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Tatsuoka Y, Carr ZJ, Jayakumar S, Lin HM, He Z, Farroukh A, Heerdt P. Pulmonary Hypertension and the Risk of 30-Day Postoperative Pulmonary Complications after Gastrointestinal Surgical or Endoscopic Procedures: A Retrospective Propensity Score-Weighted Cohort Analysis. J Clin Med 2024; 13:1996. [PMID: 38610760 PMCID: PMC11012853 DOI: 10.3390/jcm13071996] [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: 02/15/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Pulmonary hypertension (PH) patients are at higher risk of postoperative complications. We analyzed the association of PH with 30-day postoperative pulmonary complications (PPCs). Methods: A single-center propensity score overlap weighting (OW) retrospective cohort study was conducted on 164 patients with a mean pulmonary artery pressure (mPAP) of >20 mmHg within 24 months of undergoing elective inpatient abdominal surgery or endoscopic procedures under general anesthesia and a control cohort (N = 1981). The primary outcome was PPCs, and the secondary outcomes were PPC sub-composites, namely respiratory failure (RF), pneumonia (PNA), aspiration pneumonia/pneumonitis (ASP), pulmonary embolism (PE), length of stay (LOS), and 30-day mortality. Results: PPCs were higher in the PH cohort (29.9% vs. 11.2%, p < 0.001). When sub-composites were analyzed, higher rates of RF (19.3% vs. 6.6%, p < 0.001) and PNA (11.2% vs. 5.7%, p = 0.01) were observed. After OW, PH was still associated with greater PPCs (RR 1.66, 95% CI (1.05-2.71), p = 0.036) and increased LOS (median 8.0 days vs. 4.9 days) but not 30-day mortality. Sub-cohort analysis showed no difference in PPCs between pre- and post-capillary PH patients. Conclusions: After covariate balancing, PH was associated with a higher risk for PPCs and prolonged LOS. This elevated PPC risk should be considered during preoperative risk assessment.
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Affiliation(s)
- Yoshio Tatsuoka
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, USA; (Y.T.)
- Department of Anesthesiology, Yale New Haven Hospital, New Haven, CT 06510, USA
| | - Zyad J. Carr
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, USA; (Y.T.)
- Department of Anesthesiology, Yale New Haven Hospital, New Haven, CT 06510, USA
| | - Sachidhanand Jayakumar
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Hung-Mo Lin
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, USA; (Y.T.)
- Department of Anesthesiology, Yale New Haven Hospital, New Haven, CT 06510, USA
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT 06520, USA
| | - Zili He
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT 06520, USA
| | - Adham Farroukh
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA 01803, USA
| | - Paul Heerdt
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, USA; (Y.T.)
- Department of Anesthesiology, Yale New Haven Hospital, New Haven, CT 06510, USA
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2
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Wu L, Narasimhan B, Bhatia K, Wu E, Li P, Ho KS, Shah AN, Kantharia BK. One Year Outcomes of Atrial Fibrillation Ablation: Contemporary Analysis of the United States Nationwide Readmission Database. Pacing Clin Electrophysiol 2022; 45:1151-1159. [PMID: 35656924 DOI: 10.1111/pace.14543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/06/2022] [Accepted: 05/27/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Data on long-term outcomes of catheter ablation (CA) for atrial fibrillation (AF) in outside of clinical trials settings are sparse. OBJECTIVE We aimed to assess outcomes and readmissions at 1 year following admission for CA for AF. METHODS Utilizing the Nationwide Readmissions Database (2016-2018), we identified patients with CA among all patients with a primary admission diagnosis of AF, and a control group by propensity score match adjusted for age, sex, comorbidities, CHA₂DS₂-VASc scores, and the hospital characteristics. The primary outcome was a composite of unplanned heart failure (HF), AF and stroke-related readmissions and death at 1 year, and secondary outcomes were hospital outcomes and all-cause readmission rates. RESULTS The study cohort consisted of 29,771 patients undergoing CA and 