1
|
Mathis MR, Janda AM, Yule SJ, Dias RD, Likosky DS, Pagani FD, Stakich-Alpirez K, Kerray FM, Schultz ML, Fitzgerald D, Sturmer D, Manojlovich M, Krein SL, Caldwell MD. Nontechnical Skills for Intraoperative Team Members. Anesthesiol Clin 2023; 41:803-818. [PMID: 37838385 PMCID: PMC10703542 DOI: 10.1016/j.anclin.2023.03.013] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Nontechnical skills, defined as the set of cognitive and social skills used by individuals and teams to reduce error and improve performance in complex systems, have become increasingly recognized as a key contributor to patient safety. Efforts to characterize, quantify, and teach nontechnical skills in the context of perioperative care continue to evolve. This review article summarizes the essential behaviors for safety, described in taxonomies for nontechnical skills assessments developed for intraoperative clinical team members (eg, surgeons, anesthesiologists, scrub practitioners, perfusionists). Furthermore, the authors describe emerging methods to advance understanding of the impact of nontechnical skills on perioperative outcomes.
Collapse
Affiliation(s)
- Michael R Mathis
- Department of Anesthesiology, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Allison M Janda
- Department of Anesthesiology, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Steven J Yule
- Department of Clinical Surgery, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, Scotland
| | - Roger D Dias
- Department of Emergency Medicine, Brigham & Women's Hospital/Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Korana Stakich-Alpirez
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Fiona M Kerray
- Department of Clinical Surgery, University of Edinburgh, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, Scotland
| | - Megan L Schultz
- Department of Cardiac Surgery, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - David Fitzgerald
- Department of Clinical Sciences, Medical University of South Carolina College of Health Professions, A 151 Rutledge Avenue, Charleston, SC 29403, USA
| | - David Sturmer
- Department of Perfusion, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Milisa Manojlovich
- School of Nursing, University of Michigan, 426 N Ingalls Street, Ann Arbor, MI 48104, USA
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA
| | - Matthew D Caldwell
- Department of Anesthesiology, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| |
Collapse
|
2
|
Kamyszek RW, Newman N, Ragheb JW, Sjoding MW, Joo H, Maile MD, Cassidy RB, Golbus JR, Engoren MC, Mathis MR. Differences between patients in whom physicians agree versus disagree about the preoperative diagnosis of heart failure. J Clin Anesth 2023; 90:111226. [PMID: 37549434 DOI: 10.1016/j.jclinane.2023.111226] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/29/2023] [Accepted: 07/30/2023] [Indexed: 08/09/2023]
Abstract
STUDY OBJECTIVE To quantify preoperative heart failure (HF) diagnostic agreement and identify characteristics of patients in whom physicians agreed versus disagreed about the diagnosis. DESIGN Observational cohort study. SETTING Patients undergoing major non-cardiac surgery at an academic center between 2015 and 2019. PATIENTS 40,659 patients undergoing major non-cardiac surgery, among which a stratified subsample of 1018 patients with and without documented HF was reviewed. INTERVENTIONS Via a panel of physicians frequently managing patients with HF (cardiologists, cardiac anesthesiologists, intensivists), detailed chart reviews were performed (two per patient; median review time 32 min per reviewer per patient) to render adjudicated HF diagnoses. MEASUREMENTS Adjudicated diagnostic agreement measures (percent agreement, Krippendorf's alpha) and univariate comparisons (standardized differences) between patients in whom physicians agreed versus disagreed about the preoperative HF diagnosis. MAIN RESULTS Among patients with documented HF, physicians agreed about the diagnosis in 80.0% of cases (consensus positive), disagreed in 13.8% (disagreement), and refuted the diagnosis in 6.3% (consensus negative). Conversely, among patients without documented HF, physicians agreed about the diagnosis in 88.0% (consensus negative), disagreed in 8.4% (disagreement), and refuted the diagnosis in 3.6% (consensus positive). The estimated agreement for the 40,659 cases was 91.1% (95% CI 88.3%-93.9%); Krippendorff's alpha was 0.77 (0.75-0.80). Compared to patients in whom physicians agreed about a HF diagnosis, patients in whom physicians disagreed exhibited fewer guideline-defined HF diagnostic criteria. CONCLUSIONS Physicians usually agree about HF diagnoses adjudicated via chart review, although disagreement is not uncommon and may be partly explained by heterogeneous clinical presentations. Our findings inform preoperative screening processes by identifying patients whose characteristics contribute to physician disagreement via chart review. Clinical Trial Number / Registry URL: Not applicable.
Collapse
Affiliation(s)
- Reed W Kamyszek
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Noah Newman
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jacqueline W Ragheb
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael W Sjoding
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hyeon Joo
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael D Maile
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ruth B Cassidy
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jessica R Golbus
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA.
| |
Collapse
|
3
|
Joo H, Mathis MR, Tam M, James C, Han P, Mangrulkar RS, Friedman CP, Vydiswaran VGV. Applying AI and Guidelines to Assist Medical Students in Recognizing Patients With Heart Failure: Protocol for a Randomized Trial. JMIR Res Protoc 2023; 12:e49842. [PMID: 37874618 PMCID: PMC10630872 DOI: 10.2196/49842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/16/2023] [Accepted: 09/20/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The integration of artificial intelligence (AI) into clinical practice is transforming both clinical practice and medical education. AI-based systems aim to improve the efficacy of clinical tasks, enhancing diagnostic accuracy and tailoring treatment delivery. As it becomes increasingly prevalent in health care for high-quality patient care, it is critical for health care providers to use the systems responsibly to mitigate bias, ensure effective outcomes, and provide safe clinical practices. In this study, the clinical task is the identification of heart failure (HF) prior to surgery with the intention of enhancing clinical decision-making skills. HF is a common and severe disease, but detection remains challenging due to its subtle manifestation, often concurrent with other medical conditions, and the absence of a simple and effective diagnostic test. While advanced HF algorithms have been developed, the use of these AI-based systems to enhance clinical decision-making in medical education remains understudied. OBJECTIVE This research protocol is to demonstrate our study design, systematic procedures for selecting surgical cases from electronic health records, and interventions. The primary objective of this study is to measure the effectiveness of interventions aimed at improving HF recognition before surgery, the second objective is to evaluate the impact of inaccurate AI recommendations, and the third objective is to explore the relationship between the inclination to accept AI recommendations and their accuracy. METHODS Our study used a 3 × 2 factorial design (intervention type × order of prepost sets) for this randomized trial with medical students. The student participants are asked to complete a 30-minute e-learning module that includes key information about the intervention and a 5-question quiz, and a 60-minute review of 20 surgical cases to determine the presence of HF. To mitigate selection bias in the pre- and posttests, we adopted a feature-based systematic sampling procedure. From a pool of 703 expert-reviewed surgical cases, 20 were selected based on features such as case complexity, model performance, and positive and negative labels. This study comprises three interventions: (1) a direct AI-based recommendation with a predicted HF score, (2) an indirect AI-based recommendation gauged through the area under the curve metric, and (3) an HF guideline-based intervention. RESULTS As of July 2023, 62 of the enrolled medical students have fulfilled this study's participation, including the completion of a short quiz and the review of 20 surgical cases. The subject enrollment commenced in August 2022 and will end in December 2023, with the goal of recruiting 75 medical students in years 3 and 4 with clinical experience. CONCLUSIONS We demonstrated a study protocol for the randomized trial, measuring the effectiveness of interventions using AI and HF guidelines among medical students to enhance HF recognition in preoperative care with electronic health record data. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/49842.
Collapse
Affiliation(s)
- Hyeon Joo
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Marty Tam
- Department of Internal Medicine, Cardiology, University of Michigan, Ann Arbor, MI, United States
| | - Cornelius James
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Peijin Han
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, United States
| | - Rajesh S Mangrulkar
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Charles P Friedman
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
- School of Information, University of Michigan, Ann Arbor, MI, United States
| | - V G Vinod Vydiswaran
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
- School of Information, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
4
|
Lazzareschi DV, Fong N, Mavrothalassitis O, Whitlock EL, Chen CL, Chiu C, Adelmann D, Bokoch MP, Chen LL, Liu KD, Pirracchio R, Mathis MR, Legrand M. Intraoperative Use of Albumin in Major Noncardiac Surgery: Incidence, Variability, and Association With Outcomes. Ann Surg 2023; 278:e745-e753. [PMID: 36521076 PMCID: PMC10481928 DOI: 10.1097/sla.0000000000005774] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The impact of albumin use during major surgery is unknown, and a dearth of evidence governing its use in major noncardiac surgery has long precluded its standardization in clinical guidelines. OBJECTIVE In this study, we investigate institutional variation in albumin use among medical centers in the United States during major noncardiac surgery and explore the association of intraoperative albumin administration with important postoperative outcomes. METHODS The study is an observational retrospective cohort analysis performed among 54 U.S. hospitals in the Multicenter Perioperative Outcomes Group and includes adult patients who underwent major noncardiac surgery under general anesthesia between January 2014 and June 2020. The primary endpoint was the incidence of albumin administration. Secondary endpoints are acute kidney injury (AKI), net-positive fluid balance, pulmonary complications, and 30-day mortality. Albumin-exposed and albumin-unexposed cases were compared within a propensity score-matched cohort to evaluate associations of albumin use with outcomes. RESULTS Among 614,215 major surgeries, predominantly iso-oncotic albumin was administered in 15.3% of cases and featured significant inter-institutional variability in use patterns. Cases receiving intraoperative albumin involved patients of higher American Society of Anesthesiologists physical status and featured larger infused crystalloid volumes, greater blood loss, and vasopressor use. Overall, albumin was most often administered at high-volume surgery centers with academic affiliation, and within a propensity score-matched cohort (n=153,218), the use of albumin was associated with AKI (aOR 1.24, 95% CI 1.20-1.28, P <0.001), severe AKI (aOR 1.45, 95% CI 1.34-1.56, P <0.001), net-positive fluid balance (aOR 1.18, 95% CI 1.16-1.20, P <0.001), pulmonary complications (aOR 1.56, 95% CI 1.30-1.86, P <0.001), and 30-day all-cause mortality (aOR 1.37, 95% CI 1.26-1.49, P <0.001). CONCLUSIONS Intravenous albumin is commonly administered among noncardiac surgeries with significant inter-institutional variability in use in the United States. Albumin administration was associated with an increased risk of postoperative complications.
