Postoperative prophylactic antibiotics for facial fractures: A systematic review and meta-analysis.

OBJECTIVE: Perioperative antibiotic prophylaxis in patients undergoing surgery for maxillofacial fractures is standard practice. However, the use of postoperative antibiotic prophylaxis remains controversial. This systematic review and meta-analysis sought to evaluate the effect of postoperative antibiotic therapy on the incidence of surgical site infection (SSI) in patients with maxillofacial fractures. METHODS: MEDLINE, Embase, and the Cochrane Library were searched from inception through October 2017. Randomized controlled trials (RCTs) and cohort studies evaluating the efficacy of pre-, peri-, and postoperative antibiotic prophylaxis in preventing SSI in maxillofacial fractures were included. Data were extracted from studies using a standardized data collection form, with two reviewers independently performing extraction and quality assessment for each study. Risk ratios (RRs) for SSI were pooled using a random-effects model. RESULTS: Among 2,150 potentially eligible citations, 13 studies met inclusion criteria and provided data to be included in a meta-analysis. The addition of postoperative antibiotic prophylaxis to a standard preoperative and/or perioperative antibiotic regimen showed no significant difference in the risk of SSI (RR = 1.11 [95% CI: 0.86-1.44], P > .1). There were also no differences in the risk of SSI when restricting the analysis to mandibular fractures (eight studies, RR = 1.22 [95% CI: 0.92-1.62]) or open surgical techniques (eight studies, RR = 1.02 [95% CI: 0.62-1.67]). A sensitivity analysis did not find any significant differences in risk when restricting to RCTs (seven trials, RR = 1.00 [95% CI: 0.61-1.67]) or cohort studies (six studies, RR = 1.21 [95% CI: 0.89-1.63]). CONCLUSIONS: Our findings, along with the available evidence, does not support the routine use of postoperative antibiotic prophylaxis in patients with maxillofacial fractures. Avoiding the unnecessary use of antibiotic therapy in the postoperative period could have important implications for healthcare costs and patient outcomes. Laryngoscope, 129:82-95, 2019.

Comparison of hospital risk-standardized mortality rates calculated by using in-hospital and 30-day models: an observational study with implications for hospital profiling.

BACKGROUND: In-hospital mortality measures, which are widely used to assess hospital quality, are not based on a standardized follow-up period and may systematically favor hospitals with shorter lengths of stay (LOSs). OBJECTIVE: To assess the agreement between performance measures of U.S. hospitals by using risk-standardized in-hospital and 30-day mortality rates. DESIGN: Observational study. SETTING: Nonfederal acute care hospitals in the United States with at least 30 admissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia from 2004 to 2006. PATIENTS: Medicare fee-for-service patients admitted for AMI, HF, or pneumonia from 2004 to 2006. MEASUREMENTS: The primary outcomes were in-hospital and 30-day risk-standardized mortality rates (RSMRs). RESULTS: Included patients comprised 718,508 admissions to 3135 hospitals for AMI, 1,315,845 admissions to 4209 hospitals for HF, and 1,415,237 admissions to 4498 hospitals for pneumonia. The hospital-level mean patient LOS varied across hospitals for each condition, ranging from 2.3 to 13.7 days for AMI, 3.5 to 11.9 days for HF, and 3.8 to 14.8 days for pneumonia. The mean RSMR differences (30-day RSMR minus in-hospital RSMR) were 5.3% (SD, 1.3) for AMI, 6.0% (SD, 1.3) for HF, and 5.7% (SD, 1.4) for pneumonia; distributions varied widely across hospitals. Performance classifications differed between the in-hospital and 30-day models for 257 hospitals (8.2%) for AMI, 456 (10.8%) for HF, and 662 (14.7%) for pneumonia. Hospital mean LOS was positively correlated with in-hospital RSMRs for all 3 conditions. LIMITATION: Medicare claims data were used for risk adjustment. CONCLUSION: In-hospital mortality measures provide a different assessment of hospital performance than 30-day mortality and are biased in favor of hospitals with shorter LOSs. PRIMARY FUNDING SOURCE: The Centers for Medicare & Medicaid Services and National Heart, Lung, and Blood Institute.

Hospital volume and 30-day mortality for three common medical conditions.

