 or 4 and above 5 had 30-day readmission rates of 19%, and 29%, respectively.
We then applied this risk scoring model to patients enrolled in PACT to determine how many of them would have been identified as high risk for readmission based on the regression model.
RESULTS:
A total of 393 patients were enrolled in PACT in a year and completed a 5 week intervention. Eighty seven percent had 1 cardiac comorbid illness (76% CAD, 66% CHF, and 17% Afib). Readmission data was available through 2010 thus, the analysis was completed for 111 patients. Ninety-five percent of PACT enrollees had a risk score greater than 3: 19 patients (17.1%) had a risk score of 3-4, and 87 patients (78.4%) had a risk score of 5 or greater.
CONCLUSIONS:
Hospitalization history alone is a reasonable proxy to more formal multivariable regression models in predicting 30-day readmission risk. If substantiated through further study, this could have national implications for real time high risk patient identification for transitional services.
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Vouyouka A, Egorova N, Moskowitz A, Gelijns A, Marin M, Faries P. Comparative Analysis of Endarterectomy and Stenting For the Treatment of Carotid Stenosis in Women. J Vasc Surg 2011. [DOI: 10.1016/j.jvs.2011.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Egorova NN, Vouyouka AG, McKinsey JF, Faries PL, Kent KC, Moskowitz AJ, Gelijns A. Effect of gender on long-term survival after abdominal aortic aneurysm repair based on results from the Medicare national database. J Vasc Surg 2011; 54:1-12.e6; discussion 11-2. [PMID: 21498023 DOI: 10.1016/j.jvs.2010.12.049] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 11/30/2010] [Accepted: 12/13/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Historically, women have higher procedurally related mortality rates than men for abdominal aortic aneurysm (AAA) repair. Although endovascular aneurysm repair (EVAR) has improved these rates for men and women, effects of gender on long-term survival with different types of AAA repair, such as EVAR vs open aneurysm repair (OAR), need further investigation. To address this issue, we analyzed survival in matched cohorts who received EVAR or OAR for both elective (eAAA) and ruptured AAA (rAAA). METHODS Using the Medicare Beneficiary Database (1995-2006), we compiled a cohort of patients who underwent OAR or EVAR for eAAA (n = 322,892) or rAAA (n = 48,865). Men and women were matched by propensity scores, accounting for baseline demographics, comorbid conditions, treating institution, and surgeon experience. Frailty models were used to compare long-term survival of the matched groups. RESULTS Perioperative mortality for eAAAs was significantly lower among EVAR vs OAR recipients for both men (1.84% vs 4.80%) and women (3.19% vs 6.37%, P < .0001). One difference, however, was that the survival benefit of EVAR was sustained for the 6 years of follow-up in women but disappeared in 2 years in men. Similarly, the survival benefit of men vs women after elective EVAR disappeared after 1.5 to 2 years. For rAAAs, 30-day mortality was significantly lower for EVAR recipients compared with OAR recipients, for both men (33.43% vs 43.70% P < .0001) and women (41.01% vs 48.28%, P = .0201). Six-year survival was significantly higher for men who received EVAR vs those who received OAR (P = .001). However, the survival benefit for women who received EVAR compared with OAR disappeared in 6 months. Survival was also substantially higher for men than women after emergent EVAR (P = .0007). CONCLUSIONS Gender disparity is evident from long-term outcomes after AAA repair. In the case for rAAA, where the long-term outcome for women was significantly worse than for men, the less invasive EVAR treatment did not appear to benefit women to the same extent that it did for men. Although the long-term outcome after open repair for elective AAA was also worse for women, EVAR benefit for women was sustained longer than for men. These associations require further study to isolate specific risk factors that would be potential targets for improving AAA management.
