Cost-Effectiveness of HIV Screening in Emergency Departments: Results From the Pragmatic Randomized HIV Testing Using Enhanced Screening Techniques in Emergency Departments Trial

STUDY OBJECTIVE

Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial.

METHODS

This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed.

RESULTS

The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests.

CONCLUSION

Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.

Practical Guide to Clinical Trial Publication

This Guide to Statistics and Methods describes the process for publishing about a clinical trial by planning its clinical relevance, knowing the audience, and following reporting guidelines.

The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial: rationale and design of an emergency department-based randomized clinical trial of linkage-to-care strategies for hepatitis C

BACKGROUND

Hepatitis C (HCV) poses a major public health problem in the USA. While early identification is a critical priority, subsequent linkage to a treatment specialist is a crucial step that bridges diagnosed patients to treatment, cure, and prevention of ongoing transmission. Emergency departments (EDs) serve as an important clinical setting for HCV screening, although optimal methods of linkage-to-care for HCV-diagnosed individuals remain unknown. In this article, we describe the rationale and design of The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial.

METHODS

The DETECT Hep C Linkage-to-Care Trial will be a single-center prospective comparative effectiveness randomized two-arm parallel-group superiority trial to test the effectiveness of linkage navigation and clinician referral among ED patients identified with untreated HCV with a primary hypothesis that linkage navigation plus clinician referral is superior to clinician referral alone when using treatment initiation as the primary outcome. Participants will be enrolled in the ED at Denver Health Medical Center (Denver, CO), an urban, safety-net hospital with approximately 75,000 annual adult ED visits. This trial was designed to enroll a maximum of 280 HCV RNA-positive participants with one planned interim analysis based on methods by O'Brien and Fleming. This trial will further inform the evaluation of cost effectiveness, disparities, and social determinants of health in linkage-to-care, treatment, and disease progression.

DISCUSSION

When complete, the DETECT Hep C Linkage-to-Care Trial will significantly inform how best to perform linkage-to-care among ED patients identified with HCV.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04026867 Original date: July 1, 2019 URL: https://clinicaltrials.gov/ct2/show/NCT04026867.

Practical Guide to Surgical Clinical Trial Implementation, Oversight, and Regulatory Aspects

This Guide to Statistics and Methods describes the steps necessary for a successful trial implementation that can safeguard credible results and conclusions while minimizing potential harm.

Practical Guide to Adjuncts to Clinical Trials in Surgery

This Guide to Statistics and Methods discusses adjunct outcome parameters that optimize patient-centered, timely, efficient, and equitable components in randomized clinical trials.

Practical Guide to Design Choice of Randomized Clinical Trials in Surgery

This Guide to Statistics and Methods provides an overview of the strengths and weaknesses of several randomized clinical trial design options.

Predictive accuracy of adding shock index to the American College of Surgeons' minimum criteria for full trauma team activation

BACKGROUND

The American College of Surgeons requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation: hypotension, gunshot wound to the neck or torso, Glasgow Coma Scale (GCS) score < 9, respiratory compromise, transfers receiving blood transfusion, or physician discretion. Our goal was to evaluate the effect of adding varying shock index (SI) thresholds to the ACS-6 in an adult trauma population with the hypothesis that SI would significantly improve sensitivity at the expense of an acceptable decrease in specificity.

METHODS

We performed a secondary analysis of EMS and trauma registry data from an urban Level I trauma center. Consecutive patients > 15 years of age were included from 1993 through 2006. SI at thresholds of ≥0.8, ≥0.85, ≥0.9, and ≥1 were evaluated. Primary outcome was emergency operative (within 1 h of arrival) or procedural (cricothyrotomy or thoracotomy) intervention (EOPI); secondary outcomes were Injury Severity Score (ISS) > 15, ISS > 24, a composite of EOPI or ISS > 15, and urgent operative intervention (within 4 h).

RESULTS

A total of 20,872 patients were included, 27% with an ISS > 15 and 5% who underwent EOPI. Sensitivity and specificity of the ACS-6 alone for EOPI were 86% (95% confidence interval [CI] = 84% to 88%) and 81% (95% CI = 80% to 81%), respectively. Inclusion of SI thresholds of 0.8, 0.85, 0.9, and 1 resulted in sensitivities of 95% (95% CI = 93% to 96%), 93% (CI = 91% to 94%), 92% (95% CI = 90% to 93%), and 90% (95% CI = 88% to 92%), respectively, and specificities of 52% (95% CI = 51% to 52%), 59% (95% CI = 58% to 59%), 64% (95% CI = 64% to 65%), and 72% (95% CI = 71% to 73%), respectively. Similar trends were found for each secondary outcome.