Collapse
Affiliation(s)
| | - Nicholas Fong
- University of California, San Francisco, School of Medicine
| | | | | | - Catherine L. Chen
- University of California, San Francisco, School of Medicine
- Philip R. Lee Institute for Health Policy Studies at University of California, San Francisco
| | - Catherine Chiu
- University of California, San Francisco, School of Medicine
| | | | | | - Lee-Lynn Chen
- University of California, San Francisco, School of Medicine
| | | | | | - Michael R. Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, San Francisco, CA
| | | |
Collapse
|
5
|
Mathis MR, Janda AM, Kheterpal S, Schonberger RB, Pagani FD, Engoren MC, Mentz GB, Shook DC, Muehlschlegel JD. Patient-, Clinician-, and Institution-level Variation in Inotrope Use for Cardiac Surgery: A Multicenter Observational Analysis. Anesthesiology 2023; 139:122-141. [PMID: 37094103 PMCID: PMC10524016 DOI: 10.1097/aln.0000000000004593] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Indexed: 04/26/2023]
Abstract
BACKGROUND Conflicting evidence exists regarding the risks and benefits of inotropic therapies during cardiac surgery, and the extent of variation in clinical practice remains understudied. Therefore, the authors sought to quantify patient-, anesthesiologist-, and hospital-related contributions to variation in inotrope use. METHODS In this observational study, nonemergent adult cardiac surgeries using cardiopulmonary bypass were reviewed across a multicenter cohort of academic and community hospitals from 2014 to 2019. Patients who were moribund, receiving mechanical circulatory support, or receiving preoperative or home inotropes were excluded. The primary outcome was an inotrope infusion (epinephrine, dobutamine, milrinone, dopamine) administered for greater than 60 consecutive min intraoperatively or ongoing upon transport from the operating room. Institution-, clinician-, and patient-level variance components were studied. RESULTS Among 51,085 cases across 611 attending anesthesiologists and 29 hospitals, 27,033 (52.9%) cases received at least one intraoperative inotrope, including 21,796 (42.7%) epinephrine, 6,360 (12.4%) milrinone, 2,000 (3.9%) dobutamine, and 602 (1.2%) dopamine (non-mutually exclusive). Variation in inotrope use was 22.6% attributable to the institution, 6.8% attributable to the primary attending anesthesiologist, and 70.6% attributable to the patient. The adjusted median odds ratio for the same patient receiving inotropes was 1.73 between 2 randomly selected clinicians and 3.55 between 2 randomly selected institutions. Factors most strongly associated with increased likelihood of inotrope use were institutional medical school affiliation (adjusted odds ratio, 6.2; 95% CI, 1.39 to 27.8), heart failure (adjusted odds ratio, 2.60; 95% CI, 2.46 to 2.76), pulmonary circulation disorder (adjusted odds ratio, 1.72; 95% CI, 1.58 to 1.87), loop diuretic home medication (adjusted odds ratio, 1.55; 95% CI, 1.42 to 1.69), Black race (adjusted odds ratio, 1.49; 95% CI, 1.32 to 1.68), and digoxin home medication (adjusted odds ratio, 1.48; 95% CI, 1.18 to 1.86). CONCLUSIONS Variation in inotrope use during cardiac surgery is attributable to the institution and to the clinician, in addition to the patient. Variation across institutions and clinicians suggests a need for future quantitative and qualitative research to understand variation in inotrope use affecting outcomes and develop evidence-based, patient-centered inotrope therapies. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Michael R. Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Allison M. Janda
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Milo C. Engoren
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Graciela B. Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Douglas C. Shook
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jochen D. Muehlschlegel
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
6
|
Leis AM, Mathis MR, Kheterpal S, Zawistowski M, Mukherjee B, Pace N, O'Reilly-Shah VN, Smith JA, Karvonen-Gutierrez CA. Cardiometabolic disease and obesity patterns differentially predict acute kidney injury after total joint replacement: a retrospective analysis. Br J Anaesth 2023; 131:37-46. [PMID: 37188560 PMCID: PMC10308436 DOI: 10.1016/j.bja.2023.04.001] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent yet understudied postoperative total joint arthroplasty complication. This study aimed to describe cardiometabolic disease co-occurrence using latent class analysis, and associated postoperative AKI risk. METHODS This retrospective analysis examined patients ≥18 years old undergoing primary total knee or hip arthroplasties within the US Multicenter Perioperative Outcomes Group of hospitals from 2008 to 2019. AKI was defined using modified Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Latent classes were constructed from eight cardiometabolic diseases including hypertension, diabetes, and coronary artery disease, excluding obesity. A mixed-effects logistic regression model was constructed for the outcome of any AKI and the exposure of interaction between latent class and obesity status adjusting for preoperative and intraoperative covariates. RESULTS Of 81 639 cases, 4007 (4.9%) developed AKI. Patients with AKI were more commonly older and non-Hispanic Black, with more significant comorbidity. A latent class model selected three groups of cardiometabolic patterning, labelled 'hypertension only' (n=37 223), 'metabolic syndrome (MetS)' (n=36 503), and 'MetS+cardiovascular disease (CVD)' (n=7913). After adjustment, latent class/obesity interaction groups had differential risk of AKI compared with those in 'hypertension only'/non-obese. Those 'hypertension only'/obese had 1.7-fold increased odds of AKI (95% confidence interval [CI]: 1.5-2.0). Compared with 'hypertension only'/non-obese, those 'MetS+CVD'/obese had the highest odds of AKI (odds ratio 3.1, 95% CI: 2.6-3.7), whereas 'MetS+CVD'/non-obese had 2.2 times the odds of AKI (95% CI: 1.8-2.7; model area under the curve 0.76). CONCLUSIONS The risk of postoperative AKI varies widely between patients. The current study suggests that the co-occurrence of metabolic conditions (diabetes mellitus, hypertension), with or without obesity, is a more important risk factor for acute kidney injury than individual comorbid diseases.
Collapse
Affiliation(s)
- Aleda M Leis
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA.
| | - Michael R Mathis
- Department of Anaesthesiology, University of Michigan, Ann Arbor, MI, USA; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anaesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Matthew Zawistowski
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Bhramar Mukherjee
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA; Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Nathan Pace
- Department of Anaesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Vikas N O'Reilly-Shah
- Department of Anaesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | - Jennifer A Smith
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | |
Collapse
|
7
|
Pienta MJ, Noly PE, Janda AM, Tang PC, Bitar A, Mathis MR, Aaronson KD, Pagani FD, Likosky DS. Rescuing the right ventricle: A conceptual framework to target new interventions for patients receiving a durable left ventricular assist device. J Thorac Cardiovasc Surg 2023; 165:2126-2131. [PMID: 35527048 DOI: 10.1016/j.jtcvs.2022.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Michael J Pienta
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Pierre-Emmanuel Noly
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Allison M Janda
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Mich
| | - Paul C Tang
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Abbas Bitar
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Michael R Mathis
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Francis D Pagani
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Donald S Likosky
- Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.
| |
Collapse
|
8
|
Lazzareschi DV, Fong N, Pirracchio R, Mathis MR, Legrand M. Leveraging observational data to identify targeted patient populations for future randomized trials. Res Sq 2023:rs.3.rs-2641628. [PMID: 37205590 PMCID: PMC10187375 DOI: 10.21203/rs.3.rs-2641628/v1] [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] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Randomized controlled trials reported in the literature are often affected by poor generalizability, and pragmatic trials have become an increasingly utilized workaround approach to overcome logistical limitations and explore routine interventions demonstrating equipoise in clinical practice. Intravenous albumin, for example, is commonly administered in the perioperative setting despite lacking supportive evidence. Given concerns for cost, safety, and efficacy, randomized trials are needed to explore the clinical equipoise of albumin therapy in this setting, and we therefore present an approach to identifying populations exposed to perioperative albumin to encourage clinical equipoise in patient selection and optimize study design for clinical trials.
Collapse
|
9
|
Privratsky JR, Fuller M, Raghunathan K, Ohnuma T, Bartz RR, Schroeder R, Price TM, Martinez MR, Sigurdsson MI, Mathis MR, Naik B, Krishnamoorthy V. Postoperative Acute Kidney Injury by Age and Sex: A Retrospective Cohort Association Study. Anesthesiology 2023; 138:184-194. [PMID: 36512724 PMCID: PMC10439699 DOI: 10.1097/aln.0000000000004436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) after noncardiac surgery is common and has substantial health impact. Preclinical and clinical studies examining the influence of sex on AKI have yielded conflicting results, although they typically do not account for age-related changes. The objective of the study was to determine the association of age and sex groups on postoperative AKI. The authors hypothesized that younger females would display lower risk of postoperative AKI than males of similar age, and the protection would be lost in older females. METHODS This was a multicenter retrospective cohort study across 46 institutions between 2013 and 2019. Participants included adult inpatients without pre-existing end-stage kidney disease undergoing index major noncardiac, nonkidney/urologic surgeries. The authors' primary exposure was age and sex groups defined as females 50 yr or younger, females older than 50 yr, males 50 yr or younger, and males older than 50 yr. The authors' primary outcome was development of AKI by Kidney Disease-Improving Global Outcomes serum creatinine criteria. Exploratory analyses included associations of ascending age groups and hormone replacement therapy home medications with postoperative AKI. RESULTS Among 390,382 patients, 25,809 (6.6%) developed postoperative AKI (females 50 yr or younger: 2,190 of 58,585 [3.7%]; females older than 50 yr: 9,320 of 14,4047 [6.5%]; males 50 yr or younger: 3,289 of 55,503 [5.9%]; males older than 50 yr: 11,010 of 132,447 [8.3%]). When adjusted for AKI risk factors, compared to females younger than 50 yr (odds ratio, 1), the odds of AKI were higher in females older than 50 yr (odds ratio, 1.51; 95% CI, 1.43 to 1.59), males younger than 50 yr (odds ratio, 1.90; 95% CI, 1.79 to 2.01), and males older than 50 yr (odds ratio, 2.06; 95% CI, 1.96 to 2.17). CONCLUSIONS Younger females display a lower odds of postoperative AKI that gradually increases with age. These results suggest that age-related changes in women should be further studied as modifiers of postoperative AKI risk after noncardiac surgery. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Jamie R. Privratsky
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
- Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Matthew Fuller
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
- Durham VA Medical Center, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Raquel R. Bartz
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Rebecca Schroeder
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
- Durham VA Medical Center, Durham, NC, USA
| | - Thomas M. Price
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Michael R. Martinez
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Martin I. Sigurdsson
- Division of Anesthesia and Intensive Care Medicine, Landspitali -The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik Iceland
| | - Michael R. Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Bhiken Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| |
Collapse
|
10
|
Ebadi-Tehrani MM, Smith ED, Chang AC, Ailawadi G, Blank R, Palardy M, Mathis MR. Transesophageal Echocardiography for Cardiac Surgery Patients With Prior Esophagectomies: Insights From a 15-Year Institutional Experience. J Am Soc Echocardiogr 2022; 36:438-440. [PMID: 36592873 DOI: 10.1016/j.echo.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/31/2022] [Accepted: 12/27/2022] [Indexed: 01/01/2023]
Affiliation(s)
- Mehran M Ebadi-Tehrani
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Eric D Smith
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Andrew C Chang
- Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ross Blank
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Maryse Palardy
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| |
Collapse
|
11
|
Golbus JR, Joo H, Janda AM, Maile MD, Aaronson KD, Engoren MC, Cassidy RB, Kheterpal S, Mathis MR. Preoperative clinical diagnostic accuracy of heart failure among patients undergoing major noncardiac surgery: a single-centre prospective observational analysis. BJA Open 2022; 4:100113. [PMID: 36643721 PMCID: PMC9835767 DOI: 10.1016/j.bjao.2022.100113] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/16/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
Background Reliable diagnosis of heart failure during preoperative evaluation is important for perioperative management and long-term care. We aimed to quantify preoperative heart failure diagnostic accuracy and explore characteristics of patients with heart failure misdiagnoses. Methods We performed an observational cohort study of adults undergoing major noncardiac surgery at an academic hospital between 2015 and 2019. A preoperative clinical diagnosis of heart failure was defined using keywords from the history and clinical examination or administrative documentation. Across stratified subsamples of cases with and without clinically diagnosed heart failure, health records were intensively reviewed by an expert panel to develop an adjudicated heart failure reference standard using diagnostic criteria congruent with consensus guidelines. We calculated agreement among experts, and analysed performance of clinically diagnosed heart failure compared with the adjudicated reference standard. Results Across 40 555 major noncardiac procedures, a stratified subsample of 511 patients was reviewed by the expert panel. The prevalence of heart failure was 9.1% based on clinically diagnosed compared with 13.3% (95% confidence interval [CI], 10.3-16.2%) estimated by the expert panel. Overall agreement and inter-rater reliability (kappa) among heart failure experts were 95% and 0.79, respectively. Based upon expert adjudication, heart failure was clinically diagnosed with an accuracy of 92.8% (90.6-95.1%), sensitivity 57.4% (53.1-61.7%), specificity 98.3% (97.1-99.4%), positive predictive value 83.5% (80.3-86.8%), and negative predictive value 93.8% (91.7-95.9%). Conclusions Limitations exist to the preoperative clinical diagnosis of heart failure, with nearly half of cases undiagnosed preoperatively. Considering the risks of undiagnosed heart failure, efforts to improve preoperative heart failure diagnoses are warranted.