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Affiliation(s)
- Natalia N Egorova
- Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA
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Giacovelli JK, Egorova N, Dayal R, Gelijns A, McKinsey J, Kent KC. Outcomes of carotid stenting compared with endarterectomy are equivalent in asymptomatic patients and inferior in symptomatic patients. J Vasc Surg 2010; 52:906-13, 913.e1-4. [DOI: 10.1016/j.jvs.2010.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 05/04/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
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Greco G, Egorova NN, Kent KC, Zwolak RM, Manganaro A, Moskowitz A, Gelijns A, Riles TS. RR19. Carotid Artery Disease: Risk Factor Analysis in a Cohort of 3.9 Million Individuals. J Vasc Surg 2010. [DOI: 10.1016/j.jvs.2010.02.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Egorova NN, Vouyouka A, McKinsey JF, Faries P, Kent KC, Moskowitz A, Gelijns A. PVSS2. Effect of Gender on Long-term Survival After Abdominal Aortic Aneurysm (AAA) Repair: Results From Medicare National Database. J Vasc Surg 2010. [DOI: 10.1016/j.jvs.2010.02.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Egorova NN, Guillerme S, Gelijns A, Morrissey N, Dayal R, McKinsey JF, Nowygrod R. An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety. J Vasc Surg 2010; 51:878-85, 885.e1. [DOI: 10.1016/j.jvs.2009.10.102] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 10/06/2009] [Accepted: 10/06/2009] [Indexed: 11/27/2022]
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Russo MJ, Gelijns A, Aaronson K, Miller L, Hong K, Oz M, Ascheim D, Pagani F, Naka Y, Rose E, Moskowitz A. CHANGING COST-EFFECTIVENESS OF LEFT VENTRICULAR ASSIST DEVICES AS DESTINATION THERAPY. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60170-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Egorova N, Giacovelli JK, Gelijns A, Greco G, Moskowitz A, McKinsey J, Kent KC. Defining high-risk patients for endovascular aneurysm repair. J Vasc Surg 2009; 50:1271-9.e1. [PMID: 19782526 DOI: 10.1016/j.jvs.2009.06.061] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Revised: 06/30/2009] [Accepted: 06/30/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) is commonly used as a minimally invasive technique for repairing infrarenal aortic aneurysms. There have been recent concerns that a subset of high-risk patients experience unfavorable outcomes with this intervention. To determine whether such a high-risk cohort exists and to identify the characteristics of these patients, we analyzed the outcomes of Medicare patients treated with EVAR from 2000-2006. METHODS We identified 66,943 patients who underwent EVAR from Inpatient Medicare database. The overall 30-day mortality was 1.6%. A risk model for perioperative mortality was developed by randomly selecting 44,630 patients; the other one third of the dataset was used to validate the model. The model was deemed reliable (Hosmer-Lemeshow statistics were P = .25 for the development, P = .24 for the validation model) and accurate (c = 0.735 and c = 0.731 for the development and the validation model, respectively). RESULTS In our scoring system, where scores ranged between 1 and 7, the following were identified as significant baseline factors that predict mortality: renal failure with dialysis (score = 7); renal failure without dialysis (score = 3); clinically significant lower extremity ischemia (score = 5); patient age >or=85 years (score = 3), 75-84 years (score = 2), 70-74 years (score = 1); heart failure (score = 3); chronic liver disease (score = 3); female gender (score = 2); neurological disorders (score = 2); chronic pulmonary disease (score = 2); surgeon experience in EVAR <3 procedures (score = 1); and hospital annual volume in EVAR <7 procedures (score = 1). The majority of Medicare patients who were treated (96.6%, n = 64,651) had a score of 9 or less, which correlated with a mortality <5%. Only 3.4% of patients had a mortality >or=5% and 0.8% of patients (n = 509) had a score of 13 or higher, which correlated with a mortality >10%. CONCLUSION We conclude that there is a high-risk cohort of patients that should not be treated with EVAR because of prohibitively high mortality; however, this cohort is small. Our scoring system, which is based on patient and institutional factors, provides criteria that can be easily used by clinicians to quantify perioperative risk for EVAR candidates.
