RESUMEN
Background: To evaluate trends in frequency, mortality and treatment for non-traumatic vascular emergencies (VE) in the US. Methods: VE in the Nationwide Inpatient Sample (2005-2014) were identified. ICD-9 CM diagnosis and procedures codes captured six common VE. Results: 228,210,504 emergency admissions with 317,396 procedures for VE were estimated. Mean age was 67.8 years and were primarily men (56.1 %; p < 0.0001). The commonest VE was Acute Limb Ischemia (ALI) (82.4 %) followed by ruptured AAA (10.8 %) and Acute Mesenteric Ischemia (4.71 %). VE increased from 132.8 per 100,000 admissions in 2005 to 153.6 in 2014 (p < 0.001), with mortality decrease for all VE (13.8 % vs. 9.1 %; p < 0.0001). Length of stay decreased (median 8 vs. 7 days; p < 0.0001) but cost of care increased (median $ 25,443 vs. $ 29,353; p < 0.0001). Endovascular treatment increased overall for VE from 23.7 % in 2005 to 37.2 % in 2014 (p < 0.0001). Hospital mortality for VE decreased overall, except ruptured thoracoabdominal aortic aneurysm with mortality decrease with endovascular treatment (34.3 vs. 11.1; p = 0.04) and mortality increase with open treatment (44.7 vs. 47.6; p = 0.06). ALI overall mortality decreased from 8.1 % to 5.7 % (p < 0.0001) due to reduced open surgical mortality from 9.6 % to 7.4 % (p < 0.0001); endovascular mortality did not improve over time (4.0 % vs. 3.4 %; p = 0.45). Hospital mortality also increased for endovascular treatment of ruptured thoracic aortic aneurysm (rTAA) from 14.9 % to 27.4 % (p = 0.0003) during this period. Conclusions: VE frequency increased with a decrease in overall mortality over time. Overall hospital stay has decreased but with an increase in the cost of care. Open surgical mortality for VE has also decreased overall, suggesting perioperative care improvements, with the exception of ruptured thoracoabdominal aortic aneurysm. Endovascular utilization for VE has significantly increased; associated with lower mortality for most VE, although an increase in hospital mortality after endovascular repair of rTAA was seen. This may be due to an increased implementation of endovascular repair for patients not previously eligible for surgery due to high risk. We recommend careful selection of patients for rTAA treatment as mortality has increased despite endovascular therapy and at an increased cost of care.
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Aneurisma de la Aorta Abdominal , Pacientes Internos , Anciano , Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta , Urgencias Médicas , Procedimientos Endovasculares , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: Acute limb ischemia is a common vascular emergency requiring immediate intervention. Thrombolysis has been widely utilized for acute limb ischemia; the purpose of this study is to analyze contemporary trends, outcomes and complications of thrombolysis for acute limb ischemia. METHODS: Patients were identified from the Nationwide Inpatient Sample (2003-2013) using ICD-9. Patients undergoing emergency thrombolysis for acute limb ischemia were evaluated. Three groups were analyzed: thrombolysis alone, thrombolysis and endovascular procedure (T+ENDO), and failed thrombolysis requiring open surgery (T+OPEN). RESULTS: A total of 162,240 patients with acute limb ischemia were estimated: 33,615 patients (20.7%) underwent thrombolysis as the initial treatment. Mean age was 66.2 ± 34.9 years with 54% male. The utilization of thrombolysis increased significantly during the study period (16.8-24.2%, p < 0.0001). The most common group was thrombolysis and endovascular procedure (40.7%), followed by thrombolysis alone (34.1%), and T+OPEN (25.2%). Thrombolysis and endovascular procedure increased significantly over time (31.6-47.8%, p < 0.0001) whereas thrombolysis alone and T+OPEN significantly decreased (39.6-28.6% and 28.7-23.6%, respectively, p < 0.0001). Overall mortality was 4.9%; thrombolysis and endovascular procedure compared to thrombolysis alone and T-OPEN had a lower mortality rate (3.2% vs. 6.1% and 5.9%, p < 0001). The overall stroke rate was 1.9%; thrombolysis alone had the highest stroke rate (3.0%, p < 0.0001) with thrombolysis and endovascular procedure the lowest (1.2%) and T+OPEN 1.7%. The highest amputation rate was T+OPEN (11.6%, p < 0.001) compared to thrombolysis and endovascular procedure (5.1%) and thrombolysis alone (5.3%). T+OPEN had the highest incidence of cardiac (5.5%), respiratory (7.3%) and renal complications (12.5%), pneumonia (4.0%), and fasciotomy (16.8%) (all p < 0.0001). CONCLUSION: Thrombolysis remains an effective treatment for acute limb ischemia with increased utilization over time. There was a significant increase in thrombolysis and endovascular procedure leading to improved outcomes. Thrombolysis alone carried the highest mortality and stroke rate, with T+OPEN associated with the highest amputation and complications. Although thrombolysis is effective, 25% of patients required an open procedure suggesting that patient selection for thrombolysis first instead of open surgery continues to be a clinical challenge.