CONCLUSION

The addition of SI to the ACS-6 for trauma team activation increased sensitivity for EOPI with a larger decrease in specificity across all thresholds. Inclusion of a SI threshold of ≥0.9 closely aligns with under- and overtriage benchmarks in this trauma registry cohort using a strict definition of trauma team activation need.

Feasibility Study of a Quasi-experimental Regional Opioid Safety Prescribing Program in Veterans Health Administration Emergency Departments

BACKGROUND

The Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) was implemented in 2013 and was associated with a 25% relative decrease in the dispensing of opioids. Although emergency department (ED) providers play a role in the initiation and continuation of opioids, the incumbent OSI did not target EDs.

OBJECTIVE

The goal of this feasibility study was to leverage the existing VHA OSI and test a novel ED-based quality improvement (QI) program to decrease opioid prescribing in multiple ED settings.

METHODS

This was a quasi-experimental study of phased-in implementation of a QI ED-based OSI. The general setting for this pilot were four VHA EDs across the Veterans Integrated Services Network (VISN) region 19: Denver, Oklahoma City, Muskogee, and Salt Lake City. We developed and disseminated a dashboard to assess ED-specific prescribing rates and an ED-tailored toolkit to implement the program. Academic detailing pharmacists provided focused audits and feedback with the highest prescribing providers. We measured change in ED-provider prescribing rate of opioids for patients discharged from the ED, by provider and aggregated up to facility level, pre- and postimplementation.

RESULTS

Interrupted time-series analysis of provider-level data from the program implementation sites indicated a significant decrease in the trend for proportion of opioid prescriptions relative to the preintervention trend. The results of the analysis suggest that the intervention was associated with accelerating the rate at which ED provider prescribing rates decreased.

CONCLUSION

Due to the high volume of patients and the vital role the ED plays in patient treatment and hospital admissions, it is evident that the ED is an important site for QI programs as well as the implementation of opioid safety measures. Given the findings of this pilot, we believe that implementation of a national Veterans Affairs ED OSI implementation is feasible practice.

1858. Use and Perceptions of an Institution-Specific Antibiotic Prescribing “App” among Emergency Department and Urgent Care Clinicians

Background

We developed an application (app), accessible by mobile device or computer, to provide institution-specific antibiotic prescribing recommendations for common infections. The app was disseminated to emergency department (ED) and urgent care clinicians in August 2014. The purpose of this study was to assess current use of the app and its perceived impact on prescribing.

Methods

We developed and administered an online survey. The survey instrument was pre-tested by a survey methodologist, two emergency medicine physicians, an infectious diseases (ID) physician, and an ID pharmacist and subsequently pilot-tested in a group of 70 providers. The final survey was administered to all clinicians in the Denver Health ED and two urgent care centers, including physicians, advanced practice providers, and Emergency Medicine residents. Respondents were eligible if they had worked at least one ED or urgent care shift within 90 days and either personally prescribe antibiotics or oversee other clinicians who prescribe antibiotics.

Results

Of 156 clinicians, 99 responded, of whom 93 were eligible, for a response rate of 65%. Eligible respondents included 38 attending physicians, 18 advanced practice providers, and 37 residents. 91 (98%) had ever used the antibiotic app, and of those, 84 (93%) considered themselves to be regular users. 85% of users primarily accessed the app by smartphone. Mean (standard deviation [SD]) reported use was 3.0 (2.3) episodes per shift. 85% of users reported the app to be very useful (range: not at all useful to very useful). Among users of common prescribing resources including UpToDate™, Sanford Guide™, EMRA Guide to Antibiotics™, and the Johns Hopkins Guide to Antibiotics™, the institutional app had the highest reported usefulness. The mean (SD) perceived effect on accuracy of antibiotic choice, accuracy of dosing, consistency of prescribing, and effect on decreasing durations of therapy was 4.5 (0.5), 4.50 (0.6), 4.4 (0.7), and 3.5 (0.7), respectively (range: 1–5, with higher scores indicating greater effect).