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Affiliation(s)
- Natalia Egorova
- Department of Health Policy, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Russo MJ, Davies RR, Hong KN, Chen JM, Argenziano M, Moskowitz A, Ascheim DD, George I, Stewart AS, Williams M, Gelijns A, Naka Y. Matching high-risk recipients with marginal donor hearts is a clinically effective strategy. Ann Thorac Surg 2009; 87:1066-70; discussion 1071. [PMID: 19324129 DOI: 10.1016/j.athoracsur.2008.12.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 12/03/2008] [Accepted: 12/05/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND The purpose of this study is to determine the clinical outcomes associated with alternate listing transplantation, which utilizes "marginal" donor organs by transplanting them into high-risk recipients who fail to meet the standard criteria for transplantation. METHODS The United Network for Organ Sharing provided de-identified patient-level data. Analysis focused on patients undergoing heart transplantation between January 1, 1999, and December 31, 2005 (n = 13,024). High-risk criteria included age more than 65 years old, retransplantation, hepatitis C-positive, human immunodeficiency virus-positive, creatinine clearance less than 30 mL/min, diabetes mellitus with peripheral vascular disease, and diabetes with creatinine clearance less than 40 mL/min. Marginal donor criteria included age more than 55 years, diabetes mellitus, hepatitis C-positive, human immunodeficiency virus-positive, ejection fraction less than 45%, and donor:recipient weight less than 0.7. RESULTS Survival in the standard transplant group, defined as non-high-risk patients who received nonmarginal organs, was better than in all other groups (p < 0.001). Alternate listing transplantation patients had the worst survival (p < 0.001). The 5-year survival for the alternate listing transplantation group was 51.4%, compared with 75.1% in the standard transplant group; the standard transplant patients, with the lowest incidence of in-hospital infection (21.1%) and dialysis (7.1%), also had the best transplant hospitalization outcomes (p < 0.001). In contrast, alternate listing transplantation patients had the highest incidence of in-hospital infection (35.4%; p < 0.001). Length of stay during transplant hospitalization was also shortest in the standard transplant group (18.8 days; p < 0.001). CONCLUSIONS Alternate listing transplantation is associated with greater morbidity and resource utilization compared with standard transplantation. However, this strategy offers a median survival of 5.2 years to patients who would otherwise be expected to live 1 year, and therefore, may be reasonably applied to expand the benefits of transplantation. Further studies examining the costs and quality of life related to this approach are needed.
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Affiliation(s)
- Mark J Russo
- Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York, USA.
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Boyle A, John R, Moazami N, Ewald G, Salerno C, Walsh M, Teuteberg J, Kormos R, Anyanwu A, Pinney S, Desai S, Burton N, Kirklin J, Pamboukian S, Park S, Redfield M, Ascheim D, Parides M, Rawiel U, Moquete E, Joyce L, Gelijns A, O'Connell J, McGee E, Sun B, Feldman D, Camacho M, Zucker M. 45: U.S. Experience with a Novel Centrifugal LVAD in Bridge to Transplant (BTT) Patients. J Heart Lung Transplant 2009. [DOI: 10.1016/j.healun.2008.11.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Giacovelli JK, Egorova N, Nowygrod R, Gelijns A, Kent KC, Morrissey NJ. Insurance status predicts access to care and outcomes of vascular disease. J Vasc Surg 2008; 48:905-11. [PMID: 18586449 DOI: 10.1016/j.jvs.2008.05.010] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2008] [Revised: 04/23/2008] [Accepted: 05/04/2008] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine if insurance status predicts severity of vascular disease at the time of treatment or outcomes following intervention. METHODS Hospital discharge databases from Florida and New York from 2000-2005 were analyzed for lower extremity revascularization (LER, n = 73,532), carotid revascularization (CR, n = 116,578), or abdominal aortic aneurysm repair (AAA, n = 35,593), using ICD-9 codes for diagnosis and procedure. The indications for intervention as well as the post-operative outcomes were examined assigning insurance status as the independent variable. Patients covered under a variety of commercial insurers, as well as Medicare, were compared to those who either had no insurance or were covered by Medicaid. RESULTS Patients without insurance or with Medicaid were at significantly greater risk of presenting with a ruptured AAA compared to insured (non-Medicaid) patients; while insurance status did not seem to impact post-operative mortality rates for elective and ruptured AAA repair. The uninsured or Medicaid recipients presented with symptomatic carotid disease nearly twice as often as the insured, but stroke rates after CR did not differ significantly based on insurance status. Patients with Medicaid or without insurance were more likely to present with limb threatening ischemia than claudication. In contrast to AAA repair and CR, the outcomes of LER were worse in the uninsured and Medicaid beneficiaries who had higher rates of post-revascularization amputation compared to the insured (non-Medicaid) group. CONCLUSION Insurance status predicts disease severity at the time of treatment, but once treated, the outcomes are similar among insurance categories, with the exception of lower extremity revascularization. This data suggests inferior access to preventative vascular care in the Medicaid and the uninsured populations.