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Fibrinolíticos/administración & dosificación , Isquemia/tratamiento farmacológico , Extremidad Inferior/irrigación sanguínea , Terapia Trombolítica/tendencias , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica/tendencias , Toma de Decisiones Clínicas , Terapia Combinada , Conversión a Cirugía Abierta/tendencias , Bases de Datos Factuales , Procedimientos Endovasculares/tendencias , Femenino , Fibrinolíticos/efectos adversos , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/cirugía , Masculino , Persona de Mediana Edad , Selección de Paciente , Pautas de la Práctica en Medicina/tendencias , Factores de Riesgo , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
Objectives Chronic kidney disease (CKD) has been identified as a significant risk factor for poor post-surgical outcomes. This study was designed to provide a contemporary analysis of carotid endarterectomy (CEA) outcomes in patients with CKD, end-stage renal disease (ESRD), and normal renal function (NF). Methods The Nationwide Inpatient Sample data 2006-2012 was queried to select patients aging 40 years old and above who underwent CEA during two days after admission and had a diagnosis of ESRD on long-term hemodialysis, patients with non-dialysis-dependent CKD, or NF. Patients with acute renal failure were excluded. We subsequently compared procedure outcomes and hospital resource utilization in these patients. Results Totally 573,723 CEA procedures were estimated: 4801 (ESRD)' 32,988 (CKD)' and 535,934 (NF). Mean age was 71.0 years, 57.7% were males, and 73.7% were white. Overall hospital mortality was 0.20%: 0.69% (ESRD), 0.35% (CKD), and 0.19% (NF), p < 0.0005 between groups. The overall stroke rate was 1.6%: 1.8% (ESRD), 2.0% (CKD), and 1.6% (NF). Comparing NF to CKD there was a significant difference: p < 0.0001. For CKD patients, compared to NF patients, there was an increased risk in cardiac complications (odds ratio = 1.2; 95% CI 1.15-1.32), respiratory complications (odds ratio = 1.2; 95% CI 1.15-1.32), and stroke (odds ratio = 1.1; 95% CI 1.04-1.23). For ESRD patients compared to NF patients there was an increased risk in respiratory complications (odds ratio = 1.3; 95% CI 1.08-1.47) and sepsis (odds ratio = 4.4; 95% CI 3.23-5.94). Mean length of stay and cost were: 2.8 d and $13,903 (ESRD), 2.2 d and $12,057 (CKD), and 1.8 d and $10,130 (NF), all p < 0.0001. Conclusions Patients with ESRD undergoing CEA had an increased risk of respiratory and septic complications, but not a higher risk of stroke compared to patients with normal renal function. The greatest risks of postoperative stroke, respiratory, and cardiac complications were found in patients with CKD. A diagnosis of ESRD and CKD were both found to significantly increase hospital mortality, length of stay and cost. Where clinicians typically consider ESRD patients the highest risk for CEA, further consideration should be given to patients with CKD not yet on dialysis as they had the higher risk of cardiac complications and stroke compared to the others evaluated.
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Enfermedades de las Arterias Carótidas/cirugía , Endarterectomía Carotidea , Fallo Renal Crónico/epidemiología , Insuficiencia Renal Crónica/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades de las Arterias Carótidas/economía , Enfermedades de las Arterias Carótidas/mortalidad , Distribución de Chi-Cuadrado , Toma de Decisiones Clínicas , Bases de Datos Factuales , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/economía , Endarterectomía Carotidea/mortalidad , Femenino , Tasa de Filtración Glomerular , Cardiopatías/epidemiología , Costos de Hospital , Mortalidad Hospitalaria , Humanos , Riñón/fisiopatología , Fallo Renal Crónico/economía , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/fisiopatología , Tiempo de Internación , Modelos Logísticos , Enfermedades Pulmonares/epidemiología , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Selección de Paciente , Insuficiencia Renal Crónica/economía , Insuficiencia Renal Crónica/mortalidad , Insuficiencia Renal Crónica/fisiopatología , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: The multilevel designation system given to U.S. trauma centers has proven useful in providing injury-level-appropriate care and guiding field triage. Despite the system, patients are often transferred to Level I trauma centers for higher-level care/specialized services. OBJECTIVES: The objective of this study is to assess whether there is a difference in outcomes of patients transferred to Level I centers compared with direct admissions. METHODS: The Nationwide Inpatient Sample was queried to identify patients involved in motor vehicle accidents, using International Classification of Diseases, Ninth Revision, Clinical Modification E-codes. Patients that were admitted to Level I trauma centers were identified using American College of Surgeons or American Trauma Society designations. RESULTS: There were 343,868 patients that met inclusion criteria. Of these patients, 29.2% (100,297) were admitted to Level I trauma centers, 5.7% (5691) of which were identified as trauma transfers. The lead admitting diagnosis for transfers was pelvic fracture (11.5%). Caucasians were 2.62 times as likely to be transferred as African-Americans (confidence interval 2.32-2.97), and 3.71 times as likely as Hispanics (confidence interval 3.25-4.23). Despite transfer patients having higher adjusted severity scores and higher adjusted risk of mortality, there were no differences in mortality (p = 0.95). CONCLUSIONS: Nationally, trauma transfers do not have an increase in mortality when compared with directly admitted patients, despite a higher adjusted severity of illness and higher adjusted risk of mortality.
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Accidentes de Tránsito , Transferencia de Pacientes/estadística & datos numéricos , Centros Traumatológicos/estadística & datos numéricos , Heridas y Lesiones/mortalidad , Adulto , Anciano , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Triaje , Adulto JovenRESUMEN
BACKGROUND: After injury, base deficit (BD) and lactate are common measures of shock. Lactate directly measures anaerobic byproducts, whereas BD is calculated and multifactorial. Although recent studies suggest superiority for lactate in predicting mortality, most were small or analyzed populations with heterogeneous injury severity. Our objective was to compare initial BD with lactate as predictors of inhospital mortality in a large cohort of blunt trauma patients all presenting with hemorrhagic shock. MATERIALS AND METHODS: The Glue Grant multicenter prospective cohort database was queried; demographic, injury, and physiologic parameters were compiled. Survivors, early deaths (≤24 h), and late deaths were compared. Profound shock (lactate ≥ 4 mmol/L) and severe traumatic brain injury subgroups were identified a priori. Chi-square, t-test, and analysis of variance were used as appropriate for analysis. Multivariable logistic regression and area under the receiver operating characteristic curve analysis assessed survival predictors. P < 0.05 was significant. RESULTS: A total of 1829 patients met inclusion; 289 (15.8%) died. Both BD and lactate were higher for nonsurvivors (P < 0.00001). After multivariable regression, both lactate (odds ratio [OR] 1.17; 95% confidence interval [CI]: 1.12-1.23; P < 0.00001) and BD (OR 1.04; 95% CI: 1.01-1.07; P < 0.005) predicted overall mortality. However, when excluding early deaths (n = 77), only lactate (OR 1.12 95% CI: 1.06-1.19; P < 0.0001) remained predictive but not BD (OR 1.00 95% CI: 0.97-1.04; P = 0.89). For the shock subgroup, (n = 915), results were similar with lactate, but not BD, predicting both early and late deaths. Findings also appear independent of traumatic brain injury severity. CONCLUSIONS: After severe blunt trauma, initial lactate better predicts inhospital mortality than initial BD. Initial BD does not predict mortality for patients who survive >24 h.
