Axillary vs Femoral Arterial Cannulation in Acute Type A Dissection: International Multicenter Data

BACKGROUND

Cannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD).

METHODS

The study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral.

RESULTS

The proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia.

CONCLUSIONS

Axillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment.

Long-term outcomes after recurrent acute thoracic aortic dissection: Insights from the International Registry of Aortic Dissection

OBJECTIVE

With an aging population and advancements in imaging, recurrence of thoracic aortic dissection is becoming more common.

METHODS

All patients enrolled in the International Registry of Aortic Dissection from 1996 to 2023 with type A and type B acute aortic dissection were identified. Among them, initial dissection and recurrent dissection were discerned. The study period was categorized into 3 eras: historic era, 1996 to 2005; middle era, 2006 to 2015; most recent era, 2016 to 2023. Propensity score matching was applied between initial dissection and recurrent dissection. Outcome of interests included long-term survival and cumulative incidence of major aortic events defined by the composite of reintervention, aortic rupture, and new dissection.

RESULTS

The proportion of recurrent dissection increased from 5.9% in the historic era to 8.0% in the most recent era in the entire dissection cohort. In patients with type A dissection, propensity score matching between initial dissection and recurrent dissection yielded 326 matched pairs. Kaplan-Meier curves showed similar long-term survival between the 2 groups. However, the cumulative incidence of major aortic events was significantly higher in the recurrent dissection group (40.3% ± 6.2% vs 17.8% ± 5.1% at 4 years in the initial dissection group, P = .02). For type B dissection, 316 matched pairs were observed after propensity score matching. Long-term survival and the incidence of major aortic events were equivalent between the 2 groups.

CONCLUSIONS

The case volume of recurrent dissection or the ability to detect recurrent dissection has increased over time. Acute type A recurrent dissection was associated with a higher risk of major aortic events than initial dissection. Further judicious follow-up may be crucial after type A recurrent dissection.

Neurological event rates and associated risk factors in acute type B aortic dissections treated by thoracic aortic endovascular repair

OBJECTIVES

Thoracic endovascular aortic repair is the method of choice in patients with complicated type B acute aortic dissection. However, thoracic endovascular aortic repair carries a risk of periprocedural neurological events including stroke and spinal cord ischemia. We aimed to look at procedure-related neurological complications within a large cohort of patients with type B acute aortic dissection treated by thoracic endovascular aortic repair.

METHODS

Between 1996 and 2021, the International Registry of Acute Aortic Dissection collected data on 3783 patients with type B acute aortic dissection. For this analysis, 648 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair were included (69.4% male, mean age 62.7 ± 13.4 years). Patients were excluded who presented with a preexisting neurologic deficit or received adjunctive procedures. Demographics, clinical symptoms, and outcomes were analyzed. The primary end point was the periprocedural incidence of neurological events (defined as stroke, spinal cord ischemia, transient neurological deficit, or coma). Predictors for perioperative neurological events and follow-up outcomes were considered as secondary end points.

RESULTS

Periprocedure neurological events were noted in 72 patients (11.1%) and included strokes (n = 29, 4.6%), spinal cord ischemias (n = 21, 3.3%), transient neurological deficits (n = 16, 2.6%), or coma (n = 6, 1.0%). The group with neurological events had a significantly higher in-hospital mortality (20.8% vs 4.3%, P < .001). Patients with neurological events were more likely to be female (40.3% vs 29.3%, P = .077), and aortic rupture was more often cited as an indication for thoracic endovascular aortic repair (38.8% vs 16.5%, P < .001). In patients with neurological events, more stent grafts were used (2 vs 1 stent graft, P = .002). Multivariable logistic regression analysis showed that aortic rupture (odds ratio, 3.12, 95% confidence interval, 1.44-6.78, P = .004) and female sex (odds ratio, 1.984, 95% confidence interval, 1.031-3.817, P = .040) were significantly associated with perioperative neurological events.