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Affiliation(s)
- Jeannine K Giacovelli
- Division of Vascular Surgery, New York Presbyterian Hospital, Columbia College of Physicians and Surgeons, Weill Medical College of Cornell University, New York, NY, USA
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Morrissey NJ, Giacovelli J, Egorova N, Gelijns A, Moskowitz A, McKinsey J, Kent KC, Greco G. Disparities in the treatment and outcomes of vascular disease in Hispanic patients. J Vasc Surg 2007; 46:971-8. [PMID: 17980283 DOI: 10.1016/j.jvs.2007.07.021] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2007] [Accepted: 07/05/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Hispanic population represents the fastest growing minority in the United States. As the population grows and ages, the vascular surgery community will be providing increasing amounts of care to this diverse group. To appropriately administer preventive and therapeutic care, it is important to understand the incidence, risk factors, and natural history of vascular disease in Hispanic patients. METHODS We analyzed hospital discharge databases from New York and Florida to determine the rate of lower extremity revascularization (LER), carotid revascularization (CR), and abdominal aortic aneurysm (AAA) repair in Hispanics relative to the general population. The rates of common comorbidities, the indications for the procedures, and outcomes during the same hospitalization as the index procedure were determined. Multivariate logistic regression analysis was used to determine the differences between Hispanics and white non-Hispanics with respect to rate of procedure, symptoms at presentation, and outcome after procedure. Demographic variables and length of stay were also analyzed. RESULTS The rate of LER, CR, and AAA repair was significantly lower in Hispanic patients than in white non-Hispanics. Despite this lower rate of intervention, Hispanics were significantly more likely than whites to present with limb-threatening lower extremity ischemia (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.91 to 2.29), symptomatic carotid artery disease (OR, 1.57; 95% CI, 1.4 to 1.75), and ruptured AAA (OR, 1.26; 95% CI, 1.04-1.52) than white non-Hispanics These differences were maintained after controlling for the presence of diabetes mellitus and other comorbidities. Hispanic patients had higher rates of amputation during the same hospitalization after LER (6.2% vs 3.4%, P < .0001) and higher mortality after elective AAA repair (5% vs 3.4%, P = .0032). Length of stay after LER, CR, and AAA repair was longer for Hispanic patients than white non-Hispanics. CONCLUSION Significant disparities in the rate of utilization of three common vascular surgical procedures exist between Hispanic patients and the general population. In addition, Hispanics appear to present with more advanced disease and have worse outcomes in some cases. Reasons for these disparities must be determined to improve these results in the fastest growing segment of our society.
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Affiliation(s)
- Nicholas J Morrissey
- Division of Vascular Surgery, New York Presbyterian Hospital, Columbia College of Physicians and Surgeons, Weill Medical College of Cornell University, New York, NY 10032, USA.