63,988 controls. Patients undergoing CA were younger with lower CHA₂DS₂-VASc scores and less comorbidities. Over a follow-up of 170 ±1.1 days, the primary outcome occurred in 5.2% in CA group and 6.0% of controls (hazard ratio [HR] and 95% confidence interval [CI]: 0.86 [0.76-0.94], p = 0.002). CA affected AF and stroke related readmission, but showed no effect on HF and mortality outcome.Male sex (HR: 0.83 [0.74-0.94], p = 0.03), younger age (HR: 0.71 [0.61-0.83], p<0.001], and lower CHA₂DS₂-VASc scores (HR: 0.68 [0.55-0.84], p<0.001) were associated with lower risk of primary outcome with CA. CONCLUSION In this study, CA for AF was associated with significantly lower AF and stroke-related admissions, but not to HF or all cause readmission. Better outcomes were seen among males, younger patients and in patients with less comorbidities and low CHA₂DS₂-VASc scores. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Lingling Wu
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Mount Sinai-Morningside Hospital, New York, NY, USA.,University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bharat Narasimhan
- Mount Sinai-Morningside Hospital, New York, NY, USA.,Houston Methodist Hospital, Houston, TX, USA
| | - Kirtipal Bhatia
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Mount Sinai-Morningside Hospital, New York, NY, USA
| | - Ellen Wu
- University of Alabama at Birmingham, Birmingham, AL, USA.,Immunowake Inc., Birmingham, AL, USA
| | - Pengyang Li
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Kam S Ho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Mount Sinai-Morningside Hospital, New York, NY, USA
| | - Arti N Shah
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,NYC Health and Hospitals, Elmhurst, Queens, NY, USA.,Cardiovascular and Heart Rhythm Consultants, New York, NY, USA
| | - Bharat K Kantharia
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Mount Sinai-Morningside Hospital, New York, NY, USA.,Cardiovascular and Heart Rhythm Consultants, New York, NY, USA
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3
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Wu L, Narasimhan B, Ho KS, Zheng Y, Shah AN, Kantharia BK. Safety and complications of catheter ablation for atrial fibrillation: Predictors of complications from an updated analysis the National Inpatient Database. J Cardiovasc Electrophysiol 2021; 32:1024-1034. [PMID: 33650749 DOI: 10.1111/jce.14979] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/09/2021] [Accepted: 02/18/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Catheter ablation is increasingly employed in the management of atrial fibrillation (AF). Data regarding safety of ablation of AF is largely derived from controlled clinical trials. OBJECTIVES The aim of this study was to analyze safety and complications of AF ablation performed in a "real world" setting outside of clinical trials, and obtain insights on predictors of complications. METHODS We utilized the National Inpatient Sample database, to identify all patients who underwent AF ablations between 2015 and 2017 using International Classification of Disease-Tenth revision codes. Complications were defined as per the Agency for Health Care Research and Quality Guidelines. Statistical tests including multivariate logistic regression were performed to determine predictors of complications. RESULTS Among 14,875 cases of AF ablation between 2015 and 2017, a total of 1884 complications were identified among 1080 (7.2%) patients. Patients with complications were likely to be older and female with a higher burden of comorbidities. A 27% increase in complications was observed from 2015 to 2017, driven by an increase in pericardial complications. Multivariate regression analysis revealed that pulmonary hypertension (adjusted odds ratio [aOR]: 1.99, p = .041) and chronic kidney disease (CKD; aOR: 1.67, p = .024), were independent predictors of complications. Centers with higher procedural volumes were associated with lower complication rates. CONCLUSIONS Complication rates related to AF ablations remain substantially high. Presence of pulmonary hypertension and CKD are predictive of higher procedural complications. Furthermore, hospital procedure volume is an important factor that correlates with complication rates.
