Obstacles to early discharge after cardiac surgery.

CONTEXT: Cardiovascular disease and cardiac surgery, in particular, are associated with a large expenditure of healthcare resources. Identifying the factors that affect length of stay for patients hospitalized for cardiac surgery and ways to safely and effectively shorten stays could have significant impact on healthcare costs. OBJECTIVE: To identify obstacles to and the effects of early discharge on outcome after cardiac surgery. STUDY DESIGN: A prospective approach using a protocol consisting of modifying anesthesia, limiting the use of postoperative narcotics, early extubation, and early mobilization, with a goal of discharge at < 5 days. PATIENTS AND METHODS: The study group consisted of 422 consecutive patients (age range 15-89 years, 65% males): coronary artery bypass graft (CABG) (n = 290), valve procedures (n = 54), and CABG + valve procedures (n = 78). The discharge criteria included hemodynamic stability, normal bowel function, independence in activities of daily living, absence of fever, and no incision problems. RESULTS: Predictors of prolonged postoperative stay were prolonged intensive care unit stay (P < 0.0001), postoperative atrial fibrillation (P = 0.0006), preoperative congestive heart failure (P = 0.002), combined CABG and valve procedure (P = 0.005), prolonged ventilator support (P = 0.01), increasing age (P = 0.012), history of peripheral vascular disease (P = 0.02), and female gender (P = 0.025). The 30-day readmission rate for the early discharge group was 7.8% vs 16.2% for the late discharge group (P = 0.01). The mortality rate for the entire group was 3.3%.

Intraoperative transesophageal echocardiography and epiaortic ultrasound for assessment of atherosclerosis of the thoracic aorta.

OBJECTIVES: This study sought to determine the role of transesophageal echocardiography (TEE) and epiaortic ultrasound in the detection of atherosclerosis of the ascending aorta in patients undergoing cardiac surgery. BACKGROUND: Atherosclerosis of the ascending aorta is a major risk factor for perioperative stroke and systemic embolism in patients undergoing cardiac surgery. METHODS: Forty-four patients underwent prospective evaluation of the ascending aorta with two ultrasound techniques-epiaortic ultrasound and biplane TEE-and by palpation. The severity of atherosclerosis was graded on a four-point scale as normal, mild, moderate or severe. RESULTS: A comparison of results with biplane TEE and those with epiaortic ultrasound yielded a kappa value of 0.12 (95% confidence interval 0 to 0.25), indicating poor correlation between the two. Compared with epiaortic ultrasound, biplane TEE significantly underestimated the severity of ascending aortic atherosclerosis, and this underestimation was more marked in the distal ascending aorta (p < 0.0001). When compared with epiaortic ultrasound and biplane TEE, palpation of the ascending aorta significantly underestimated the presence and severity of atherosclerosis (p < 0.0001 for both). CONCLUSIONS: Epiaortic ultrasound is more accurate than TEE for identification of atherosclerosis of the ascending aorta, but both ultrasound techniques are superior to palpation. Epiaortic ultrasound and TEE provide complementary information regarding thoracic aortic atherosclerosis. Modification of surgical technique on the basis of results of intraoperative epiaortic ultrasound and TEE in elderly patients undergoing cardiac procedures may prevent atheroembolic complications.

Managed care involvement by cardiovascular specialists: prevalence, attitudes and influence on practice.

