The accuracy of the National Death Index when personal identifiers other than Social Security number are used

Off-pump Coronary Bypass Surgery in Patients with Low Ejection Fraction

Objective

Long-term survival after off-pump surgery in patients with low ejection fraction was investigated.

Methods

Three hundred forty-six patients with ejection fraction 30% or less with isolated off-pump coronary artery bypass surgery (OPCAB) were compared with a propensity matched historical group operated on-pump (ONCAB) and with data from literature after percutaneous coronary intervention and OPCAB surgery.

Results

The lower invasiveness of OPCAB contributed to a significantly better 30-day survival, shorter postoperative length of stay, and fewer in-hospital complications. Incomplete revascularization of the posterior and lateral territories of the heart correlated with higher 1-year mortality. The probability of survival for 8 years after OPCAB was 50.1% (n = 76) versus 49.7% (n = 82) for ONCAB without comparable data from literature for OPCAB or percutaneous coronary intervention in these high-risk patients.

Conclusions

OPCAB surgery in patients with low ejection fraction is a viable alternative but so far without demonstrable long-term survival advantage to ONCAB.

Overall and cancer related mortality among patients with ocular inflammation treated with immunosuppressive drugs: retrospective cohort study

CONTEXT

Whether immunosuppressive treatment adversely affects survival is unclear.

OBJECTIVE

To assess whether immunosuppressive drugs increase mortality.

DESIGN

Retrospective cohort study evaluating overall and cancer mortality in relation to immunosuppressive drug exposure among patients with ocular inflammatory diseases. Demographic, clinical, and treatment data derived from medical records, and mortality results from United States National Death Index linkage. The cohort's mortality risk was compared with US vital statistics using standardised mortality ratios. Overall and cancer mortality in relation to use or non-use of immunosuppressive drugs within the cohort was studied with survival analysis.

SETTING

Five tertiary ocular inflammation clinics. Patients 7957 US residents with non-infectious ocular inflammation, 2340 of whom received immunosuppressive drugs during follow up. Exposures Use of antimetabolites, T cell inhibitors, alkylating agents, and tumour necrosis factor inhibitors.

MAIN OUTCOME MEASURES

Overall mortality, cancer mortality.

RESULTS

Over 66 802 person years (17 316 after exposure to immunosuppressive drugs), 936 patients died (1.4/100 person years), 230 (24.6%) from cancer. For patients unexposed to immunosuppressive treatment, risks of death overall (standardised mortality ratio 1.02, 95% confidence interval [CI] 0.94 to 1.11) and from cancer (1.10, 0.93 to 1.29) were similar to those of the US population. Patients who used azathioprine, methotrexate, mycophenolate mofetil, ciclosporin, systemic corticosteroids, or dapsone had overall and cancer mortality similar to that of patients who never took immunosuppressive drugs. In patients who used cyclophosphamide, overall mortality was not increased and cancer mortality was non-significantly increased. Tumour necrosis factor inhibitors were associated with increased overall (adjusted hazard ratio [HR] 1.99, 95% CI 1.00 to 3.98) and cancer mortality (adjusted HR 3.83, 1.13 to 13.01).

CONCLUSIONS

Most commonly used immunosuppressive drugs do not seem to increase overall or cancer mortality. Our results suggesting that tumour necrosis factor inhibitors might increase mortality are less robust than the other findings; additional evidence is needed.

The impact of left ventricular hypertrophy on early and long-term survival after coronary artery bypass grafting

BACKGROUND

Left ventricular hypertrophy (LVH) can itself contribute to increased rates of cardiovascular events. We sought to determine the impact of LVH on in-hospital and long-term mortality after coronary artery bypass grafting (CABG).

METHODS

Between 1992 and 2003, 4140 consecutive patients underwent CABG. Long-term survival data (mean follow-up 7.0 years) were obtained from the National Death Index. The impact of LVH on in-hospital mortality was determined by multivariate logistic regression analysis. Patients with and without LVH were compared by Cox proportional hazard models and risk-adjusted Kaplan-Meier curves.

RESULTS

There were 977 patients (23.6%) with LVH. Their mean EuroSCORE was 7.4 +/- 3.4 and there were 40 in-hospital deaths (4.1%) in this group. Multivariate logistic regression showed that patients with LVH had less elective operations, higher Canadian Cardiovascular Society Functional Class, more previous myocardial infarctions and higher percentages of 3-vessel disease, hypertension, current congestive heart failure, malignant ventricular arrhythmias, chronic obstructive pulmonary disease, calcified aorta, low ejection fraction, intravenous nitroglycerine, previous percutaneous coronary interventions and smoking. After adjustment for all available pre, intra and postoperative variables LVH was not an independent predictor for in-hospital mortality (OR 1.04, 95% CIs 0.60-1.81, P = 0.891). Risk-adjusted Kaplan-Meier survival curves showed decreased long-term survival in patients with LVH after the first 3 years (HR 1.24, 95% CIs 1.06-1.44, P = 0.006).