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Affiliation(s)
- Lingling Wu
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Mount Sinai-Morningside Hospital, New York, New York, USA
| | - Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Mount Sinai-Morningside Hospital, New York, New York, USA
| | - Kam S Ho
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Mount Sinai-Morningside Hospital, New York, New York, USA
| | - Yingying Zheng
- East Carolina University, Greenville, North Carolina, USA
| | - Arti N Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,NYC Health and Hospitals, Elmhurst, Queens, New York, USA.,Cardiovascular and Heart Rhythm Consultants, New York, New York, USA
| | - Bharat K Kantharia
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Mount Sinai-Morningside Hospital, New York, New York, USA.,Cardiovascular and Heart Rhythm Consultants, New York, New York, USA
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4
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Alemu BT, Beydoun HA, Olayinka O, Young B. Temporal trends in rates of opioid misuse among delivery-related hospitalizations in North Carolina from 2000 to 2014. J Addict Dis 2021; 39:270-282. [PMID: 33416040 DOI: 10.1080/10550887.2020.1859048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Opioid misuse during pregnancy is increasing at an alarming rate across the United States. To determine the prevalence, temporal trends, and resource usage of delivery-related hospitalizations of women who misuse opioids in North Carolina from 2000 to 2014. A retrospective, cross-sectional study was conducted using the State Inpatient Databases. Annual prevalence was calculated, and linear trends were assessed using logistic regression. Temporal trends in hospital charges and length of stay (LOS) were analyzed using ordinary least squares regression with a loge-transformed response. Of 1,937,455 delivery-related hospitalizations in NC, 6,084 were associated with opioid misuse, a prevalence of 3.14 cases per 1,000 delivery-related discharges. During the study period, the prevalence of opioid misuse during pregnancy in NC increased 955%, from 0.9 cases per 1,000 discharges in 2000 to 9.5 cases per 1,000 discharges in 2014, an average annual rate increase of 1.18 cases (95% CI, 1.16-1.21; P < 0.0001). Median LOS for women who misuse opioids remained stable at three days, whereas the median charge per delivery-related hospitalization significantly increased from $6,311 in 2000 to $9,019 in 2010 (annual average change [AAC], 282.2; 95% CI, 182.9-381.5; P < 0.0001) and from $8,908 in 2011 to $10,864 in 2014 (AAC, 667.5; 95% CI, 275.2-1059.9; P < 0.0001). Health care providers and policymakers in NC are advised to introduce system-wide public health responses focused on prevention and increased access to evidence-based treatment that improves the health of the mothers and neonates who are exposed to opioids.
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Affiliation(s)
- Brook T Alemu
- Health Sciences Program, School of Health Sciences, Western Carolina University, Cullowhee, NC, USA
| | - Hind A Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Department of Defense, Fort Belvoir, VA, USA
| | - Olaniyi Olayinka
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Beth Young
- Department of Social Work, College of Health and Human Sciences, Western Carolina University, Cullowhee, NC, USA
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Bhattacharya PT, Hameed AMA, Bhattacharya ST, Chirinos JA, Hwang WT, Birati EY, Menachem JN, Chatterjee S, Giri JS, Kawut SM, Kimmel SE, Mazurek JA. Risk factors for 30-day readmission in adults hospitalized for pulmonary hypertension. Pulm Circ 2020; 10:2045894020966889. [PMID: 33282194 PMCID: PMC7686634 DOI: 10.1177/2045894020966889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/24/2020] [Indexed: 01/15/2023] Open
Abstract
Readmissions for pulmonary hypertension are poorly understood and understudied.
We sought to determine national estimates and risk factors for 30-day
readmission after pulmonary hypertension-related hospitalizations. We utilized
the Healthcare Cost and Utilization Project Nationwide Readmission Database,
which has weighted estimates of roughly 35 million discharges in the US. Adult
patients with primary International Classification of Disease, Ninth Revision,
Clinical Modification diagnosis codes of 416.0 and 416.8 for primary and
secondary pulmonary hypertension with an index admission between 2012 and 2014
and any readmission within 30 days of the index event were identified.
