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1.
JAMA Surg ; 158(10): 1078-1087, 2023 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-37556154

RESUMO

Importance: Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective: To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants: This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures: Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures: In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results: This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance: These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.


Assuntos
Serviço Hospitalar de Emergência , Centros de Traumatologia , Adulto , Criança , Humanos , Masculino , Feminino , Estudos Retrospectivos , Mortalidade Hospitalar , Análise de Sistemas
2.
JAMA Surg ; 157(4): 303-310, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35171210

RESUMO

IMPORTANCE: The long-term benefits of off-pump ("beating heart") vs on-pump coronary artery bypass grafting (CABG) remain controversial. OBJECTIVE: To evaluate the 10-year outcomes and costs of off-pump vs on-pump CABG in the Department of Veterans Affairs (VA) Randomized On/Off Bypass (ROOBY) trial. DESIGN, SETTING, AND PARTICIPANTS: From February 27, 2002, to May 7, 2007, 2203 veterans in the ROOBY trial were randomly assigned to off-pump or on-pump CABG procedures at 18 participating VA medical centers. Per protocol, the veterans were observed for 10 years; the 10-year, post-CABG clinical outcomes and costs were assessed via centralized abstraction of electronic medical records combined with merges to VA and non-VA databases. With the use of an intention-to-treat approach, analyses were performed from May 7, 2017, to December 9, 2021. INTERVENTIONS: On-pump and off-pump CABG procedures. MAIN OUTCOMES AND MEASURES: The 10-year coprimary end points included all-cause death and a composite end point identifying patients who had died or had undergone subsequent revascularization (ie, percutaneous coronary intervention [PCI] or repeated CABG); these 2 end points were measured dichotomously and as time-to-event variables (ie, time to death and time to composite end points). Secondary 10-year end points included PCIs, repeated CABG procedures, changes in cardiac symptoms, and 2018-adjusted VA estimated costs. Changes from baseline to 10 years in post-CABG, clinically relevant cardiac symptoms were evaluated for New York Heart Association functional class, Canadian Cardiovascular Society angina class, and atrial fibrillation. Outcome differences were adjudicated by an end points committee. Given that pre-CABG risks were balanced, the protocol-driven primary and secondary hypotheses directly compared 10-year treatment-related effects. RESULTS: A total of 1104 patients (1097 men [99.4%]; mean [SD] age, 63.0 [8.5] years) were enrolled in the off-pump group, and 1099 patients (1092 men [99.5%]; mean [SD] age, 62.5 [8.5] years) were enrolled in the on-pump group. The 10-year death rates were 34.2% (n = 378) for the off-pump group and 31.1% (n = 342) for the on-pump group (relative risk, 1.05; 95% CI, 0.99-1.11; P = .12). The median time to composite end point for the off-pump group (4.6 years; IQR, 1.4-7.5 years) was approximately 4.3 months shorter than that for the on-pump group (5.0 years; IQR, 1.8-7.9 years; P = .03). No significant 10-year treatment-related differences were documented for any other primary or secondary end points. After the removal of conversions, sensitivity analyses reconfirmed these findings. CONCLUSIONS AND RELEVANCE: No off-pump CABG advantages were found for 10-year death or revascularization end points; the time to composite end point was lower in the off-pump group than in the on-pump group. For veterans, in the absence of on-pump contraindications, a case cannot be made for supplanting the traditional on-pump CABG technique with an off-pump approach. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01924442.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea , Doença da Artéria Coronariana , Intervenção Coronária Percutânea , Veteranos , Canadá , Ponte de Artéria Coronária , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
3.
J Trauma Acute Care Surg ; 92(1): 193-200, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34225349

RESUMO

BACKGROUND: While injury is a leading cause of death and debility in older adults, the relationship between intensity of care and trauma remains unknown. The focus of this analysis is to measure the overall intensity of care delivered to injured older adults during hospitalization. METHODS: We used Centers for Medicare and Medicaid Services Medicare fee-for-service claims data (2013-2014), to identify emergency department-based claims for moderate and severe blunt trauma in age-eligible beneficiaries. Medical procedures associated with care intensity were identified using a modified Delphi method. A latent class model was estimated using the identified procedures, intensive care unit length of stay, demographics, and injury characteristics. Clinical phenotypes for each class were explored. RESULTS: A total of 683,398 cases were classified as low- (73%), moderate- (23%), and high-intensity care (4%). Greater age and reduced injury severity were indicators of lower intensity, while males, non-Whites, and nonfall mechanisms were more common with high intensity. Intubation/mechanical ventilation was an indicator of high intensity and often occurred with at least one other procedure or an extended intensive care unit stay. CONCLUSION: This work demonstrates that, although heterogeneous, care for blunt trauma can be evaluated using a single novel measure. LEVEL OF EVIDENCE: For prognostic/epidemiological studies, level III.