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Rose E, Feller E, Naka Y, Griffith B, Boyle A, John R, Kormos R, Teuteberg J, Woodard J, Rawiel U, Moskowitz A, Gelijns A, Parides M, Ascheim D, Joyce L. Feasibility Trial Results of the VentrAssist 3rd Generation LVAD for Bridge to Cardiac Transplantion. J Card Fail 2007. [DOI: 10.1016/j.cardfail.2007.06.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Neaton JD, Normand SL, Gelijns A, Starling RC, Mann DL, Konstam MA. Designs for Mechanical Circulatory Support Device Studies. J Card Fail 2007; 13:63-74. [PMID: 17339005 DOI: 10.1016/j.cardfail.2006.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Revised: 12/13/2006] [Accepted: 12/15/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is increased interest in mechanical circulatory support devices (MCSDs), such as implantable left ventricular assist devices (LVADs), as "destination" therapy for patients with advanced heart failure. Because patient availability to evaluate these devices is limited and randomized trials have been slow in enrolling patients, a workshop was convened to consider designs for MCSD development including alternatives to randomized trials. METHODS AND RESULTS A workshop was jointly planned by the Heart Failure Society of America and the US Food and Drug Administration and was convened in March 2006. One of the panels was asked to review different designs for evaluating new MCSDs. Randomized trials have many advantages over studies with no controls or with nonrandomized concurrent or historical controls. These advantages include the elimination of bias in the assignment of treatments and the balancing, on average, of known and unknown baseline covariates that influence response. These advantages of randomization are particularly important for studies in which the treatments may not differ from one another by a large amount (eg, a head-to-head study of an approved LVAD with a new LVAD). However, researchers have found it difficult to recruit patients to randomized studies because the number of clinical sites that can carry out the studies is not large. Also, there is a reluctance to randomize patients when the control device is considered technologically inferior. Thus ways of improving the design of randomized trials were discussed, and the advantages and disadvantages of alternative designs were considered. CONCLUSIONS The panel concluded that designs should include a randomized component. Randomized designs might be improved by allowing the control device to be chosen before randomization, by first conducting smaller vanguard studies, and by allowing crossovers in trials with optimal medical management controls. With use of data from completed trials, other databases, and registries, alternative designs that include both a randomized component (eg, 2:1 allocation for new device versus control) and a nonrandomized component (eg, concurrent nonrandomized control, historical control, or a comprehensive cohort design) should be evaluated. This will require partnerships among academic, government, and industry scientists.
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Affiliation(s)
- James D Neaton
- University of Minnesota School of Public Health, Minneapolis, Minnesota 55415, USA
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Greco G, Egorova N, Anderson PL, Gelijns A, Moskowitz A, Nowygrod R, Arons R, McKinsey J, Morrissey NJ, Kent KC. Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms. J Vasc Surg 2006; 43:453-459. [PMID: 16520154 DOI: 10.1016/j.jvs.2005.11.024] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Accepted: 11/06/2005] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The successful application of endovascular techniques for the elective repair of abdominal aortic aneurysms (AAAs) has stimulated a strong interest in their possible use in dealing with a long-standing surgical challenge: the ruptured abdominal aortic aneurysm (RAAA). The use of a conventional open procedure to repair ruptured aneurysms is associated with a high operative mortality of 45% to 50%. In this study, we evaluated the current frequency of endovascular repair of RAAAs in four large states and the impact of this technique on patient outcome. METHODS We examined discharge data sets from 2000 through 2003 from the four states of California, Florida, New Jersey, and New York, whose combined population represents almost a third of the United States population. Proportions and trends were analyzed by chi2 analysis and continuous variables by the Student's t test. RESULTS We found that since the year 2000, endovascular repair has begun to emerge as a viable treatment option for RAAAs, accounting for the repair of 6.2% of cases in 2003. During the same period, the use of open procedures for RAAAs declined. The overall mortality rate for the 4-year period was significantly lower for endovascular vs open repair (39.3% vs. 47.7%, P = .005). Moreover, compared with open repair, endovascular repair resulted in a significantly lower rate of pulmonary, renal, and bleeding complications. Survival after endovascular repair correlated with hospital experience, as assessed by the overall volume of elective and nonelective endovascular procedures. For endovascular repairs, mortality ranged from 45.9% for small volume hospitals to 26% for large volume hospitals (P = .0011). Volume was also a determinant of mortality for open repairs, albeit to a much lesser extent (51.5% for small volume hospitals, 44.3% for large volume hospitals; P < .0001). CONCLUSION We observed a benefit to using endovascular procedures for RAAAs in institutions with significant endovascular experience; however, the analysis of administrative data cannot rule out selection bias as an explanation of better outcomes. These data strongly endorse the need for prospective studies to clarify to what extent the improved survival in RAAA patients is to be attributed to the endovascular approach rather than the selection of low-risk patients.
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Affiliation(s)
- Giampaolo Greco
- International Center for Health Outcomes and Innovation Research (inCHOIR), Columbia University, New York, NY 10032, USA.