CONCLUSIONS

In this highly selected group from dedicated aortic centers, more than 1 in 10 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair had neurological events, in particular women. Further research is needed to identify the causes and presentation of these events after thoracic endovascular aortic repair, especially among women.

Editor's Choice - Trends in Management and Outcomes of Type B Aortic Dissection: A Report From the International Registry of Aortic Dissection

OBJECTIVE

To describe the trends in management and outcomes of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection.

METHODS

From 1996 - 2022, 3 908 patients were divided into similar sized quartiles (T1, T2, T3, and T4). In hospital outcomes were analysed for each quartile. Survival rates following admission were compared using Kaplan-Meier analyses with Mantel-Cox Log rank tests.

RESULTS

Endovascular treatment increased from 19.1% in T1 to 37.2% in T4 (ptrend < .001). Correspondingly, medical therapy decreased from 65.7% in T1 to 54.0% in T4 (ptrend < .001), and open surgery from 14.8% in T1 to 7.0% in T4 (ptrend < .001). In hospital mortality decreased in the overall cohort from 10.7% in T1 to 6.1% in T4 (ptrend < .001), as well as in medically, endovascularly and surgically treated patients (ptrend = .017, .033, and .011, respectively). Overall post-admission survival at three years increased (T1: 74.8% vs. T4: 77.3%; p = .006).

CONCLUSION

Considerable changes in the management of acute type B aortic dissection were observed over time, with a significant increase in the use of endovascular treatment and a corresponding reduction in open surgery and medical management. These changes were associated with a decreased overall in hospital and three year post-admission mortality rate among quartiles.

Educational Attainment and Cardiovascular Risk Among Patients in Cardiac Rehabilitation

We explored whether patient educational attainment impacted changes in cardiovascular risk factors during cardiac rehabilitation (CR). An observational study was conducted using participant data who completed phase 2 of CR from January 2011 to February 2020 at an academic medical center. The patient cohort was referred to CR after a major cardiac event or to outpatients with stable angina. Patients were excluded if they had no recorded food frequency assessment (FFA) score at CR orientation and graduation. The eligible sample of 1,307 patients were further divided: (1) low educational attainment group (<16 years formal education: high school, high school/general educational development, trade school, and associate's degree) and (2) high educational attainment group (>16 years formal education: bachelor's degree, some postgraduate, master's degree, PhD, and MD). The outcomes included measurements of the FFA, body composition, biophysical health, and psychologic distress. Most patients were male (71.2%), non-Hispanic White (82.2%), and married (73.0%). There were more patients with a high educational attainment (56.8%) than patients with a low educational attainment (43.2%). All measured cardiovascular markers improved after CR for both education level groups. The change in mean FFA score (0.163, p = 0.11) and Brief Symptom Inventory-53 global severity index score (0.422, p = 0.34) did not differ significantly. We observed an improvement in cardiovascular risk measures upon CR participation. These improvements were not limited to high educational attainment patients because we found few differences in the change of risk between the 2 groups. Future studies should continue investigating the impact of education on cardiovascular outcomes as an important social determinant of health.

Cardiometabolic Risk and Dietary Behaviors in Middle-School Children Consuming School-Sourced Lunch

OBJECTIVE

Childhood obesity remains a major public health issue. This study assessed the association between school-sourced lunches and cardiometabolic risk factors in middle-school students.

METHODS

Data from health behavior surveys and physiologic screenings in a Michigan middle-school wellness program between 2005 and 2019 were used to analyze the association of school lunch consumption with cardiometabolic risk factors (overweight/obesity, non-fasting lipids/glucose, blood pressure) and dietary behaviors (fruit/vegetable consumption, intake of sugar-sweetened beverages/foods). Students were divided into three groups based on their responses to the survey item if they 1) always, 2) sometimes, or 3) never consumed school-sourced lunches. Groups were compared using descriptive statistics and chi-squared tests.

RESULTS

Students consuming school-sourced lunches were more likely to have overweight or obesity, without significant differences in total, HDL, or LDL cholesterol. There was no difference in non-fasting glucose levels, blood pressure, or resting heart rate. Students consuming school sourced lunch were more likely to have increased sugary and fatty food or beverage consumption. Students consuming school sourced lunch were more likely to attend school in a low or middle socioeconomic status region.