CONCLUSIONS

Patients with LVH showed similar in-hospital mortality when compared with patients without LVH. However, LVH was a detrimental risk factor for late mortality, especially after the third postoperative year. These data suggest the need for a more frequent long-term follow-up among patients with LVH undergoing CABG.

Adding socioeconomic status to Framingham scoring to reduce disparities in coronary risk assessment

BACKGROUND

The purpose of the study was to examine the potential of adding socioeconomic status (SES) to Framingham Risk Scoring (FRS) to improve coronary heart disease (CHD) prediction by SES.

METHODS

We assessed the effect of measures of SES (<12 years of education or low income) on model discrimination and calibration when added to FRS in a prospective cohort, Atherosclerosis Risk in Communities. We validated use of this model in a second cohort, the National Health and Nutritional Examination Survey linked to the National Death Index.

RESULTS

Based on FRS alone, persons of higher and lower SES had a predicted CHD risk of 3.7% and 3.9%, respectively, compared with observed risks of 3.2% and 5.6%. Adding SES to a model with FRS improved calibration with predicted risk estimates of 3.1% and 5.2% for those with higher and lower SES, mitigating the discrepancy between predicted and observed CHD events for low-SES persons. Model discrimination (area under the receiver operator curve) was not significantly affected, and consistent findings were observed in the validation sample. Inclusion of SES in the model resulted in upgrading of risk classification for 15.1% of low-SES participants (95% CI 13.9-29.4%).

CONCLUSIONS

Standard FRS underestimates CHD risk for those at low SES; treatment decisions ignoring SES may exacerbate SES disparities. Adding SES to CHD risk assessment reduces this bias.

Prediction of survival after coronary revascularization: modeling short-term, mid-term, and long-term survival

BACKGROUND

Many clinical prediction rules for short-term mortality after coronary revascularization have been developed, validated, and introduced into routine clinical practice. Few rules exist for predicting long-term survival in the modern era of coronary revascularization. We report on the development and validation of models for predicting long-term survival after coronary artery bypass graft surgery and percutaneous coronary intervention on the basis of recent experience.

METHODS

We linked 1987 through 2001 coronary artery bypass graft surgery and 1992 through 2001 percutaneous coronary intervention data from our northern New England registries on 35,000 patients with complete data on risk factors to the National Death Index, ascertaining 7,000 deaths. We partitioned time after revascularization into three periods on the basis of exploratory analysis using generalizations of Cox's semiparametric model to nonproportional hazards and nonlinear log-hazards. These periods were 0 to 3 months, 4 to 18 months, and 19 months and later. For each period, Cox's regression model was used to regress survival on risk factors yielding three models, which were then combined to make long-term predictions.

RESULTS

These models were incorporated into easy-to-use software that yields predicted survival for up to 8 years after revascularization. The Harrell concordance statistic ranged from 72% to 83% for these models.

CONCLUSIONS

We developed and internally validated models that accurately predict long-term survival after coronary artery bypass graft surgery and percutaneous coronary intervention as currently performed. These models using routine clinical data, can be solved with available software, and could be used to enhance informed, patient-centered clinical decision making on the choice of revascularization procedure.

Weekend versus weekday admission and mortality after acute pulmonary embolism

BACKGROUND

Optimal management of acute pulmonary embolism (PE) requires medical expertise, diagnostic testing, and therapies that may not be available consistently throughout the entire week. We sought to assess whether associations exist between weekday or weekend admission and mortality and length of hospital stay for patients hospitalized with PE.

METHODS AND RESULTS

We evaluated patients discharged with a primary diagnosis of PE from 186 acute care hospitals in Pennsylvania (January 2000 to November 2002). We used random-effect logistic models to study the association between weekend admission and 30-day mortality and used discrete survival models to study the association between weekend admission and time to hospital discharge, adjusting for hospital (region, size, and teaching status) and patient factors (race, insurance, severity of illness, and use of thrombolytic therapy). Among 15 531 patient discharges with PE, 3286 patients (21.2%) had been admitted on a weekend. Patients admitted on weekends had a higher unadjusted 30-day mortality rate (11.1% versus 8.8%) than patients admitted on weekdays, with no difference in length of stay. Patients admitted on weekends had significantly greater adjusted odds of dying (odds ratio 1.17, 95% confidence interval 1.03 to 1.34) than patients admitted on weekdays. The higher mortality among patients hospitalized on weekends was driven by the increased mortality rate among the most severely ill patients.

CONCLUSIONS

Patients with PE who are admitted on weekends have a significantly higher short-term mortality than patients admitted on weekdays. Quality-improvement efforts should aim to ensure a consistent approach to the management of PE 7 days a week.

Are health-related quality-of-life and self-rated health associated with mortality? Insights from Translating Research Into Action for Diabetes (TRIAD)

AIMS

To determine if health-related quality-of-life and self-rated health are associated with mortality in persons with diabetes.

