Comparing No-Show Rates of Neurology Outpatients with and without Parkinson's Disease: A Real-World Assessment of the Parkinsonian Personality Profile.

BACKGROUND: Parkinson's disease (PD) has been hypothesized to be associated with certain personality traits, including conscientiousness and punctuality. However, research aimed at quantifying these traits is largely derived from questionnaire-based personality inventories rather than real-world observations. OBJECTIVE: To explore the presence of a parkinsonian personality profile by assessing the no-show rate of patients with PD versus other neurological disorders. METHODS: We extracted data from our electronic health record for all neurology appointments over a 78-month interval. Additionally, we obtained primary care appointment data for the same patients over the same timeframe. For each appointment we collected appointment date/time, check-in time, provider, age, sex, insurance type, days between appointment date and scheduling, diagnosis code, and no-show status. RESULTS: 19,433 unique patients (400 with PD) accounting for a total of 252,347 outpatient appointments were included in our analysis. The overall no-show rate for PD patients was 3% versus 7.4% for patients with other neurologic disorders (OND). No show rates for PD patients were lower than those with OND for both neurology appointments (2.7% versus 13.6%) and for primary care visits (3.1% versus 5.9%). CONCLUSIONS: Patients with PD have lower no-show rates than patients with OND. Additionally, the no-show rate for patients with PD did not differ between their neurology and primary care appointments, confirming that patient's personality rather than provider traits account for this difference, and supporting the presence of a parkinsonian personality.

The economic impact of minimally invasive total hip arthroplasty.

We compared hospital length of stay (LOS) and costs between (1) minimally invasive total hip surgery (MIS) combined with an active hip pathway (AHP) and (2) long incision total hip surgery (LIS) with a passive hip pathway (PHP). A prospective consecutive cohort of 214 MIS/AHP patients was compared to a concurrent cohort of 265 LIS/PHP patients. The MIS/AHP cohort had significantly decreased LOS (1.5 days vs. 3.8 days, P < .001) and hospital costs ($12.8 thousand vs. $16.7 thousand, P < .001). The complication rates were similar for MIS/AHP and LIS/PHP. We conclude that, compared to LIS/PHP, MIS/AHP significantly shortened LOS by an average of 2.3 days, and significantly reduced hospital costs by an average of $3.9 thousand per patient.

The value of aortic valve replacement in elderly patients: an economic analysis.

OBJECTIVE: Economists have designed frameworks to measure the economic value of improvements in health and longevity. Heart valve replacement surgery has significantly prolonged life expectancy and quality of life. For the example of aortic valve replacement, what is its economic value according to this framework? METHODS: From 1961 through 2003, a total of 4617 adult patients underwent aortic valve replacement by one team of cardiac surgeons. These patients were provided with a prospective lifetime follow-up service. As of 2005, observed follow-up was 31,671 patient-years, with a maximum of 41 years. A statistical model was used to generate the future life-years of patients currently alive. The value of life-years proposed by economists was applied to determine the economic value of the additional life given to these patients by aortic valve replacement. RESULTS: The total life-years after aortic valve replacement were 53,323, with a gross value of 14.6 billion dollars. The total expected life-years without surgery were 10,157, with an estimated value of 3.0 billion dollars. Thus the net life-years gained by AVR were 43,166, worth 11.6 billion dollars. Subtracting the 451 million dollars total lifetime cost of surgery, the net value of the life-years gained by AVR was 11.2 billion dollars. The mean net value decreases according to age at surgery but is still worth 600,000 dollars for octogenarians and 200,000 dollars for nonagenarians. CONCLUSION: According to the economic concept of the value of a statistical life, the return on the investment for aortic valve replacement is enormous for patients of all ages, even very elderly patients.

Cost-effectiveness of aortic valve replacement in the elderly: an introductory study.