CONCLUSIONS

In this large cohort of middle-school children, consuming school-sourced lunches was associated with a greater prevalence of overweight and obesity and consumption of fatty foods and sugary beverages. School-based interventions should target methods to reduce consumption of sugary beverages and unhealthy snacks and promote consumption of fruits and vegetables, particularly among high-risk individuals.

Postoperative acute kidney injury after thoracic endovascular aortic repair for acute type B aortic dissection

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has evolved as the standard for treating complicated acute type B aortic dissection (ATBAD). Acute kidney injury (AKI) is a common complication in critically ill patients and is commonly observed in patients with ATBAD. The purpose of the study was to characterize AKI after TEVAR.

METHODS

All patients who underwent TEVAR for ATBAD from 2011 through 2021 were identified using the International Registry of Acute Aortic Dissection. The primary end point was AKI. A generalized linear model analysis was performed to identify a factor associated with postoperative AKI.

RESULTS

A total of 630 patients presented with ATBAD and underwent TEVAR. The indication for TEVAR was complicated ATBAD in 64.3%, high-risk uncomplicated ATBAD in 27.6%, and uncomplicated ATBAD in 8.1%. Of 630 patients, 102 (16.2%) developed postoperative AKI (AKI group) and 528 patients (83.8%) did not (non-AKI group). The most common indication for TEVAR was malperfusion (37.5%). In-hospital mortality was significantly higher in the AKI group (18.6% vs 4%; P < .001). Postoperatively, cerebrovascular accident, spinal cord ischemia, limb ischemia, and prolonged ventilation were more commonly observed in the AKI group. The expected mortality was similar at 2 years between the two groups (P = .51). Overall, the preoperative AKI was observed in 95 (15.7%) in the entire cohort consisting of 60 (64.5%) in the AKI group and 35 (6.8%) in the non-AKI group. A history of CKD (odds ratio, 4.6; 95% confidence interval, 1.5-14.1; P = .01) and preoperative AKI (odds ratio, 24.1; 95% confidence interval, 10.6-55.0; P < .001) were independently associated with postoperative AKI.

CONCLUSIONS

The incidence of postoperative AKI was 16.2% in patients undergoing TEVAR for ATBAD. Patients with postoperative AKI had a higher rate of in-hospital morbidities and mortality than those without. A history of CKD and preoperative AKI were independently associated with postoperative AKI.

Identifying Factors for Low-Risk Participation in Alternative Cardiac Rehabilitation Models for Patients with Coronary Heart Disease Using MI'S SCOREPAD

Introduction

Although a recent joint society scientific statement (the American Association of Cardiovascular Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology) suggests home-based cardiac rehab (CR) is appropriate for low- and moderate-risk patients, there are no paradigms to define such individuals with coronary heart disease.

Methods

We reviewed a decade of data from all patients with coronary heart disease enrolled in a single CR center (University of Michigan) to identify the prevalence of low-risk factors, which may inform on consideration for participation in alternative models of CR. Low-risk factors included not having any of the following: metabolic syndrome, presence of implantable cardioverter defibrillator or permanent pacemaker, active smoking, prior stroke, congestive heart failure, obesity, advanced renal disease, poor exercise capacity, peripheral arterial disease, angina, or clinical depression (MI'S SCOREPAD). We report on the proportion of participants with these risk factors and the proportion with all of these low-risk factors.

Results

The mean age of CR participants (n = 1984) was 63 years; 25% were women, and 82% were non-Hispanic White. The mean number of low-risk factors was 8.5, which was similar in the 2011-2012 and 2018-2019 cohorts (8.5 vs. 8.3, respectively, P = 0.08). Additionally, 9.3% of the 2011-2012 cohort and 7.6% of the 2018-2019 cohort had all 11 of the low-risk factors.