Collapse
Affiliation(s)
- Jessica R. Golbus
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Hyeon Joo
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Allison M. Janda
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Michael D. Maile
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Keith D. Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Milo C. Engoren
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Ruth B. Cassidy
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Michael R. Mathis
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
- Department of Computational Bioinformatics, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
12
|
Mathis MR, Engoren MC, Williams AM, Biesterveld BE, Croteau AJ, Cai L, Kim RB, Liu G, Ward KR, Najarian K, Gryak J. Prediction of Postoperative Deterioration in Cardiac Surgery Patients Using Electronic Health Record and Physiologic Waveform Data. Anesthesiology 2022; 137:586-601. [PMID: 35950802 PMCID: PMC10227693 DOI: 10.1097/aln.0000000000004345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative hemodynamic deterioration among cardiac surgical patients can indicate or lead to adverse outcomes. Whereas prediction models for such events using electronic health records or physiologic waveform data are previously described, their combined value remains incompletely defined. The authors hypothesized that models incorporating electronic health record and processed waveform signal data (electrocardiogram lead II, pulse plethysmography, arterial catheter tracing) would yield improved performance versus either modality alone. METHODS Intensive care unit data were reviewed after elective adult cardiac surgical procedures at an academic center between 2013 and 2020. Model features included electronic health record features and physiologic waveforms. Tensor decomposition was used for waveform feature reduction. Machine learning-based prediction models included a 2013 to 2017 training set and a 2017 to 2020 temporal holdout test set. The primary outcome was a postoperative deterioration event, defined as a composite of low cardiac index of less than 2.0 ml min-1 m-2, mean arterial pressure of less than 55 mmHg sustained for 120 min or longer, new or escalated inotrope/vasopressor infusion, epinephrine bolus of 1 mg or more, or intensive care unit mortality. Prediction models analyzed data 8 h before events. RESULTS Among 1,555 cases, 185 (12%) experienced 276 deterioration events, most commonly including low cardiac index (7.0% of patients), new inotrope (1.9%), and sustained hypotension (1.4%). The best performing model on the 2013 to 2017 training set yielded a C-statistic of 0.803 (95% CI, 0.799 to 0.807), although performance was substantially lower in the 2017 to 2020 test set (0.709, 0.705 to 0.712). Test set performance of the combined model was greater than corresponding models limited to solely electronic health record features (0.641; 95% CI, 0.637 to 0.646) or waveform features (0.697; 95% CI, 0.693 to 0.701). CONCLUSIONS Clinical deterioration prediction models combining electronic health record data and waveform data were superior to either modality alone, and performance of combined models was primarily driven by waveform data. Decreased performance of prediction models during temporal validation may be explained by data set shift, a core challenge of healthcare prediction modeling. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Michael R Mathis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan; Department of Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, Michigan; Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; and Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Aaron M Williams
- Department of General Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Ben E Biesterveld
- Department of General Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Alfred J Croteau
- Department of General Surgery, Hartford HealthCare Medical Group, Hartford, Connecticut
| | - Lingrui Cai
- Department of Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, Michigan
| | - Renaid B Kim
- Department of Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, Michigan
| | - Gang Liu
- Department of Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, Michigan
| | - Kevin R Ward
- Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan; and Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Kayvan Najarian
- Department of Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, Michigan; Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; and Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Jonathan Gryak
- Department of Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, Michigan; and Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
13
|
Larach DB, Lewis A, Bastarache L, Pandit A, He J, Sinha A, Douville NJ, Heung M, Mathis MR, Mosley JD, Wanderer JP, Kheterpal S, Zawistowski M, Brummett CM, Siew ED, Robinson-Cohen C, Kertai MD. Limited clinical utility for GWAS or polygenic risk score for postoperative acute kidney injury in non-cardiac surgery in European-ancestry patients. BMC Nephrol 2022; 23:339. [PMID: 36271344 PMCID: PMC9587619 DOI: 10.1186/s12882-022-02964-8] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 09/27/2022] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Prior studies support a genetic basis for postoperative acute kidney injury (AKI). We conducted a genome-wide association study (GWAS), assessed the clinical utility of a polygenic risk score (PRS), and estimated the heritable component of AKI in patients who underwent noncardiac surgery. METHODS We performed a retrospective large-scale genome-wide association study followed by a meta-analysis of patients who underwent noncardiac surgery at the Vanderbilt University Medical Center ("Vanderbilt" cohort) or Michigan Medicine, the academic medical center of the University of Michigan ("Michigan" cohort). In the Vanderbilt cohort, the relationship between polygenic risk score for estimated glomerular filtration rate and postoperative AKI was also tested to explore the predictive power of aggregating multiple common genetic variants associated with AKI risk. Similarly, in the Vanderbilt cohort genome-wide complex trait analysis was used to estimate the heritable component of AKI due to common genetic variants. RESULTS The study population included 8248 adults in the Vanderbilt cohort (mean [SD] 58.05 [15.23] years, 50.2% men) and 5998 adults in Michigan cohort (56.24 [14.76] years, 49% men). Incident postoperative AKI events occurred in 959 patients (11.6%) and in 277 patients (4.6%), respectively. No loci met genome-wide significance in the GWAS and meta-analysis. PRS for estimated glomerular filtration rate explained a very small percentage of variance in rates of postoperative AKI and was not significantly associated with AKI (odds ratio 1.050 per 1 SD increase in polygenic risk score [95% CI, 0.971-1.134]). The estimated heritability among common variants for AKI was 4.5% (SE = 4.5%) suggesting low heritability. CONCLUSION The findings of this study indicate that common genetic variation minimally contributes to postoperative AKI after noncardiac surgery, and likely has little clinical utility for identifying high-risk patients.
Collapse
Affiliation(s)
- Daniel B Larach
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adam Lewis
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anita Pandit
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Jing He
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anik Sinha
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Nicholas J Douville
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
- Institute of Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan D Mosley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for AKI (VIP-AKI), Tennessee Valley Health System, Nashville Veterans Affairs Hospital, Nashville, TN, USA
| | - Cassianne Robinson-Cohen
- Vanderbilt O'Brien Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Miklos D Kertai
- Division of Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, Medical Arts Building, Office 526E, Nashville, TN, 37212, USA.
| |
Collapse
|
14
|
Bardia A, Deshpande R, Michel G, Yanez D, Dai F, Pace NL, Schuster K, Mathis MR, Kheterpal S, Schonberger RB. Demonstration and Performance Evaluation of Two Novel Algorithms for Removing Artifacts From Automated Intraoperative Temperature Data Sets: Multicenter, Observational, Retrospective Study. JMIR Perioper Med 2022; 5:e37174. [PMID: 36197702 PMCID: PMC9591708 DOI: 10.2196/37174] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The automated acquisition of intraoperative patient temperature data via temperature probes leads to the possibility of producing a number of artifacts related to probe positioning that may impact these probes' utility for observational research. OBJECTIVE We sought to compare the performance of two de novo algorithms for filtering such artifacts. METHODS In this observational retrospective study, the intraoperative temperature data of adults who received general anesthesia for noncardiac surgery were extracted from the Multicenter Perioperative Outcomes Group registry. Two algorithms were developed and then compared to the reference standard-anesthesiologists' manual artifact detection process. Algorithm 1 (a slope-based algorithm) was based on the linear curve fit of 3 adjacent temperature data points. Algorithm 2 (an interval-based algorithm) assessed for time gaps between contiguous temperature recordings. Sensitivity and specificity values for artifact detection were calculated for each algorithm, as were mean temperatures and areas under the curve for hypothermia (temperatures below 36 C) for each patient, after artifact removal via each methodology. RESULTS A total of 27,683 temperature readings from 200 anesthetic records were analyzed. The overall agreement among the anesthesiologists was 92.1%. Both algorithms had high specificity but moderate sensitivity (specificity: 99.02% for algorithm 1 vs 99.54% for algorithm 2; sensitivity: 49.13% for algorithm 1 vs 37.72% for algorithm 2; F-score: 0.65 for algorithm 1 vs 0.55 for algorithm 2). The areas under the curve for time × hypothermic temperature and the mean temperatures recorded for each case after artifact removal were similar between the algorithms and the anesthesiologists. CONCLUSIONS The tested algorithms provide an automated way to filter intraoperative temperature artifacts that closely approximates manual sorting by anesthesiologists. Our study provides evidence demonstrating the efficacy of highly generalizable artifact reduction algorithms that can be readily used by observational studies that rely on automated intraoperative data acquisition.
Collapse
Affiliation(s)
- Amit Bardia
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, United States
| | - George Michel
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, United States
| | - David Yanez
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, United States
| | - Feng Dai
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, United States
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, United States
| | - Kevin Schuster
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - Robert B Schonberger
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
15
|
Maile MD, Mathis MR, Jewell ES, Mentz GB, Engoren MC. Identification of intraoperative management strategies that have a differential effect on patients with reduced left ventricular ejection fraction: a retrospective cohort study. BMC Anesthesiol 2022; 22:288. [PMID: 36088308 PMCID: PMC9463783 DOI: 10.1186/s12871-022-01817-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
There are few data to guide the intraoperative management of patients with reduced left ventricular ejection fraction (LVEF). This study aimed to describe how patients with reduced LVEF are managed differently and to identify and treatments had a different risk profile in this population.
Methods
We performed a retrospective cohort study of adult patients who underwent general anesthesia for non-cardiac surgery. The effect of anesthesia medications and fluid balance was compared between those with and without a reduced preoperative LVEF. The primary outcome was a composite of acute kidney injury, myocardial injury, pulmonary complications, and 30-day mortality. Multivariable logistic regression was used to adjust for confounders. Treatments that affected patients with reduced LVEF differently were defined as those associated with the primary outcome that also had a significant interaction with LVEF.
Results
A total of 9420 patients were included. Patients with reduced LVEF tended to have a less positive fluid balance. Etomidate, calcium, and phenylephrine were use more frequently, while propofol and remifentanil were used less frequently. Remifentanil affected patients with reduced LVEF differently than those without (interaction term OR 2.71, 95% CI 1.30–5.68, p = 0.008). While the use of remifentanil was associated with fewer complications in patients with normal systolic function (OR 0.54, 95% CI 0.42–0.68, p < 0.001), it was associated with an increase in complications in patients with reduced LVEF (OR = 3.13, 95% CI 3.06–5.98, p = 0.026).
Conclusions
Patients with a reduced preoperative LVEF are treated differently than those with a normal LVEF when undergoing non-cardiac surgery. An association was found between the use of remifentanil and an increase in postoperative adverse events that was unique to this population. Future research is needed to determine if this relationship is secondary to the medication itself or reflects a difference in how remifentanil is used in patients with reduced LVEF.
Collapse
|
16
|
Legrand M, Bagshaw SM, Koyner JL, Schulman IH, Mathis MR, Bernholz J, Coca S, Gallagher M, Gaudry S, Liu KD, Mehta RL, Pirracchio R, Ryan A, Steubl D, Stockbridge N, Erlandsson F, Turan A, Wilson FP, Zarbock A, Bokoch MP, Casey JD, Rossignol P, Harhay MO. Optimizing the Design and Analysis of Future AKI Trials. J Am Soc Nephrol 2022; 33:1459-1470. [PMID: 35831022 PMCID: PMC9342638 DOI: 10.1681/asn.2021121605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
AKI is a complex clinical syndrome associated with an increased risk of morbidity and mortality, particularly in critically ill and perioperative patient populations. Most AKI clinical trials have been inconclusive, failing to detect clinically important treatment effects at predetermined statistical thresholds. Heterogeneity in the pathobiology, etiology, presentation, and clinical course of AKI remains a key challenge in successfully testing new approaches for AKI prevention and treatment. This article, derived from the "AKI" session of the "Kidney Disease Clinical Trialists" virtual workshop held in October 2021, reviews barriers to and strategies for improving the design and implementation of clinical trials in patients with, or at risk of, developing AKI. The novel approaches to trial design included in this review span adaptive trial designs that increase the knowledge gained from each trial participant; pragmatic trial designs that allow for the efficient enrollment of sufficiently large numbers of patients to detect small, but clinically significant, treatment effects; and platform trial designs that use one trial infrastructure to answer multiple clinical questions simultaneously. This review also covers novel approaches to clinical trial analysis, such as Bayesian analysis and assessing heterogeneity in the response to therapies among trial participants. We also propose a road map and actionable recommendations to facilitate the adoption of the reviewed approaches. We hope that the resulting road map will help guide future clinical trial planning, maximize learning from AKI trials, and reduce the risk of missing important signals of benefit (or harm) from trial interventions.
Collapse
Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, California
- French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Trialists, Nancy, France
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Ivonne H Schulman
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Michael R Mathis
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Steven Coca
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Stéphane Gaudry
- French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Trialists, Nancy, France
- Département de Réanimation, Medical and surgical intensive care unit, Assistance Publique-Hôpitaux de Paris Hôpital Avicenne, Bobigny, France
- Common and Rare Kidney Diseases, Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMR-S 1155, Paris, France
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, California
| | - Ravindra L Mehta
- Department of Medicine, University of California San Diego, San Diego, California
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Medicine, University of California San Francisco, San Francisco, California
| | - Abigail Ryan
- Division of Chronic Care Management, Chronic Care Policy Group, Center for Medicare, Center for Medicare and Medicaid Services, Baltimore, Maryland
| | - Dominik Steubl
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Norman Stockbridge
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - Alparslan Turan
- Department of Anesthesiology, Lerner College of Medicine of Case Western University, Cleveland, Ohio
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - F Perry Wilson
- Section of Nephrology and Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, California
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patrick Rossignol
- French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Trialists, Nancy, France
- University of Lorraine, INSERM CIC 1433, Nancy, France
- Nancy CHRU, INSERM U1116, Nancy, French national institute of Health and Medical Research, unit 1116, Nancy, France
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Laboratory, PAIR (Palliative and Advanced Illness Research) Center, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
17
|
Kim RB, Alge OP, Liu G, Biesterveld BE, Wakam G, Williams AM, Mathis MR, Najarian K, Gryak J. Prediction of postoperative cardiac events in multiple surgical cohorts using a multimodal and integrative decision support system. Sci Rep 2022; 12:11347. [PMID: 35790802 PMCID: PMC9256604 DOI: 10.1038/s41598-022-15496-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/24/2022] [Indexed: 12/01/2022] Open
Abstract
Postoperative patients are at risk of life-threatening complications such as hemodynamic decompensation or arrhythmia. Automated detection of patients with such risks via a real-time clinical decision support system may provide opportunities for early and timely interventions that can significantly improve patient outcomes. We utilize multimodal features derived from digital signal processing techniques and tensor formation, as well as the electronic health record (EHR), to create machine learning models that predict the occurrence of several life-threatening complications up to 4 hours prior to the event. In order to ensure that our models are generalizable across different surgical cohorts, we trained the models on a cardiac surgery cohort and tested them on vascular and non-cardiac acute surgery cohorts. The best performing models achieved an area under the receiver operating characteristic curve (AUROC) of 0.94 on training and 0.94 and 0.82, respectively, on testing for the 0.5-hour interval. The AUROCs only slightly dropped to 0.93, 0.92, and 0.77, respectively, for the 4-hour interval. This study serves as a proof-of-concept that EHR data and physiologic waveform data can be combined to enable the early detection of postoperative deterioration events.