OBJECTIVE: With increased life expectancy and improved technology, valve replacement is being offered to increasing numbers of elderly patients with satisfactory clinical results. By using standard econometric techniques, we estimated the relative cost-effectiveness of aortic valve replacement by drawing on a large prospective database at our institution. By using aortic valve replacement as an example, this introductory report paves the way to more definitive studies of these issues in the future. METHODS: From 1961 to 2003, 4617 adult patients underwent aortic valve replacement at our service. These patients were provided with a prospective lifetime follow-up. As of 2005, these patients had accumulated 31,671 patient-years of follow-up (maximum 41 years) and had returned 22,396 yearly questionnaires. A statistical model was used to estimate the future life years of patients who are currently alive. In the absence of direct estimates of utility, quality-adjusted life years were estimated from New York Heart Association class. The cost-effectiveness ratio was calculated by the patient's age at surgery. RESULTS: The overall cost-effectiveness ratio was approximately 13,528 dollars per quality-adjusted life year gained. The cost-effectiveness ratio increased according to age at surgery, up to 19,826 dollars per quality-adjusted life year for octogenarians and 27,182 dollars per quality-adjusted life year for nonagenarians. CONCLUSIONS: Given the limited scope of this introductory study, aortic valve replacement is cost-effective for all age groups and is very cost-effective for all but the most elderly according to standard econometric rules of thumb.

Validating the Clinical Outcomes Assessment Program risk model for percutaneous coronary intervention.

BACKGROUND: The Clinical Outcomes Assessment Program (COAP) from the state of Washington recently published a risk model for hospital mortality after percutaneous coronary intervention (PCI), which was validated by a consortium of hospitals in 4 northeastern states. The Providence Health System (PHS) Cardiovascular Study Group data was used to further validate this COAP model using data from PHS hospitals in 3 western states. METHODS: All 13124 consecutive PCI procedures performed in 6 PHS hospitals from July 2001 through June 2004 were included. The c index was used to test model discrimination. The Hosmer-Lemeshow test, the le Cessie-van Houwelingen-Copas test, and the cumulative sum method were used to test model calibration. RESULTS: The patient profiles of the COAP data and the PHS data were similar. The overall mortality was 1.6% for COAP and 1.4% for PHS. The subgroup mortalities were also similar. When applying the COAP model to the PHS data, the c index (95% CI) was 0.893 (0.859-0.928), indicating excellent discrimination, and the le Cessie-van Houwelingen-Copas test and the cumulative sum method showed good global goodness of fit. CONCLUSION: The COAP model for hospital mortality was successfully validated using PHS data. With the advance of technology and changing patient profile, PCI models must be periodically checked for possible updating to reflect contemporary practice. Predictors in a PCI risk model should be objective, have standard definitions, and be easy to obtain to facilitate the transportability of the model.

Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project.

OBJECTIVE: To describe the main findings of the Portland Diabetic Project, which elucidates the adverse relationship between hyperglycemia and outcomes of cardiac surgical procedures in patients with diabetes and delineates the protective effects of intravenous insulin therapy in reducing those adverse outcomes. RESULTS: In this ongoing 17-year prospective, nonrandomized, interventional study of 4,864 patients with diabetes who underwent an open-heart surgical procedure, we investigated the effects of hyperglycemia, and its subsequent reduction by continuous intravenous insulin (CII) therapy, on in-hospital outcomes. Increasing blood glucose levels were found to be directly associated with increasing rates of death, deep sternal wound infections (DSWI), length of hospital stay (LOS), and hospital cost. In separate multivariate analyses, increasing hyperglycemia was found to be independently predictive of increasing mortality (P<0.0001), DSWI (P = 0.017), and LOS (P<0.002). Conversely, CII therapy, designed to achieve predetermined target blood glucose levels, independently reduced the risks of death and DSWI by 57% and 66%, respectively (P<0.0001 for both). Target blood glucose levels of less than 150 mg/dL and a 3-day postoperative duration of CII therapy are both important variables that determine the effect of the CII therapy on improved outcomes. Coronary artery bypass grafting-related mortality (2.5%) and DSWI rates (0.8%) in patients with diabetes were normalized to those of the nondiabetic population by the use of the Portland CII Protocol. CONCLUSION: Perioperative hyperglycemia in patients undergoing a cardiac surgical procedure affects biochemical and physiologic functions, which, in turn, adversely alter mortality, LOS, and infection rates. The Portland CII Protocol is a cost-efficient method that effectively eliminates hyperglycemia and reduces postoperative morbidity and mortality in patients with diabetes undergoing an open-heart operation. CII protocols should be the standard care for glycometabolic control in all patients undergoing cardiac surgical procedures.