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Acidosis/etiología , Mortalidad Hospitalaria , Ácido Láctico/sangre , Choque Hemorrágico/mortalidad , Heridas no Penetrantes/mortalidad , Acidosis/diagnóstico , Adulto , Anciano , Biomarcadores/sangre , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Pronóstico , Curva ROC , Estudios Retrospectivos , Factores de Riesgo , Choque Hemorrágico/sangre , Choque Hemorrágico/etiología , Índices de Gravedad del Trauma , Heridas no Penetrantes/sangre , Heridas no Penetrantes/complicacionesRESUMEN
OBJECTIVES: After rural injury, evaluation at local hospitals with transfer to regional trauma centres may delay definitive care. This study sought to determine the impact of such delays on outcomes in patients with TBI within a mature regional trauma system. METHODS: The ETMC Level 1 Trauma registry was queried from 2008-2013 for patients with blunt TBI, aged ≥ 18 and admitted ≤ 24 hours from injury and stratified them as 'transfer' vs 'direct' admission. Demographics, transfer distance, transfer times and outcomes were compared using Chi-square, t-test and multivariable logistic regression; p < 0.05 was significant. RESULTS: During the study period, 1845 patients met inclusion criteria: 947 'direct' and 898 'transfers'. For transfers, median distance was 60.1 miles; mean time to initial care was 1.2 ± 2.7 hours and time to Level 1 care was 5.0 ± 2.4 hours. Transfer patients were older (56 vs 49 years; p < 0.01) and had more comorbidities, but had lower mean ISS (15.9 vs 18.8; p < 0.01) and lower mortality (7.0 vs 10.3%; p < 0.03), complications and LOS. Neurosurgical intervention was comparable (p = 0.88), as was mortality for patients with ISS ≥ 15 (12.4% vs 14.8%; p = 0.28). After regression analysis, advanced age and increasing ISS, not distance or time, predicted mortality. CONCLUSION: Neither transfer distance nor time independently contributed to mortality for TBI after rural injury. An established regional trauma system, with initial local stabilization using ATLS principles, may help reduce negative outcomes for injured patients in rural settings.
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Lesiones Encefálicas/epidemiología , Lesiones Encefálicas/psicología , Transferencia de Pacientes , Adolescente , Adulto , Distribución por Edad , Anciano , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Texas/epidemiología , Factores de Tiempo , Centros Traumatológicos , Índices de Gravedad del Trauma , Adulto JovenRESUMEN
BACKGROUND: Blunt carotid arterial injury (BCI) is a rare injury associated with motor vehicle collision (MVC). There are few population based analyses evaluating carotid injury associated with blunt trauma and their associated injuries as well as outcomes. METHODS: The Nationwide Inpatient Sample (NIS) 2003-2010 data was queried to identify patients after MVC who had documented BCI during their hospitalizations utilizing ICD-9-CM codes. Demographics, associated injuries, interventions performed, length of stay, and cost were evaluated. RESULTS: 1,686,867 patients were estimated having sustained MVC; 1,168 BCI were estimated. No patients with BCI had open repair, 4.24 % had a carotid artery stent (CAS), and 95.76 % of patients had no operative intervention. Age groups associated with BCI were: 18-24 (27.8 %), 47-60 (22.3 %), 35-46 (20.6 %), 25-34 (19.1 %), >61 (10.2 %). Associated injuries included long bone fractures (28.5 %), stroke and intracranial hemorrhage (28.5 %), cranial injuries (25.6 %), thoracic injuries (23.6 %), cervical fractures (21.8 %), facial fractures (19.9 %), skull fractures (18.8 %), pelvic fractures (18.5 %), hepatic (13.3 %) and splenic (9.2 %) injuries. Complications included respiratory (44.2 %), bleeding (16.1 %), urinary tract infections (8.9 %), and sepsis (4.9 %). Overall mortality was 14.1 % without differences with regard to intervention (18.5 % vs. 13.9 %; P = 0.36). Stroke and intracranial hemorrhage was associated with a 2.7 times greater risk of mortality. Mean length of stay for patients with BCI undergoing stenting compared to no intervention were similar (13.1 days vs. 15.9 days) but had a greater mean cost ($83,030 vs. $63,200, p = 0.3). CONCLUSION: BCI is a rare injury associated with MVC, most frequently reported in younger patients. Frequently associated injuries were long bone fractures, stroke and intracranial hemorrhage, thoracic injuries, and pelvic fractures which are likely associated with the force/mechanism of injury. The majority of patients were treated without intervention, but when CAS was utilized, it did not impact mortality and trended toward increased costs.
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Traumatismos de las Arterias Carótidas/economía , Traumatismos de las Arterias Carótidas/epidemiología , Heridas no Penetrantes/economía , Heridas no Penetrantes/epidemiología , Accidentes de Tránsito/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Traumatismos de las Arterias Carótidas/terapia , Comorbilidad , Costos y Análisis de Costo , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores Socioeconómicos , Heridas y Lesiones/epidemiología , Heridas no Penetrantes/terapia , Adulto JovenRESUMEN
OBJECTIVE: Cilostazol, an antiplatelet agent with vasodilating properties, has not been well evaluated in conjunction lower extremity revascularization (LER). We evaluated the association between cilostazol and limb salvage after endovascular or open surgery for LER. METHODS: Patients aged ≥65 years undergoing LER were identified from 2007 to 2008 Medicare Provider Analysis and Review and Carrier files using International Classification of Diseases-9 Edition-Clinical Modification and Current Procedural Terminology-4 codes. Covariates included demographics, comorbidities, and disease severity. Use of cilostazol was identified using National Drug Codes and Part D files. Outcomes were compared using χ(2) and Kaplan-Meier analyses and Cox regression. RESULTS: We identified 22,954 patients undergoing LER: 8128 (35.4%) with claudication, 3056 (13.3%) with rest pain, and 11,770 (51.3%) with ulceration/gangrene. Among them, 1999 patients (8.7%) used cilostazol before LER. More patients received endovascular (14,353) than open (8601) procedures. Cilostazol users had fewer amputations than nonusers at 30 days (7.8% vs 13.4%), 90 days (10.7% vs 18.0%), and 1 year (14.8% vs 24.0%; P < .0001 for all). Cox proportional hazards regression with adjustment for age, gender, race, comorbidities, type of procedure, and atherosclerosis severity showed noncilostazol users were more likely to undergo amputation ≤1 year after surgery (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.02-1.29; P = .02). Subgroup analyses using Cox proportional hazards models adjusted for age, gender, and comorbidities demonstrated significantly improved 1-year amputation-free survival for patients with renal failure (HR, 1.61; 95% CI, 1.28-2.02; P < .001) and diabetes (HR, 1.61; 95% CI, 1.36-1.92; P < .001) who were taking cilostazol. CONCLUSIONS: In patients undergoing LER, cilostazol use was associated with improved 1-year freedom from amputation. Patients with renal failure and diabetes also demonstrated a significant benefit from taking cilostazol. Further studies are needed to evaluate the benefits of cilostazol after LER.