Assuntos
Cuidados Críticos , Unidades de Terapia Intensiva/estatística & dados numéricos , Ferimentos não Penetrantes , Idoso , Cuidados Críticos/métodos , Cuidados Críticos/estatística & dados numéricos , Técnica Delphi , Feminino , Humanos , Revisão da Utilização de Seguros , Análise de Classes Latentes , Tempo de Internação , Masculino , Medicare/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/métodos , Índices de Gravidade do Trauma , Estados Unidos/epidemiologia , Ferimentos não Penetrantes/classificação , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/epidemiologia , Ferimentos não Penetrantes/terapia
4.
J Trauma Acute Care Surg ; 88(1): 42-50, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31524837

RESUMO

BACKGROUND: Many injured patients presenting to Level III/IV trauma centers will be transferred to Level I/II centers, but how these transfers influence benchmarking at Level III/IV centers has not been described. We hypothesized that the apparent observed to expected (O:E) mortality ratios at Level III/IV centers are influenced by the location at which mortality is measured in transferred patients. METHODS: We conducted a retrospective study of adult patients presenting to Level III/IV trauma centers in Pennsylvania from 2008 to 2017. We used probabilistic matching to match patients transferred between centers. We used a risk-adjusted mortality model to estimate predicted mortality, which we compared with observed mortality at discharge from the Level III/IV center (O) or observed mortality at discharge from the Level III/IV center for nontransferred patients and at discharge from the Level I/II center for transferred patients (O). RESULTS: In total, 9,477 patients presented to 11 Level III/IV trauma centers over the study period (90% white; 49% female; 97% blunt mechanism; median Injury Severity Score, 8; interquartile range, 4-10). Of these, 4,238 (44%) were transferred to Level I/II centers, of which 3,586 (85%) were able to be matched. Expected mortality in the overall cohort was 332 (3.8%). A total of 332 (3.8%) patients died, of which 177 (53%) died at the initial Level III/IV centers (O). Including posttransfer mortality for transferred patients in addition to observed mortality in nontransferred patients (O) resulted in worse apparent O:E ratios for all centers and significant differences in O:E ratios for the overall cohort (O:E, 0.53; 95% confidence interval, 0.45-0.61 vs. O:E, 1.00, 95% confidence interval, 0.92-1.11; p < 0.001). CONCLUSION: Apparent O:E mortality ratios at Level III/IV centers are influenced by the timing of measurement. To provide fair and accurate benchmarking and identify opportunities across the continuum of the trauma system, a system of shared attribution for outcomes of transferred patients should be devised.


Assuntos
Benchmarking/métodos , Transferência de Pacientes/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Ferimentos e Lesões/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Benchmarking/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/cirurgia
5.
Circ Cardiovasc Qual Outcomes ; 12(4): e005119, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-31001997

RESUMO

BACKGROUND: Studies of the relationship between patient self-reported angina symptoms using the Seattle Angina Questionnaire (SAQ) and angiographic findings after coronary artery bypass grafting surgery (CABG) are lacking. Nested within a randomized controlled trial, this prospective observational cohort comparison study aimed to assess which clinical characteristics and angiographic findings are associated with self-reported angina 1 year after CABG. METHODS AND RESULTS: Patients from the ROOBY trial (Randomized On/Off Bypass) with protocol-specified 1-year post-CABG coronary angiography and SAQ assessments were included (n=1258). Patients reporting no angina (62.3%) within 4 weeks before the 1-year post-CABG study visit on the SAQ angina frequency domain were compared with patients reporting angina (37.7%). Multivariable modeling identified clinical variables and angiographic findings associated with angina. Sequential univariate and multivariable modeling found the following demographic and clinical factors were associated with angina after CABG: younger age, worse preoperative SAQ angina frequency score, smoking, diabetes mellitus, and pre-CABG depression. The only 1-year angiographic finding significantly associated with angina was incomplete revascularization of the left anterior descending (LAD) territory. Graft occlusions, incomplete revascularization of non-LAD territories, and ≥70% lesions in nonrevascularized native coronary arteries were not correlated with the presence or absence of angina. Further, only 30.6% of subjects reporting angina at 1 year had a residual major coronary artery stenosis of ≥70%. CONCLUSIONS: Self-reported angina 1 year after CABG is associated with younger age, worse baseline SAQ angina frequency score, smoking, diabetes mellitus, and depression. The only angiographic finding associated with angina was a poorly revascularized LAD territory. These results may help guide physicians when counseling patients on expected improvements in angina symptoms and in making decisions regarding the need for coronary angiography after CABG. Whether intensive treatment of these comorbidities improves post-CABG angina symptoms requires further study. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00032630.