OBJECTIVES: The purpose of this study was to determine the involvement in and attitudes toward managed care by cardiovascular specialists and the influence of such programs on their practices. BACKGROUND: No in-depth study has measured the impact of managed care on cardiovascular specialists. Therefore, we conducted a mail survey to determine the prevalence of managed care arrangements among cardiovascular specialists and variations among pediatric and adult cardiologists and cardiovascular surgeons; the types of managed care arrangements in which cardiovascular specialists are engaged; the reasons why those not participating in managed care have chosen not to do so; and the general attitudes among cardiovascular specialists with regard to various aspects of managed care. In addition, we evaluated the impact of managed care among several aspects of cardiovascular practice. METHODS: A questionnaire was mailed in the spring of 1993 to 4,577 practicing, domestic, American College of Cardiology (ACC) members selected at random from within each primary cardiovascular specialty group (adult cardiologists, pediatric cardiologists and cardiovascular surgeons). Additional data concerning practice characteristics were cross tabulated using results from the 1992 ACC membership profile survey. RESULTS: In total, 1,961 of the 4,577 members responded to the survey, representing a 43% response rate. Of all survey respondents, 76% reported entering into at least one relationship with a health maintenance organization (HMO) or preferred provider organization (PPO). Of those not participating in managed care arrangements, the most frequently mentioned reason was "concern over the quality of care." This reason was cited by 51% of those not entering into HMO relationships and 41% of those not participating in PPOs. The majority of respondents indicated that they do not strongly object to the gatekeeper approach to managing nonemergent patients, although more than half indicated concern that gatekeepers may not be appropriate in the management of cardiac emergencies. In addition, cardiovascular specialists report that under managed care, referrals have not increased, income has decreased, and managed care formularies have not substantially affected their ability to prescribe appropriate medication to their patients. CONCLUSIONS: Despite concerns over the quality of care and contract requirements and general philosophical opposition of cardiovascular specialists, most are becoming integrated into managed care environments.

Strategy for the reduction of stroke incidence in cardiac surgical patients.

Atherosclerosis of the ascending aorta (AAA) and severe carotid artery disease are risk factors for stroke in cardiac surgical patients. Twelve hundred of a consecutive series of 1,334 patients 50 years of age or older having a cardiac operation were screened for the presence of AAA by intraoperative ultrasonographic scanning and for the presence of carotid artery occlusive disease (791 of 798 patients > or = 65 years of age and younger symptomatic patients) by carotid duplex scanning. Coronary artery disease was present in 88% of the patients. Patients with moderate or severe AAA (n = 231; 19.3% of the total) were treated by ascending aortic replacement (n = 27) or by modified, less extensive techniques (n = 168) to avoid the atherosclerotic areas. Thirty-three patients had combined carotid endarterectomy and cardiac operation. Thirty-day mortality and stroke rates for the 1,200 patients were 4.0% and 1.6%, respectively. The stroke rate was low (1.1%) among the 969 patients with no or mild AAA. It was zero among 27 patients with moderate or severe AAA who had ascending aortic replacement and among the 33 patients who had carotid endarterectomy. The stroke rates were higher for 111 patients with moderate or severe ascending aortic disease who had only minor interventions (6.3%) and for 16 patients with severe carotid artery disease who did not have carotid endarterectomy (18.7%). Screening for AAA and carotid artery disease and aggressive surgical treatment of moderate or severe AAA and severe or symptomatic carotid artery disease appears to reduce the frequency of stroke in older cardiac surgical patients.

Costs and benefits associated with treatment for coronary artery disease.

Direct and indirect costs of medical and of surgical treatment are presented for patients entered into the Birmingham portion of the Coronary Artery Surgery Study. For comparison, similar results are shown for the Birmingham portion of the national Cooperative Unstable Angina Study. In the Unstable Angina Study, mean inpatient costs at the end of 1 year in the study were $6867 for medical therapy, $10,574 for surgical therapy and $23,045 for those who failed medical therapy and required late surgery. A stepwise multiple regression analysis shows that the single best predictor of cost was the number of myocardial infarctions that the patient had while in the study. A discriminant-function analysis identified 85% of the medical patients who required late surgery. A significantly lower proportion of surgical than medical patients returned to work. Total inpatient costs for patients in the Coronary Artery Surgery Study (i.e, patients with stable angina) were $3432, $11,100 and $13,554 for medical, surgical and late surgical patients, respectively, for the first year in the study. There was no significant difference in the percentage of medical and surgical patients who were working at the end of 1 year. According to their own perceptions, the surgical group was in the best and the late surgical group in the worst health.