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Amputación Quirúrgica , Procedimientos Endovasculares , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/terapia , Inhibidores de Agregación Plaquetaria/uso terapéutico , Tetrazoles/uso terapéutico , Vasodilatadores/uso terapéutico , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Cilostazol , Comorbilidad , Supervivencia sin Enfermedad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Recuperación del Miembro , Modelos Logísticos , Masculino , Medicare , Análisis Multivariante , Oportunidad Relativa , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/mortalidad , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: This study evaluated the utilization of preoperative statins and their impact on perioperative outcomes in patients undergoing open or endovascular aortic repair. METHODS: Patients ≥50 years of age with non-ruptured abdominal aortic aneurysm repair were identified in MedPAR files 2007-2008 utilizing ICD-9-CM codes. Preoperative statins use was identified using National Drug Codes in Part D. Chi-square test, multivariable logistic regression, Kaplan-Meier and Cox regression modeling were performed. RESULTS: In all, 19,323 patients were identified undergoing abdominal aortic aneurysm repair (14,602 endovascular aortic repair and 4721 open aortic repair); 9913 (50.3%) used statins before surgery. Bivariate analysis demonstrated lower rates of hospital, 30-, 90-day and 1-year mortality in patients with statins compared to those without statins after endovascular aortic repair (1.0% vs. 1.45%, p = 0.01; 1.51% vs. 2.3%, p = 0.0004; 3.05% vs. 4.66%, p < 0.0001; 7.91% vs. 11.56%, p < 0.0001, respectively). Multivariable logistic regression adjusting for age, gender, race, comorbidities and procedure demonstrated preoperative statins use was associated with a mortality reduction at 90-days postoperatively (odds ratio = 0.80; 95% CI 0.70-0.91, p = 0.0014) and 1-year postoperatively (odds ratio = 0.76; 95% CI 0.69-0.84, p = 0.0001). CONCLUSIONS: Only half of the patients undergoing abdominal aortic aneurysm repair were prescribed preoperative statins. After adjustment, statins were significantly associated with improved survival during 1 year after surgery and a decreased incidence of lower extremity embolic complications after endovascular aortic repair. These data support a beneficial role of statin use prior to surgery for patients undergoing abdominal aortic aneurysm repair. Further prospective studies are needed to assess the benefit of statins in the perioperative period after 365 days.
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Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Procedimientos Quirúrgicos Vasculares , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/mortalidad , Distribución de Chi-Cuadrado , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Medicare Part D , Persona de Mediana Edad , Análisis Multivariante , Modelos de Riesgos Proporcionales , Factores Protectores , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
BACKGROUND: We hypothesized that infectious complications after open surgery (OPEN) and endovascular repair (EVAR) of nonruptured abdominal aortic aneurysms (AAAs) negatively affected long-term outcomes. METHODS: Elective OPEN and EVAR cases were selected from 2005-2007 Medicare databases, and rates of postoperative infection, readmission, and longitudinal mortality were compared. RESULTS: Forty thousand eight hundred ninety-two EVARs and 16,669 OPEN AAA repairs were evaluated. Patients with OPEN developed infection during and after the index hospitalization (12.8% and 4.9%, respectively) more often than those who had undergone EVAR (3.2% and 3.9%, respectively; P < 0.0001 for both). Patients with hospital-acquired infection compared to noninfectious ones were more likely to die during the index hospitalization (odds ratio [OR]: 3.7 [95% confidence interval {CI}: 3.22-4.30]) and within 30 days after discharge (OR: 3.6 [95% CI: 2.83-4.45]). They also were more likely to be readmitted to the hospital during 30 days after index discharge (OR: 1.8 [95% CI: 1.63-1.94]). Index infections associated with the greatest readmission were urinary tract infection after OPEN and sepsis after EVAR. Hospital-acquired infection significantly increased the duration of hospital stay (14.2 ± 13.2 vs 4.0 ± 4.4 days; P < 0.0001) and total hospital charges ($133,070 ± $136,100 vs $66,359 ± $45,186; P < 0.0001). The most common infections to develop 30 days after initial discharge were surgical site infection after EVAR (1.27%) and urinary tract infection after OPEN (1.38%). CONCLUSION: Hospital-acquired infections had a dramatic effect by increasing hospital and 30-day mortality, readmission rates, and hospital resource use after AAA repair. Programs minimizing infectious complications may decrease future readmissions and mortality after AAA repair.