Predictors of 30-day readmission were identified using multivariable logistic
regression with adjustment for covariates. Results showed that the national
estimate for Primary Pulmonary Hypertension vs Secondary Pulmonary
Hypertension-related index events between 2012 and 2014 with 30-day readmission
was 247 vs 2550 corresponding to a national readmission risk estimate of 17% vs
18.3%, respectively. The presence of fluid and electrolyte disorders, renal
failure, and alcohol abuse were associated with increased risk of readmission in
Primary Pulmonary Hypertension, while factors associated with Secondary
Pulmonary Hypertension readmissions included anemia, congestive heart failure,
lung disease, fluid and electrolyte disorders, renal failure, diabetes, and
liver disease. The median cost of Primary Pulmonary Hypertension admissions and
readmissions were $46,132 (IQR: $25,384–$85,647) and $41,604.50 (IQR:
$22,481.50–$84,420.50), respectively. The median costs of Secondary Pulmonary
Hypertension admissions and readmissions were $34,893 (IQR: $19,670–$66,143) and
$36,279 (IQR: $19,059–$74,679), respectively. In conclusion, approximately 19%
of Primary Pulmonary Hypertension and Secondary Pulmonary Hypertension
hospitalizations result in 30-day readmission, with significant costs accrued
during the index hospitalization and readmission. With evolving clinical
terminology and diagnostic codes, future study will need to better clarify
underlying factors associated with readmissions amongst pulmonary hypertension
sub-types, and identify methods and procedures to minimize readmission risk.
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Affiliation(s)
- Priyanka T Bhattacharya
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Asif M Abdul Hameed
- Department of Pulmonary Disease and Critical Care Medicine, Wayne State University, Detroit, MI, USA
| | | | - Julio A Chirinos
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Wei-Ting Hwang
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Edo Y Birati
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan N Menachem
- Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Saurav Chatterjee
- Department of Cardiovascular Medicine, St Francis Hospital of the University of Connecticut, Hartford, CT, USA
| | - Jay S Giri
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Steven M Kawut
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen E Kimmel
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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6
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Palmieri PA, Leyva-Moral JM, Camacho-Rodriguez DE, Granel-Gimenez N, Ford EW, Mathieson KM, Leafman JS. Hospital survey on patient safety culture (HSOPSC): a multi-method approach for target-language instrument translation, adaptation, and validation to improve the equivalence of meaning for cross-cultural research. BMC Nurs 2020; 19:23. [PMID: 32308560 PMCID: PMC7153229 DOI: 10.1186/s12912-020-00419-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 03/31/2020] [Indexed: 12/03/2022] Open
Abstract
Background The Hospital Survey on Patient Safety Culture (HSOPSC) is widely utilized in multiple languages across the world. Despite culture and language variations, research studies from Latin America use the Spanish language HSOPSC validated for Spain and the United States. Yet, these studies fail to report the translation method, cultural adaptation process, and the equivalence assessment strategy. As such, the psychometric properties of the HSOPSC are not well demonstrated for cross-cultural research in Latin America, including Peru. The purpose of this study was to develop a target-language HSOPSC for cross-cultural research in Peru that asks the same questions, in the same manner, with the same intended meaning, as the source instrument. Methods This study used a mixed-methods approach adapted from the translation guideline recommended by Agency for Healthcare Research and Quality. The 3-phase, 7-step process incorporated translation techniques, pilot testing, cognitive interviews, clinical participant review, and subject matter expert evaluation. Results The instrument was translated and evaluated in 3 rounds of cognitive interview (CI). There were 37 problem items identified in round 1 (14 clarity, 12 cultural, 11 mixed); and resolved to 4 problems by round 3. The pilot-testing language clarity inter-rater reliability was S-CVI/Avg = 0.97 and S-CVI/UA = 0.86; and S-CVI/Avg = 0.96 and S-CVI/UA = 0.83 for cultural relevance. Subject matter expert agreement in matching items to the correct dimensions was substantially equivalent (Kappa = 0.72). Only 1 of 12 dimensions had a low Kappa (0.39), borderline fair to moderate. The remaining dimensions performed well (7 = almost perfect, 2 = substantial, and 2 = moderate). Conclusions The HSOPSC instrument developed for Peru was markedly different from the other Spanish-language versions. The resulting items were equivalent in meaning to the source, despite the new language and different cultural context. The analysis identified negatively worded items were problematic for target-language translation. With the limited literature about negatively worded items in the context of cross-cultural research, further research is necessary to evaluate this finding and the recommendation to include negatively worded items in instruments. This study demonstrates cross-cultural research with translated instruments should adhere to established guidelines, with cognitive interviews, based on evidence-based strategies.