Collapse
Affiliation(s)
- Renaid B Kim
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Olivia P Alge
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Gang Liu
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Ben E Biesterveld
- Department of Surgery, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Glenn Wakam
- Department of Surgery, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Aaron M Williams
- Department of Surgery, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Kayvan Najarian
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, 48109, USA.,Michigan Institute for Data Science (MIDAS), University of Michigan, Ann Arbor, MI, 48109, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, 48109, USA
| | - Jonathan Gryak
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, 48109, USA. .,Michigan Institute for Data Science (MIDAS), University of Michigan, Ann Arbor, MI, 48109, USA.
| |
Collapse
|
18
|
Mathis MR, Schonberger RB, Whitlock EL, Vogt KM, Lagorio JE, Jones KA, Conroy JM, Kheterpal S. Opportunities Beyond the Anesthesiology Department: Broader Impact Through Broader Thinking. Anesth Analg 2022; 134:242-252. [PMID: 33684091 PMCID: PMC8423864 DOI: 10.1213/ane.0000000000005428] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Ensuring a productive clinical and research workforce requires bringing together physicians and communities to improve health, by strategic targeting of initiatives with clear and significant public health relevance. Within anesthesiology, the traditional perspective of the field's health impact has focused on providing safe and effective intraoperative care, managing critical illness, and treating acute and chronic pain. However, there are limitations to such a framework for anesthesiology's public health impact, including the transient nature of acute care episodes such as the intraoperative period and critical illness, and a historical focus on analgesia alone-rather than the complex psychosocial milieu-for pain management. Due to the often episodic nature of anesthesiologists' interactions with patients, it remains challenging for anesthesiologists to achieve their full potential for broad impact and leadership within increasingly integrated health systems. To unlock this potential, anesthesiologists should cultivate new clinical, research, and administrative roles within the health system-transcending traditional missions, seeking interdepartmental collaborations, and taking measures to elevate anesthesiologists as dynamic and trusted leaders. This special article examines 3 core themes for how anesthesiologists can enhance their impact within the health care system and pursue new collaborative health missions with nonanesthesiologist clinicians, researchers, and administrative leaders. These themes include (1) reframing of traditional anesthesiologist missions toward a broader health system-wide context; (2) leveraging departmental and institutional support for professional career development; and (3) strategically prioritizing leadership attributes to enhance system-wide anesthesiologist contributions to improving overall patient health.
Collapse
Affiliation(s)
- Michael R. Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Elizabeth L. Whitlock
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Keith M. Vogt
- Departments of Anesthesiology & Perioperative Medicine and Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - John E. Lagorio
- Department of Anesthesiology, Mercy Health, Muskegon, MI, USA
| | - Keith A. Jones
- Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joanne M. Conroy
- Department of Anesthesiology, Dartmouth Geisel School of Medicine, Hanover NH, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
19
|
Janda AM, Spence J, Dubovoy T, Belley-Côté E, Mentz G, Kheterpal S, Mathis MR. Multicentre analysis of practice patterns regarding benzodiazepine use in cardiac surgery. Br J Anaesth 2022; 128:772-784. [PMID: 35101244 PMCID: PMC9074791 DOI: 10.1016/j.bja.2021.11.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 03/17/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is controversy regarding optimal use of benzodiazepines during cardiac surgery, and it is unknown whether and to what extent there is variation in practice. We sought to describe benzodiazepine use and sources of variation during cardiac surgeries across patients, clinicians, and institutions. METHODS We conducted an analysis of adult cardiac surgeries across a multicentre consortium of USA academic and private hospitals from 2014 to 2019. The primary outcome was administration of a benzodiazepine from 2 h before anaesthesia start until anaesthesia end. Institutional-, clinician-, and patient-level variables were analysed via multilevel mixed-effects models. RESULTS Of 65 508 patients cared for by 825 anaesthesiology attending clinicians (consultants) at 33 institutions, 58 004 patients (88.5%) received benzodiazepines with a median midazolam-equivalent dose of 4.0 mg (inter-quartile range [IQR], 2.0-6.0 mg). Variation in benzodiazepine dosage administration was 54.7% attributable to institution, 14.7% to primary attending anaesthesiology clinician, and 30.5% to patient factors. The adjusted median odds ratio for two similar patients receiving a benzodiazepine was 2.68 between two randomly selected clinicians and 4.19 between two randomly selected institutions. Factors strongly associated (adjusted odds ratio, <0.75, or >1.25) with significantly decreased likelihoods of benzodiazepine administration included older age (>80 vs ≤50 yr; adjusted odds ratio=0.04; 95% CI, 0.04-0.05), university affiliation (0.08, 0.02-0.35), recent year of surgery (0.42, 0.37-0.49), and low clinician case volume (0.44, 0.25-0.75). Factors strongly associated with significantly increased likelihoods of benzodiazepine administration included cardiopulmonary bypass (2.26, 1.99-2.55), and drug use history (1.29, 1.02-1.65). CONCLUSIONS Two-thirds of the variation in benzodiazepine administration during cardiac surgery are associated with institutions and attending anaesthesiology clinicians (consultants). These data, showing wide variations in administration, suggest that rigorous research is needed to guide evidence-based and patient-centred benzodiazepine administration.
Collapse
Affiliation(s)
- Allison M Janda
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
| | - Jessica Spence
- Departments of Anesthesia and Critical Care, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Timur Dubovoy
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Emilie Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Divisions of Cardiology and Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
20
|
Templeton TW, Miller SA, Lee LK, Kheterpal S, Mathis MR, Goenaga-Díaz EJ, Templeton LB, Saha AK. Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study. Anesthesiology 2021; 135:842-853. [PMID: 34543405 PMCID: PMC8607983 DOI: 10.1097/aln.0000000000003971] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND One-lung ventilation in children remains a specialized practice with low case numbers even at tertiary centers, preventing an assessment of best practices. The authors hypothesized that certain case factors may be associated with a higher risk of intraprocedural hypoxemia in children undergoing thoracic surgery and one-lung ventilation. METHODS The Multicenter Perioperative Outcomes database and a local quality improvement database were queried for documentation of one-lung ventilation in children 2 months to 3 yr of age inclusive between 2010 and 2020. Patients undergoing vascular or other cardiac procedures were excluded. All records were reviewed electronically for the presence of hypoxemia, oxygen saturation measured by pulse oximetry (Spo2) less than 90% for 3 min or more continuously, and severe hypoxemia, Spo2 less than 90% for 5 min or more continuously during one-lung ventilation. Records were also assessed for hypercarbia, end-tidal CO2 greater than 60 mmHg for 5 min or more or a Paco2 greater than 60 on arterial blood gas. Covariates assessed for association with these outcomes included age, weight, American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status 3 or greater, duration of one-lung ventilation, preoperative Spo2 less than 98%, bronchial blocker versus endobronchial intubation, left operative side, video-assisted thoracoscopic surgery, lower tidal volume ventilation (tidal volume less than or equal to 6 ml/kg plus positive end expiratory pressure greater than or equal to 4 cm H2O for more than 80% of the duration of one-lung ventilation), and type of procedure. RESULTS Three hundred six cases from 15 institutions were included for analysis. Hypoxemia and severe hypoxemia occurred in 81 of 306 (26%) patients and 56 of 306 (18%), respectively. Hypercarbia occurred in 153 of 306 (50%). Factors associated with lower risk of hypoxemia in multivariable analysis included left operative side (odds ratio, 0.45 [95% CI, 0.251 to 0.78]) and bronchial blocker use (odds ratio, 0.351 [95% CI, 0.177 to 0.67]). Additionally, use of a bronchial blocker was associated with a reduced risk of severe hypoxemia (odds ratio, 0.290 [95% CI, 0.125 to 0.62]). CONCLUSIONS Use of a bronchial blocker was associated with a lower risk of hypoxemia in young children undergoing one-lung ventilation. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- T Wesley Templeton
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Scott A Miller
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lisa K Lee
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, California
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Eduardo J Goenaga-Díaz
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Leah B Templeton
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amit K Saha
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
21
|
Mathis MR, Yule S, Wu X, Dias RD, Janda AM, Krein SL, Manojlovich M, Caldwell MD, Stakich-Alpirez K, Zhang M, Corso J, Louis N, Xu T, Wolverton J, Pagani FD, Likosky DS. The impact of team familiarity on intra and postoperative cardiac surgical outcomes. Surgery 2021; 170:1031-1038. [PMID: 34148709 PMCID: PMC8733606 DOI: 10.1016/j.surg.2021.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/19/2021] [Accepted: 05/14/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Familiarity among cardiac surgery team members may be an important contributor to better outcomes and thus serve as a target for enhancing outcomes. METHODS Adult cardiac surgical procedures (n = 4,445) involving intraoperative providers were evaluated at a tertiary hospital between 2016 and 2020. Team familiarity (mean of prior cardiac surgeries performed by participating surgeon/nonsurgeon pairs within 2 years before the operation) were regressed on cardiopulmonary bypass duration (primary-an intraoperative measure of care efficiency) and postoperative complication outcomes (major morbidity, mortality), adjusting for provider experience, surgeon 2-year case volume before the surgery, case start time, weekday, and perioperative risk factors. The relationship between team familiarity and outcomes was assessed across predicted risk strata. RESULTS Median (interquartile range) cardiopulmonary bypass duration was 132 minutes (91-192), and 698 (15.7%) patients developed major postoperative morbidity. The relationship between team familiarity and cardiopulmonary bypass duration significantly differed across predicted risk strata (P = .0001). High (relative to low) team familiarity was associated with reduced cardiopulmonary bypass duration for medium-risk (-24 minutes) and high-risk (-27 minutes) patients. Increasing team familiarity was not significantly associated with the odds of major morbidity and mortality. CONCLUSION Team familiarity, which was predictive of improved intraoperative efficiency without compromising major postoperative outcomes, may serve as a novel quality improvement target in the setting of cardiac surgery.
Collapse
Affiliation(s)
- Michael R Mathis
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI. https://twitter.com/Michael_Mathis
| | - Steven Yule
- Department of Clinical Surgery, University of Edinburgh, Scotland; Department of Surgery, Brigham & Women's Hospital/Harvard Medical School, Boston, MA. https://twitter.com/NOTSS_lab
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Roger D Dias
- Department of Emergency Medicine, Brigham & Women's Hospital/ Harvard Medical School, Boston, MA. https://twitter.com/RogerDDias
| | - Allison M Janda
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, MI. https://twitter.com/Sarahlkrein
| | - Milisa Manojlovich
- School of Nursing, University of Michigan, Ann Arbor, MI. https://twitter.com/mmanojlo
| | - Matthew D Caldwell
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | | | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jason Corso
- Department of Electrical Engineering and Computer Science, College of Engineering, University of Michigan, Ann Arbor, MI. https://twitter.com/ProfJasonCorso
| | - Nathan Louis
- Department of Electrical Engineering and Computer Science, College of Engineering, University of Michigan, Ann Arbor, MI
| | - Tongbo Xu
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jeremy Wolverton
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI. https://twitter.com/JeremyWolverton
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI. https://twitter.com/FPaganiMD
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI.