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Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Infección Hospitalaria/etiología , Procedimientos Endovasculares/efectos adversos , Sepsis/etiología , Infección de la Herida Quirúrgica/etiología , Infecciones Urinarias/etiología , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/economía , Aneurisma de la Aorta Abdominal/mortalidad , Implantación de Prótesis Vascular/economía , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Infección Hospitalaria/economía , Infección Hospitalaria/mortalidad , Infección Hospitalaria/terapia , Bases de Datos Factuales , Procedimientos Quirúrgicos Electivos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/mortalidad , Femenino , Precios de Hospital , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Modelos Logísticos , Masculino , Medicare , Análisis Multivariante , Oportunidad Relativa , Alta del Paciente , Readmisión del Paciente , Medición de Riesgo , Factores de Riesgo , Sepsis/economía , Sepsis/mortalidad , Sepsis/terapia , Infección de la Herida Quirúrgica/economía , Infección de la Herida Quirúrgica/mortalidad , Infección de la Herida Quirúrgica/terapia , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Infecciones Urinarias/economía , Infecciones Urinarias/mortalidad , Infecciones Urinarias/terapiaRESUMEN
OBJECTIVES: Catheter-based revascularization has emerged as an alternative to surgical bypass for the tibioperoneal vessels. The purpose of this analysis was to describe the outcomes of tibial angioplasty interventions for critical limb ischemia (CLI) in the hospitalized Medicare population, to examine in-hospital complications, to define the 30-day readmission and mortality rates, and to assess secondary procedures performed in this population. METHODS: In-patients with CLI undergoing tibioperoneal angioplasty were identified using The Centers for Medicare & Medicaid Services in-patient claims for 2005 to 2007. In-hospital complications, mortality, 30-day secondary procedures, and 30-day rehospitalization after discharge were described. RESULTS: A total of 13,258 in-patients underwent tibioperoneal angioplasty (54.2% men; 75.7% white, 17.1% African American; 42.8% gangrene, 46.7% rest pain, 10.5% claudication) and 29.3% had a stent, 47.3% had femoral-popliteal angioplasty, and 20.1% had atherectomy during their initial procedure. Initial hospital complications included renal complications (8.1%), respiratory complications and pneumonia (5.1%), and cardiac complications with acute myocardial infarction (3.2%). Mortality in-hospital was 2.8% and at 30 days was 6.7%. Thirty-day rehospitalization rate was 29.6%. Thirty-day reinterventions included repeat angiogram (8.5%), repeat tibioperoneal angioplasty (3.2%), open bypass (2.1%), and lower extremity amputations (23.8%). Gangrene was the most frequent diagnosis at rehospitalization (13.5%). Patients with gangrene as an indication for tibioperoneal angioplasty were 1.8 times (95% confidence interval [CI], 1.56-2.10) as likely as patients with rest pain to be rehospitalized during 30 days after discharge. Among comorbidities, predictors of 30-day rehospitalization included chronic renal failure (odds ratio [OR], 1.4; 95% CI, 1.27-1.52), chronic pulmonary disease (OR, 1.1; 95% CI, 1.01-1.25), and congestive heart failure (CHF; OR, 1.1; 95% CI, 1.01-1.22). About one-quarter of patients (23.8%) within 30 days after their initial procedure underwent amputation at any level of the lower limb. CONCLUSION: Tibioperoneal angioplasty is associated with frequent in-hospital complications, an overall 30-day amputation rate of 23.8% for all procedures and indications, and a 30-day rehospitalization rate of almost 30%. Further detailed analysis of tibioperoneal intervention is essential to define best treatment strategies and to minimize complications and readmission rates.
Asunto(s)
Angioplastia , Isquemia/terapia , Extremidad Inferior/irrigación sanguínea , Medicare , Arterias Tibiales , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Angioplastia/efectos adversos , Angioplastia/instrumentación , Angioplastia/mortalidad , Distribución de Chi-Cuadrado , Enfermedad Crítica , Femenino , Humanos , Isquemia/mortalidad , Isquemia/cirugía , Recuperación del Miembro , Modelos Logísticos , Masculino , Oportunidad Relativa , Readmisión del Paciente , Retratamiento , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Improving patient safety has become a national priority. Patient safety indicators (PSIs) are validated tools to identify potentially preventable adverse events. No studies currently exist for evaluating lower extremity (LE) vascular procedures and the occurrence of PSIs. METHODS: The Nationwide Inpatient Sample (2003-2007) was queried for elective LE angioplasty (endo) and bypass (open). PSIs appropriate to surgery were analyzed by χ(2) and logistic regression analyses. RESULTS: A total of 226,501 LE interventions (104,491 endo; 122,010 open) were evaluated. The rate of developing any PSI was 7.74% (open) and 8.51% (endo), P < .0001. In the latter group, PSI9 (postoperative hemorrhage or hematoma) with the rate 4.74% was a predominant indicator that was associated with an almost three times greater likelihood of death in this group. PSI predictors included advanced age (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.55-1.75 for oldest vs youngest patients), females (OR, 1.18; 95% CI, 1.13-1.22), blacks (OR, 1.10; 95% CI, 1.04-1.17), congestive heart failure (OR, 1.83; 95% CI, 1.72-1.96), diabetes mellitus (OR, 1.20; 95% CI, 1.12-1.28), renal failure (OR, 2.31; 95% CI, 2.14-2.50), hospital teaching status (OR, 1.21; 95% CI, 1.17-1.26), and larger hospitals (OR, 1.11; 95% CI, 1.05-1.17). PSI occurrence was associated with increased cost ($28,387 vs $13,278; P < .0001). CONCLUSIONS: Endovascular procedures were found to have lower mortality rates overall, but were found to have a greater number of safety events occur primarily due to bleeding complications in women and the elderly. PSIs were associated with advanced age, black race, and comorbidities. Adverse events added significant cost, occurred more frequently in teaching and large hospitals, and future organizational analysis may improve safety and reduce cost.
Asunto(s)
Angioplastia/efectos adversos , Hospitales , Extremidad Inferior/irrigación sanguínea , Enfermedades Vasculares Periféricas/terapia , Complicaciones Posoperatorias/prevención & control , Mejoramiento de la Calidad , Indicadores de Calidad de la Atención de Salud , Procedimientos Quirúrgicos Vasculares/efectos adversos , Adolescente , Adulto , Negro o Afroamericano , Factores de Edad , Anciano , Anciano de 80 o más Años , Angioplastia/economía , Angioplastia/mortalidad , Distribución de Chi-Cuadrado , Comorbilidad , Bases de Datos como Asunto , Femenino , Hematoma/etiología , Hematoma/prevención & control , Costos de Hospital , Hospitales/estadística & datos numéricos , Hospitales de Enseñanza , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Enfermedades Vasculares Periféricas/economía , Enfermedades Vasculares Periféricas/mortalidad , Enfermedades Vasculares Periféricas/cirugía , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/mortalidad , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/prevención & control , Mejoramiento de la Calidad/economía , Mejoramiento de la Calidad/estadística & datos numéricos , Indicadores de Calidad de la Atención de Salud/economía , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Resultado del Tratamiento , Estados Unidos , Procedimientos Quirúrgicos Vasculares/economía , Procedimientos Quirúrgicos Vasculares/mortalidad , Adulto JovenRESUMEN
OBJECTIVES: To evaluate the incidence of postoperative sepsis after elective procedures, to define surgical procedures with the greatest risk for developing sepsis, and to evaluate patient and hospital confounders. BACKGROUND DATA: The development of sepsis after elective surgical procedures imposes a significant clinical and resource utilization burden in the United States. We evaluated the development of sepsis after elective procedures in a nationally representative patient cohort and assessed the effect of sociodemographic and hospital characteristics on the development of postoperative sepsis. METHODS: The Nationwide inpatient sample was queried between 2002 and 2006 and patients developing sepsis after elective procedures were identified using the patient safety indicator "Postoperative Sepsis" (PSI-13). Case-mix adjusted rates were calculated by using a multivariate logistic regression model for sepsis risk and an indirect standardization method. RESULTS: A total of 6,512,921 weighted elective surgical cases met the inclusion criteria and 78,669 cases (1.21%) developed postoperative sepsis. Case-mix adjustment for age, race, gender, hospital bed size, hospital location, hospital teaching status, and patient income demonstrated esophageal, pancreatic, and gastric procedures represented the greatest risk for the development of postoperative sepsis. Thoracic, adrenal, and hepatic operations accounted for the greatest mortality rates if sepsis developed. Increasing age, Blacks, Hispanics, and men were more likely to develop sepsis. Decreased median household income, larger hospital bed size, urban hospital location, and nonteaching status were associated with greater rates of postoperative sepsis. CONCLUSIONS: The development of postoperative sepsis is multifactorial and procedures, most likely to develop sepsis, did not demonstrate the greatest mortality after sepsis developed. Factors associated with the development of sepsis included race, age, hospital size, hospital location, and patient income. Further evaluation of high-risk procedures, populations, and environments may assist in reducing this costly complication.