METHODS

Survey and medical record data were obtained from 7892 patients with diabetes in Translating Research Into Action for Diabetes (TRIAD), a multicenter prospective observational study of diabetes care in managed care. Vital status at follow-up was determined from the National Death Index. Multivariable proportional hazard models were used to determine if a generic measure of health-related quality-of-life (EQ-5D) and self-rated health measured at baseline were associated with 4-year all-cause, cardiovascular, and noncardiovascular mortality.

RESULTS

At baseline, the mean EQ-5D score for decedents was 0.73 (S.D.=0.20) and for survivors was 0.81 (S.D.=0.18) (p<0.0001). Fifty-five percent of decedents and 36% of survivors (p<0.0001) rated their health as fair or poor. Lower EQ-5D scores and fair or poor self-rated health were associated with higher rates of mortality after adjusting for the demographic, socioeconomic, and clinical risk factors for mortality.

CONCLUSIONS

Health-related quality-of-life and self-rated health predict mortality in persons with diabetes. Health-related quality-of-life and self-rated health may provide additional information on patient risk independent of demographic, socioeconomic, and clinical risk factors for mortality.

Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis

The objectives of this study are to determine risk factors associated with deep sternal wound infections (DSWIs) following cardiac surgery, and to describe their impact on long-term survival. Data was obtained from a departmental database. Analysis included 7,978 consecutive patients who underwent cardiac surgery between 1997 and 2003. To identify risk factors for DSWI, regression analysis was performed. The probability scores obtained from logistic regression were used for propensity analysis of 2 groups. Kaplan-Meier analysis with log-rank test and Cox proportional hazard models were then used in survival analysis. DSWI developed in 123 of 7,978 patients (1.5%). Preoperative predictors of DSWI were body mass index >30 kg/m(2) (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1 to 2.4; P < 0.05), diabetes mellitus (OR, 2.4; 95% CI, 1.6 to 3.4; P < 0.001), urgent operation (OR, 1.7; 95% CI, 1.2 to 2.6; P < 0.05), smoking history within past year (OR, 2.7; 95% CI, 1.5 to 4.9; P < 0.001), smoking history within past 2 weeks (OR, 2.6; 95% CI, 1.5 to 4.5; P < 0.001), and a history of stroke (OR, 1.9; 95% CI, 1.1 to 3.1; P < 0.005). In addition, total length of hospital stay (OR, 1.01; 95% CI, 1.01 to 1.02; P < 0.05) and sepsis and/or endocarditis following surgery (OR, 5.1; 95% CI, 2.9 to 9.0; P < 0.001) were also predictive of DSWI. Patients with DSWI had a prolonged total length of hospital stay (40.3 days versus 16.1 days; P < 0.001), and higher 30-day mortality (1.6% versus 7.3% in DSWI group, P < 0.05). There were no differences between groups in 4-year and 8-year survival rates, with 77.2% and 61.8%, respectively, in patients with DSWI compared with 78.0% and 67.5% in patients without DSWI (P = 0.16). After adjustments for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 0.9 (95% CI, 0.6 to 1.2, P = 0.39). Though DSWIs are associated with increased early mortality, patients undergoing cardiac surgery complicated by DSWI do not experience worse long-term survival.

Impact of early and delayed stroke on in-hospital and long-term mortality after isolated coronary artery bypass grafting

Stroke after coronary artery bypass grafting (CABG) is an infrequent, yet devastating complication with increased morbidity and mortality. We sought to determine risk factors for early (intraoperatively to 24 hours) and delayed (>24 hours to discharge) stroke and to identify their impact on long-term mortality after CABG. We studied 4,140 consecutive patients who underwent isolated CABG from 1992 to 2003. Long-term survival data (mean follow-up 7.4 years) were obtained from the National Death Index. Independent predictors for stroke and in-hospital mortality were determined by multivariate logistic regression analysis including all available preoperative, intraoperative, and postoperative risk factors. Independent predictors for long-term mortality were determined by multivariate Cox regression analysis. One hundred two patients (2.5%) developed early stroke and 36 patients (0.9%) delayed stroke. Independent predictors for early stroke were age, recent myocardial infarction, smoking, femoral vascular disease, body mass index, reoperation for bleeding, postoperative sepsis and/or endocarditis, and respiratory failure, whereas those for delayed stroke were female gender, white race, preoperative renal failure, respiratory failure, and postoperative renal failure. Early stroke was an independent predictor for in-hospital (odds ratio 3.49, 95% confidence interval [CI] 1.56 to 7.80, p = 0.002) and long-term (hazard ratio 1.70, 95% CI 1.30 to 2.21, p <0.001) mortalities. Delayed stroke was not an independent predictor for in-hospital (odds ratio 0.90, 95% CI 0.23 to 3.51, p = 0.878) or long-term (hazard ratio 0.66, 95% CI 0.38 to 1.17, p = 0.156) mortality. In conclusion, risk factors for early in-hospital stroke differ from those of delayed in-hospital stroke after CABG. Early stroke is an independent predictor for in-hospital and long-term mortalities, suggesting the need for a more frequent follow-up and appropriate pharmacologic therapy after discharge.