Employment status after coronary artery bypass surgery.

With a few exceptions, prevailing data on return to work after coronary artery bypass surgery indicate no net gain in employment status for at least several years after the operation. Despite the improved surgical experience and advances in the medical management of postoperative patients, only limited employment benefits occur after surgery, and no gains in work rehabilitation over the past decade have been noted. Several characteristics--preoperative work status, nonwork income, occupation, relief of symptoms, age, perception of health, education and severity of disease--appear to be important for estimating the likelihood of employment after surgery. Other influences, such as attitudes of the family, employers and physicians, undoubtedly alter the probability of return to the work force, but are less well documented. Unless constructive approaches toward work rehabilitation are made, the possibility of return to gainful employment should not be considered an indication for or a necessary consequence of coronary artery bypass surgery.

Research related to surgical treatment of coronary artery disease.

In the past 20 years, basic and clinical research have provided new information on coronary artery surgery. For example, several studies have shown that coronary artery bypass grafting is more effective than medical treatment in relieving the symptoms of chronic disabling angina pectoris. However, we still do not have definitive answers to many questions. What factors in the patient, in the operation and in the care after operation determine success in surgical treatment? Does the operation prolong useful life? Is the operation affordable? These questions are difficult. Further research is needed to solve complex problems relating to surgical vs medical treatment of coronary artery disease.

Unstable angina pectoris: an examination of modes and costs of therapy.

Debate exists over the most appropriate form of treatment for patients with unstable angina pectoris. This study examined 106 patients randomized at the University of Alabama in Birmingham as part of the National Cooperative Study Group and focuses on the phenomenon of patients who fail medical therapy and thus require late surgery, and the costs of therapy. Discriminant function analysis revealed that the significant predictors (p less than 0.01) of patients who would later require surgery were: total number of vessels diseased, angina severly, presence of congestive heart failure, hypertension, and number of years that the patient had had angina. By means of this analysis, 85% of the late surgery patients were correctly predicted. Late surgery patients averaged 2.4 diseased vessels vs 1.5 for persistent medical patients (p less than 0.01). Mean charges for the first 2 years in the study were $6,226 (SD $2,967) for persistent medical patients, $10,416 (SD $2,146) for surgery patients, and $20,059 (SD $10,748) for late surgery patients (p less than 0.001). These data indicate that surgery is clearly an expensive procedure; but that it is more expensive for late surgery patients, who have total costs that are twice as high as surgical costs and 3.5 times as high as persistent medical costs.

Unstable angina pectoris: a comparison of the costs of medical and surgical treatment.

This study compares the inpatient costs of therapy of patients with unstable angina pectoris randomized to surgical or medical therapy at the University of Alabama in Birmingham as part of the National Cooperative Study Group. For 74 patients followed up for 2 years, the mean inpatient charges were $4,728 for 22 medically treated patients, $9,528 for 34 surgically treated patients and $20,215 for 18 patients who crossed over from medical to surgical therapy. Differences among the three groups were statistically significant (P less than 0.001). Stepwise multiple regression analysis of total inpatient charges with medical and procedural factors as explanatory variables showed that a history of congestive heart failure, the number of infarctions during the period of the study, the duration of the longest anginal attack, the type of unstable angina and the type of treatment were significant predictors of total inpatient cost, with an R2 value of 0.829 (P less than 0.001). These variables explain the cost of treatment. One should not infer that they will also predict the appropriate type of treatment for patients with unstable angina. Although the cost of surgical therapy was double the cost of therapy for patients treated only medically, those medically treated patients whose therapy failed and who subsequently required surgery incurred mean costs twice those of the surgically treated patients and four times of patients who received only medical therapy. Reassessment of previous criticism of the high cost of surgical therapy is indicated.