Asunto(s)
Procedimientos Quirúrgicos Electivos/efectos adversos , Sepsis/epidemiología , Adolescente , Adulto , Anciano , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Sepsis/etiología , Estados Unidos/epidemiología , Adulto JovenRESUMEN
OBJECTIVE: This study was conducted to evaluate and compare the rates of postoperative infectious complications and death after elective vascular surgery, define vascular procedures with the greatest risk of developing nosocomial infections, and assess the effect of infection on health care resource utilization. METHODS: The Nationwide Inpatient Sample (2002-2006) was used to identify major vascular procedures by International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) codes. Infectious complications identified included pneumonia, urinary tract infections (UTI), postoperative sepsis, and surgical site infections (SSI). Case-mix-adjusted rates were calculated using a multivariate logistic regression model for infectious complication or death as an outcome and indirect standardization. RESULTS: A total of 870,778 elective vascular surgical procedures were estimated and evaluated with an overall postoperative infection rate of 3.70%. Open abdominal aortic surgery had the greatest rate of postoperative infections, followed by open thoracic procedures and aorta-iliac-femoral bypass. Thoracic endovascular aneurysm repair (TEVAR) infectious complication rates were two times greater than after EVAR (P < .0001). Pneumonia was the most common infectious complication after open aortic surgery (6.63%). UTI was the most common after TEVAR (2.86%) and EVAR (1.31%). Infectious complications were greater in octogenarians (P < .0002), women (P < .0001), and blacks (P < .0001 vs whites and Hispanics). Nosocomial infections after elective vascular surgery significantly increased hospital length of stay (13.8 +/- 15.4 vs 3.5 +/- 4.2 days; P < .001) and reported total hospital cost ($37,834 +/- $42,905 vs $11,851 +/- $11,816; P < .001). CONCLUSIONS: Elective vascular surgical procedures vary widely in the estimated risk of postoperative infection. Open aortic surgery and endarterectomy of the head and neck vessels have, respectively, the greatest and the lowest reported incidence for postoperative infectious complications. Women, octogenarians, and blacks have the highest risk of infectious complications after elective vascular surgery. Disparities in the development of infectious complications on a systems level were also found in larger hospitals and teaching hospitals. Hospital infectious complications were found to significantly increase health care resource utilization. Strategies that reduce nosocomial complications and target high-risk procedures may offer significant future cost savings.
Asunto(s)
Infección Hospitalaria/etiología , Infección de la Herida Quirúrgica/etiología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Adolescente , Adulto , Negro o Afroamericano/estadística & datos numéricos , Factores de Edad , Anciano , Anciano de 80 o más Años , Ahorro de Costo , Análisis Costo-Beneficio , Infección Hospitalaria/economía , Infección Hospitalaria/etnología , Infección Hospitalaria/mortalidad , Infección Hospitalaria/prevención & control , Bases de Datos como Asunto , Procedimientos Quirúrgicos Electivos , Femenino , Costos de la Atención en Salud , Recursos en Salud/economía , Recursos en Salud/estadística & datos numéricos , Disparidades en Atención de Salud , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Control de Infecciones/economía , Tiempo de Internación/economía , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Infección de la Herida Quirúrgica/economía , Infección de la Herida Quirúrgica/etnología , Infección de la Herida Quirúrgica/mortalidad , Infección de la Herida Quirúrgica/prevención & control , Resultado del Tratamiento , Estados Unidos/epidemiología , Procedimientos Quirúrgicos Vasculares/economía , Procedimientos Quirúrgicos Vasculares/mortalidad , Población Blanca/estadística & datos numéricos , Adulto JovenRESUMEN
Frailty has been associated with poor postoperative outcomes. This study evaluated the 5-factor modified frailty index (mFI-5) to assess complications, mortality, discharge disposition, and readmission in patients undergoing lower extremity (LE) bypass for critical limb ischemia (CLI).The National Surgical Quality Improvement Program vascular module (2011-2017) was utilized to identify patients undergoing LE bypass for CLI. Adverse events included infectious complications, bleeding complications, prolonged ventilation, amputation, readmission, and death. Patients were divided into groups based on mFI-5 scores: mFI1 (0), mFI2 (0.2), mFI3 (0.4), and mFI4 (0.6-1). Data were analyzed using the Cochran-Mantel-Haenszel statistic for general association and multivariable logistic regression. About 11,530 patients undergoing bypass for CLI were identified (42% rest pain and 58% tissue loss; 23% mFI1, 31% mFI2, 27% mFI3, and 19% mFI4; 64% men and 36% women). An increase in mFI-5 was associated with higher 30-day mortality (mFI1 = 0.62%; mFI12 = 1.45%; mFI13 = 1.35%; and mFI14 = 3.09%; P < .0001). After adjustment for age, mFI4 was associated with increased mortality compared with mFI1 (odds ratio, 3.80; 95% confidence interval, 1.69-8.54). Increased mFI-5 was associated with bleeding complications, wound infections, urinary tract infections, prolonged ventilation, sepsis, unplanned reoperations, and discharge to nonhome destination (all P < .01). Compared with mFI1 (13.5%), mFI4 was associated with increased 30-day readmission (24.8%, P < .0001). In patients undergoing LE bypass for CLI, higher mFI-5 was associated with increased postoperative complications, in-hospital and 30-day mortality, nonhome discharge, and 30-day readmission. The mFI-5 as an easily calculated tool can identify patients at high risk for inferior outcomes. It should be incorporated into discharge planning after LE bypass for CLI.