Assuntos
Angina Pectoris/diagnóstico por imagem , Angiografia Coronária , Ponte de Artéria Coronária/efeitos adversos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Medidas de Resultados Relatados pelo Paciente , Idoso , Angina Pectoris/etiologia , Oclusão de Enxerto Vascular/etiologia , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs
6.
Ann Thorac Surg ; 107(1): 92-98, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30273568

RESUMO

BACKGROUND: For diabetic patients who require coronary artery bypass graft (CABG) operation, controversy persists whether an off-pump or an on-pump approach may be advantageous. This US-based, multicenter, randomized, controlled trial, Department of Veterans Affairs Randomization On versus Off Bypass Follow-up Study, compared diabetic patients' 5-year clinical outcomes for off-pump versus on-pump procedures. METHODS: From 2002 to 2008, 835 medically treated (ie, oral hypoglycemic agent or insulin) diabetic patients underwent either off-pump (n = 402) or on-pump (n = 433) CABG. Five-year primary end points included all-cause death and major adverse cardiovascular events (MACE; composite included all-cause death, myocardial infarction, or repeat revascularization). Secondary 5-year end points included cardiac death and MACE-related components. With baseline risk factors balanced, outcomes were evaluated by using a p value less than or equal to 0.01; nonsignificant trends were reported for p values greater than 0.01 and less than or equal to 0.15. RESULTS: Five-year all-cause death rates were 20.2% off pump versus 14.1% on pump (p = 0.0198). No differences were seen in MACE (32.6% off-pump approach versus 28.6% on-pump approach, p = 0.216), repeat revascularization (12.4% off-pump approach versus 11.8% on-pump approach, p = 0.770), and nonfatal myocardial infarction (12.7% off-pump approach versus 10.4% on-pump approach, p = 0.299). Cardiac death trended worse with off-pump CABG (9.0%) than with on-pump CABG (6.25%, p = 0.137). Sensitivity analyses that removed conversions confirmed these findings. CONCLUSIONS: With a 6.1% absolute difference, a strong trend toward improved 5-year survival was observed with on-pump CABG for medically treated diabetic patients. No off-pump advantage was found for any 5-year end points. A future clinical trial now appears warranted to rigorously compare off-pump versus on-pump longer term outcomes for diabetic patients.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/cirurgia , Complicações do Diabetes/complicações , Complicações Pós-Operatórias/epidemiologia , Idoso , Doença da Artéria Coronariana/mortalidade , Complicações do Diabetes/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Taxa de Sobrevida
7.
Surg Endosc ; 33(6): 1693-1709, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30357523

RESUMO

BACKGROUND: Laparoscopic surgical procedures (LSP) have grown in popularity due to their purported benefits of improved effectiveness and efficiency. This study summarizes the Cochrane systematic reviews' (CSRs') evidence comparing the use of LSP versus open procedures used for surgical patient management and comparing the CSRs' quality and consistency of LSP evidence reported across time and different surgical specialties. METHODS: The Cochrane Database was searched to identify CSRs comparing LSP versus open procedures; 36 CSRs and 15 CSR protocols were found as of February 16, 2016. Each CSR's clinical outcomes and major conclusions were evaluated; CSR's quality and completeness were assessed using PRISMA and AMSTAR criteria. Overall, CSRs' reporting variations across specialties and trends over time were summarized. RESULTS: A weighted analysis across all 36 CSRs found improved outcomes with LSP (odds ratio 0.90; 95% confidence interval 0.88, 0.92). Substantial CSR variation was found in the patient inclusion/exclusion criteria and clinical endpoints used. Individually, most CSR analyses showed no significant difference (65.4%) between LSP versus open procedures; 25.8% showed a LSP benefit versus 8.9% an open benefit. As a major conclusion, a positive LSP impact was documented by 8/36 (22.2%) CSRs; but only half of these CSRs decisively concluded that there was a LSP advantage. Undeclared conflicts of interest were identified in 9/36 CSRs (25.0%), raising the potential for a reporting bias. Both CSR variabilities (i.e., missing population, intervention, comparison, outcome, study design statements) and PRISMA-related deficiencies were documented. CONCLUSIONS: Overall, CSR evidence supports a LSP advantage; however, clinical decisions must be driven by CSR procedure-specific evidence. Variations and inconsistencies in CSR design and reporting identified future opportunities to improve CSR quality by increasing the methodological transparency, standardizing CSR reporting, and documenting comprehensively any non-financial conflicts of interest (i.e., ongoing research and historical publications) for all CSR team members.