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Nowygrod R, Egorova N, Greco G, Anderson P, Gelijns A, Moskowitz A, McKinsey J, Morrissey N, Kent KC. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg 2006; 43:205-16. [PMID: 16476588 DOI: 10.1016/j.jvs.2005.11.002] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2005] [Accepted: 11/02/2005] [Indexed: 11/17/2022]
Abstract
BACKGROUND The recent evolution in treatments for peripheral vascular disease has dated available mortality statistics for vascular intervention. Moreover, many of our current mortality statistics are derived from single-institution studies that are often not reflective of outcomes in general practice. To provide current and generalizable data regarding mortality and trends for peripheral vascular interventions, we examined two national data sets (Nationwide Inpatient Sample, 1998-2003, and National Hospital Discharge Survey, 1979-2003) and four states (New York, California, Florida, and New Jersey, 1998-2003). METHODS Four procedures--abdominal aortic aneurysm repair (nonruptured), lower extremity revascularization, amputation, and carotid revascularization--were selected by cross-referencing International Classification of Diseases, 9th Revision, diagnostic and procedural codes. For significance, the t test was used for continuous variables, the chi2 test was used for dichotomous variables, and the chi2 test was used for mortality trends. RESULTS From 1998 to 2003, there was a progressive decrease in the national per capita rate of amputations: 13.2% overall and 21.2% for major amputations (P < .0001). Nationally and regionally, mortality has only slightly declined. For lower extremity revascularization, after a sharp increase during the 1980s to 100,000 open procedures, the volume remained constant for 10 years and began to decline in 1998, reaching 70,000 cases in 2003. In contrast, since 1996, endovascular interventions have increased 40%. Mortality during the 1998 to 2003 period remained virtually stable at 1.5% to 2% for endovascular procedures and 3% to 4% for open procedures. The overall volume of abdominal aortic aneurysm repair has not changed substantially for the past 6 years; however, endovascular repair is now used for nearly half the cases (46.5% regional and 43.0% national). Mortality for open repair has not changed, remaining at approximately 5%, whereas for endovascular repair, mortality has declined from 2.6% in 2000 to less than 1.5% in 2003. After the rapid increase in open carotid revascularization in the early 1990s, the total volume has declined 5% nationally from 1998 to 2003. Regional data demonstrated an overall 12% reduction in carotid revascularization volume since 1998; this reduction was due to a 16% decline in open carotid revascularization. During this same period, the use of angioplasty-stent carotid revascularization doubled. Mortality for the open procedures is 0.5% and is significantly higher (2%-3%) for endovascular carotid revascularization. Stroke rates for endovascular carotid revascularization are also higher: 2.13% vs 1.28% for open procedures (P < .0001). CONCLUSIONS Dramatic shifts in the management of peripheral vascular disease have occurred together with an overall decline in mortality. There seems to be a significant mortality advantage for endovascular as compared with traditional surgery except for carotid endarterectomy. The increasing safety of vascular interventions should be considered when deciding which patients to treat but with the caveat that endovascular interventions are not always safer than open repair.
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Affiliation(s)
- Roman Nowygrod
- Columbia Weill Cornell Division of Vascular Surgery, Columbia University, New York, NY, USA.
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Park SJ, Tector A, Piccioni W, Raines E, Gelijns A, Moskowitz A, Rose E, Holman W, Furukawa S, Frazier OH, Dembitsky W. Left ventricular assist devices as destination therapy: A new look at survival. J Thorac Cardiovasc Surg 2005; 129:9-17. [PMID: 15632819 DOI: 10.1016/j.jtcvs.2004.04.044] [Citation(s) in RCA: 166] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The REMATCH trial compared the use of left ventricular assist devices with optimal medical management for patients with end-stage heart failure. When the trial met its primary end point criteria in July 2001, left ventricular assist device therapy was shown to significantly improve survival and quality of life. With extended follow-up, 2 critical questions emerge: (1) Did these benefits persist, and (2) did outcomes improve over the course of the trial, given the evolving nature of the technology? METHODS We analyzed survival in this randomized trial by using the product-limit method of Kaplan and Meier. Changes in the benefits of therapy were analyzed by examining the effect of the enrollment period. RESULTS The survival rates for patients receiving left ventricular assist devices (n = 68) versus patients receiving optimal medical management (n = 61) were 52% versus 28% at 1 year and 29% versus 13% at 2 years ( P = .008, log-rank test). As of July 2003, 11 patients were alive on left ventricular assist device support out of a total 16 survivors (including 3 patients receiving optimal medical management who crossed over to left ventricular assist device therapy). There was a significant improvement in survival for left ventricular assist device-supported patients who enrolled during the second half of the trial compared with the first half ( P = .03). The Minnesota Living with Heart Failure scores improved significantly over the course of the trial. CONCLUSION The extended follow-up confirms the initial observation that left ventricular assist device therapy renders significant survival and quality-of-life benefits compared with optimal medical management for patients with end-stage heart failure. Furthermore, we observed an improvement in the survival of patients receiving left ventricular assist devices over the course of the trial, suggesting the effect of greater clinical experience.