Conclusion

In this observational study, we provide a first paradigm of identifying factors among coronary heart disease patients that may be considered low-risk and likely high-gain for participation in alternative models of CR. Further work is needed to track clinical outcomes in patients with these factors to determine thresholds for enrolling participants in alternative forms of CR.

Acute Kidney Injury in Patients Undergoing Surgery for Type A Acute Aortic Dissection

BACKGROUND

Acute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details.

METHODS

Patients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI.

RESULTS

A total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001).

CONCLUSIONS

AKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI.

Survival after operative repair of acute type A aortic dissection varies according to the presence and type of preoperative malperfusion

OBJECTIVE

Approximately one-quarter of patients with acute type A aortic dissection (TAAD) present with concomitant malperfusion of coronary arteries, mesenteric circulation, lower extremities, kidneys, brain, and/or coma. It is generally accepted that TAAD patients who present with malperfusion experience higher mortality rates than patients without, although how specific malperfusion syndromes, alone or in combination, affect mortality is not well described.

METHODS

The International Registry of Acute Aortic Dissection database was queried for patients who underwent surgical repair of TAAD. Patients were stratified according to the presence/absence of malperfusion at presentation. Multivariable logistic regression was used to evaluate in-hospital mortality according to malperfusion type. Kaplan-Meier estimates were used to estimate 30-day postoperative survival.

RESULTS

Six thousand four hundred thirty-seven patients underwent surgical repair of acute TAAD, of whom 2642 (41%) had 1 or more preoperative malperfusion syndromes. Mesenteric malperfusion (adjusted odds ratio [AOR], 4.84; P < .001) was associated with the highest odds of in-hospital mortality, followed by coma (AOR, 1.88; P = .007), limb ischemia (AOR, 1.73; P = .008), and coronary malperfusion (AOR, 1.51; P = .02). Renal malperfusion (AOR, 1.37; P = .24) and neurologic deficit (AOR, 1.35; P = .28) were not associated with increased in-hospital mortality. In patients who survived to discharge, there was no difference in 1-year postdischarge survival in the malperfusion and no malperfusion cohorts (P = .36).

CONCLUSIONS

Survival during the index admission after TAAD repair varies according to the presence and type of malperfusion syndromes, with mesenteric malperfusion being associated with the highest odds of in-hospital death. Not only the presence of malperfusion but rather specific malperfusion syndromes should be considered when assessing a patient's risk of undergoing TAAD repair.

Lifestyle Behaviors and Cardiometabolic Health in Middle-School Children

Background: Lifestyle behaviors (LB), defined by diet and physical activity, are associated with cardiometabolic health among adults. The association of LB with cardiometabolic health among middle-school children is uncertain. Methods: An abbreviated version of the School Physical Activity and Nutrition survey was used to examine LB among students participating in a wellness program between 2004 and 2018. Students were incorporated into three groups determined by self-reported healthy LB (≥6, 4-5, ≤3 behaviors), including; ≤1 serving/day sugary foods/beverages; ≤1 serving/day fried/fatty foods; ≥1 serving/day fruits and vegetables; ≤2 hours of screen time/day; ≥1 day/week of physical education; ≥1 team sport/year; and ≥1 session/week of moderate to vigorous activity. Baseline cardiometabolic parameters [BMI, lipids, glucose, and blood pressure (BP)], resting heart rate (HR), and HR recovery were examined in association with LB groups. Results: Of 2538 children, 488 (19.2%) reported ≥6, 1219 (48.0%) reported 4-5, and 831 (32.7%) reported ≤3 LB. White or Asian race and higher socioeconomic status were associated with ≥6 LB (p < 0.001). Students performing ≤3 LB exhibited higher BMI (p < 0.001), BP (p = 0.001), resting HR (p < 0.001), and HR recovery (p < 0.001). Students performing ≥6 LB were less likely to be overweight (p < 0.001), obese (p < 0.001), or have low high-density lipoprotein (p = 0.05); however, more likely to have elevated triglycerides (p < 0.01). Conclusions: Among middle-school students, baseline BMI, BP, resting, and recovery HR were higher among children reporting fewer healthy LB. Students performing more healthy LB were less likely to be overweight or obese. Efforts to improve LB among middle-school children may be important for primordial cardiovascular prevention efforts.