Methods for identifying long-term adverse effects of treatment in patients with eye diseases: the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study

PURPOSE

To evaluate potential epidemiologic methods for studying long-term effects of immunosuppression on the risk of mortality and fatal malignancy, and present the methodological details of the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study.

METHODS

Advantages and disadvantages of potential study designs for evaluating rare, late-occurring events are reviewed, and the SITE Cohort Study approach is presented.

RESULTS

The randomized, controlled trial is the most robust method for evaluating treatment effects, but long study duration, high costs, and ethical concerns when studying toxicity limit its use in this setting. Retrospective cohort studies are potentially more cost-effective and timely, if records exist providing the desired information over sufficient follow-up time in the past. Case-control methods require extremely large sample sizes to evaluate risk associated with rare exposures, and recall bias is problematic when studying mortality. The SITE Cohort Study is a retrospective cohort study. Past use of antimetabolites, T-cell inhibitors, alkylating agents, and other immunosuppressives is ascertained from medical records of approximately 9,250 ocular inflammation patients at five tertiary centers over up to 30 years. Mortality and cause-specific mortality outcomes over approximately 100,000 person-years are ascertained using the National Death Index. Immunosuppressed and non-immunosuppressed groups of patients are compared with each other and general population mortality rates from US vital statistics. Calculated detectable differences for mortality/fatal malignancy with respect to the general population are 22%/49% for antimetabolites, 28%/62% for T-cell inhibitors, and 36%/81% for alkylating agents.

CONCLUSIONS

Information from the SITE Cohort Study should clarify whether use of these immunosuppressive drugs for ocular inflammation increases the risk of mortality and fatal cancer. This epidemiologic approach may be useful for evaluating long-term risks of systemic therapies for other ocular diseases.

Hospital volume and patient outcomes in pulmonary embolism

BACKGROUND

In numerous high-risk medical and surgical conditions, a greater volume of patients undergoing treatment in a given setting or facility is associated with better survival. For patients with pulmonary embolism, the relation between the number of patients treated in a hospital (volume) and patient outcome is unknown.

METHODS

We studied discharge records from 186 acute care hospitals in Pennsylvania for a total of 15 531 patients for whom the primary diagnosis was pulmonary embolism. The study outcomes were all-cause mortality in hospital and within 30 days after presentation for pulmonary embolism and the length of hospital stay. We used logistic models to study the association between hospital volume and 30-day mortality and discrete survival models to study the association between in-hospital mortality and time to hospital discharge.

RESULTS

The median annual hospital volume for pulmonary embolism was 20 patients (interquartile range 10-42). Overall in-hospital mortality was 6.0%, whereas 30-day mortality was 9.3%. In multivariable analysis, very-high-volume hospitals (> or = 42 cases per year) had a significantly lower odds of in-hospital death (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.51-0.99) and of 30-day death (OR 0.71, 95% CI 0.54-0.92) than very-low-volume hospitals (< 10 cases per year). Although patients in the very-high-volume hospitals had a slightly longer length of stay than those in the very-low-volume hospitals (mean difference 0.7 days), there was no association between volume and length of stay.

INTERPRETATION

In hospitals with a high volume of cases, pulmonary embolism was associated with lower short-term mortality. Further research is required to determine the causes of the relation between volume and outcome for patients with pulmonary embolism.

A feasible method for linkage studies avoiding clerical review: linkage of the national HIV/AIDS surveillance databases with the National Death Index in Australia

OBJECTIVE

To assess the sensitivity and specificity of linkage of HIV/AIDS diagnoses in Australia to the National Death Index (NDI).

METHODS

An aggregated file containing 19,772 matched HIV/AIDS diagnoses reported to the national HIV/AIDS databases from 1980 to 30 June 2004 was linked to the NDI using probabilistic linkage methods based on the namecode, date of birth, and sex as identifiers. Based on the 6,900 HIV/AIDS known deaths reported by 1 January 2003 and 1,455 known non-deaths with an active follow-up beyond 1 January 2003, the different combinations of weights assigned to matched pairs were examined to obtain maximum sensitivity and specificity.

RESULTS

The trade-off between sensitivity and specificity was used to obtain an optimal linkage. The optimal linkage was found to link 5,658 of the 6,900 HIV/AIDS known deaths (a sensitivity of 82%), and 116 false positives of the 1,455 known not deaths (specificity of 92%). Causes of deaths were recorded for 86.5% of deaths that were linked to the NDI.

CONCLUSION

This is a feasible method for conducting linkage studies if both the identifying deaths and non-deaths are available. The relatively poor sensitivity could be due to limited identifiers available for linkage on the HIV/AIDS databases.

Thoracoscore predicts midterm mortality in patients undergoing thoracic surgery

OBJECTIVE

Thoracoscore is the first multivariate model for the prediction of in-hospital mortality after general thoracic surgery. We aimed to evaluate the performance of Thoracoscore in predicting in-hospital and midterm all-cause mortality.