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Anderson PL, Gelijns A, Moskowitz A, Arons R, Gupta L, Weinberg A, Faries PL, Nowygrod R, Kent KC. Understanding trends in inpatient surgical volume: vascular interventions, 1980-2000. J Vasc Surg 2004; 39:1200-8. [PMID: 15192558 DOI: 10.1016/j.jvs.2004.02.039] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To help understand past and future trends in vascular intervention, we examined changes in the rate of utilization, patient demographics, and length of stay from 1980 to 2000. METHODS We reviewed the ICD-9 codes for all vascular procedures using the National Hospital Discharge Survey of non-federal United States hospitals (1980-2000). RESULTS The number of vascular procedures performed in this country increased from 412,557 in 1980 to 801,537 in 2000 (per capita increase of >50%). This increase was most evident in elderly patients (>75 years, 67% per capita increase in discharges). Long hospital stays (> or =7 days) for vascular procedures fell 41%, and short hospital stays (<24 hours) increased 15% over the period of study. The frequency of abdominal aortic aneurysm repairs remained relatively constant. Except for an interval in the late 1980s, and a minor decrease from 1997 to 2000, the frequency of carotid endartarectomy rose dramatically (69%). Lower extremity revascularizations increased steadily until 1990 but then declined 12%. From 1995 to 2000, there was a 27% per capita decrease in the number of renal-mesenteric operations. Correspondingly, over the past 5 years there has been a 979% growth in the number of percutaneous/endovascular interventions. Despite a substantial number of interventions for lower extremity vascular disease, there was a concomitant increase in the number of major and minor amputations. CONCLUSION Interventions for vascular disease have increased dramatically, with a major shift toward less invasive treatments, particularly for the renal and mesenteric vessels and the lower extremities. These trends in procedural use suggest that vascular surgeons need to embrace catheter-based approaches if they want to remain leaders in the treatment of peripheral vascular diseases.
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Affiliation(s)
- Patrice L Anderson
- International Center for Health Outcomes and Innovation Reseach (InCHOIR), New York Presbyterian Hospital, Department of Surgery, 600 W. 168th Street, New York, NY 10032, USA.
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Anderson PL, Arons RR, Moskowitz AJ, Gelijns A, Magnell C, Faries PL, Clair D, Nowygrod R, Kent KC. A statewide experience with endovascular abdominal aortic aneurysm repair: Rapid diffusion with excellent early results. J Vasc Surg 2004; 39:10-9. [PMID: 14718804 DOI: 10.1016/j.jvs.2003.07.020] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to compare survival and outcomes of endovascular versus open repair of abdominal aortic aneurysms (AAAs) in New York State (NYS). METHODS We used the NYS discharge dataset Statewide Planning and Research Cooperative System (SPARCS) to analyze the outcomes of elective admission for nonruptured (International Classification of Diseases-9th revision [ICD-9] 441.4) open aneurysm repair (38.44) and endovascular aneurysm repair (39.71) during the years 2000-2002. The ICD-9 code for endovascular repair was introduced in late 2000, thus capturing 3 months of empiric data for 2000. RESULTS There has been a significant increase in the number of AAA procedures performed in NYS (comparing before and after 2000: average, 1419 vs 1701; P =.0001), temporally coinciding with the implementation of training programs after US Food and Drug Administration approval of endovascular grafts and the new payment code. From 2000 to 2002 the number of NYS hospitals performing endovascular repairs increased from 24 to 60. By 2002 there were more endovascular repairs being performed than open repairs (871 vs 783). The target population for these surgical interventions showed interesting differences. In 2002, women had a 43% chance of receiving an endograft, whereas men had a 55% probability. The use of endovascular repair over the observation period was relatively constant in patients younger than 65 years. In patients older than 65 years, and especially those older than 75 years, endovascular use increased substantially, so that by 2002 older patients were more likely to undergo endovascular repair than open repair. Patients who underwent endovascular repair