| | | |
Collapse
|
22
|
Cummings BC, Ansari S, Motyka JR, Wang G, Medlin RP, Kronick SL, Singh K, Park PK, Napolitano LM, Dickson RP, Mathis MR, Sjoding MW, Admon AJ, Blank R, McSparron JI, Ward KR, Gillies CE. Predicting Intensive Care Transfers and Other Unforeseen Events: Analytic Model Validation Study and Comparison to Existing Methods. JMIR Med Inform 2021; 9:e25066. [PMID: 33818393 PMCID: PMC8061893 DOI: 10.2196/25066] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/15/2021] [Accepted: 04/03/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND COVID-19 has led to an unprecedented strain on health care facilities across the United States. Accurately identifying patients at an increased risk of deterioration may help hospitals manage their resources while improving the quality of patient care. Here, we present the results of an analytical model, Predicting Intensive Care Transfers and Other Unforeseen Events (PICTURE), to identify patients at high risk for imminent intensive care unit transfer, respiratory failure, or death, with the intention to improve the prediction of deterioration due to COVID-19. OBJECTIVE This study aims to validate the PICTURE model's ability to predict unexpected deterioration in general ward and COVID-19 patients, and to compare its performance with the Epic Deterioration Index (EDI), an existing model that has recently been assessed for use in patients with COVID-19. METHODS The PICTURE model was trained and validated on a cohort of hospitalized non-COVID-19 patients using electronic health record data from 2014 to 2018. It was then applied to two holdout test sets: non-COVID-19 patients from 2019 and patients testing positive for COVID-19 in 2020. PICTURE results were aligned to EDI and NEWS scores for head-to-head comparison via area under the receiver operating characteristic curve (AUROC) and area under the precision-recall curve. We compared the models' ability to predict an adverse event (defined as intensive care unit transfer, mechanical ventilation use, or death). Shapley values were used to provide explanations for PICTURE predictions. RESULTS In non-COVID-19 general ward patients, PICTURE achieved an AUROC of 0.819 (95% CI 0.805-0.834) per observation, compared to the EDI's AUROC of 0.763 (95% CI 0.746-0.781; n=21,740; P<.001). In patients testing positive for COVID-19, PICTURE again outperformed the EDI with an AUROC of 0.849 (95% CI 0.820-0.878) compared to the EDI's AUROC of 0.803 (95% CI 0.772-0.838; n=607; P<.001). The most important variables influencing PICTURE predictions in the COVID-19 cohort were a rapid respiratory rate, a high level of oxygen support, low oxygen saturation, and impaired mental status (Glasgow Coma Scale). CONCLUSIONS The PICTURE model is more accurate in predicting adverse patient outcomes for both general ward patients and COVID-19 positive patients in our cohorts compared to the EDI. The ability to consistently anticipate these events may be especially valuable when considering potential incipient waves of COVID-19 infections. The generalizability of the model will require testing in other health care systems for validation.
Collapse
Affiliation(s)
- Brandon C Cummings
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Sardar Ansari
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Jonathan R Motyka
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Guan Wang
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Richard P Medlin
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Steven L Kronick
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Karandeep Singh
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States.,Michigan Institute for Data Science, University of Michigan, Ann Arbor, MI, United States
| | - Pauline K Park
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Lena M Napolitano
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Robert P Dickson
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Microbiology & Immunology, University of Michigan, Ann Arbor, MI, United States
| | - Michael R Mathis
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Michael W Sjoding
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Andrew J Admon
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Michigan Institute for Data Science, University of Michigan, Ann Arbor, MI, United States
| | - Ross Blank
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Jakob I McSparron
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Kevin R Ward
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Michigan Institute for Data Science, University of Michigan, Ann Arbor, MI, United States.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Christopher E Gillies
- Michigan Center for Integrative Research in Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.,Michigan Institute for Data Science, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
23
|
Mathis MR, Duggal NM, Janda AM, Fennema JL, Yang B, Pagani FD, Maile MD, Hofer RE, Jewell ES, Engoren MC. Reduced Echocardiographic Inotropy Index after Cardiopulmonary Bypass Is Associated With Complications After Cardiac Surgery: An Institutional Outcomes Study. J Cardiothorac Vasc Anesth 2021; 35:2732-2742. [PMID: 33593647 DOI: 10.1053/j.jvca.2021.01.041] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Despite advances in echocardiography and hemodynamic monitoring, limited progress has been made to effectively quantify left ventricular function during cardiac surgery. Traditional measures, including left ventricular ejection fraction (LVEF) and cardiac index, remain dependent on loading conditions; more complex measures remain impractical in a dynamic surgical setting. However, the Smith-Madigan Inotropy Index (SMII) and potential-to-kinetic energy ratio (PKR) offer promise as measures calculable during cardiac surgery and potentially predictive of outcomes. Using echocardiographic and hemodynamic monitoring data, the authors aimed to calculate SMII and PKR values after cardiopulmonary bypass and understand associations with postoperative outcomes, adjusting for previously identified risk factors. DESIGN Observational cohort study. SETTING Tertiary care academic hospital. PATIENTS The study comprised 189 elective adult cardiac surgical procedures from 2015-2016. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The primary outcome was postoperative mortality or organ system complication (stroke, prolonged ventilation, reintubation, cardiac arrest, acute kidney injury, new-onset atrial fibrillation). After adjustment, SMII <0.83 W/m2 independently predicted the primary outcome (adjusted odds ratio 2.19, 95% confidence interval 1.08-4.42); whereas PKR, LVEF, and cardiac index demonstrated no associations. When SMII and PKR were incorporated into a EuroSCORE II risk model, predictive performance improved (net reclassification index improvement 0.457; p = 0.001); whereas a model incorporating LVEF and cardiac index demonstrated no improvement (0.130; p = 0.318). CONCLUSION The present study demonstrated that SMII, but not PKR, as a measure of cardiac function was associated with major complications. The study's data may guide investigations of more suitable perioperative goal-directed therapies to reduce complications after cardiac surgery.
Collapse
Affiliation(s)
- Michael R Mathis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI; Department of Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, MI.
| | - Neal M Duggal
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Allison M Janda
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Jordan L Fennema
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Bo Yang
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Michael D Maile
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Ryan E Hofer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth S Jewell
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI
| |
Collapse
|
24
|
Maile MD, Mathis MR, Habib RH, Schwann TA, Engoren MC. Association of Both High and Low Left Ventricular Ejection Fraction With Increased Risk After Coronary Artery Bypass Grafting. Heart Lung Circ 2021; 30:1091-1099. [PMID: 33516659 DOI: 10.1016/j.hlc.2020.11.005] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/20/2020] [Accepted: 11/05/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND While reduced left ventricular ejection fraction (LVEF) is a known risk factor for complications after coronary artery bypass grafting (CABG), the relevance of higher LVEF values has not been established. Currently, most risk stratification tools consider LVEF values above a certain point as normal. However, since this does not account for insufficient ventricular filling or increased adrenergic tone, higher values may have clinical significance. To improve our understanding of this situation, we investigated the relationship of preoperative LVEF values with short- and long-term outcomes after CABG using a strategy that allowed for the identification of nonlinear relationships. We hypothesised that both higher and lower values are independently associated with increased postoperative complications and death in this population. METHODS We performed a single-centre retrospective cohort study of patients undergoing isolated CABG surgery. All patients had a preoperative measurement of their LVEF. Surgery involving mitral valve repair was excluded in order to eliminate the impact of mitral regurgitation. The primary outcome was long-term mortality; secondary outcomes included atrial fibrillation, operative mortality, and a composite outcome including any postoperative adverse event. Fractional polynomial equations were used to model the relationship between LVEF and outcomes so we could account for nonlinear relationships if present. Adjustments for confounders were made using multivariable logistic regression and Cox models. RESULTS A total of 7,932 subjects were included in the study. After adjusting for patient and surgical characteristics, LVEF remained associated with the primary outcome as well as the composite outcome of any postoperative adverse event. Both these relationships were best described by a J-shaped curve given that higher LVEF values were associated with increased risk, albeit not as high has lower values. Regarding long-term mortality, individuals with a preoperative LVEF of 60% demonstrated the longest survival. A statistically significant relationship was not found between LVEF and operative mortality or atrial fibrillation after adjustment for confounders. CONCLUSIONS Higher preoperative LVEF values may be associated with increased risk for patients undergoing CABG surgery. Future studies are needed to better characterise this phenotype.
Collapse
Affiliation(s)
- Michael D Maile
- Division of Critical Care Medicine, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA. https://twitter.com/MikeMaile_MD
| | - Michael R Mathis
- Division of Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, IL, USA
| | - Thomas A Schwann
- Division of Cardiac Surgery, Department of Surgery, University of Massachusetts, University of Massachusetts-Baystate, Springfield, MA, USA
| | - Milo C Engoren
- Division of Critical Care Medicine, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
25
|
Likosky D, Yule SJ, Mathis MR, Dias RD, Corso JJ, Zhang M, Krein SL, Caldwell MD, Louis N, Janda AM, Shah NJ, Pagani FD, Stakich-Alpirez K, Manojlovich MM. Novel Assessments of Technical and Nontechnical Cardiac Surgery Quality: Protocol for a Mixed Methods Study. JMIR Res Protoc 2021; 10:e22536. [PMID: 33416505 PMCID: PMC7822723 DOI: 10.2196/22536] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/03/2020] [Accepted: 11/10/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Of the 150,000 patients annually undergoing coronary artery bypass grafting, 35% develop complications that increase mortality 5 fold and expenditure by 50%. Differences in patient risk and operative approach explain only 2% of hospital variations in some complications. The intraoperative phase remains understudied as a source of variation, despite its complexity and amenability to improvement. OBJECTIVE The objectives of this study are to (1) investigate the relationship between peer assessments of intraoperative technical skills and nontechnical practices with risk-adjusted complication rates and (2) evaluate the feasibility of using computer-based metrics to automate the assessment of important intraoperative technical skills and nontechnical practices. METHODS This multicenter study will use video recording, established peer assessment tools, electronic health record data, registry data, and a high-dimensional computer vision approach to (1) investigate the relationship between peer assessments of surgeon technical skills and variability in risk-adjusted patient adverse events; (2) investigate the relationship between peer assessments of intraoperative team-based nontechnical practices and variability in risk-adjusted patient adverse events; and (3) use quantitative and qualitative methods to explore the feasibility of using objective, data-driven, computer-based assessments to automate the measurement of important intraoperative determinants of risk-adjusted patient adverse events. RESULTS The project has been funded by the National Heart, Lung and Blood Institute in 2019 (R01HL146619). Preliminary Institutional Review Board review has been completed at the University of Michigan by the Institutional Review Boards of the University of Michigan Medical School. CONCLUSIONS We anticipate that this project will substantially increase our ability to assess determinants of variation in complication rates by specifically studying a surgeon's technical skills and operating room team member nontechnical practices. These findings may provide effective targets for future trials or quality improvement initiatives to enhance the quality and safety of cardiac surgical patient care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/22536.
Collapse
Affiliation(s)
- Donald Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Steven J Yule
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Roger D Dias
- STRATUS Center for Medical Simulation, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jason J Corso
- Department of Electrical Engineering and Computer Science, School of Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Matthew D Caldwell
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Nathan Louis
- Department of Electrical Engineering and Computer Science, School of Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Allison M Janda
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Nirav J Shah
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | | | | |
Collapse
|
26
|
Richer J, Hill HL, Wang Y, Yang ML, Hunker KL, Lane J, Blackburn S, Coleman DM, Eliason J, Sillon G, D’Agostino MD, Jetty P, Mongeon FP, Laberge AM, Ryan SE, Fendrikova-Mahlay N, Coutinho T, Mathis MR, Zawistowski M, Hazen SL, Katz AE, Gornik HL, Brummett CM, Abecasis G, Bergin IL, Stanley JC, Li JZ, Ganesh SK. A Novel Recurrent COL5A1 Genetic Variant Is Associated With a Dysplasia-Associated Arterial Disease Exhibiting Dissections and Fibromuscular Dysplasia. Arterioscler Thromb Vasc Biol 2020; 40:2686-2699. [PMID: 32938213 PMCID: PMC7953329 DOI: 10.1161/atvbaha.119.313885] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE While rare variants in the COL5A1 gene have been associated with classical Ehlers-Danlos syndrome and rarely with arterial dissections, recurrent variants in COL5A1 underlying a systemic arteriopathy have not been described. Monogenic forms of multifocal fibromuscular dysplasia (mFMD) have not been previously defined. Approach and Results: We studied 4 independent probands with the COL5A1 pathogenic variant c.1540G>A, p.(Gly514Ser) who presented with arterial aneurysms, dissections, tortuosity, and mFMD affecting multiple arteries. Arterial medial fibroplasia and smooth muscle cell disorganization were confirmed histologically. The COL5A1 c.1540G>A variant is predicted to be pathogenic in silico and absent in gnomAD. The c.1540G>A variant is on a shared 160.1 kb haplotype with 0.4% frequency in Europeans. Furthermore, exome sequencing data from a cohort of 264 individuals with mFMD were examined for COL5A1 variants. In this mFMD cohort, COL5A1 c.1540G>A and 6 additional relatively rare COL5A1 variants predicted to be deleterious in silico were identified and were associated with arterial dissections (P=0.005). CONCLUSIONS COL5A1 c.1540G>A is the first recurring variant recognized to be associated with arterial dissections and mFMD. This variant presents with a phenotype reminiscent of vascular Ehlers-Danlos syndrome. A shared haplotype among probands supports the existence of a common founder. Relatively rare COL5A1 genetic variants predicted to be deleterious by in silico analysis were identified in ≈2.7% of mFMD cases, and as they were enriched in patients with arterial dissections, may act as disease modifiers. Molecular testing for COL5A1 should be considered in patients with a phenotype overlapping with vascular Ehlers-Danlos syndrome and mFMD.