Identifying trigger concepts to screen emergency department visits for diagnostic errors

OBJECTIVES

The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.

METHODS

We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED.

RESULTS

Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings.

CONCLUSIONS

We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance.

Factors Associated With Potentially Missed Diagnosis of Appendicitis in the Emergency Department

IMPORTANCE

Appendicitis may be missed during initial emergency department (ED) presentation.

OBJECTIVE

To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged ≥18 years) and children (aged <18 years) who had previous ED visits within 30 days of an appendicitis diagnosis.

MAIN OUTCOMES AND MEASURES

Potentially missed diagnosis of appendicitis. Adjusted odds ratios (AORs) for abdominal pain and its combinations with other symptoms associated with appendicitis were compared between patients with a same-day diagnosis of appendicitis and patients with a potentially missed diagnosis of appendicitis.

RESULTS

Of 187 461 patients with a diagnosis of appendicitis, a total of 123 711 (66%; 101 375 adults [81.9%] and 22 336 children [18.1%]) were eligible for analysis. Among adults, 51 923 (51.2%) were women, with a mean (SD) age of 44.3 (18.2) years; among children, 9631 (43.1%) were girls, with a mean (SD) age of 12.2 (18.2) years. The frequency of potentially missed appendicitis was 6060 of 101 375 adults (6.0%) and 973 of 22 336 children (4.4%). Patients with isolated abdominal pain (adults, AOR, 0.65; 95% CI, 0.62-0.69; P < .001; children, AOR, 0.79; 95% CI, 0.69-0.90; P < .001) or with abdominal pain and nausea and/or vomiting (adults, AOR, 0.90; 95% CI, 0.84-0.97; P = .003; children, AOR, 0.84; 95% CI, 0.71-0.98; P = .03) were less likely to have missed appendicitis. Patients with abdominal pain and constipation (adults, AOR, 1.51; 95% CI, 1.31-1.75; P < .001; children, AOR, 2.43; 95% CI, 1.86-3.17; P < .001) were more likely to have missed appendicitis. Stratified by the presence of undifferentiated symptoms, women (abdominal pain, AOR, 1.68; 95% CI, 1.58-1.78; nausea and/or vomiting, AOR, 1.68; 95% CI, 1.52-1.85; fever, AOR, 1.32; 95% CI, 1.10-1.59; diarrhea, AOR, 1.19; 95% CI, 1.01-1.40; and constipation, AOR, 1.50; 95% CI, 1.24-1.82) and girls (abdominal pain, AOR, 1.64; 95% CI, 1.43-1.88; nausea and/or vomiting, AOR, 1.74; 95% CI, 1.42-2.13; fever, AOR, 1.55; 95% CI, 1.14-2.11; diarrhea, AOR, 1.80; 95% CI, 1.19-2.74; and constipation, AOR, 1.25; 95% CI, 0.88-1.78) as well as patients with a comorbidity index of 2 or greater (adults, abdominal pain, AOR, 3.33; 95% CI, 3.09-3.60; nausea and/or vomiting, AOR, 3.66; 95% CI, 3.23-4.14; fever, AOR, 5.00; 95% CI, 3.79-6.60; diarrhea, AOR, 4.27; 95% CI, 3.39-5.38; and constipation, AOR, 4.17; 95% CI, 3.08-5.65; children, abdominal pain, AOR, 2.42; 95% CI, 1.93-3.05; nausea and/or vomiting, AOR, 2.55; 95% CI, 1.89-3.45; fever, AOR, 4.12; 95% CI, 2.71-6.25; diarrhea, AOR, 2.17; 95% CI, 1.18-3.97; and constipation, AOR, 2.19; 95% CI, 1.30-3.70) were more likely to have missed appendicitis. Adult patients who received computed tomographic scans at the initial ED visit (abdominal pain, AOR, 0.58; 95% CI, 0.52-0.65; nausea and/or vomiting, AOR, 0.63; 95% CI, 0.52-0.75; fever, AOR, 0.41; 95% CI, 0.29-0.58; diarrhea, AOR, 0.83; 95% CI, 0.58-1.20; and constipation, AOR, 0.60; 95% CI, 0.39-0.94) were less likely to have missed appendicitis.