METHODS

We retrospectively evaluated 1675 patients who underwent thoracic surgery (lung resections [n = 626], mediastinum [n = 535], pleura and pericardium [n = 268], esophagus [n = 88], chest wall [n = 90], trachea [n = 45], and other procedures [n = 23]) from October 2002 to March 2006 at a single institution. Midterm survival data (mean follow-up 25 +/- 16 months) were obtained from the National Death Index. Kaplan-Meier survival plots of the quartiles of Thoracoscore were constructed and compared with the log-rank test with adjustment for trend.

RESULTS

Starting from the lower-risk to the higher-risk quartile, the in-hospital mortality rates were 0% (0/418), 1% (4/415), 2.5% (11/435), and 9.6% (54/407). Thoracoscore was a strong independent predictor for in-hospital mortality (odds ratio 1.20, 95% confidence intervals 1.15-.25; P < .001). The 2-year survivals of the Thoracoscore quartiles were 98.7% +/- 0.6%, 87.0% +/- 1.8%, 73.8% +/- 2.3%, and 54.8% +/- 2.7%, respectively (P < .0001). Thoracoscore was a strong independent predictor for midterm mortality (hazard ratio 1.12, 95% confidence intervals 1.11-1.14; P < .001).

CONCLUSION

Thoracoscore is a good and useful clinical tool for preoperative prediction of in-hospital and midterm mortality among patients undergoing general thoracic surgery.

Accuracy of the Australian National Death Index: comparison with adjudicated fatal outcomes among Australian participants in the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) study

OBJECTIVE

To assess the accuracy of the Australian National Death Index (NDI) in identifying deaths and recording cardiovascular and cancer causes of death.

METHODS

Adjudicated mortality data from Australian participants in the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) study up until September 1999 were used as reference. Nine hundred and eighty deceased subjects and 4,841 surviving subjects were matched to the NDI by name, date of birth, date of death and postcode. Matching rigour was confirmed by manual review. Deaths ascribed to cardiovascular and cancer causes within the NDI were also compared against LIPID-adjudicated causes.

RESULTS

The NDI displayed 93.7% sensitivity and 100% specificity for the identification of deaths. Mis-recording of identifiers was responsible for 69% of known deaths not matching to the NDI and, if eliminated, would have increased the sensitivity to 98.0%. Among deceased subjects who matched to the NDI, cause of death was recorded in 96.2%. The sensitivity and specificity for cardiovascular deaths were 92.5% and 89.6%, respectively, and for cancer deaths 95.2% and 99.2%, respectively.

CONCLUSION

Much of the inaccuracy of the NDI could potentially be overcome by the use of unique identifiers. Among deaths identified by the NDI, those due to cardiovascular disease are more likely to be inaccurately recorded than cancer-related deaths, probably because less uncertainty surrounds the presence or absence of terminal malignant disease.

Risk factors for mortality among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE

We sought to examine demographic, socioeconomic, and biological predictors of all-cause, cardiovascular, and noncardiovascular mortality in patients with diabetes.

RESEARCH DESIGN AND METHODS

Survey, medical record, and administrative data were obtained from 8,733 participants in the Translating Research Into Action for Diabetes Study, a multicenter, prospective, observational study of diabetes care in managed care. Data on deaths (n = 791) and cause of death were obtained from the National Death Index after 4 years. Predictors examined included age, sex, race, education, income, duration, and treatment of diabetes, BMI, smoking, microvascular and macrovascular complications, and comorbidities.

RESULTS

Predictors of adjusted all-cause mortality included older age (hazard ratio [HR] 1.04 [95% CI 1.03-1.05]), male sex (1.57 [1.35-1.83]), lower income (< $15,000 vs. > $75,000, HR 1.82 [1.30-2.54]; $15,000-$40,000 vs. > $75,000, HR 1.58 [1.15-2.17]), longer duration of diabetes (> or = 9 years vs. < 9 years, HR 1.20 [1.02-1.41]), lower BMI (< 26 vs. 26-30 kg/m2, HR 1.43 [1.13-1.69]), smoking (1.44 [1.20-1.74]), nephropathy (1.46 [1.23-2.73]), macrovascular disease (1.46 [1.23-1.74]), and greater Charlson index (> or = 2-3 vs. < 1, HR 2.01 [1.04-3.90]; > or = 3 vs. < 1, HR 4.38 [2.26-8.47]). The predictors of cardiovascular and noncardiovascular mortality were different. Macrovascular disease predicted cardiovascular but not noncardiovascular mortality.

CONCLUSIONS

Among people with diabetes and access to medical care, older age, male sex, smoking, and renal disease are important predictors of mortality. Even within an insured population, socioeconomic circumstance is an important independent predictor of health.