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Affiliation(s)
- Patrick A Palmieri
- 1Office of the Vice Chancellor for Research, Universidad Norbert Wiener, Av. Arequipa 444, 15046 Lima, Peru.,2College of Graduate Health Studies, A. T. Still University, 800 West Jefferson Street, Kirksville, MO 63501 USA.,3School of Nursing, Walden University, 100 S Washington Ave, Suite 900, Minneapolis, MN 55401 USA.,4EBHC South America: A Joanna Briggs Institute Affiliated Group, Universidad Norbert Wiener, Av. Arequipa 444, Lima, 15046 Lima, Peru
| | - Juan M Leyva-Moral
- 5Departament d'Infermeria, Facultat de Medicina, Universitat Autonoma de Barcelona, Avda. Can Domenech, Building M. Office M3/211, 08193 Bellaterra (Cerdanyola del Vallès), Barcelona, Spain.,Center for Health Sciences Research, Universidad María Auxiliadora, Av. Canto Bello 431, 15408 Lima, Peru.,7EBHC South America: A Joanna Briggs Institute Affiliated Group, Universidad Norbert Wiener, Av. Arequipa 444, 15046 Lima, Peru
| | - Doriam E Camacho-Rodriguez
- 7EBHC South America: A Joanna Briggs Institute Affiliated Group, Universidad Norbert Wiener, Av. Arequipa 444, 15046 Lima, Peru.,8School of Nursing, Universidad Cooperativa de Colombia, Calle 30, Santa Marta, Magdalena Colombia
| | - Nina Granel-Gimenez
- 5Departament d'Infermeria, Facultat de Medicina, Universitat Autonoma de Barcelona, Avda. Can Domenech, Building M. Office M3/211, 08193 Bellaterra (Cerdanyola del Vallès), Barcelona, Spain
| | - Eric W Ford
- 9School of Public Health, University of Alabama at Birmingham, Ryals Public Health Building, 1665 University Blvd., Ryals 310E, Birmingham, AL 35233 USA
| | - Kathleen M Mathieson
- 2College of Graduate Health Studies, A. T. Still University, 800 West Jefferson Street, Kirksville, MO 63501 USA
| | - Joan S Leafman
- 2College of Graduate Health Studies, A. T. Still University, 800 West Jefferson Street, Kirksville, MO 63501 USA
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Kalogera E, Nelson G, Liu J, Hu QL, Ko CY, Wick E, Dowdy SC. Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Am J Obstet Gynecol 2018; 219:563.e1-563.e19. [PMID: 30031749 DOI: 10.1016/j.ajog.2018.07.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/06/2018] [Accepted: 07/13/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Armstrong Institute at Johns Hopkins, developed the Safety Program for Improving Surgical Care and Recovery, which integrates principles of implementation science into adoption of enhanced recovery pathways and promotes evidence-based perioperative care. OBJECTIVE The objective of this study is to review the enhanced recovery pathways literature in gynecologic surgery and provide the framework for an Improving Surgical Care and Recovery pathway for gynecologic surgery. STUDY DESIGN We searched PubMed and Cochrane Central Register of Controlled Trials databases from 1990 through October 2017. Studies were included in hierarchical and chronological order: meta-analyses, systematic reviews, randomized controlled trials, and interventional and observational studies. Enhanced recovery pathways components relevant to gynecologic surgery were identified through review of existing pathways. A PubMed search for each component was performed in gynecologic surgery and expanded to include colorectal surgery as needed to have sufficient evidence to support or deter a process. This review focuses on surgical components; anesthesiology components are reported separately in a companion article in the anesthesiology literature. RESULTS Fifteen surgical components were identified: patient education, bowel preparation, elimination of nasogastric tubes, minimization of surgical drains, early postoperative mobilization, early postoperative feeding, early intravenous fluid discontinuation, early removal of urinary catheters, use of laxatives, chewing gum, peripheral mu antagonists, surgical site infection reduction bundle, glucose management, and preoperative and postoperative venous thromboembolism prophylaxis. In addition, 14 components previously identified in the colorectal Improving Surgical Care and Recovery pathway review were included in the final pathway. CONCLUSION Evidence and existing guidelines support 29 protocol elements for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery in gynecologic surgery.