Assuntos
Laparoscopia , Revisões Sistemáticas como Assunto , Humanos
8.
BMC Med Educ ; 18(1): 225, 2018 Oct 03.
Artigo em Inglês | MEDLINE | ID: mdl-30285708

RESUMO

BACKGROUND: Clinical feedback is an important part of residency training, yet literature suggests this complex interaction is not completely understood. In particular, little is known about what resident versus attending physicians expect as feedback. This study investigates this gap in knowledge by examining differences in interactions that residents and attendings view as feedback. METHODS: Surveys containing sample clinical feedback scenarios were distributed to residents and attending physicians in emergency medicine and general surgery at a large academic medical center. Respondents were asked to decide whether useful feedback was provided in each scenario, and responses were compared between the two groups. Continuous features were summarized with medians, interquartile ranges (IQRs), and ranges; categorical features were summarized with frequency counts and percentages. Comparisons of features between residents and attendings were evaluated using Wilcoxon rank sum, chi-square, and Fisher exact tests. Statistical analyses were performed using version 9.4 of the SAS software package (SAS Institute, Inc.; Cary, NC). All tests were two-sided and p-values < 0.05 were considered statistically significant. RESULTS: Seventy-two individuals responded to the survey out of approximately 110 invitations sent (65%), including 35 (49%) residents and 37 (51%) attendings. Of 35 residents, 31 indicated their level of training, which included 13 (42%) PGY-1, 9 (29%) PGY-2, 6 (19%) PGY-3, and 3 (10%) PGY-4, respectively. Of 37 attendings, 34 indicated the number of years since completion of residency or last fellowship, at a median of 9 years (IQR 4-14; range 1-31). No significant difference was found in residents' and attendings' perceptions of what constituted feedback in the sample scenarios. CONCLUSIONS: While this study did not find a statistical difference in perception of feedback between residents and attendings, additional factors should be considered when investigating perceived feedback deficiencies. Further research is needed to better understand and improve the clinical feedback process.


Assuntos
Atitude do Pessoal de Saúde , Competência Clínica , Retroalimentação Psicológica , Internato e Residência/normas , Corpo Clínico Hospitalar/normas , Feminino , Humanos , Masculino , Equipe de Assistência ao Paciente/normas
9.
Am J Cardiol ; 121(6): 709-714, 2018 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-29402422

RESUMO

Optimal antiplatelet therapy after coronary artery bypass graft (CABG) surgery remains controversial. This study evaluated the role of dual antiplatelet therapy using aspirin and clopidogrel (DAPT) versus antiplatelet therapy using aspirin only (ASA) on post-CABG clinical outcomes and costs. In the Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) trial, clopidogrel use after CABG was prospectively collected beginning in year 2 of this study to include 1,525 of the 2,203 original ROOBY patients who received aspirin after CABG. Discretionarily, surgeons after CABG administered either DAPT or ASA treatments. The ROOBY trial's primary 30-day composite (mortality or perioperative morbidity), 1-year composite (all-cause death, repeat revascularization, or nonfatal myocardial infarction), and costs were compared for these 2 strategies. Of the 1,525 subjects, 511 received DAPT and 1,014 received ASA. DAPT subjects, compared with ASA subjects, had lower rates of preoperative left ventricular ejection fraction of ≥45% (78.8% vs 85.7%, p <0.001), on-pump CABG (36.6% vs 57.1%, p = 0.001), and endoscopic vein harvesting (30.0% vs 42.8%, p <0.001). ASA patients were more likely to have earlier aspirin administration and receive 325 versus 81 mg dosages. The 30-day composite outcome rate was significantly lower for DAPT patients compared with ASA patients (3.3% vs 7.1%, p = 0.003), but the 1-year composite outcome was equal between the 2 groups (12.0% vs12.0%, p = 1.0). At 1 year, there were no cost differences between the 2 groups. Propensity analyses did not significantly alter the results. In conclusion, DAPT appeared safe and was associated with fewer 30-day adverse outcomes than aspirin only and with no 1-year outcome or cost differences.


Assuntos
Aspirina/administração & dosagem , Clopidogrel/administração & dosagem , Ponte de Artéria Coronária , Doença das Coronárias/cirurgia , Inibidores da Agregação Plaquetária/administração & dosagem , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle , Idoso , Aspirina/economia , Clopidogrel/economia , Comorbidade , Doença das Coronárias/mortalidade , Custos e Análise de Custo , Quimioterapia Combinada , Feminino , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/economia , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Resultado do Tratamento
10.
J Card Surg ; 32(12): 751-756, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29239024