had significantly more hypertension, coronary artery disease, diabetes, and hyperlipidemia than did patients who underwent open repair. Yet the mean length of stay for endovascular procedures was approximately 3.6 days, and for open procedures was about 10.3 days, across all 3 years (P = <.0001). Moreover, patients who underwent endovascular repair had statistically fewer postoperative complications and significantly lower mortality. In-hospital mortality in 2001 was 3.55% for open repair and 1.14% for endovascular repair (P =.0018), and in 2002 these rates were 4.21% versus 0.8% (P <.0001), respectively. CONCLUSION This dataset suggests that endovascular AAA repairs are being performed in a patient population with a higher frequency of comorbidities. However, endovascular repairs still are associated with significantly lower in-hospital mortality, fewer postoperative complications, and a dramatically shorter length of stay. These results suggest that, despite the rapid diffusion of this new technique, early perioperative outcomes may be superior to those with conventional open repair. However, prospective clinical studies are needed to confirm these insights, and such studies may require the infrastructure of consortia of hospitals or society-based registries.
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Affiliation(s)
- Patrice L Anderson
- International Center for Health Outcomes and Innovation Research, College of Physicians and Surgeons, and Mailman School of Public Health, Columbia University, 600 W. 168th Street, 7th Floor, New York, NY 10032, USA.
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Stevenson LW, Kormos RL, Bourge RC, Gelijns A, Griffith BP, Hershberger RE, Hunt S, Kirklin J, Miller LW, Pae WE, Pantalos G, Pennington DG, Rose EA, Watson JT, Willerson JT, Young JB, Barr ML, Costanzo MR, Desvigne-Nickens P, Feldman AM, Frazier OH, Friedman L, Hill JD, Konstam MA, McCarthy PM, Michler RE, Oz MC, Rosengard BR, Sapirstein W, Shanker R, Smith CR, Starling RC, Taylor DO, Wichman A. Mechanical cardiac support 2000: current applications and future trial design. June 15-16, 2000 Bethesda, Maryland. J Am Coll Cardiol 2001; 37:340-70. [PMID: 11153769 DOI: 10.1016/s0735-1097(00)01099-8] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Banta HD, Gelijns A. An early system for the identification and assessment of future health care technology. The Dutch STG Project. Int J Technol Assess Health Care 1999; 14:607-12. [PMID: 9885450 DOI: 10.1017/s0266462300011910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This article is based on the report, Anticipating and Assessing Health Care Technology, written in the Netherlands between 1985-88. The project was carried out because of increasing concern in the Dutch Ministry of Health (STG, then WVC) about the costs and benefits of new technologies for health care. At that time, there were no established models for early identification, so the project was not only the most extensive such effort to that date, but had to develop its own methods. Overseen by a special commission, the project staff identified many future and emerging technologies in health care and assessed selected technologies. Although the actual information produced was quickly dated and the project was discontinued in 1988, it did stimulate the Ministry of Health to ask the Dutch Health Council (Gezondheidsraad) to continuously identify important new technologies. The reports also demonstrated the potential usefulness of such an effort to Dutch policy makers, and probably to those in other countries as well.
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Affiliation(s)
- H D Banta
- Netherlands Organization for Applied Scientific Research (TNO)
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Abstract
This paper contrasts a dynamic and interactive view of technological change with the linear model of medical innovation that is still so deeply ingrained in many policy discussions. In particular, it focuses on the role of feedback mechanisms between the users and the developers of medical technology and the demand and supply forces (including competition among medical specialties) determining this feedback. It explores three distinct mechanisms by which technological change may contribute to rising health care spending: intensity of use of existing technology, introduction of new technologies, and expanded application of these new technologies.
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