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Affiliation(s)
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Center, Calgary, Alberta, Canada
| | - Jessica Liu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, Emory University, Atlanta, GA
| | - Q Lina Hu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, University of California, Los Angeles, CA
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; Department of Surgery, University of California, Los Angeles, CA
| | - Elizabeth Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN.
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Tanenbaum JE, Knapik DM, Fitzgerald SJ, Marcus RE. National Incidence of Reportable Quality Metrics in the Knee Arthroplasty Population. J Arthroplasty 2017; 32:2941-2946. [PMID: 28602536 DOI: 10.1016/j.arth.2017.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/13/2017] [Accepted: 05/11/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) characterizes adverse quality events in the inpatient setting as patient safety indicators (PSI). The incidence of PSI has not been quantified in the total knee arthroplasty (TKA) population. METHODS All patients in the Nationwide Inpatient Sample who underwent primary TKA during an inpatient episode in 2013 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Disease, Ninth Revision diagnosis code algorithms used by CMS. Multivariable logistic regression was used to determine significant associations between patient level covariates (demographics, comorbidities, and hospital characteristics) and the risk of experiencing one or more PSI after TKA. RESULTS We identified 132,453 primary TKA patients in the Nationwide Inpatient Sample in 2013. We estimated the national incidence rate of experiencing one or more PSI as 0.98%. After adjusting for patient demographics and hospital characteristics, we found that relative to Medicaid/self-pay patients, neither Medicare nor privately insured patients faced significantly different risk of experiencing one or more PSI after TKA. However, alcohol abuse, deficiency anemia, congestive heart failure, coagulopathy, and electrolyte imbalance were associated with increased risk of experiencing one or more PSI after TKA. CONCLUSION The national incidence of PSI among TKA patients was lower than has been reported in other surgical populations. CMS uses the incidence of adverse quality events (measured using PSI) in part to determine hospital reimbursement. As value-based payment becomes more widely adopted in the United States, initiatives designed to eliminate and reduce PSI incidence can benefit vulnerable patient populations, physicians, and hospital systems.
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Affiliation(s)
- Joseph E Tanenbaum
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
| | - Derrick M Knapik
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
| | - Steven J Fitzgerald
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
| | - Randall E Marcus
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
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9
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Tanenbaum JE, Alentado VJ, Miller JA, Lubelski D, Benzel EC, Mroz TE. Association between insurance status and patient safety in the lumbar spine fusion population. Spine J 2017; 17:338-345. [PMID: 27765713 PMCID: PMC5508741 DOI: 10.1016/j.spinee.2016.10.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/04/2016] [Accepted: 10/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar fusion is a common and costly procedure in the United States. Reimbursement for surgical procedures is increasingly tied to care quality and patient safety as part of value-based reimbursement programs. The incidence of adverse quality events among lumbar fusion patients is unknown using the definition of care quality (patient safety indicators [PSI]) used by the Centers for Medicare and Medicaid Services (CMS). The association between insurance status and the incidence of PSI is similarly unknown in lumbar fusion patients. PURPOSE This study sought to determine the incidence of PSI in patients undergoing inpatient lumbar fusion and to quantify the association between primary payer status and PSI in this population. STUDY DESIGN A retrospective cohort study was carried out. PATIENT SAMPLE The sample comprised all adult patients aged 18 years and older who were included in the Nationwide Inpatient Sample (NIS) that underwent lumbar fusion from 1998 to 2011. OUTCOME MEASURE The incidence of one or more PSI, a validated