Early and midterm outcome after off-pump coronary artery bypass grafting in patients with left ventricular dysfunction

BACKGROUND

The purpose of this study was to define the early outcome and the potential for midterm survival in patients with left ventricular dysfunction (LVD) who undergo off-pump coronary artery bypass (OPCAB) and to compare these results with those of conventional coronary artery bypass grafting (CABG).

METHODS

Medical records of patients with LVD (n = 732) between January 1998 and March 2002 were retrospectively reviewed. There were 523 patients with moderate LVD (ejection fraction, 30%-50%; 463 CABG versus 60 OPCAB) and 209 patients with severe LVD (ejection fraction, < 30%; 136 CABG versus 73 OPCAB). Midterm survival data (mean follow-up, 2.3 years) were obtained from the National Death Index. Groups were compared by multivariate Cox proportional hazard models, and Kaplan-Meier curves were plotted.

RESULTS

CABG patients had lower European System for Cardiac Operative Risk Evaluation values (5.3 versus 7.2 and 8.0 versus 9.6 in moderate and severe LVD subgroups, respectively; P < .001). There were no differences (OPCAB versus CABG) in 30-day mortality (3.3% versus 1.9%, moderate LVD group, P = .366; 6.8% versus 4.4%, severe LVD group, P = .521), length of stay (9.3 versus 8.6 days, moderate LVD group, P = .683; 11.9 versus 11.8 days, severe LVD group, P = .423), and postoperative complications (13.3% versus 11.0%, moderate LVD group, P = 0.663; 16.4% versus 20.6%, severe LVD group, P = .581). Successful coronary bypass in patients with severe LVD was associated with 68.2% and 66.2% actuarial 48-month survival rates for the CABG and OPCAB patients, respectively (P = .336), and these rates rose to 86.0% and 82.9% in patients with moderate LVD (P = .121). When CABG patients with moderate LVD were considered the reference group, the adjusted hazard ratio of OPCAB patients with moderate LVD for midterm mortality was 1.32 (95% confidence interval, 0.61-2.87; P = .481). CABG and OPCAB patients with severe LVD had the same adjusted hazard ratio of 1.86, and this figure was statistically significant compared with the value for the reference group (P = .011 and P = .039, respectively).

CONCLUSIONS

Patients with LVD can derive midterm benefit from coronary bypass. OPCAB in higher-risk patients had early and midterm outcomes similar to those of CABG.

The importance of independent risk-factors for long-term mortality prediction after cardiac surgery

The purpose of the present study was to determine independent predictors for long-term mortality after cardiac surgery. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed to score in-hospital mortality and recent studies have shown its ability to predict long-term mortality as well. We compared forecasts based on EuroSCORE with other models based on independent predictors. Medical records of patients with cardiac surgery who were discharged alive (n = 4852) were retrospectively reviewed. Their operative surgical risks were calculated according to EuroSCORE. Patients were randomly divided into two groups: training dataset (n = 3233) and validation dataset (n = 1619). Long-term survival data (mean follow-up 5.1 years) were obtained from the National Death Index. We compared four models: standard EuroSCORE (M1); logistic EuroSCORE (M2); M2 and other preoperative, intra-operative and post-operative selected variables (M3); and selected variables only (M4). M3 and M4 were determined with multivariable Cox regression analysis using the training dataset. The estimated five-year survival rates of the quartiles in compared models in the validation dataset were: 94.5%, 87.8%, 77.1%, 64.9% for M1; 95.1%, 88.0%, 80.5%, 64.4% for M2; 93.4%, 89.4%, 80.8%, 64.1% for M3; and 95.8%, 90.9%, 81.0%, 59.9% for M4. In the four models, the odds of death in the highest-risk quartile was 8.4-, 8.5-, 9.4- and 15.6-fold higher, respectively, than the odds of death in the lowest-risk quartile (P < 0.0001 for all). EuroSCORE is a good predictor of long-term mortality after cardiac surgery. We developed and validated a model using selected preoperative, intra-operative and post-operative variables that has better discriminatory ability.

Does bilateral internal thoracic artery grafting increase long-term survival of diabetic patients?

BACKGROUND

The purpose of the present study was to determine whether long-term survival in diabetic patients increased after bilateral internal thoracic artery (BITA) coronary bypass compared with matched patients with single internal thoracic artery (SITA) coronary bypass.

METHODS

The propensity for BITA was determined using logistic regression analysis and each BITA patient was matched with one SITA patient. Between January 1992 and March 2002, 980 matched diabetic patients (490 BITA versus 490 SITA) underwent coronary artery bypass surgery. Long-term survival data were obtained from the National Death Index (mean follow-up, 4.7 +/- 3.0 years). Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots.

