Ideal cardiovascular health and all-cause or cardiovascular mortality in a longitudinal study of the Thai National Health Examination Survey IV and V.

The relationship of ideal cardiovascular health (CVH) and health outcomes has been rarely assessed in middle-income countries. We determined the ideal CVH metrics and association with all-cause and cardiovascular (CVD) mortality in the Thai population. We used baseline data from two rounds of the National Health Examination survey (15,219 participants in 2009 and 14,499 in 2014), and assessed all-cause and CVD deaths until 2020. The prevalence of 5-7 ideal CVH metrics in 2009 was 10.4% versus 9.5% in 2014. During a median follow-up of 7.1 years, the all-cause and CVD mortality rates were 19.4 and 4.6 per 1000 person-years for 0-1 ideal CVH metrics, and 13.0 and 2.1, 9.6 and 1.5, 6.0 and 1.0, and 2.9 and 0.4 per 1000 person-years for 2, 3, 4, and 5-7 ideal CVH metrics, respectively. Participants with 2, 3, 4, or 5-7 ideal metrics had a significantly lower risk of mortality than those with 0-1 ideal CVH metrics (adjusted hazard ratios: 0.75, 0.70, 0.60, and 0.47 for all-cause, and 0.54, 0.52, 0.50, and 0.31 for CVD, respectively). Individuals with a higher number of the modified ideal CVH metrics have a lower risk of all-cause and CVD mortality.

Impact of acute care surgery model in aspects of patients with upper gastrointestinal hemorrhage: result from a single tertiary care center in Thailand.

BACKGROUND: Even though an acute care surgery (ACS) model has been implemented worldwide, there are still relatively few studies on its efficacy in developing countries, which often have limited capacity and resources. To evaluate ACS efficacy in a developin country, we compared mortality rates and intervention timeliness at a tertiary care center in Thailand among patients with an upper gastrointestinal hemorrhage (UGIH). METHODS: This retrospective study compared two 24-month periods between pre-ACS and post-ACS implementations from July 1, 2014, to June 30, 2018. Medical records from consecutive patients with UGIH in the surgical department of Chonburi Hospital, Thailand, were reviewed. The primary outcome was UGIH mortality rate differences between pre-ACS and post-ACS implementations. Differences in complications rate, length of hospital stay (LOS), time to esophagogastroduodenoscopy (EGD) and proportion of patients undergoing esophagogastroduodenoscopy (%EGD) in the same admission were also analyzed using unpaired t-test and Fisher's exact test. Baseline characteristic differences between the pre-ACS and post-ACS periods were controlled for in multiple linear and logistic regression models. RESULTS: A total of 421 patients were included (162 pre-ACS and 259 post-ACS). Results showed a mortality rate of 24% in post-ACS compared with 41% in pre-ACS period (p<0.001). Overall complications (38% vs 27%), LOS (6.4 days vs 5.6 days) and time to EGD (44 hours vs 25 hours) were also significantly reduced, whereas %EGD increased (70% vs 89%). After adjusting for covariates, patients in the post-ACS period had lower risk of death (OR 0.54, p=0.040), lower risk of developing respiratory complications (OR 0.52, p=0.036), higher chance of receiving EGD in the same admission (OR 2.94, p<0.001) and shortened time to EGD for 19 hours (p<0.001). DISCUSSION: Our results provide evidence that ACS can be implemented to improve patient outcomes at medical centers in developing countries with limited resources. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups.

BACKGROUND: Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest. METHODS: This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios. RESULTS: Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest. CONCLUSIONS: Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study. LEVEL OF EVIDENCE: Economic/decision, level II.