Conclusion

Among ED and urgent care clinicians, an institution-specific antibiotic app was widely utilized and perceived to be a useful clinical resource that impacted prescribing. Institution-specific apps may be effective tools to promote uptake of local prescribing guidance.

Disclosures

All authors: No reported disclosures.

Variability in opioid prescribing in veterans affairs emergency departments and urgent cares

OBJECTIVE

The Veterans Health Administration (VHA) is the largest integrated health care system in the U.S., serving approximately 2.5 million Veterans in the Emergency Department/Urgent Care Centers (ED/UCC) each year. Variation in opioid prescribing by ED/UCC providers in the VHA is described.

METHODS

This is an observational study using administrative data from the VHA Pharmacy Benefits Management Services database to assess ED/UCC providers' opioid prescribing rates between October 1st, 2014 to June 30th, 2017 in 121 U.S. facilities. The opioid prescribing rate was defined as the number of opioid prescriptions written by the provider divided by the number of patients discharged from the ED/UCC by that provider, by quarter. A regression analysis was performed to estimate the association between time and prescribing rates by provider.

RESULTS

Overall, the national trend in median prescribing rates decreased by 25.5% (p value = 0.00) from 9.1% ([range 1.5%-25.6%] to 6.4% [range 0.8%-21.8%]). The greatest rates of decline occurred between January 1st, 2016 to June 30th, 2017. The rate of provider opioid prescribing demonstrated wide variability between facilities (range: 0.5% to 39.1%). The prescribing rate for ED/UCC providers ranged from 0.2% to 100%. Between June 2016 and May 2017, 24 VHA ED/UCC providers were the highest opioid prescribers nationally in at least two of the four quarters (22%-70%), with rates two- to three-fold higher than their peers.

CONCLUSION

ED/UCC providers in the VHA system nationally vary considerably in rates of opioid prescribing. A focused initiative tailored for ED/UCC providers is needed to decrease opioid prescribing variability.

Intraocular pressure is not associated with acute mountain sickness

OBJECTIVE

Acute mountain sickness (AMS) is common at high altitude and may lead to high altitude cerebral edema (HACE) if not properly recognized. Previous studies have suggested that AMS is associated with increases in intracranial pressure (ICP). Increased ICP has been associated with increased intra-ocular pressure (IOP). This study was designed to determine the association between IOP and AMS.

METHODS

Subjects were recruited from a convenience sample of travelers in the Khumbu region of Nepal, elevation 14,410 ft (4392 m). Study participation involved completion of a questionnaire to assess for AMS by the Lake Louise Score (LLS), followed by three IOP measurements in each eye. Investigators were blinded to the LLS. Subjects with a history of ocular surgery were excluded. Three IOP measurements per eye were made using an applanation tonometer (Tono-Pen XL(®), Reichart Technologies) and averaged across both eyes. Multivariable logistic regression analysis was used to estimate the association between IOP and AMS while adjusting for age, ascent or descent, and use of acetazolamide. IOP and blood O2 saturation were compared using a Spearman correlation coefficient.

RESULTS

161 subjects were enrolled with a median age of 36 (IQR: 29-45) years; 60% were male, 75% were ascending, and 64% were taking acetazolamide; additionally, 38%, (95% CI: 31%-47%) were diagnosed with AMS (LLS ≥3). The median IOP was 21 (IQR 18-24) mmHg. The logistic regression model demonstrated no association between IOP and AMS as measured by LLS (odds ratio [OR] 1.0, 95% CI: 0.9-1.1),age (OR 1.0, 95% CI: 0.9-1.0) or with use of acetazolamide (OR 1.4, 95% CI: 0.6-2.6). Ascent (OR 0.4, 95% CI: 0.2-0.9) was negatively associated with IOP but not significantly so. IOP and O2 saturation were not correlated (p=0.93).

CONCLUSIONS

IOP measured at high altitude is not associated with the diagnosis of AMS. Other approaches to diagnose AMS easily and accurately are needed.

The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers

Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.

Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration

Joint Commission National Patient Safety Goal 15 calls for organizations "to identify patients at risk for suicide." Overt suicidal behavior accounts for 0.6% of emergency department (ED) visits, but incidental suicidal ideation is found in 3%-11.6%. This is the first multicenter study of suicide screening in EDs. Of 2,243 patients in six diverse emergency settings, 1,068 (47.7%) were screened with a brief instrument. Depression was endorsed by 369 (34.5%); passive suicidal ideation by 79 (7.3%); and active suicidal ideation by 24 (2.3%). One hundred thirty-seven (12.8%) reported prior attempts, including 35 (3.3%) with current suicidal ideation. Almost half of those with current ideation had a prior attempt (43.8%) versus those without current ideation, 10.3%, χ2 (1) = 75.59, p < .001. Twenty cases (25%) were admitted to medical services, but only 10 (12.5%) received mental health assessment; none were admitted directly to a psychiatry service. The prevalence of suicidal ideation here is similar to previous studies but the frequency of prior attempts has not been reported. The 35 cases with current ideation and prior attempt are at risk. As they did not present psychiatrically, they would likely have gone undetected. Despite reporting these cases to clinical staff, few received risk assessment.

Evaluating age in the field triage of injured persons

STUDY OBJECTIVE

We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect of a mandatory age triage criterion for field triage.

METHODS

This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ≥16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume.

RESULTS

Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers.

CONCLUSION

Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.

2009 US emergency department HIV testing practices

OBJECTIVES

We characterize HIV testing practices and programs in US emergency departments (EDs) in 2009.

METHODS

A national Web-based survey of members of the National ED HIV Testing Consortium, participants in the 2007 Centers for Disease Control and Prevention (CDC)-sponsored ED HIV Testing Workshops, all US academic EDs, and a weighted random sample of US community EDs with snowball sampling to recruit additional testing sites was conducted. Data collected included geographic location, estimated seroprevalence, indications for testing, method of consent, weekly number of tests, funding, and costs.

RESULTS

Of 619 sites surveyed, 338 (54.6%) responded. A total of 277 (82.0%) reported conducting any HIV testing, and 75 (22.2%) reported systematic HIV testing programs, operationally defined as having testing or screening organized at the departmental or institutional level. systematic HIV testing programs were concentrated in the Northeast, at high-volume urban EDs, and in regions with higher HIV/AIDS prevalence. Most systematic HIV testing programs had existed for less than or equal to 3 years, and nearly one third reported using an opt-out approach for consent. Among systematic HIV testing programs, the number of patients tested ranged from less than 1 to 2,100 tests per week. Overall, universal screening was the most commonly reported screening method reported overall, and rates of HIV positivity were consistently above the CDC threshold of 0.1%.

CONCLUSION

The number of EDs conducting HIV testing has grown substantially since release of the 2006 CDC HIV testing recommendations. Although many EDs have systematic HIV testing programs, the majority do not. Ongoing surveillance will be required to quantify the evolution of ED-based HIV testing and the factors that facilitate or impede expanded translation.

Nomenclature and definitions for emergency department human immunodeficiency virus (HIV) testing: report from the 2007 conference of the National Emergency Department HIV Testing Consortium

Early diagnosis of persons infected with human immunodeficiency virus (HIV) through diagnostic testing and screening is a critical priority for individual and public health. Emergency departments (EDs) have an important role in this effort. As EDs gain experience in HIV testing, it is increasingly apparent that implementing testing is conceptually and operationally complex. A wide variety of HIV testing practice and research models have emerged, each reflecting adaptations to site-specific factors and the needs of local populations. The diversity and complexity inherent in nascent ED HIV testing practice and research are associated with the risk that findings will not be described according to a common lexicon. This article presents a comprehensive set of terms and definitions that can be used to describe ED-based HIV testing programs, developed by consensus opinion from the inaugural meeting of the National ED HIV Testing Consortium. These definitions are designed to facilitate discussion, increase comparability of future reports, and potentially accelerate wider implementation of ED HIV testing.

Intraoperative injection of technetium-99m sulfur colloid is effective in the detection of sentinel lymph nodes in breast cancer

BACKGROUND

Our objective was to determine if intraoperative injection of technetium-99m-labeled sulfur colloid is as effective as preoperative injection in the detection of sentinel lymph nodes (SLNs).

METHODS

Two hundred consecutive patients with breast cancer underwent SLN biopsy examination. Radiocolloid was injected in the preoperative area (group A) or immediately after induction of anesthesia in the operating room (group B).