RESULTS

Multivariate Cox regression analysis determined that BITA grafting had no significant effect on long-term survival (hazard ratio 0.89, 95% confidence interval: 0.69 to 1.14, p = 0.343). There were no differences in 30-day mortality (3.9% for BITA versus 3.7%, p = 0.999) and major postoperative complications except for length of stay (11.4 days for BITA versus 12.7 days, p < 0.001). Five-year survival rate was 79.9% in the BITA group and 75.7% in the SITA group (p = 0.252). There was no difference in 5-year survival rate between matched patients younger than 60 or from 70 to 79 years old. However, BITA patients aged 60 to 69 years had better 5-year survival rates (84.1% versus 71.0%, p = 0.0196), whereas the opposite was observed in patients aged more than 79 years (5-year survival for BITA 43.1% versus 70.0%, p = 0.016).

CONCLUSIONS

Bilateral internal thoracic artery grafting had no significant effect on long-term survival for diabetic patients, but it may increase long-term survival in patients aged 60 to 69 years, whereas SITA grafting may be beneficial for patients more than 79 years old.

Comparison of three measurements of cardiac surgery mortality for the Northern New England Cardiovascular Disease Study Group

BACKGROUND

There is no consensus on the optimal period during which to assess death after coronary artery bypass graft (CABG) surgery. Three measures are commonly used: in-hospital, 30-day, and procedural (either in-hospital or 30-day) mortality. We used a regional database to calculate the CABG mortality rate using each of these mortality measures.

METHODS

Data were collected prospectively on 31,592 consecutive isolated CABG surgeries in northern New England between January 1992 and December 2001. These data were linked to the National Death Index to obtain vital status through December 2001, and used to calculate 30-day and procedural mortality rates. Procedural mortality was defined as death occurring either within the hospital setting or within 30 days of the index procedure. Regional registry data were used to calculate in-hospital mortality rates.

RESULTS

Mortality rates and their 95% confidence intervals were calculated. In all but one medical center, the in-hospital mortality was the lowest rate, while in all centers the procedural mortality rate was the highest. There were 1,082 deaths captured by the procedural mortality measure. Of these, 927 were included in the in-hospital mortality measure; 956 occurred within 30 days of surgery.

CONCLUSIONS

Each of the measures studied has its advantages and may be used to assess the mortality outcomes of cardiac surgery. The more important issue other than the specific measure used is our ability to measure and validate it conveniently and accurately in actual practice.

Long-Term Mortality, Cause of Death, and Temporal Trends in Complications after Percutaneous Aortic Balloon Valvuloplasty for Calcific Aortic Stenosis

We sought to assess survival, predictors of adverse outcomes, and complication rates in a more recent series of adults undergoing percutaneous aortic balloon valvuloplasty (PABV) for symptomatic calcific aortic stenosis. While aortic valve replacement is the treatment of choice for adults with symptomatic calcific aortic stenosis, PABV has been used in selected patients who are not good surgical candidates. Registries of patients who underwent PABV over 15 years ago have shown poor long-term survival and high procedural complication rates. This single-center cohort study enrolled consecutive adults undergoing PABV between 1989 and 2005 for calcific aortic stenosis. Demographic, hemodynamic, and procedural data, as well as vital status, were collected by chart review and query of the National Death Index. The study included 78 patients: mean age 78 +/- 11 years, 51% female, 90% heart failure, 61% coronary disease, and 8% end-stage renal disease. While 22% had a major procedural complication, this rate tended to decrease over time (P=0.068). In the cohort, 87% died with a median survival of 6.6 months. According to NDI records, the primary cause of death was cardiac in 54% of deaths. Survival was significantly higher in patients <or=70 years and those bridged to aortic valve replacement. PABV in patients who are elderly and not candidates for bridge to aortic valve replacement is associated with poor long-term survival. The decrease in the complication rate over the past 15 years has important implications regarding the morbidity associated with percutaneous aortic valve replacement techniques.

Accuracy and completeness of mortality data in the Department of Veterans Affairs

Background

One of the national mortality databases in the U.S. is the Beneficiary Identification and Record Locator Subsystem (BIRLS) Death File that contains death dates of those who have received any benefits from the Department of Veterans Affairs (VA). The completeness of this database was shown to vary widely from cohort to cohort in previous studies. Three other sources of death dates are available in the VA that can complement the BIRLS Death File. The objective of this study is to evaluate the completeness and accuracy of death dates in the four sources available in the VA and to examine whether these four sources can be combined into a database with improved completeness and accuracy.

Methods

A random sample of 3,000 was drawn from 8.3 million veterans who received benefits from the VA between 1997 and 1999 and were alive on January 1, 1999 according to at least one source. Death dates found in BIRLS Death File, Medical SAS Inpatient Datasets, Medicare Vital Status, and Social Security Administration (SSA) Death Master File were compared with dates obtained from the National Death Index. A combined dataset from these sources was also compared with National Death Index dates.

Results

Compared with the National Death Index, sensitivity (or the percentage of death dates correctly recorded in a source) was 77.4% for BIRLS Death File, 12.0% for Medical SAS Inpatient Datasets, 83.2% for Medicare Vital Status, and 92.1% for SSA Death Master File. Over 95% of death dates in these sources agreed exactly with dates from the National Death Index. Death dates in the combined dataset demonstrated 98.3% sensitivity and 97.6% exact agreement with dates from the National Death Index.