Collapse
Affiliation(s)
- Julie Richer
- Department of Medical Genetics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- These authors contributed equally to this work
| | - Hannah L. Hill
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
- These authors contributed equally to this work
| | - Yu Wang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
- These authors contributed equally to this work
| | - Min-Lee Yang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kristina L. Hunker
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jamie Lane
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Susan Blackburn
- Clinical Trials Unit -Heart Vessel, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dawn M. Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jonathan Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Guillaume Sillon
- Division of Medical Genetics, Departments of Specialized Medicine and Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Maria-Daniela D’Agostino
- Division of Medical Genetics, Departments of Specialized Medicine and Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Prasad Jetty
- Division of Vascular Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - François-Pierre Mongeon
- Division of Non Invasive Cardiology, Department of Specialized Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Anne-Marie Laberge
- Medical Genetics, Department of Pediatrics, CHU Ste-Justine, Quebec, Canada
| | - Stephen E. Ryan
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Thais Coutinho
- Division of Cardiology and Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Michael R. Mathis
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Matthew Zawistowski
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Stanley L. Hazen
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alex E. Katz
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Heather L. Gornik
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Chad M. Brummett
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Goncalo Abecasis
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Ingrid L. Bergin
- Unit for Laboratory Animal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - James C. Stanley
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jun Z. Li
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Santhi K. Ganesh
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
27
|
Dubovoy TZ, Saager L, Shah NJ, Colquhoun DA, Mathis MR, Kapeles S, Mentz G, Kheterpal S, Vaughn MT. Utilization Patterns of Perioperative Neuromuscular Blockade Reversal in the United States: A Retrospective Observational Study From the Multicenter Perioperative Outcomes Group. Anesth Analg 2020; 131:1510-1519. [PMID: 33079874 PMCID: PMC7593983 DOI: 10.1213/ane.0000000000005080] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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] [Indexed: 12/18/2022]
Abstract
BACKGROUND Following the introduction of sugammadex to the US clinical practice, scarce data are available to understand its utilization patterns. This study aimed to characterize patient, procedure, and provider factors associated with sugammadex administration in US patients. METHODS This retrospective observational study was conducted across 24 Multicenter Perioperative Outcomes Group institutions in the United States with sugammadex on formulary at the time of the study. All American Society of Anesthesiologists (ASA) physical status I-IV adults undergoing noncardiac surgery from 2014 to 2018 receiving neuromuscular blockade (NMB) were eligible. The study established 3 periods based on the date of first documented sugammadex use at each institution: the presugammadex period, 0- to 6-month transitional period, and 6+ months postsugammadex period. The primary outcome was reversal using sugammadex during the postsugammadex period-defined as 6 months after sugammadex was first utilized at each institution. A multivariable mixed-effects logistic regression model controlling for institution was developed to assess patient, procedure, and provider factors associated with sugammadex administration. RESULTS A total of 934,798 cases met inclusion criteria. Following the 6-month transitional period, sugammadex was used on average in 40.0% (95% confidence interval [CI], 39.8-40.2) of cases receiving NMB. Multivariable analysis demonstrated sugammadex use to be associated with train-of-four count of 0-1 (adjusted odds ratio = 4.06; 95% CI, 33.83-4.31) or 2 (2.45; 2.29-2.62) vs 3-4 twitches before reversal; the amount of NMB administered (3.01; 2.88-3.16) for the highest effective dose 95 quartile compared to the lowest quartile; advanced age (1.83; 1.71-1.95) compared to age <41; male sex (1.36; 1.32-1.39) compared to female sex; major thoracic surgery (1.26; 1.13-1.39); congestive heart failure (1.17, 1.07-1.28); and ASA III or IV (1.13; 1.10-1.16) versus ASA I or II. CONCLUSIONS Our data demonstrate broad early clinical adoption of sugammadex following Food and Drug Administration approval. Sugammadex is used preferentially in cases with higher degrees of NMB before reversal and in patients with greater burden of comorbidities and known risk factors for residual blockade or pulmonary complications.
Collapse
Affiliation(s)
- Timur Z Dubovoy
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Leif Saager
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Nirav J Shah
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Douglas A Colquhoun
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Michael R Mathis
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Steven Kapeles
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, Wisconsin
| | - Graciela Mentz
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Sachin Kheterpal
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Michelle T Vaughn
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
28
|
Mathis MR, Engoren MC, Joo H, Maile MD, Aaronson KD, Burns ML, Sjoding MW, Douville NJ, Janda AM, Hu Y, Najarian K, Kheterpal S. Early Detection of Heart Failure With Reduced Ejection Fraction Using Perioperative Data Among Noncardiac Surgical Patients: A Machine-Learning Approach. Anesth Analg 2020; 130:1188-1200. [PMID: 32287126 DOI: 10.1213/ane.0000000000004630] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) is a condition imposing significant health care burden. Given its syndromic nature and often insidious onset, the diagnosis may not be made until clinical manifestations prompt further evaluation. Detecting HFrEF in precursor stages could allow for early initiation of treatments to modify disease progression. Granular data collected during the perioperative period may represent an underutilized method for improving the diagnosis of HFrEF. We hypothesized that patients ultimately diagnosed with HFrEF following surgery can be identified via machine-learning approaches using pre- and intraoperative data. METHODS Perioperative data were reviewed from adult patients undergoing general anesthesia for major surgical procedures at an academic quaternary care center between 2010 and 2016. Patients with known HFrEF, heart failure with preserved ejection fraction, preoperative critical illness, or undergoing cardiac, cardiology, or electrophysiologic procedures were excluded. Patients were classified as healthy controls or undiagnosed HFrEF. Undiagnosed HFrEF was defined as lacking a HFrEF diagnosis preoperatively but establishing a diagnosis within 730 days postoperatively. Undiagnosed HFrEF patients were adjudicated by expert clinician review, excluding cases for which HFrEF was secondary to a perioperative triggering event, or any event not associated with HFrEF natural disease progression. Machine-learning models, including L1 regularized logistic regression, random forest, and extreme gradient boosting were developed to detect undiagnosed HFrEF, using perioperative data including 628 preoperative and 1195 intraoperative features. Training/validation and test datasets were used with parameter tuning. Test set model performance was evaluated using area under the receiver operating characteristic curve (AUROC), positive predictive value, and other standard metrics. RESULTS Among 67,697 cases analyzed, 279 (0.41%) patients had undiagnosed HFrEF. The AUROC for the logistic regression model was 0.869 (95% confidence interval, 0.829-0.911), 0.872 (0.836-0.909) for the random forest model, and 0.873 (0.833-0.913) for the extreme gradient boosting model. The corresponding positive predictive values were 1.69% (1.06%-2.32%), 1.42% (0.85%-1.98%), and 1.78% (1.15%-2.40%), respectively. CONCLUSIONS Machine-learning models leveraging perioperative data can detect undiagnosed HFrEF with good performance. However, the low prevalence of the disease results in a low positive predictive value, and for clinically meaningful sensitivity thresholds to be actionable, confirmatory testing with high specificity (eg, echocardiography or cardiac biomarkers) would be required following model detection. Future studies are necessary to externally validate algorithm performance at additional centers and explore the feasibility of embedding algorithms into the perioperative electronic health record for clinician use in real time.
Collapse
Affiliation(s)
- Michael R Mathis
- From the Department of Anesthesiology.,Center for Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, Michigan.,Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | | | - Hyeon Joo
- From the Department of Anesthesiology
| | | | - Keith D Aaronson
- Department of Internal Medicine - Cardiovascular Medicine Division, University of Michigan Health System, Ann Arbor, Michigan
| | - Michael L Burns
- From the Department of Anesthesiology.,Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Michael W Sjoding
- Center for Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, Michigan.,Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Department of Internal Medicine - Pulmonary and Critical Care Division, University of Michigan Health System, Ann Arbor, Michigan
| | | | | | - Yaokun Hu
- From the Department of Anesthesiology
| | - Kayvan Najarian
- Center for Computational Medicine and Bioinformatics, University of Michigan Health System, Ann Arbor, Michigan.,Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Sachin Kheterpal
- From the Department of Anesthesiology.,Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
29
|
Colquhoun DA, Shanks AM, Kapeles SR, Shah N, Saager L, Vaughn MT, Buehler K, Burns ML, Tremper KK, Freundlich RE, Aziz M, Kheterpal S, Mathis MR. Considerations for Integration of Perioperative Electronic Health Records Across Institutions for Research and Quality Improvement: The Approach Taken by the Multicenter Perioperative Outcomes Group. Anesth Analg 2020; 130:1133-1146. [PMID: 32287121 DOI: 10.1213/ane.0000000000004489] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Use of the electronic health record (EHR) has become a routine part of perioperative care in the United States. Secondary use of EHR data includes research, quality, and educational initiatives. Fundamental to secondary use is a framework to ensure fidelity, transparency, and completeness of the source data. In developing this framework, competing priorities must be considered as to which data sources are used and how data are organized and incorporated into a useable format. In assembling perioperative data from diverse institutions across the United States and Europe, the Multicenter Perioperative Outcomes Group (MPOG) has developed methods to support such a framework. This special article outlines how MPOG has approached considerations of data structure, validation, and accessibility to support multicenter integration of perioperative EHRs. In this multicenter practice registry, MPOG has developed processes to extract data from the perioperative EHR; transform data into a standardized format; and validate, deidentify, and transfer data to a secure central Coordinating Center database. Participating institutions may obtain access to this central database, governed by quality and research committees, to inform clinical practice and contribute to the scientific and clinical communities. Through a rigorous and standardized approach to ensure data integrity, MPOG enables data to be usable for quality improvement and advancing scientific knowledge. As of March 2019, our collaboration of 46 hospitals has accrued 10.7 million anesthesia records with associated perioperative EHR data across heterogeneous vendors. Facilitated by MPOG, each site retains access to a local repository containing all site-specific perioperative data, distinct from source EHRs and readily available for local research, quality, and educational initiatives. Through committee approval processes, investigators at participating sites may additionally access multicenter data for similar initiatives. Emerging from this work are 4 considerations that our group has prioritized to improve data quality: (1) data should be available at the local level before Coordinating Center transfer; (2) data should be rigorously validated against standardized metrics before use; (3) data should be curated into computable phenotypes that are easily accessible; and (4) data should be collected for both research and quality improvement purposes because these complementary goals bolster the strength of each endeavor.
Collapse
Affiliation(s)
- Douglas A Colquhoun
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Amy M Shanks
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Steven R Kapeles
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nirav Shah
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Leif Saager
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.,Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Michelle T Vaughn
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kathryn Buehler
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael L Burns
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kevin K Tremper
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Michael Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Sachin Kheterpal
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael R Mathis
- From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| |
Collapse
|
30
|
Douville NJ, Surakka I, Leis A, Douville CB, Hornsby WE, Brummett CM, Kheterpal S, Willer CJ, Engoren M, Mathis MR. Use of a Polygenic Risk Score Improves Prediction of Myocardial Injury After Non-Cardiac Surgery. Circ Genom Precis Med 2020; 13:e002817. [PMID: 32517536 DOI: 10.1161/circgen.119.002817] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND While postoperative myocardial injury remains a major driver of morbidity and mortality, the ability to accurately identify patients at risk remains limited despite decades of clinical research. The role of genetic information in predicting myocardial injury after noncardiac surgery (MINS) remains unknown and requires large scale electronic health record and genomic data sets. METHODS In this retrospective observational study of adult patients undergoing noncardiac surgery, we defined MINS as new troponin elevation within 30 days following surgery. To determine the incremental value of polygenic risk score (PRS) for coronary artery disease, we added the score to 3 models of MINS risk: revised cardiac risk index, a model comprised entirely of preoperative variables, and a model with combined preoperative plus intraoperative variables. We assessed performance without and with PRSs via area under the receiver operating characteristic curve and net reclassification index. RESULTS Among 90 053 procedures across 40 498 genotyped individuals, we observed 429 cases with MINS (0.5%). PRS for coronary artery disease was independently associated with MINS for each multivariable model created (odds ratio=1.12 [95% CI, 1.02-1.24], P=0.023 in the revised cardiac risk index-based model; odds ratio, 1.19 [95% CI, 1.07-1.31], P=0.001 in the preoperative model; and odds ratio, 1.17 [95% CI, 1.06-1.30], P=0.003 in the preoperative plus intraoperative model). The addition of clinical risk factors improved model discrimination. When PRS was included with preoperative and preoperative plus intraoperative models, up to 3.6% of procedures were shifted into a new outcome classification. CONCLUSIONS The addition of a PRS does not significantly improve discrimination but remains independently associated with MINS and improves goodness of fit. As genetic analysis becomes more common, clinicians will have an opportunity to use polygenic risk to predict perioperative complications. Further studies are necessary to determine if PRSs can inform MINS surveillance.