Asunto(s)
Fragilidad , Isquemia , Extremidad Inferior , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Enfermedad Arterial Periférica/complicaciones , Anciano , Femenino , Humanos , Claudicación Intermitente/mortalidad , Claudicación Intermitente/cirugía , Isquemia/mortalidad , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/cirugía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapiaRESUMEN
OBJECTIVES: A variety of endovascular specialists perform carotid artery stenting (CAS), but little data exist on outcomes and resource utilization among these specialists. We analyzed differences in outcomes after CAS was performed by radiologists (RAD), cardiologists (CRD), and vascular surgeons (VAS). METHODS: Secondary data analysis of the 2005-2006 State Inpatient Databases for New Jersey were analyzed. Patients with elective admission to the hospital who had CAS procedure Asunto(s)
Angioplastia
, Enfermedades de las Arterias Carótidas/cirugía
, Competencia Clínica
, Fuerza Laboral en Salud
, Costos de Hospital
, Evaluación de Procesos y Resultados en Atención de Salud
, Pautas de la Práctica en Medicina
, Especialización
, Stents
, Angioplastia/efectos adversos
, Angioplastia/economía
, Angioplastia/instrumentación
, Cardiología
, Enfermedades de las Arterias Carótidas/economía
, Ahorro de Costo
, Análisis Costo-Beneficio
, Cuidados Críticos
, Bases de Datos como Asunto
, Economía Médica
, Cardiopatías/etiología
, Humanos
, Enfermedades Renales/etiología
, Tiempo de Internación
, New Jersey
, Pautas de la Práctica en Medicina/economía
, Radiología Intervencionista
, Stents/economía
, Accidente Cerebrovascular/etiología
, Factores de Tiempo
, Resultado del Tratamiento
, Procedimientos Quirúrgicos Vasculares
RESUMEN
OBJECTIVES: Lower extremity percutaneous transluminal angioplasty (LE PTA) is currently performed by a variety of endovascular specialists. We hypothesized that cardiologists (CRD) and vascular surgeons (VAS) may have different practice patterns, indications for intervention, and hospital resource utilization. METHODS: Using the State Inpatient Databases for New Jersey (2003-2007), patients with elective admission undergoing PTA procedures with indications of claudication, rest pain, and gangrene/ulceration were examined. Physician specialty was determined based on all procedures performed. We contrasted by specialty, the indication for LE PTA for the procedure, volume, and hospital resource utilization. RESULTS: Of the 1887 cases of LE PTA, VAS performed 866 (45.9%) and CRD 1021 (54.1%) procedures. The mean patient age was 68.0 years (CRD) vs 70.7 years (VAS), P = .0163. Indications for intervention were compared for CRD vs VAS: claudication 80.7% vs 60.7%, (P < .002); rest pain 6.2% vs 16.0%, (P < .002); gangrene/ulceration 13.1% vs 23.3%, (P < .002). Stents (64.8% of cases) were utilized similarly among physicians (P = .18), and mean hospital length of stay were similar (2.38 days vs 2.41 days, P = .85). Hospital charges by indication varied between CRD vs VAS (all procedures: $49,748 vs $42,158 [P < .0001]). Revenue center charges were different between CRD vs VAS: medical surgical supply $19,128 vs $12,737, (P < .0001); pharmacy $1,959 vs $1,115, (P < .0001). Only 10.7% of CRD were high volume practitioners, compared with 36.8% among VAS (P < .05). High volume practitioners had significantly lower hospital charges ($41,730 vs $51,014, P < .001). CONCLUSIONS: Cardiologists performing lower extremity angioplasty were more likely to treat patients with claudication than those with rest pain or gangrene/ulceration. Despite treating younger patients with less severe peripheral vascular disease, cardiologists used significantly greater hospital resources. High practitioner volume, regardless of specialty, was associated with lower hospital resource utilization. Reducing variations in indication and practitioner volume may offer substantial cost savings for lower extremity endovascular interventions.
Asunto(s)
Angioplastia de Balón/estadística & datos numéricos , Cardiología , Recursos en Salud/estadística & datos numéricos , Claudicación Intermitente/terapia , Extremidad Inferior/irrigación sanguínea , Evaluación de Procesos y Resultados en Atención de Salud , Enfermedades Vasculares Periféricas/terapia , Pautas de la Práctica en Medicina , Procedimientos Quirúrgicos Vasculares , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Angioplastia de Balón/economía , Cardiología/economía , Competencia Clínica , Ahorro de Costo , Bases de Datos como Asunto , Femenino , Gangrena , Recursos en Salud/economía , Costos de Hospital , Humanos , Claudicación Intermitente/economía , Claudicación Intermitente/etiología , Tiempo de Internación , Masculino , Persona de Mediana Edad , New Jersey , Oportunidad Relativa , Selección de Paciente , Enfermedades Vasculares Periféricas/complicaciones , Enfermedades Vasculares Periféricas/economía , Pautas de la Práctica en Medicina/economía , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/economía , Adulto JovenRESUMEN
OBJECTIVES: With the evolution of endovascular techniques, carotid artery stenting (CAS) has been compared to carotid endarterectomy (CEA). Several studies have reported inferior results with CAS in the elderly. The objective of this study was to evaluate national outcomes of CAS and CEA and to compare utilization and outcomes of these procedures in different age groups. METHODS: We evaluated the 2005 Nationwide Inpatient Sample for hospitalizations with a procedure of CAS or CEA within 2 days after admission at age 60 years and above. Procedures were analyzed with respect to patient demographics and associated complications. RESULTS: A total of 80,498 carotid interventions (73,929 CEA and 6,569 CAS) were identified. The overall incidence of stroke was 4.16% after CAS and 2.66% after CEA (P < .0001). CAS was more often utilized in octogenarians than in younger patients (8.55% in 80+ vs 7.92% in 60-69 years; P < .0002). Increased age was not associated with greater stroke rates after CAS or CEA (P = .19 and .06, respectively). Octogenarians, compared to younger patients, had greater cardiac, pulmonary, and renal complications after CEA (3.0% vs 1.9%, 1.9% vs 1.0%, and 1.4% vs 0.54%, respectively; P < .0001). When adjusted by age, gender, complications, and Elixhauser comorbidities, patients after CAS were 1.6 times as likely to have a stroke (confidence interval [CI] = 1.37-1.78) when compared to CEA. Significant predictors of postoperative hospital mortality were stroke (odds ratio [OR] = 29.0; 95% CI = 21.5-39.1), cardiac complications (OR = 6.4; 95% CI = 4.4-9.1), pulmonary complications (OR = 3.5; 95% CI = 2.31-5.19), and renal failure (OR = 2.5; 95% CI = 1.6-3.8). With increasing age, overall mortality steadily increased after CAS (from 0.23% to 0.67%; P = .0409) but remained stable after CEA. CONCLUSION: Octogenarians did not have a higher risk of stroke after CAS when compared to younger patients. Stroke was the strongest predictor of hospital mortality. The increased utilization of CAS in the aged, which had significantly higher stroke rates in all age groups studied, may account for the greater hospital mortality seen after CAS in the elderly. Further studies focused on the aged are needed to define the best management strategies in the elderly.