BACKGROUND: The association between hospital volume and the death rate for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia remains unclear. It is also not known whether a volume threshold for such an association exists. METHODS: We conducted cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries who were hospitalized between 2004 and 2006 in acute care hospitals in the United States for acute myocardial infarction, heart failure, or pneumonia. Using hierarchical logistic-regression models for each condition, we estimated the change in the odds of death within 30 days associated with an increase of 100 patients in the annual hospital volume. Analyses were adjusted for patients' risk factors and hospital characteristics. Bootstrapping procedures were used to estimate 95% confidence intervals to identify the condition-specific volume thresholds above which an increased volume was not associated with reduced mortality. RESULTS: There were 734,972 hospitalizations for acute myocardial infarction in 4128 hospitals, 1,324,287 for heart failure in 4679 hospitals, and 1,418,252 for pneumonia in 4673 hospitals. An increased hospital volume was associated with reduced 30-day mortality for all conditions (P<0.001 for all comparisons). For each condition, the association between volume and outcome was attenuated as the hospital's volume increased. For acute myocardial infarction, once the annual volume reached 610 patients (95% confidence interval [CI], 539 to 679), an increase in the hospital volume by 100 patients was no longer significantly associated with reduced odds of death. The volume threshold was 500 patients (95% CI, 433 to 566) for heart failure and 210 patients (95% CI, 142 to 284) for pneumonia. CONCLUSIONS: Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality.

Differences in patient survival after acute myocardial infarction by hospital capability of performing percutaneous coronary intervention: implications for regionalization.

BACKGROUND: There are increasing calls for regionalization of acute myocardial infarction (AMI) care in the United States to hospitals with the capacity to perform percutaneous coronary intervention (PCI). Whether regionalization will improve outcomes depends in part on the magnitude of existing differences in outcomes between PCI and non-PCI hospitals within the same health care region. METHODS: A 100% sample of claims from Medicare fee-for-service beneficiaries 65 years or older hospitalized for AMI between January 1, 2004, and December 31, 2006, was used to calculate hospital-level, 30-day risk-standardized mortality rates (RSMRs). The RSMRs between PCI and local non-PCI hospitals were compared within local health care regions defined by hospital referral regions (HRRs). RESULTS: A total of 523 119 AMI patients was admitted to 1382 PCI hospitals, and 194 909 AMI patients were admitted to 2491 non-PCI hospitals in 295 HRRs with at least 1 PCI and 1 non-PCI hospital. Although PCI hospitals had lower RSMRs than non-PCI hospitals (mean, 16.1% vs 16.9%; P < .001), considerable overlap was seen in RSMRs between non-PCI and PCI hospitals within the same HRR. In 80 HRRs, the RSMRs at the best-performing PCI hospital were lower than those at local non-PCI hospitals by 3% or more. Among the remaining HRRs, the RSMRs at the best-performing PCI hospital were lower by 1.5% to 3.0% in 104 HRRs and by greater than 0 to 1.5% in 74 HRRs. In 37 HRRs, the RSMRs at the best-performing PCI hospital were no better or were higher than at local non-PCI hospitals. CONCLUSIONS: The magnitude of benefit from comprehensively regionalizing AMI care to PCI hospitals appears to vary greatly across HRRs. These findings support a tailored regionalization policy that targets areas with the greatest outcome differences between PCI and local non-PCI hospitals.

Recent declines in hospitalizations for acute myocardial infarction for Medicare fee-for-service beneficiaries: progress and continuing challenges.

BACKGROUND: Amid recent efforts to reduce cardiovascular risk, whether rates of acute myocardial infarction (AMI) in the United States have declined for elderly patients is unknown. METHODS AND RESULTS: Medicare fee-for-service patients hospitalized in the United States with a principal discharge diagnosis of AMI were identified through the use of data from the Centers for Medicare and Medicaid Services from 2002 to 2007, a time period selected to reduce changes arising from the new definition of AMI. The Medicare beneficiary denominator file was used to determine the population at risk. AMI hospitalization rates were calculated annually per 100,000 beneficiary-years with Poisson regression analysis and stratified according to age, sex, and race. The annual AMI hospitalization rate in the fee-for-service Medicare population fell from 1131 per 100,000 beneficiary-years in 2002 to 866 in 2007, a relative 23.4% decline. After adjustment for age, sex, and race, the AMI hospitalization rate declined by 5.8%/y. From 2002 to 2007, white men experienced a 24.4% decrease in AMI hospitalizations, whereas black men experienced a smaller decline (18.0%; P<0.001 for interaction). Black women had a smaller decline in AMI hospitalization rate compared with white women (18.4% versus 23.3%, respectively; P<0.001 for interaction). CONCLUSIONS: AMI hospitalization rates fell markedly in the Medicare fee-for-service population between 2002 and 2007. However, black men and women appeared to have had a slower rate of decline compared with their white counterparts.

Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission.