RESUMO

BACKGROUND: The optimal methodology to identify cardiac versus non-cardiac cause of death following cardiac surgery has not been determined. METHODS: The Randomized On/Off Bypass Trial was a multicenter, randomized, controlled clinical trial of 2203 patients (February 2002-May 2008) comparing 1-year cardiac outcomes between off-pump and on-pump bypass surgery. In 2013, the Veterans Affairs (VA) Cooperative Studies Program funded a follow-up study to assess 5-year outcomes including mortality. Deaths were identified and confirmed using the National Death Index (NDI), VA Vital Status file, and medical records. An Endpoints Committee (EC) reviewed patient medical records and classified each cause of death as cardiac, non-cardiac, or unknown. Using pre-determined ICD-10 codes, NDI death certificates were independently used to classify deaths as cardiac or non-cardiac. Cause of death was compared between the NDI and EC classifications and concordance measured, using Kappa statistics. RESULTS: Of the 297 5-year deaths identified by the NDI and/or VA vital status file and confirmed by the EC, 219 had adequate patient records for EC cause of death determination. The EC adjudicated 141 of these deaths as non-cardiac and 78 as cardiac, while the NDI classified 150 as non-cardiac and 69 as cardiac; agreement was 77.6% (kappa 0.500; P < 0.001). CONCLUSIONS: Since concordance between EC and NDI cause of death classifications was only moderate, caution should be exercised in relying exclusively on NDI data to determine cause of death. A hybrid approach, integrating multiple information sources, may provide the most accurate approach to classifying cause of death.


Assuntos
Causas de Morte , Ponte de Artéria Coronária sem Circulação Extracorpórea , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Prontuários Médicos , Sistema de Registros , Feminino , Seguimentos , Humanos , Masculino , Estudos Prospectivos , Estados Unidos , United States Department of Veterans Affairs
12.
J Trauma Acute Care Surg ; 83(4): 698-704, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28538625

RESUMO

BACKGROUND: Failure to rescue (FTR) is defined as death after an adverse event. The original metric was derived in elective surgical populations and reclassifies deaths not preceded by recorded adverse events as FTR cases under the assumption these deaths resulted from missed adverse events. This approach lacks face validity in trauma because patients often die without adverse events as a direct result of injury. Another common approach simply excludes deaths without recorded adverse events, but this approach reduces the reliability of the FTR metric. We hypothesized that a hybrid metric excluding expected deaths but otherwise including patients without recorded adverse events in FTR analysis would improve face validity and reliability relative to existing methods. METHODS: Using 3 years of single-state adult trauma registry data from 30 trauma centers, we constructed 3 FTR metrics: (1) excluding deaths not preceded by adverse events (FTR-E), (2) reclassifying deaths not preceded by adverse events (FTR-R), and (3) including deaths not preceded by adverse events in FTR analysis except those with predicted mortality or greater than 50% (FTR-T). Mortality, adverse event, and FTR rates were calculated under each method, and reliability was tested using Spearman correlation for split-sample center rankings. RESULTS: A total of 89,780 patients were included (median age, 57 years [interquartile range, 26-73 years]; 85% were white; 59% were male; 92% had blunt mechanism of injury; median Injury Severity Score, 9 [interquartile range, 5-14]). The FTR rates varied by metric (FTR-E, 11.2%; FTR-R, 31.2%; FTR-T, 21.4%), as did the proportion of deaths preceded by adverse events (FTR-E, 28%; FTR-R, 100%; FTR-T, 60%). Spit-sample reliability was higher FTR-T than FTR-E (ρ = 0.59 vs. = 0.27, p < 0.001). CONCLUSIONS: A trauma-specific FTR metric increases face validity and reliability relative to other FTR methods that may be used in trauma populations. Future trauma outcomes studies examining FTR rates should use a metric designed for this cohort. LEVEL OF EVIDENCE: Retrospective cohort study, outcomes, level III.


Assuntos
Mortalidade Hospitalar , Centros de Traumatologia , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Sistema de Registros , Estudos Retrospectivos , Índices de Gravidade do Trauma , Falha de Tratamento
13.
J Card Surg ; 31(1): 23-30, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26543019

RESUMO

BACKGROUND/AIM: Clinical risk models are commonly used to predict short-term coronary artery bypass grafting (CABG) mortality but are less commonly used to predict long-term mortality. The added value of long-term mortality clinical risk models over traditional actuarial models has not been evaluated. To address this, the predictive performance of a long-term clinical risk model was compared with that of an actuarial model to identify the clinical variable(s) most responsible for any differences observed. METHODS: Long-term mortality for 1028 CABG patients was estimated using the Hannan New York State clinical risk model and an actuarial model (based on age, gender, and race/ethnicity). Vital status was assessed using the Social Security Death Index. Observed/expected (O/E) ratios were calculated, and the models' predictive performances were compared using a nested c-index approach. Linear regression analyses identified the subgroup of risk factors driving the differences observed. RESULTS: Mortality rates were 3%, 9%, and 17% at one-, three-, and five years, respectively (median follow-up: five years). The clinical risk model provided more accurate predictions. Greater divergence between model estimates occurred with increasing long-term mortality risk, with baseline renal dysfunction identified as a particularly important driver of these differences. CONCLUSIONS: Long-term mortality clinical risk models provide enhanced predictive power compared to actuarial models. Using the Hannan risk model, a patient's long-term mortality risk can be accurately assessed and subgroups of higher-risk patients can be identified for enhanced follow-up care. More research appears warranted to refine long-term CABG clinical risk models.