Asunto(s)
Angioplastia de Balón/instrumentación , Estenosis Carotídea/terapia , Endarterectomía Carotidea , Servicios de Salud para Ancianos , Evaluación de Procesos y Resultados en Atención de Salud , Stents , Distribución por Edad , Factores de Edad , Anciano , Anciano de 80 o más Años , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/mortalidad , Angioplastia de Balón/estadística & datos numéricos , Estenosis Carotídea/mortalidad , Estenosis Carotídea/cirugía , Bases de Datos como Asunto , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Endarterectomía Carotidea/estadística & datos numéricos , Femenino , Encuestas de Atención de la Salud , Servicios de Salud para Ancianos/estadística & datos numéricos , Cardiopatías/etiología , Cardiopatías/mortalidad , Mortalidad Hospitalaria , Humanos , Enfermedades Pulmonares/etiología , Enfermedades Pulmonares/mortalidad , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Insuficiencia Renal/etiología , Insuficiencia Renal/mortalidad , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND AND PURPOSE: Each year, as many as two million operations are complicated by surgical site infections in the United States, and surgical patients account for 30% of patients with sepsis. The purpose of this study was to determine recent trends in sepsis incidence, severity, and mortality rate after surgical procedures and to evaluate changes in the pattern of septicemia pathogens over time. METHODS: Analysis of the 1990-2006 hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for New Jersey. Patients >or= 18 years who developed sepsis after surgery were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes as defined by the Patient Safety Indicator "Postoperative Sepsis" developed by the Agency for Healthcare Research and Quality (AHRQ). Severe sepsis was defined as sepsis complicated by organ dysfunction. RESULTS: A total of 1,276,451 surgery discharges (537,843 elective [42.1%] and 738,608 non-elective [57.9%] procedures) were identified. After elective surgery, 5,865 patients (1.09%) developed postoperative sepsis, of whom 2,778 (0.52%) had severe sepsis. The incidence of postoperative sepsis after elective surgery increased from 0.67% to 1.74% (p < 0.0001) and severe sepsis after elective surgery from 0.22% to 1.12% (p < 0.0001). The sepsis mortality rate for elective procedures showed no significant change over time. The proportion of severe sepsis after elective cases increased from 32.9% to 64.6% (p < 0.0002). The rates of postoperative sepsis (4.24%) and severe sepsis (2.28%) were significantly greater for non-elective than for elective procedures (p < 0.0002). Non-elective surgical procedures had a significant increase in the rates of postoperative sepsis (3.74% to 4.51%) and severe sepsis (1.79% to 3.15%) over time (p < 0.0001) with the proportion of severe sepsis increasing from 47.7% to 69.9% (p < 0.0002). The in-hospital mortality rate after non-elective surgery decreased from 37.9% to 29.8% (p < 0.0001). CONCLUSIONS: Sepsis and death were more likely after non-elective than elective surgery. Sepsis and severe sepsis has increased significantly after elective and non-elective procedures over the last 17 years. The hospital mortality rate was reduced significantly after non-elective surgery, but no improvements were found for elective surgery patients who developed sepsis. Disparities in age, sex, and ethnicity and the development of postoperative surgical sepsis were found. Population-based studies may assist in defining temporal trends, disparities, and outcomes in sepsis not elucidated in smaller studies.
Asunto(s)
Complicaciones Posoperatorias/epidemiología , Sepsis/epidemiología , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , New Jersey/epidemiología , Complicaciones Posoperatorias/mortalidad , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Sistema de Registros , Sepsis/etiología , Sepsis/mortalidad , Distribución por Sexo , Adulto JovenRESUMEN
OBJECTIVE: Previous studies have demonstrated improved outcomes with endovascular aneurysm repair (EVAR) for the treatment of ruptured abdominal aortic aneurysms (rAAA). However, these data may not be generalizable to all regions. METHODS: Retrospective cohort study (2001-2005) using state inpatient data. RESULTS: 5,176 patients underwent repair of AAA. 700 repairs were performed for rAAA (618 [88%] with open surgery (OS) and 82 [12%] with EVAR). Mortality for rAAA was similar for EVAR and OS (45.1% vs. 52.4%, P = 0.21). Lack of insurance (OR = 5.1; 95%CI: 1.7-15.2) was a predictor of mortality. Cost of repair for rAAA was greater for EVAR ($51,339 +/- 51,719 vs. $39,967 +/- 43,354, P = 0.03) and hospital LOS was similar (14.08 +/- 17.97 vs.13.42 +/- 18.18; P = 0.8). CONCLUSION: EVAR did not offer a survival benefit in the state, had a similar hospital LOS, and was significantly more expensive. Further evaluation exploring explanations for inferior outcomes by region are required as EVAR becomes more commonly implemented for rAAA.