BACKGROUND: In 2009, the Centers for Medicare & Medicaid Services is publicly reporting hospital-level risk-standardized 30-day mortality and readmission rates after acute myocardial infarction (AMI) and heart failure (HF). We provide patterns of hospital performance, based on these measures. METHODS AND RESULTS: We calculated the 30-day mortality and readmission rates for all Medicare fee-for-service beneficiaries ages 65 years or older with a primary diagnosis of AMI or HF, discharged between July 2005 and June 2008. We compared weighted risk-standardized mortality and readmission rates across Hospital Referral Regions and hospital structural characteristics. The median 30-day mortality rate was 16.6% for AMI (range, 10.9% to 24.9%; 25th to 75th percentile, 15.8% to 17.4%; 10th to 90th percentile, 14.7% to 18.4%) and 11.1% for HF (range, 6.6% to 19.8%; 25th to 75th percentile, 10.3% to 12.0%; 10th to 90th percentile, 9.4% to 13.1%). The median 30-day readmission rate was 19.9% for AMI (range, 15.3% to 29.4%; 25th to 75th percentile, 19.5% to 20.4%; 10th to 90th percentile, 18.8% to 21.1%) and 24.4% for HF (range, 15.9% to 34.4%; 25th to 75th percentile, 23.4% to 25.6%; 10th to 90th percentile, 22.3% to 27.0%). We observed geographic differences in performance across the country. Although there were some differences in average performance by hospital characteristics, there were high and low hospital performers among all types of hospitals. CONCLUSIONS: In a recent 3-year period, 30-day risk-standardized mortality rates for AMI and HF varied among hospitals and across the country. The readmission rates were particularly high.

Statistical models and patient predictors of readmission for acute myocardial infarction: a systematic review.

BACKGROUND: Readmission after acute myocardial infarction (AMI) has been targeted for public reporting because it is a common, costly, and often preventable outcome. To assist in ongoing efforts to risk-stratify patients and profile hospitals through public reporting of performance measures, we conducted a systematic review to identify models designed to compare hospital rates of readmission or predict patients' risk of readmission after AMI and to identify studies evaluating patient characteristics associated with AMI readmission. METHODS AND RESULTS: We identified relevant English-language studies published between 1950 and 2007 by searching MEDLINE, Scopus, PsycINFO, and all 4 Ovid Evidence-Based Medicine Reviews. Eligible publications reported on readmission up to 1 year after AMI hospitalization among adults. From 751 potentially relevant articles, 35 met our predefined inclusion/exclusion criteria. Overall, none developed models to compare readmission rates among hospitals or models to predict patients' risk of readmission. All 35 examined patient characteristics associated with AMI readmission. However, studies varied in methods for case and outcome identification, used multiple types of data sources, examined differing outcomes (often either readmission alone or a composite outcome of readmission or death) over varying follow-up periods (from 30 days to 1 year), and found few patient characteristics consistently associated with readmission. CONCLUSIONS: Patient characteristics may be important predictors of AMI readmission; however, few variables were consistently identified. Thus, clinically, patient risk stratification is challenging. From a policy perspective, a validated risk-standardized model to profile hospitals using AMI readmission rates is currently unavailable in the literature.

Evaluation of proton pump inhibitor use in patients with acute coronary syndromes based on risk factors for gastrointestinal bleed.

BACKGROUND: Use of proton pump inhibitor (PPI) reduces the risk of gastrointestinal (GI) bleeding, and is generally recommended for high GI risk patients taking nonsteroidal anti-inflammatory agents. Aspirin and/or anticoagulants have been identified as increasing the risk of GI bleeding, whereby use of PPI could reduce this risk. The use of PPI in routine practice is not well defined, especially in patients with acute coronary syndromes (ACS) who require one or several antithrombotic drugs. METHODS: We analyzed the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction (PROVE IT-TIMI) 22 trial database, which enrolled patients who had been hospitalized for ACS. Patients were to be treated with aspirin, and received clopidogrel and/or warfarin at the discretion of the treating physician. We analyzed the use of PPI at baseline, which was not specified in the protocol, according to prior known GI risk factors. RESULTS: Of the 4162 patients enrolled, 781 (18.8%) received PPI during the course of this study. The use ranged from 14% to 67% across the number of GI risk factors of 0 to > or =4 (P < 0.0001). Individual factors most associated with increased use of PPI were a prior GI event (RR = 2.3, P < 0.001) and use of anticoagulants (RR = 1.49, P < 0.001), but not dual antiplatelet therapy. CONCLUSION: Use of PPI following ACS is modest, although it did increase with an increasing number of previously identified GI risk factors. Further, larger studies are warranted to validate prior, or identify new, risk factors as predictors of long-term bleeding, and improve awareness of GI bleeding risk such that use of PPI could be optimized.