CONCLUSIONS AND RELEVANCE

Regardless of age, a missed diagnosis of appendicitis was more likely to occur in women, patients with comorbidities, and patients who experienced abdominal pain accompanied by constipation. Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may mitigate the risk of a missed diagnosis.

Factors Associated with Incidental Sickness Absence among Employees in One Health Care System

Purpose.

Assess the association of taking incidental sickness absence with health risks and health status.

Design.

Observational.

Setting.

One Midwest health care system.

Subjects.

Individuals who were employed for 2 years (2006–2007) and had completed at least one health risk appraisal (HRA) in 2007 (N = 3790).

Measures.

Outcomes were any incidental sickness absence and absence duration in 2007 measured by an absence tracking system. Health risks and health status were estimated by HRAs. Program participation was captured using 7-year HRA data and 5-year wellness data.

Analysis.

Multivariate, binary logistic regression for the probability of taking any absence day among the overall population as well as four demographic subgroups; proportional odds model for the probability of taking more absence days.

Results.

Different patterns were observed in association with taking incidental sickness absence among age and gender subgroups. Among the overall population, three health risks (smoking overweight, and use of medication for relaxation) were positively associated with taking absence (at least p <. 05 for all three health risks). Participation in a wellness program for more years was also associated with a less likelihood of taking absence (odds ratio, .72; p = .002). Results from the proportional odds model were consistent with results from the binary logistic regression.

Conclusion.

Sickness absence is an important productivity concern of employers. Employers may implement early interventions to focus on preventable causes. Special interventions may target absence-causing risks such as smoking behavior and excess body weight. Study limitation includes a lack of measures for psychosocial work environment.

Assessing uncertainty in outsourcing clinical services at tertiary health centers

When tertiary health centers face capacity constraint, one feasible strategy to meet service demand is outsourcing clinical services to qualified community providers. Clinical outsourcing enables tertiary health centers to meet the expectations of service timeliness and provides good opportunities to collaborate with other health care providers. However, outsourcing may result in dependence and loss of control for the tertiary health centers. Other parties involved in clinical outsourcing such as local partners, patients, and payers may also encounter potential risks as well as enjoy benefits in an outsourcing arrangement. Recommendations on selecting potential outsourcing partners are given to minimize the risks associated with an outsourcing contract.

The effect of distance to primary care physician on health care utilization and disease burden

BACKGROUND

The relationship of distance to care with total health care utilization and disease burden is not well understood among the managed care population.

PURPOSES

The aim of this study was to examine the relationship between the distance from a patient's home to his or her primary care physician (PCP) and the patient's health characteristics.

METHODOLOGY

This was a population-based study of commercial health maintenance organization (HMO) members enrolled in one medium-sized health plan in Michigan in 2001. This study measured health care utilization from all settings (per member per year [PMPY]). Disease burden measure was based on the Adjusted Clinical Group (ACG) system. Distance was defined as straight-line distance between a member's residency and his or her PCP. Both direct standardization and regression modeling were used to assess the effect of distance on utilization.

FINDINGS

Both utilization and disease burden increased as distance increased, especially among members selecting PCPs in an academic health system (AHS). The difference in observed utilization between local (0-10 miles) and distant (>30 miles) members was 973 dollars (PMPY) for the AHS and 193 dollars (PMPY) for the community independent practice associations (IPA). Compared with age-sex adjustment, ACG adjustment reduced local-distant difference within the same practice group to a greater extent (281 dollars and 59 dollars remaining for the academic and community groups, respectively). Distance as a whole exerted a statistically significant positive effect on either disease burden score or utilization in regression modeling.