Collapse
Affiliation(s)
- Nicholas J Douville
- Department of Anesthesiology, Michigan Medicine, Ann Arbor (N.J.D., A.L., C.M.B., S.K., M.E., M.R.M.)
| | - Ida Surakka
- Division of Cardiovascular Medicine, Department of Internal Medicine (I.S.), University of Michigan, Ann Arbor
| | - Aleda Leis
- Department of Anesthesiology, Michigan Medicine, Ann Arbor (N.J.D., A.L., C.M.B., S.K., M.E., M.R.M.)
| | - Christopher B Douville
- Ludwig Center for Cancer Genetics and Therapeutics (C.B.D.), Johns Hopkins University School of Medicine, Baltimore, MD.,Sidney Kimmel Cancer Center (C.B.D.), Johns Hopkins University School of Medicine, Baltimore, MD.,Sol Goldman Pancreatic Cancer Research Center (C.B.D.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Whitney E Hornsby
- Department of Internal Medicine (W.E.H., C.J.W.), University of Michigan, Ann Arbor
| | - Chad M Brummett
- Department of Anesthesiology, Michigan Medicine, Ann Arbor (N.J.D., A.L., C.M.B., S.K., M.E., M.R.M.)
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine, Ann Arbor (N.J.D., A.L., C.M.B., S.K., M.E., M.R.M.)
| | - Cristen J Willer
- Department of Internal Medicine (W.E.H., C.J.W.), University of Michigan, Ann Arbor.,Department of Computational Medicine and Bioinformatics (C.J.W.), University of Michigan, Ann Arbor.,Department of Human Genetics (C.J.W.), University of Michigan, Ann Arbor
| | - Milo Engoren
- Department of Anesthesiology, Michigan Medicine, Ann Arbor (N.J.D., A.L., C.M.B., S.K., M.E., M.R.M.)
| | - Michael R Mathis
- Department of Anesthesiology, Michigan Medicine, Ann Arbor (N.J.D., A.L., C.M.B., S.K., M.E., M.R.M.)
| |
Collapse
|
31
|
Mathis MR, Likosky DS, Haft JW, Maile MD, Blank RS, Colquhoun DA, Janda AM, Kheterpal S, Engoren MC. Lung-protective Ventilation in Cardiac Surgery: Reply. Anesthesiology 2020; 132:1611-1613. [PMID: 32287045 PMCID: PMC7774650 DOI: 10.1097/aln.0000000000003294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
32
|
Kheterpal S, Vaughn MT, Dubovoy TZ, Shah NJ, Bash LD, Colquhoun DA, Shanks AM, Mathis MR, Soto RG, Bardia A, Bartels K, McCormick PJ, Schonberger RB, Saager L. Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER): A Multicenter Matched Cohort Analysis. Anesthesiology 2020; 132:1371-1381. [PMID: 32282427 PMCID: PMC7864000 DOI: 10.1097/aln.0000000000003256] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [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] [Indexed: 12/17/2022]
Abstract
BACKGROUND Five percent of adult patients undergoing noncardiac inpatient surgery experience a major pulmonary complication. The authors hypothesized that the choice of neuromuscular blockade reversal (neostigmine vs. sugammadex) may be associated with a lower incidence of major pulmonary complications. METHODS Twelve U.S. Multicenter Perioperative Outcomes Group hospitals were included in a multicenter observational matched-cohort study of surgical cases between January 2014 and August 2018. Adult patients undergoing elective inpatient noncardiac surgical procedures with general anesthesia and endotracheal intubation receiving a nondepolarizing neuromuscular blockade agent and reversal were included. Exact matching criteria included institution, sex, age, comorbidities, obesity, surgical procedure type, and neuromuscular blockade agent (rocuronium vs. vecuronium). Other preoperative and intraoperative factors were compared and adjusted in the case of residual imbalance. The composite primary outcome was major postoperative pulmonary complications, defined as pneumonia, respiratory failure, or other pulmonary complications (including pneumonitis; pulmonary congestion; iatrogenic pulmonary embolism, infarction, or pneumothorax). Secondary outcomes focused on the components of pneumonia and respiratory failure. RESULTS Of 30,026 patients receiving sugammadex, 22,856 were matched to 22,856 patients receiving neostigmine. Out of 45,712 patients studied, 1,892 (4.1%) were diagnosed with the composite primary outcome (3.5% sugammadex vs. 4.8% neostigmine). A total of 796 (1.7%) patients had pneumonia (1.3% vs. 2.2%), and 582 (1.3%) respiratory failure (0.8% vs. 1.7%). In multivariable analysis, sugammadex administration was associated with a 30% reduced risk of pulmonary complications (adjusted odds ratio, 0.70; 95% CI, 0.63 to 0.77), 47% reduced risk of pneumonia (adjusted odds ratio, 0.53; 95% CI, 0.44 to 0.62), and 55% reduced risk of respiratory failure (adjusted odds ratio, 0.45; 95% CI, 0.37 to 0.56), compared to neostigmine. CONCLUSIONS Among a generalizable cohort of adult patients undergoing inpatient surgery at U.S. hospitals, the use of sugammadex was associated with a clinically and statistically significant lower incidence of major pulmonary complications.
Collapse
Affiliation(s)
- Sachin Kheterpal
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (S.K., M.T.V., T.Z.D., N.J.S., D.A.C., A.M.S., M.R.M., L.S.) Center for Observational and Real World Evidence, Merck & Co. Inc, Kenilworth, New Jersey (L.D.B.) Department of Anesthesiology, Beaumont Health, Royal Oak, Michigan (R.G.S.) Department of Anesthesiology, Yale University, New Haven, Connecticut (A.B., R.B.S.) Department of Anesthesiology, University of Colorado, Aurora, Colorado (K.B.) Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York (P.J.M.). Current position: Department of Anesthesiology, University Medical Center Goettingen, Lower Saxony, Germany (L.S.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Douville NJ, Jewell ES, Duggal N, Blank R, Kheterpal S, Engoren MC, Mathis MR. Association of Intraoperative Ventilator Management With Postoperative Oxygenation, Pulmonary Complications, and Mortality. Anesth Analg 2020; 130:165-175. [PMID: 31107262 DOI: 10.1213/ane.0000000000004191] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND "Lung-protective ventilation" describes a ventilation strategy involving low tidal volumes (VTs) and/or low driving pressure/plateau pressure and has been associated with improved outcomes after mechanical ventilation. We evaluated the association between intraoperative ventilation parameters (including positive end-expiratory pressure [PEEP], driving pressure, and VT) and 3 postoperative outcomes: (1) PaO2/fractional inspired oxygen tension (FIO2), (2) postoperative pulmonary complications, and (3) 30-day mortality. METHODS We retrospectively analyzed adult patients who underwent major noncardiac surgery and remained intubated postoperatively from 2006 to 2015 at a single US center. Using multivariable regressions, we studied associations between intraoperative ventilator settings and lowest postoperative PaO2/FIO2 while intubated, pulmonary complications identified from discharge diagnoses, and in-hospital 30-day mortality. RESULTS Among a cohort of 2096 cases, the median PEEP was 5 cm H2O (interquartile range = 4-6), median delivered VT was 520 mL (interquartile range = 460-580), and median driving pressure was 15 cm H2O (13-19). After multivariable adjustment, intraoperative median PEEP (linear regression estimate [B] = -6.04; 95% CI, -8.22 to -3.87; P < .001), median FIO2 (B = -0.30; 95% CI, -0.50 to -0.10; P = .003), and hours with driving pressure >16 cm H2O (B = -5.40; 95% CI, -7.2 to -4.2; P < .001) were associated with decreased postoperative PaO2/FIO2. Higher postoperative PaO2/FIO2 ratios were associated with a decreased risk of pulmonary complications (adjusted odds ratio for each 100 mm Hg = 0.495; 95% CI, 0.331-0.740; P = .001, model C-statistic of 0.852) and mortality (adjusted odds ratio = 0.495; 95% CI, 0.366-0.606; P < .001, model C-statistic of 0.820). Intraoperative time with VT >500 mL was also associated with an increased likelihood of developing a postoperative pulmonary complication (adjusted odds ratio = 1.06/hour; 95% CI, 1.00-1.20; P = .042). CONCLUSIONS In patients requiring postoperative intubation after noncardiac surgery, increased median FIO2, increased median PEEP, and increased time duration with elevated driving pressure predict lower postoperative PaO2/FIO2. Intraoperative duration of VT >500 mL was independently associated with increased postoperative pulmonary complications. Lower postoperative PaO2/FIO2 ratios were independently associated with pulmonary complications and mortality. Our findings suggest that postoperative PaO2/FIO2 may be a potential target for future prospective trials investigating the impact of specific ventilation strategies for reducing ventilator-induced pulmonary injury.
Collapse
Affiliation(s)
- Nicholas J Douville
- From the Department of Anesthesiology, University of Michigan Health System, University of Michigan, Ann Arbor, Michigan
| | | | | | | | | | | | | |
Collapse
|
34
|
Affiliation(s)
| | - Michael R. Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| |
Collapse
|
35
|
Mathis MR, Dubovoy TZ, Caldwell MD, Engoren MC. Making Sense of Big Data to Improve Perioperative Care: Learning Health Systems and the Multicenter Perioperative Outcomes Group. J Cardiothorac Vasc Anesth 2019; 34:582-585. [PMID: 31813832 DOI: 10.1053/j.jvca.2019.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/10/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Michael R Mathis
- Department of Anesthesiology, Adult Cardiothoracic Division, University of Michigan Health System; Center for Computational Medicine and Bioinformatics, University of Michigan Health System; Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
| | - Timur Z Dubovoy
- Department of Anesthesiology, Adult Cardiothoracic Division, University of Michigan Health System
| | - Matthew D Caldwell
- Department of Anesthesiology, Adult Cardiothoracic Division, University of Michigan Health System
| | - Milo C Engoren
- Department of Anesthesiology, Adult Cardiothoracic Division, University of Michigan Health System
| |
Collapse
|
36
|
Wolford BN, Hornsby WE, Guo D, Zhou W, Lin M, Farhat L, McNamara J, Driscoll A, Wu X, Schmidt EM, Norton EL, Mathis MR, Ganesh SK, Douville NJ, Brummett CM, Kitzman J, Chen YE, Kim K, Deeb GM, Patel H, Eagle KA, Milewicz DM, Willer CJ, Yang B. Clinical Implications of Identifying Pathogenic Variants in Individuals With Thoracic Aortic Dissection. Circ Genom Precis Med 2019; 12:e002476. [PMID: 31211624 PMCID: PMC6582991 DOI: 10.1161/circgen.118.002476] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [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] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thoracic aortic dissection is an emergent life-threatening condition. Routine screening for genetic variants causing thoracic aortic dissection is not currently performed for patients or family members. METHODS We performed whole exome sequencing of 240 patients with thoracic aortic dissection (n=235) or rupture (n=5) and 258 controls matched for age, sex, and ancestry. Blinded to case-control status, we annotated variants in 11 genes for pathogenicity. RESULTS Twenty-four pathogenic variants in 6 genes (COL3A1, FBN1, LOX, PRKG1, SMAD3, and TGFBR2) were identified in 26 individuals, representing 10.8% of aortic cases and 0% of controls. Among dissection cases, we compared those with pathogenic variants to those without and found that pathogenic variant carriers had significantly earlier onset of dissection (41 versus 57 years), higher rates of root aneurysm (54% versus 30%), less hypertension (15% versus 57%), lower rates of smoking (19% versus 45%), and greater incidence of aortic disease in family members. Multivariable logistic regression showed that pathogenic variant carrier status was significantly associated with age <50 (odds ratio [OR], 5.5; 95% CI, 1.6-19.7), no history of hypertension (OR, 5.6; 95% CI, 1.4-22.3), and family history of aortic disease (mother: OR, 5.7; 95% CI, 1.4-22.3, siblings: OR, 5.1; 95% CI, 1.1-23.9, children: OR, 6.0; 95% CI, 1.4-26.7). CONCLUSIONS Clinical genetic testing of known hereditary thoracic aortic dissection genes should be considered in patients with a thoracic aortic dissection, followed by cascade screening of family members, especially in patients with age-of-onset <50 years, family history of thoracic aortic disease, and no history of hypertension.