RESULTS

The SLN detection rate was similar for groups A (96%) and B (100%; P = .2). Radioactive SLNs were detected in 95% of patients in group A and in 97% of patients in group B (P = .1). The mean number of SLNs harvested was 1.6 and 2.1 for groups A and B, respectively. There was no significant difference in positive SLNs between groups (P = .11).

CONCLUSIONS

Intraoperative injection of sulfur colloid is highly effective in the detection of SLNs, avoiding patient discomfort and surgical schedule delays.

Cardiac morbidity and mortality after surgery for gastrointestinal carcinomas

The number of Americans undergoing surgery for gastrointestinal (GI) cancer is increasing, as is the prevalence of cardiovascular disease. Clinical risk factors have been found to be useful in predicting cardiac events after vascular procedures. Their utility for predicting cardiac events after GI carcinoma surgery is unclear. We performed a retrospective review in order to determine whether clinical risk factors are useful in predicting cardiac events in patients undergoing GI carcinoma surgery and to ascertain the incidence of postoperative cardiac events. From 1998 to 2003, 333 patients were identified, with an average age of 56 years. One hundred one (30.3%) patients had one or more clinical risk factors. The overall cardiac event rate was 3.9 per cent. Age > 70 years was the only risk factor associated with a cardiac event. There was a trend toward increased cardiac risk with increasing number of risk factors. In the absence of clinical risk factors, cardiac events after surgery for GI carcinoma are low. There is an increased cardiac risk in patients > 70 years and a trend toward increased cardiac events as the number of clinical risk factors increases.

Cardiac Morbidity and Mortality after Surgery for Gastrointestinal Carcinomas

The number of Americans undergoing surgery for gastrointestinal (GI) cancer is increasing, as is the prevalence of cardiovascular disease. Clinical risk factors have been found to be useful in predicting cardiac events after vascular procedures. Their utility for predicting cardiac events after GI carcinoma surgery is unclear. We performed a retrospective review in order to determine whether clinical risk factors are useful in predicting cardiac events in patients undergoing GI carcinoma surgery and to ascertain the incidence of postoperative cardiac events. From 1998 to 2003, 333 patients were identified, with an average age of 56 years. One hundred one (30.3%) patients had one or more clinical risk factors. The overall cardiac event rate was 3.9 per cent. Age >70 years was the only risk factor associated with a cardiac event. There was a trend toward increased cardiac risk with increasing number of risk factors. In the absence of clinical risk factors, cardiac events after surgery for GI carcinoma are low. There is an increased cardiac risk in patients >70 years and a trend toward increased cardiac events as the number of clinical risk factors increases.

Predictors of Cardiac Morbidity And Mortality in Patients Undergoing Endovascular Repair of the Thoracic Aorta

The aim of this study was to determine predictors of cardiac morbidity and mortality in patients undergoing endovascular repair of the thoracic aorta. This was a retrospective cohort study that took place in a University-affiliated county hospital. Preoperative and intraoperative variables were collected from a consecutive series of patients who underwent repair of the thoracic aorta at our institution between 1998 and 2003. Perioperative complications and mortality were identified for each patient. Fifty-nine patients underwent endovascular repair of the thoracic aorta. The endografts were successfully deployed in 58 (98%) patients. Nine (15%) died perioperatively, 4 (7%) from cardiac causes. There were 12 (20%) perioperative cardiac events. A history of myocardial infarction (MI) was the only preoperative risk factor that was predictive of a cardiac event (p = 0.001). The cardiac event rate was 29% for patients who did not receive perioperative beta-blockade vs. 8% in patients who did (p = 0.04). Intraoperative predictors of MI were estimated blood loss (2480 cc vs. 680 cc, p = 0.01), intravenous (i.v.) fluids (2955 cc vs. 2010 cc, p =0.02), and length of operation (269 min vs. 178 min, p = 0.02). From these results we concluded that mortality associated with endovascular repair of thoracic aorta remains significant. Patients with a history of MI had a higher perioperative cardiac event rate. Intraoperative predictors of perioperative cardiac events included blood loss, i.v. fluid requirement, and length of operation. Perioperative beta-blockade is important in endovascular thoracic surgery as a protection against postoperative cardiac events.