and widely used metric of inpatient health-care quality and patient safety, was the primary outcome variable. METHODS The NIS data were examined for all cases of inpatient lumbar fusion from 1998 to 2011. The incidence of adverse patient safety events (PSI) was determined using publicly available lists of the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Logistic regression models were used to determine the association between primary payer status (Medicaid and self-pay relative to private insurance) and the incidence of PSI. RESULTS A total of 539,172 adult lumbar fusion procedures were recorded in the NIS from 1998 to 2011. Patients were excluded from the secondary analysis if "other" or "missing" was listed for primary insurance status. The national incidence of PSI was calculated to be 2,445 per 100,000 patient years of observation, or approximately 2.5%. In a secondary analysis, after adjusting for patient demographics and hospital characteristics, Medicaid and self-pay patients had significantly greater odds of experiencing one or more PSI during the inpatient episode relative to privately insured patients (odds ratio 1.16, 95% confidence interval 1.07-1.27). CONCLUSIONS Among patients undergoing inpatient lumbar fusion, insurance status is associated with the adverse health-care quality events used to determine hospital reimbursement by the CMS. The source of this disparity must be studied to improve the quality of care delivered to vulnerable patient populations.
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Affiliation(s)
- Joseph E Tanenbaum
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, USA; Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA.
| | - Vincent J Alentado
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, USA
| | - Jacob A Miller
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9980 Carnegie Ave, Cleveland, OH 44195, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Edward C Benzel
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA
| | - Thomas E Mroz
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA
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Berkman ND, Lohr KN, Morgan LC, Kuo TM, Morton SC. Interrater reliability of grading strength of evidence varies with the complexity of the evidence in systematic reviews. J Clin Epidemiol 2014; 66:1105-1117.e1. [PMID: 23993312 DOI: 10.1016/j.jclinepi.2013.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [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: 07/09/2012] [Revised: 05/21/2013] [Accepted: 06/05/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine consistency (interrater reliability) of applying guidance for grading strength of evidence in systematic reviews for the Agency for Healthcare Research and Quality Evidence-based Practice Center program. STUDY DESIGN AND SETTING Using data from two systematic reviews, authors tested the main components of the approach: (1) scoring evidence on the four required domains (risk of bias, consistency, directness, and precision) separately for randomized controlled trials (RCTs) and observational studies and (2) developing an overall strength of evidence grade, given the scores for each of these domains. RESULTS Conclusions about overall strength of evidence reached by experienced systematic reviewers based on the same evidence can differ greatly, especially for complex bodies of evidence. Current instructions may be sufficient for straightforward quantitative evaluations that use meta-analysis for summarizing RCT findings. In contrast, agreement suffered when evaluations did not lend themselves to meta-analysis and reviewers needed to rely on their own qualitative judgment. Three areas raised particular concern: (1) evidence from a combination of RCTs and observational studies, (2) outcomes with differing measurement, and (3) evidence that appeared to show no differences in outcomes. CONCLUSION Interrater reliability was highly variable for scoring strength of evidence domains and combining scores to reach overall strength of evidence grades. Future research can help in establishing improved methods for evaluating these complex bodies of evidence.
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Affiliation(s)
- Nancy D Berkman
- Division of Social Policy, Health, and Economics Research, RTI International Research Triangle Institute, Research Triangle Park, NC 27709-2194, USA.
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Affiliation(s)
- Maged K Rizk
- Digestive Disease Institute, Cleveland Clinic, Cleveland Ohio.