Collapse
Affiliation(s)
- Brooke N. Wolford
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Computational Medicine & Bioinformatics, Univ of Michigan, Ann Arbor, MI
| | - Whitney E. Hornsby
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Internal Medicine, Univ of Michigan, Ann Arbor, MI
| | - Dongchuan Guo
- Dept of Internal Medicine, McGovern Medical School, Univ of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Wei Zhou
- Analytic & Translational Genetics Unit, Massachusetts General Hospital & Harvard Medical School, Boston
- Stanley Center for Psychiatric Research, Broad Institute of MIT & Harvard, Cambridge, MA
- Program in Medical & Population Genetics, Broad Institute of MIT & Harvard, Cambridge, MA
| | - Maoxuan Lin
- Dept of Bioinformatics & Genomics, The Univ of North Carolina at Charlotte, Charlotte, NC
| | - Linda Farhat
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Cardiac Surgery, Univ of Michigan, Ann Arbor, MI
| | - Jennifer McNamara
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Internal Medicine, Univ of Michigan, Ann Arbor, MI
| | - Anisa Driscoll
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Office of Research - Precision Health, Ann Arbor, MI
| | - Xiaoting Wu
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Cardiac Surgery, Univ of Michigan, Ann Arbor, MI
| | | | | | - Michael R. Mathis
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Anesthesiology, Univ of Michigan, Ann Arbor, MI
| | - Santhi K. Ganesh
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Internal Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Human Genetics, Univ of Michigan, Ann Arbor, MI
| | - Nicholas J. Douville
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Anesthesiology, Univ of Michigan, Ann Arbor, MI
| | - Chad M. Brummett
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Anesthesiology, Univ of Michigan, Ann Arbor, MI
| | - Jacob Kitzman
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Internal Medicine, McGovern Medical School, Univ of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Y. Eugene Chen
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Internal Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Pharmacology, Univ of Michigan, Ann Arbor, MI
- Dept of Molecular & Integrative Physiology, Univ of Michigan, Ann Arbor, MI
| | - Karen Kim
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Cardiac Surgery, Univ of Michigan, Ann Arbor, MI
| | - G. Michael Deeb
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Cardiac Surgery, Univ of Michigan, Ann Arbor, MI
| | - Himanshu Patel
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Cardiac Surgery, Univ of Michigan, Ann Arbor, MI
| | - Kim A. Eagle
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Internal Medicine, Univ of Michigan, Ann Arbor, MI
| | - Dianna M. Milewicz
- Dept of Internal Medicine, McGovern Medical School, Univ of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Cristen J. Willer
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Computational Medicine & Bioinformatics, Univ of Michigan, Ann Arbor, MI
- Dept of Internal Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Human Genetics, Univ of Michigan, Ann Arbor, MI
| | - Bo Yang
- Univ of Michigan, Michigan Medicine, Univ of Michigan, Ann Arbor, MI
- Dept of Cardiac Surgery, Univ of Michigan, Ann Arbor, MI
| |
Collapse
|
37
|
Mathis MR, Kheterpal S, Najarian K. Artificial Intelligence for Anesthesia: What the Practicing Clinician Needs to Know: More than Black Magic for the Art of the Dark. Anesthesiology 2018; 129:619-622. [PMID: 30080689 PMCID: PMC6148374 DOI: 10.1097/aln.0000000000002384] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Health System
| | - Kayvan Najarian
- Department of Computational Medicine and Bioinformatics, and the Department of Emergency Medicine, University of Michigan Health System
| |
Collapse
|
38
|
Mathis MR, Tremper KK. By FAER Means or Foul. Anesth Analg 2018; 126:1814-1815. [DOI: 10.1213/ane.0000000000002824] [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: 11/05/2022]
|
39
|
Santiago-Lastra Y, Mathis MR, Andraska E, Thompson AL, Malaeb BS, Cameron AP, Clemens JQ, Stoffel JT. Extended Case Duration and Hypotension Are Associated With Higher-grade Postoperative Complications After Urinary Diversion for Non-oncological Disease. Urology 2017; 111:189-196. [PMID: 28923410 DOI: 10.1016/j.urology.2017.05.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/08/2017] [Accepted: 05/16/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To report survival for patients who undergo urinary diversion for benign indications and to identify risk factors for morbidity at 90 days. METHODS This is a retrospective review of consecutive urinary diversions with or without cystectomy for non-oncological indications at a single institution. The indication for diversion was intractable incontinence, upper tract deterioration, urinary fistula, and unmanageable bladder pain. Patients were categorized according to their most severe complication within 90 days of surgery, using the Clavien-Dindo system. Multivariable analysis was performed to identify factors associated with high-grade complications. Survival analysis was performed. RESULTS Between 2007 and 2014, 141 patients underwent urinary diversion for non-oncological indications. The postoperative rate of high-grade adverse events (class III or greater) was 28%. Risk factors for class III or greater complications at 90 days included prolonged intraoperative mean arterial pressure below 75% of baseline, operative duration greater than 343 minutes, and postoperative vasopressor requirement. Kaplan-Meier survival analysis demonstrated a 1- and 5-year survival of 88.4% and 77.2%, respectively. The long-term survival of patients who experienced higher-grade complications was not statistically different from the survival of the rest of the group. The study was limited by a retrospective design and sample size in identifying additional variables associated with increased risk of long-term mortality. CONCLUSION Urinary diversion for non-oncological conditions has a good 5-year survival in this cohort. Extended case duration and hemodynamic instability during or immediately after urinary diversion are associated with a high-grade complication within 90 days of the procedure.
Collapse
Affiliation(s)
| | - Michael R Mathis
- Department of Anesthesiology and Critical Care, University of Michigan Hospital and Health System, Ann Arbor, MI
| | | | - Aleda L Thompson
- Department of Anesthesiology and Critical Care, University of Michigan Hospital and Health System, Ann Arbor, MI
| | - Bahaa S Malaeb
- Department of Urology, University of Michigan Hospital and Health System, Ann Arbor, MI
| | - Anne P Cameron
- Department of Urology, University of Michigan Hospital and Health System, Ann Arbor, MI
| | - J Quentin Clemens
- Department of Urology, University of Michigan Hospital and Health System, Ann Arbor, MI
| | - John T Stoffel
- Department of Urology, University of Michigan Hospital and Health System, Ann Arbor, MI
| |
Collapse
|
40
|
Yang B, Zhou W, Jiao J, Nielsen JB, Mathis MR, Heydarpour M, Lettre G, Folkersen L, Prakash S, Schurmann C, Fritsche L, Farnum GA, Lin M, Othman M, Hornsby W, Driscoll A, Levasseur A, Thomas M, Farhat L, Dubé MP, Isselbacher EM, Franco-Cereceda A, Guo DC, Bottinger EP, Deeb GM, Booher A, Kheterpal S, Chen YE, Kang HM, Kitzman J, Cordell HJ, Keavney BD, Goodship JA, Ganesh SK, Abecasis G, Eagle KA, Boyle AP, Loos RJF, Eriksson P, Tardif JC, Brummett CM, Milewicz DM, Body SC, Willer CJ. Protein-altering and regulatory genetic variants near GATA4 implicated in bicuspid aortic valve. Nat Commun 2017; 8:15481. [PMID: 28541271 PMCID: PMC5458508 DOI: 10.1038/ncomms15481] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 03/31/2017] [Indexed: 01/09/2023] Open
Abstract
Bicuspid aortic valve (BAV) is a heritable congenital heart defect and an important risk factor for valvulopathy and aortopathy. Here we report a genome-wide association scan of 466 BAV cases and 4,660 age, sex and ethnicity-matched controls with replication in up to 1,326 cases and 8,103 controls. We identify association with a noncoding variant 151 kb from the gene encoding the cardiac-specific transcription factor, GATA4, and near-significance for p.Ser377Gly in GATA4. GATA4 was interrupted by CRISPR-Cas9 in induced pluripotent stem cells from healthy donors. The disruption of GATA4 significantly impaired the transition from endothelial cells into mesenchymal cells, a critical step in heart valve development.
Collapse
Affiliation(s)
- Bo Yang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.,Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Wei Zhou
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Jiao Jiao
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Jonas B Nielsen
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Mahyar Heydarpour
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Guillaume Lettre
- Montreal Heart Institute, Montreal, Quebec, Canada HIT 1C8.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada QC H3T 1J4
| | - Lasse Folkersen
- Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm SE-171 76, Sweden.,Center for Biological Sequence Analysis, Technical University of Denmark, Copenhagen DK-2800, Denmark
| | - Siddharth Prakash
- Department of Internal Medicine, Division of Medical Genetics, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas 77030, USA
| | - Claudia Schurmann
- The Charles Bronfman Institute for Personalized Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA
| | - Lars Fritsche
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan 48109, USA.,Norwegian University of Science and Technology, Trondheim 7491, Norway
| | - Gregory A Farnum
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Maoxuan Lin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Mohammad Othman
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan 48105, USA
| | - Whitney Hornsby
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Anisa Driscoll
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Alexandra Levasseur
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Marc Thomas
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Linda Farhat
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Marie-Pierre Dubé
- Montreal Heart Institute, Montreal, Quebec, Canada HIT 1C8.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada QC H3T 1J4
| | - Eric M Isselbacher
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Anders Franco-Cereceda
- Cardiothoracic Surgery Unit, Department of Molecular Medicine and Surgery, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm SE-171 76, Sweden
| | - Dong-Chuan Guo
- Department of Internal Medicine, Division of Medical Genetics, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas 77030, USA
| | - Erwin P Bottinger
- The Charles Bronfman Institute for Personalized Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA
| | - G Michael Deeb
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.,Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Anna Booher
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Y Eugene Chen
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.,Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Hyun Min Kang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Jacob Kitzman
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan 48109, USA.,Department of Human Genetics, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Heather J Cordell
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne NE1 3BZ, UK
| | - Bernard D Keavney
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, UK.,Manchester Heart Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester M13 9WL, UK
| | - Judith A Goodship
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne NE1 3BZ, UK
| | - Santhi K Ganesh
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA.,Department of Human Genetics, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Gonçalo Abecasis
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Kim A Eagle
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Alan P Boyle
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan 48109, USA.,Department of Human Genetics, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Ruth J F Loos
- The Charles Bronfman Institute for Personalized Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA.,The Mindich Child Health Development Institute, The Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA
| | - Per Eriksson
- Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm SE-171 76, Sweden
| | - Jean-Claude Tardif
- Montreal Heart Institute, Montreal, Quebec, Canada HIT 1C8.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada QC H3T 1J4
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Dianna M Milewicz
- Department of Internal Medicine, Division of Medical Genetics, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas 77030, USA
| | - Simon C Body
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Cristen J Willer
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan 48109, USA.,Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan 48109, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA.,Department of Human Genetics, University of Michigan, Ann Arbor, Michigan 48109, USA
| |
Collapse
|
41
|
Santiago-Lastra Y, Mathis MR, Andraska E, Thompson AM, Malaeb BS, Cameron AP, Clemens JQ, Stoffel JT. PD12-10 CASE DURATION AND PERIOPERATIVE HYPOTENSION ARE ASSOCIATED WITH GREATER INCIDENCE OF HIGH GRADE COMPLICATIONS IN PATIENTS WHO UNDERGO URINARY DIVERSION FOR BENIGN INDICATIONS. J Urol 2016. [DOI: 10.1016/j.juro.2016.02.905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
42
|
Freundlich RE, Barnet CS, Mathis MR, Shanks AM, Tremper KK, Kheterpal S. A randomized trial of automated electronic alerts demonstrating improved reimbursable anesthesia time documentation. J Clin Anesth 2013; 25:110-4. [PMID: 23333782 DOI: 10.1016/j.jclinane.2012.06.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 06/11/2012] [Accepted: 06/18/2012] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To investigate whether alerting providers to errors results in improved documentation of reimbursable anesthesia care. DESIGN Prospective randomized controlled trial. SETTING Operating room (OR) of a university hospital. INTERVENTIONS Anesthesia cases were evaluated to determine whether they met the definition for appropriate anesthesia start time over 4 separate, 45-day calendar cycles: the pre-study period, study period, immediate post-study period, and 3-year follow-up period. During the study period, providers were randomly assigned to either a control or an alert group. Providers in the alert cohort received an automated alphanumeric page if the anesthesia start time occurred concurrently with the patient entering the OR, or more than 30 minutes before entering the OR. MEASUREMENTS Three years after the intervention period, overall compliance was analyzed to assess learned behavior. MAIN RESULTS Baseline compliance was 33% ± 5%. During the intervention period, providers in the alert group showed 87% ± 6% compliance compared with 41% ± 7% compliance in the control group (P < 0.001). Long-term follow-up after cessation of the alerts showed 85% ± 4% compliance. CONCLUSIONS Automated electronic reminders for time-based billing charges are effective and result in improved ongoing reimbursement.
Collapse
Affiliation(s)
- Robert E Freundlich
- Center for Perioperative Outcomes Research, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI 48109-0048, USA.
| | | | | | | | | | | |
Collapse
|