PRACTICE IMPLICATIONS

HMO members consume more health care and had higher disease burden as their distance from their PCPs increased. The distance traveled by the individuals to their PCPs could be incorporated when adjusting managed care financial risk models. Other remedies include negotiating higher capitation rates for distant patients, carving out distant patients from any financial risk model, or excluding such patients from provider performance assessment.

Disease burden in the managed care population at an academic medical center: the effect of adding local partners

PURPOSE

Academic medical centers (AMCs) have traditionally cared for the most severely ill patients. AMCs' effort to meet the challenges of managed care contracts may be nullified by adverse selection unless payment mechanisms adequately consider the health risk of the AMC's managed care population. The authors compared the disease burden between the University of Michigan Health System (UMHS) and its community competitors and assessed the effect of adding local primary care partners through strategic outsourcing on these differences in disease burden.

METHOD

This is a population-based study from one managed care plan in Michigan. The study population was commercial members (n = 127, 892) enrolled in the plan for the entire 12 months of 2001. The authors derived several morbidity measures from age and sex, Adjusted Clinical Groups, and Aggregated Diagnosis Groups using administrative data.

RESULTS

Compared to community groups, the UMHS consistently had a higher disease burden, while the nonacademic groups as a whole had more young members with acute conditions. After the UMHS partnered with two local primary care practice groups in their area, this AMC-local partner group had an equal or lower disease burden than the remainder of the community groups that experienced a slightly higher proportion of members with multiple medical conditions.

CONCLUSIONS

The higher disease burden borne by AMCs is a complex phenomenon. Without local partners, the UMHS did experience higher disease burden, although the degree depends on the measurement of morbidity. Partnering with carefully selected local primary care groups may ameliorate the AMC's disproportionate disease burden.

Strategic Outsourcing of Clinical Services

Many academic medical centers have significant capacity constraints and limited ability to expand services to meet demand. Health care management should employ strategic thinking to deal with service demands. This article uses three organizational models to develop a theoretical framework to guide the selection of clinical services for outsourcing.

New organizational and funds flow models for an academic cancer center

The clinical impetus to develop cancer centers has been the recognition that many cancer patients require a comprehensive treatment plan coordinated across multiple specialties. Developing an effective organizational and financial structure among the multiple entities that comprise an academic cancer center has, however, been a challenge. The authors describe an effort to realize a sustainable clinical operation at the University of Michigan Comprehensive Cancer Center (UMCCC) by developing an appropriate management structure and financial model. The modified organizational structure established a clear line of administrative authority and held faculty members accountable for their effort in the UMCCC. A unified budget aligned financial incentive among all stakeholders to increase efficiency, revenue, and margin. The authors report preliminary financial evidence of the success of the new managerial structure.

The combined effect of public profiling and quality improvement efforts on heart failure management

BACKGROUND

A before-and-after study was conducted to examine the combined effect of public profiling and quality improvement activities on management of heart failure (HF) in the hospital setting.

METHODS

Thirty-one hospitals in southeastern Michigan participated in this profiling and quality improvement study. One hospital closed after the baseline measurement. Two quality indicators were developed to evaluate the key processes of HF care, and one profiling indicator was designed for public profiling. The baseline results of the profiling indicator were publicly released. The individual hospitals were identified in the profiling report by name as "having statistically higher (or lower) rates than average." Remeasurement results were compared to the baseline results by using t-tests for the individual hospitals and all 30 hospitals as an aggregate.

RESULTS

Two-thirds of the hospitals improved ejection fraction documentation; the aggregate result improved 5.4 percentage points (p < 0.05). No change was observed in the aggregate measure of prescribing angiotensin-converting enzyme inhibitors (ACEIs) to eligible HF patients at discharge. Hospitals with low baseline rates made improvement in ACEI use at discharge, but those with good baseline performance tended to decline in performance. There was a 2.2 percentage point increase (p < 0.05) in the profiling indicator.

SUMMARY AND CONCLUSIONS

There seemed to be differential impacts of interventions across indicators and hospitals. Public profiling may have the most positive impact on hospitals with low performance at baseline. Maintaining the baseline good practice was a struggle for hospitals with relatively high baseline rates.