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12
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Hasegawa K, Tsugawa Y, Brown DFM, Camargo CA. Childhood asthma hospitalizations in the United States, 2000-2009. J Pediatr 2013; 163:1127-33.e3. [PMID: 23769497 PMCID: PMC3786053 DOI: 10.1016/j.jpeds.2013.05.002] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 04/03/2013] [Accepted: 05/01/2013] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To examine temporal trends in the US incidence of childhood asthma hospitalizations, in-hospital mortality, mechanical ventilation use, and hospital charges between 2000 and 2009. STUDY DESIGN This was a serial, cross-sectional analysis of a nationally representative sample of children hospitalized with acute asthma. The Kids Inpatient Database was used to identify children aged <18 years with asthma by International Classification of Diseases, Ninth Revision, Clinical Modification code 493.xx. Outcome measures were asthma hospitalization incidence, in-hospital mortality, mechanical ventilation use, and hospital charges. We examined temporal trends of each outcome, accounting for sampling weights. Hospital charges were adjusted for inflation to 2009 US dollars. RESULTS The 4 separate years (2000, 2003, 2006, and 2009) of national discharge data included a total of 592805 weighted discharges with asthma. Between 2000 and 2009, the rate of asthma hospitalization in US children decreased from 21.1 to 18.4 per 10000 person-years (13% decrease; Ptrend < .001). Mortality declined significantly after adjusting for confounders (OR for comparison of 2009 with 2000, 0.37; 95% CI, 0.17-0.79). In contrast, there was an increase in the use of mechanical ventilation (from 0.8% to 1.0%, a 28% increase; Ptrend < .001). Nationwide hospital charges also increased from $1.27 billion to $1.59 billion (26% increase; Ptrend < .001); this increase was driven by a rise in the geometric mean of hospital charges per discharge, from $5940 to $8410 (42% increase; Ptrend < .001). CONCLUSION Between 2000 and 2009, we found significant declines in asthma hospitalization and in-hospital mortality among US children. In contrast, mechanical ventilation use and hospital charges for asthma increased significantly over this same period.
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Affiliation(s)
- Kohei Hasegawa
- Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Hoyer EH, Needham DM, Miller J, Deutschendorf A, Friedman M, Brotman DJ. Functional status impairment is associated with unplanned readmissions. Arch Phys Med Rehabil 2013; 94:1951-8. [PMID: 23810355 DOI: 10.1016/j.apmr.2013.05.028] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [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: 03/08/2013] [Revised: 04/24/2013] [Accepted: 05/26/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine whether functional status on admission to a Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP) is associated with unplanned readmission to acute care. DESIGN Retrospective cohort study. SETTING Academic hospital-based CIIRP. PARTICIPANTS Consecutive patients (N=1515) admitted to a CIIRP between January 2009 and June 2012. INTERVENTIONS Patients' functional status, the primary exposure variable, was assessed using tertiles of the total FIM score at CIIRP admission, with secondary analyses using the FIM motor and cognitive domains. A propensity score, consisting of 25 relevant clinical and demographic variables, was used to adjust for confounding in the analysis. MAIN OUTCOME MEASURES Readmission to acute care was categorized as (1) readmission before planned discharge from the CIIRP, (2) readmission within 30 days of discharge from the CIIRP, and (3) total readmissions from both groups, with total readmissions being the a priori primary outcome. RESULTS Among the 1515 patients, there were 347 total readmissions. Total readmissions were significantly associated with FIM scores, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the lowest and middle FIM tertiles versus the highest tertile (AOR=2.6; 95% CI, 1.9-3.7; P<.001 and AOR=1.7; 95% CI, 1.2-2.4; P=.002, respectively). There were similar findings for secondary analyses of readmission before planned discharge from the CIIRP (AOR=3.5; 95% CI, 2.2-5.8; P<.001 and AOR=2.1; 95% CI, 1.3-3.5l P=.002, respectively), and a weaker association for readmissions after discharge from the CIIRP (AOR=1.6; 95% CI, 1.0-2.4; P=.047 and AOR=1.3; 95% CI, 0.8-1.9; P=.28, respectively). The FIM motor domain score was more strongly associated with readmissions than the FIM cognitive score. CONCLUSIONS Functional status on admission to the CIIRP is strongly associated with readmission to acute care, particularly for motor aspects of functional status and readmission before planned discharge from the CIIRP. Efforts to reduce hospital readmissions should consider patient functional status as an important and potentially modifiable risk factor.
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Affiliation(s)
- Erik H Hoyer
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD.
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