Assuntos
Ponte de Artéria Coronária/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Análise de Regressão , Risco , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo
14.
Injury ; 47(1): 77-82, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26573899

RESUMO

INTRODUCTION: The failure to rescue (FTR) rate is the probability of death after a major complication and was defined in elective surgical cohorts. In elective surgery, the precedence rate (proportion of deaths preceded by major complications) approaches 100%, but recent studies in trauma report rates of only 20-25%. We hypothesised that use of high quality data would result precedence rates in higher than those derived from national datasets, and we further sought to characterise the nature of those deaths not preceded by major complications. METHODS: Prospectively collected data from 2006 to 2010 from a single level I trauma centre were used. Patients age >16 years with AIS ≥2 who survived beyond the trauma bay were included. Complications, mortality, FTR, and precedence rates were calculated. Chart abstraction was performed for registry deaths without recorded complications to verify the absence of complications and determine the cause of death, after which outcomes were re-calculated. RESULTS: A total of 8004 patients were included (median age 41 (IQR 25-75), 71% male, 82% blunt, median ISS 10 (IQR 5-18)). Using registry data the precedence rate was 55%, with 132/293 (45%) deaths occurring without antecedent major complications. On chart abstraction, 11/132 (8%) patients recorded in the registry as having no complication prior to death were found to have major complications. Complication and FTR rates after chart abstraction were statistically significantly different than those derived from registry data alone (complications 16.5% vs. 16.3, FTR 12.3 vs.13, p=0.001), but this difference was unlikely to be clinically meaningful. Patients dying without complications predominantly (87%) had neurologic causes of demise. CONCLUSIONS: Use of data with near-complete ascertainment of complications results in precedence rates much higher than those from national datasets. Patients dying without precedent complications at our centre largely succumbed to progression of neurologic injury. Attempts to use FTR to compare quality between centres should be limited to high quality data. LEVEL OF EVIDENCE: Level III. RETROSPECTIVE COHORT STUDY: Outcomes.


Assuntos
Procedimentos Cirúrgicos Eletivos/mortalidade , Mortalidade Hospitalar , Ressuscitação/mortalidade , Centros de Traumatologia , Adulto , Idoso , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Estudos Retrospectivos , Falha de Tratamento , Estados Unidos/epidemiologia
15.
Semin Thorac Cardiovasc Surg ; 27(2): 144-51, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26686440

RESUMO

Initiated in 1989, the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) includes more than 1085 participating centers, representing 90%-95% of current US-based adult cardiac surgery hospitals. Since its inception, the primary goal of the STS ACSD has been to use clinical data to track and improve cardiac surgical outcomes. Patients' preoperative risk characteristics, procedure-related processes of care, and clinical outcomes data have been captured and analyzed, with timely risk-adjusted feedback reports to participating providers. In 2006, STS initiated an external audit process to evaluate STS ACSD completeness and accuracy. Given the extremely high inter-rater reliability and completeness rates of STS ACSD, it is widely regarded as the "gold standard" for benchmarking cardiac surgery risk-adjusted outcomes. Over time, STS ACSD has expanded its quality horizons beyond the traditional focus on isolated, risk-adjusted short-term outcomes such as perioperative morbidity and mortality. New quality indicators have evolved including composite measures of key processes of care and outcomes (risk-adjusted morbidity and risk-adjusted mortality), longer-term outcomes, and readmissions. Resource use and patient-reported outcomes would be added in the future. These additional metrics provide a more comprehensive perspective on quality as well as additional end points. Widespread acceptance and use of STS ACSD has led to a cultural transformation within cardiac surgery by providing nationally benchmarked data for internal quality assessment, aiding data-driven quality improvement activities, serving as the basis for a voluntary public reporting program, advancing cardiac surgery care through STS ACSD-based research, and facilitating data-driven informed consent dialogues and alternative treatment-related discussions.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Bases de Dados Factuais , Avaliação de Processos em Cuidados de Saúde , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Cirurgia Torácica , Benchmarking , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/normas , Competência Clínica , Bases de Dados Factuais/normas , Humanos , Avaliação de Processos em Cuidados de Saúde/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Medição de Risco , Fatores de Risco , Sociedades Médicas , Cirurgia Torácica/normas , Fatores de Tempo , Resultado do Tratamento
16.
J Thorac Cardiovasc Surg ; 150(6): 1428-35, 1437.e1; discussion 1435-7, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26470910