Do primary care physicians or specialists provide more efficient care?

Sinusitis is a common health complaint and expenditures for its treatment are high; thus, it is necessary to promote efficient practice behaviours in managing patient care. This study compares resource utilization between primary care physicians and specialists in the treatment of Medicaid sinusitis patients in Virginia. Physician-level data from Virginia Medicaid claim files for 1993 were analysed. The efficiency frontier, representing the best achievable performance in the use of resources for treating sinusitis, is identified using Data Envelopment Analysis. Resource utilization (primary care physician visits, specialist visits, emergency room usage, prescriptions and laboratory tests) and corresponding costs are compared between generalists and otolaryngologists. It was concluded from this study that there are no discernible differences in technical efficiency between generalists and specialists in the treatment of sinusitis. Nevertheless, otolaryngologists are found to be more costly than generalists in treating sinusitis. Variation in both caseload and patient mix might explain variation in use of resources.

Regional variation in physician practice pattern: an examination of technical and cost efficiency for treating sinusitis

OBJECTIVE

An examination of the physician efficiency and resulting cost patterns by region.

DATA SOURCES

Virginia Medicaid sinusitis related claims for 1993 were aggregated to physician level (n = 178), and Area Resources File for 1993 was used to identify regions for evaluation.

STUDY DESIGN

The best practice performance in the usage of five resources (i.e., primary care physician visits, referral services, emergency room visits, prescriptions, laboratory tests) was identified using Data Envelopment Analysis (DEA). Five regions in Virginia were identified according to regional planning to evaluate the variation in efficiency across these regions.

PRINCIPAL FINDINGS

Inefficient physicians consumed significantly more resources and were 48% more costly than efficient physicians. Substantial regional variation was found and mainly attributed to the differences in use of prescriptions and laboratory procedures. Urban-rural discrepancy may explain part of the variation.

CONCLUSIONS

As this study reveals the existence of substantial variation in physician efficiency, actions should be taken to minimize the variation that is more affected by personal and structural factors. For example, information on efficient use of resources and corresponding patient outcomes can be disseminated to the attending physicians. Educational workshops can be conducted to allow sharing of experience between efficient and inefficient physicians. Efforts should also be directed to help inefficient physicians to adhere to practice guidelines.

Recent determinants of new entry of HMOs into a Medicare risk contract: a diversification strategy

This study provides knowledge of more recent entry of health maintenance organizations (HMOs) into the Medicare risk program than earlier analyses. Based on a diversification framework, this study examines new market entry from three dimensions: attractiveness of the market, market area attributes, and organizational attributes. The analysis uses a 1994-1995 cross-sectional, lagged time sample with 440 HMOs that did not have a Medicare risk contract as of January 1994; it defines an HMO's market as its service area. HMO enrollment growth in the market, individual HMO enrollment size, and adjusted average per capita cost (AAPCC) rates are found to be significant in predicting new market entry.

Organizational and market determinants of HMOs' performance of preventive practices

This study validates the measurements of performance of preventive practices and identifies organizational and market factors that affect variations in the preventive care practices of health maintenance organizations (HMOs). Confirmatory factor analysis was used to assess HMO performance, reflecting the rates of five preventive practice services. A structural equation model of the preventive practice performance of HMOs was evaluated. It was discovered that HMOs that employ more board-certified primary care practitioners have a higher rate of preventive care practices and that market competition and market forces do not influence the variation in HMO preventive care practices.

Strategic hospital alliances: impact on financial performance

Acute care hospitals have increasingly been forming local strategic hospital alliances (SHAs), which consume considerable resources in forming and may affect the competitiveness of provider markets. This research shows that SHAs and market factors, which have been perceived to be threats to hospitals, are related to hospitals' financial performance. Among the findings are that SHA members have higher net revenues but that they are not more effective at cost control. Nor do the higher net revenues result in higher cash flow. However, increasing SHA penetration in a market is related to lower net revenues per case. In addition, the penetration of private health maintenance organizations in markets is associated with lower revenues and expenses.