RESUMO

OBJECTIVE: Controversy exists regarding ideal approaches in teaching residents complex and/or new surgical techniques in part because consequences on patient outcomes are largely unknown. This study compared patient outcomes for cases in which residents (rather than attending surgeons) performed most of the distal anastomoses as primary surgeons, during on- and off-pump coronary artery bypass grafting (CABG). METHODS: This preapproved substudy of the Randomized On/Off Bypass (ROOBY) trial compared clinical outcomes and 1-year graft patency for cases in which residents versus attending surgeons were the primary operator. Comparisons were made between on-pump and off-pump techniques. RESULTS: From July 2003 through May 2007, a total of 1272 ROOBY nonemergent CABG patients were randomized at 16 Veterans Affairs centers where residents were active participants. Residents were the primary surgeon (ie, performed ≥50% of the distal anastomoses) more frequently in on-pump (77.9%) than in off-pump (67.4%) cases. Between these 2 techniques, no differences were found [corrected] in baseline patient characteristics; short-term and 1-year morbidity and mortality rates were no different for residents versus attendings in CABG cases. FitzGibbon A graft patency rates were similar for resident versus attendings completed distal anastomoses for on-pump (83.0% vs 82.4%) compared with off-pump (77.2% vs 76.6%) procedures. CONCLUSIONS: In the ROOBY trial, short-term and 1-year patient outcomes and graft patency rates did not differ between resident and attending surgeons, demonstrating that with appropriate patient selection and resident supervision, residents can perform advanced, novel surgical techniques with outcomes similar to those of attending surgeons.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea , Ponte de Artéria Coronária , Internato e Residência , Corpo Clínico Hospitalar , Grau de Desobstrução Vascular , Humanos , Resultado do Tratamento
17.
Ann Thorac Surg ; 99(1): 109-14, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25442992

RESUMO

BACKGROUND: New-onset postoperative atrial fibrillation (POAF) after coronary artery bypass graft surgery (CABG) is associated with worse in-hospital morbidity and mortality, extended hospital stays, and higher costs. Beyond the initial hospital discharge, the cost and outcomes of POAF have not been well studied. METHODS: For CABG patients with and without new-onset POAF, a retrospective propensity-matched, multivariable regression analysis was performed to compare 1-year outcomes (including health-related quality of life [HRQoL] scores and mortality rates) and costs (standardized to 2010 dollars). Regression models controlled for site and patient factors, with propensity matching used to adjust for differences in POAF versus no-POAF patients' risk profiles. RESULTS: Using the existing CABG trial database, 2,096 patient records were analyzed, including POAF patients (n = 549) versus no-POAF patients (n = 1,547). For the index CABG hospitalization, POAF patients had longer postoperative length of stay (+3.9 days) and higher discharge costs (+$13,993) than no-POAF patients. At 1 year, POAF patients had more than twice the adjusted odds of dying (p < 0.01), with higher 1-year total cumulative costs. This 1-year cost difference (+$15,593) was largely attributable to hospital-based costs during the index surgery hospitalization. There was no difference in 1-year HRQoL scores (or HRQoL score changes) between POAF patients and no-POAF patients. CONCLUSIONS: Compared with no-POAF patients, POAF patients had higher discharge and 1-year costs along with higher 1-year mortality rates, but no differences were observed in 1-year HRQoL scores. Additional research appears warranted to improve the longer-term survival rates for POAF CABG patients, targeting future POAF-specific postdischarge interventions.


Assuntos
Fibrilação Atrial/economia , Fibrilação Atrial/epidemiologia , Ponte de Artéria Coronária , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Idoso , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Veteranos
18.
J Trauma Acute Care Surg ; 77(5): 764-768, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25494430

RESUMO

BACKGROUND: As emergency care becomes increasingly regionalized, systems planners must determine how system expansion impacts existing system assets. We hypothesized that accrediting new Level II and III trauma centers impacted the trauma patient census and severity at a nearby Level I trauma center and estimated the magnitude of the impact. METHODS: We conducted an interrupted time series analysis using monthly patient counts during the past 10 years for five trauma centers located near one another in Pennsylvania. The Level I center (TC-A) operated for the entire period. A Level II center 39 miles away was accredited after 70 months (TC-B), one Level III center 46 miles away was accredited after 95 months but lost accreditation after 11 months (TC-C), and two other Level III centers 40 miles and 45 miles away were accredited after 107 months (TC-D and TC-E). RESULTS: Monthly patient volume at the Level I center, which increased gradually over the study and summed to 25,120 patients, decreased by 10.8% (p < 0.05) when TC-B was accredited and decreased by an additional 12.9% (p < 0.05) when TC-D and TC-E were accredited simultaneously. No change stemmed from temporarily accrediting TC-C. Ultimately, the Level I center treated 1,903 fewer patients than expected over 51 months, an 11.9% volume reduction, and patient severity remained consistent but mortality decreased. CONCLUSION: Accrediting Level II and Level III trauma centers reduced patient volume and reduced overall mortality at a nearby Level I center. Strategic planning of statewide trauma systems can help balance rapid access to care with maintenance of adequate annual patient volumes of critically injured patients. LEVEL OF EVIDENCE: Epidemiologic study, Level IV.

19.
Ann Thorac Surg ; 98(1): 38-44; discussion 44-5, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24841548

RESUMO

BACKGROUND: Observational studies have documented an off-pump over on-pump advantage for high-risk patients, including diabetic patients. Randomized trials have not confirmed this advantage. The VA Randomization On Versus Off Bypass (ROOBY) trial randomly assigned 2,203 coronary artery bypass graft surgery (CABG) patients at 18 sites to either on-pump (n=1,099) or off-pump (n=1,104) procedures. An a priori ROOBY aim was to evaluate treatment impact on diabetic patients. METHODS: Actively treated diabetic patients (n=835, receiving oral hypoglycemic or insulin medications) received off-pump CABG (n=402) or on-pump CABG (n=433). The primary ROOBY trial endpoints were a short-term composite (30-day operative death or major complications) and a 1-year composite (death, nonfatal acute myocardial infarction, or repeat revascularization). Secondary ROOBY endpoints included 1-year all-cause death, 1-year graft patency, 1-year changes from baseline in neurocognitive status and health-related quality of life, and costs. RESULTS: Diabetic patients' risk factors at baseline were balanced across treatments. For diabetic patients, the primary short-term composite outcome rate showed a worse trend for off-pump (8.0%) than on-pump (3.9%, p=0.013), with no difference in the 1-year primary composite outcome or 1-year death rate. One-year patency was 83.1% off-pump versus 88.4% on-pump (p=0.004). No differences were found in neurocognitive, health-related quality of life, discharge cost, and 1-year cumulative cost. CONCLUSIONS: Concordant with the ROOBY trial's overall findings, off-pump CABG yielded no advantage over on-pump CABG for actively treated diabetic patients. The 1-year graft patency was lower and the short-term composite trended higher for off-pump CABG, with no other significant outcome or cost differences.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Circulação Coronária/fisiologia , Diabetes Mellitus/terapia , Hipoglicemiantes/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Ponte de Artéria Coronária sem Circulação Extracorpórea , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Vasos Coronários/fisiopatologia , Vasos Coronários/cirurgia , Diabetes Mellitus/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Grau de Desobstrução Vascular
20.
J Trauma Acute Care Surg ; 75(3): 426-31, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24089112

RESUMO

BACKGROUND: Organ failure after injury is a significant cause of morbidity and mortality, yet its true incidence is unknown. We sought to benchmark the incidence of organ failure following injury at trauma centers and nontrauma centers using a nationally representative sample of hospital discharges. We hypothesized that injured patients receiving care at trauma centers would have a lower incidence of organ failure than those at nontrauma centers. METHODS: We used the 2006 Nationwide Inpatient Sample to identify injured adults (age ≥ 15 years) with organ dysfunction using specific DRG International Classification of Diseases-9th Rev. codes by system. After adjusting for hospital size, geographic region, comorbidities, Injury Severity Score (ISS), age, and sex, a multivariate logistic regression model was created to compare rates of organ dysfunction between trauma centers and nontrauma centers. RESULTS: We identified 396,276 injured patients, representing the patient care experience of a total of 1,939,473 patients. Among these patients, 6.5% had concurrent organ failure. Injured patients who had acute organ failure were more likely to die than injured patients without organ failure (12.4% vs. 1.7%, p < 0.001). Mortality increased with the number of organ system failures. Patients treated at trauma centers had a higher incidence of respiratory and cardiac failure compared with nontrauma centers. CONCLUSION: We offer the first national benchmark of rates of acute organ failure among injured patients. Postinjury organ failure is uncommon, but incidence increases with injury severity and correlates with mortality. Patients at trauma centers had higher rates of respiratory and cardiac failure, possibly representing differences in referral patterns or resuscitation strategies. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.


Assuntos
Benchmarking/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Insuficiência de Múltiplos Órgãos/etiologia , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/normas , Feminino , Humanos , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/epidemiologia , Centros de Traumatologia/normas , Estados Unidos/epidemiologia , Ferimentos e Lesões/epidemiologia
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