Conclusion

The BIRLS Death File is not an adequate source of mortality data for the VA population due to incompleteness. When the four sources of mortality data are carefully combined, the resulting dataset can provide more timely data for death ascertainment than the National Death Index and has comparable accuracy and completeness.

Parkinson's disease mortality among male anesthesiologists and internists

Clusters of Parkinson's disease (PD) among healthcare professionals have been interpreted as evidence of an infectious etiology. Anesthetic gases have also been associated with parkinsonism symptoms and PD among patients undergoing general anesthesia. We investigated PD mortality among large cohorts of male U.S. anesthesiologists (n = 33,040) and internal medicine physicians (n = 33,044). PD mortality for any mention on a death certificate was lower than rates in U.S. men during 1979-1995 for both groups, although anesthesiologists had a significantly elevated risk for PD as underlying cause of death for 10-year follow-up. Direct comparisons of mortality between the two cohorts indicated excess PD mortality in anesthesiologists for >10-year follow-up for any mention and for underlying cause of death. These findings lend some support to the hypothesis that infectious agents or anesthetic gases may be associated etiologically with PD.

The impact of preoperative thrombolysis on long-term survival after coronary artery bypass grafting

BACKGROUND

Coronary artery bypass grafting (CABG) is frequently used after thrombolytic therapy. However, there is little information regarding long-term survival in this setting. The purpose of the present study was to compare the long-term survival of patients subjected to CABG after thrombolysis to those without thrombolysis.

METHODS AND RESULTS

We studied 3760 consecutive patients with isolated CABG between 1992 and 2002. CABG patients without thrombolysis were compared with those who were treated with thrombolysis within 7 days before CABG. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for thrombolysis was determined by logistic regression analysis, and each patient with thrombolysis was then matched to 5 patients without thrombolysis. One hundred ninety-six patients (5.2%) were treated with thrombolysis. Patients with thrombolysis were more likely to be male, younger, and with higher rates of unstable angina, emergency operation, recent or transmural myocardial infarction, preoperative intraaortic balloon pump, hemodynamic instability, shock, intravenous nitroglycerine, left-ventricular hypertrophy, sustained ventricular arrhythmia, and higher EuroSCORE. There were no differences in early outcome between matched groups, but the 5-year actuarial survival was higher in patients with thrombolysis (90.3+/-2.2% versus 78.5+/-1.6%; P=0.0007). After adjustment for all factors, the hazard ratio of long-term mortality for patients with thrombolysis was 0.54 (95% CI, 0.36 to 0.81; P=0.003) and, if deaths during the first 12 months were excluded, 0.46 (95% CI, 0.27 to 0.76; P=0.003).

CONCLUSIONS

Patients subjected to CABG within 7 days after thrombolysis demonstrated increased long-term survival.

Assessment of independent predictors for long-term mortality between women and men after coronary artery bypass grafting: Are women different from men?

OBJECTIVE

The long-term mortality of coronary artery bypass grafting in women in not certain. The purpose of this study was to determine and compare risk factors for long-term mortality in women and men undergoing coronary artery bypass grafting.

METHODS

Between 1992 and 2002, 3760 consecutive patients (2598 men and 1162 women) underwent isolated coronary artery bypass grafting. Long-term survival data were obtained from the National Death Index (mean follow-up, 5.1 +/- 3.2 years). Multivariable Cox regression analysis was performed, including 64 preoperative, intraoperative, and postoperative factors separately in women and men.

RESULTS

There were no differences in in-hospital mortality (2.7% in men vs 2.9% in women, P = .639) and 5-year survival (82.0% +/- 0.8% in men vs 81.1% +/- 1.3% in women, P = .293). After adjustment for all independent predictors of long-term mortality, female sex was an independent predictor of improved 5-year survival (hazard ratio, 0.82; 95% confidence interval, 0.71-0.96; P = .014). Twenty-one independent predictors for long-term mortality were determined in men, whereas only 12 were determined in women. There were 9 common risk factors (age, ejection fraction, diabetes mellitus, > or =2 arterial grafts, postoperative myocardial infarction, deep sternal wound infection, sepsis and/or endocarditis, gastrointestinal complications, and respiratory failure); however, their weights were different between women and men. Malignant ventricular arrhythmias, calcified aorta, and preoperative renal failure were independent predictors only in women. Emergency operation, previous cardiac operation, peripheral vascular disease, left ventricular hypertrophy, current and past congestive heart failure, chronic obstructive pulmonary disease, body mass index of greater than 29, preoperative dialysis, thrombolysis within 7 days before coronary artery bypass grafting, intraoperative stroke, and postoperative renal failure were independent predictors only in men.

CONCLUSIONS

Despite equality between sexes in early outcome and superiority of female sex in long-term survival, there were 3 independent predictors for long-term mortality after coronary artery bypass grafting unique for women compared with 12 for men. Clinical decision making and follow-up should not be influenced by stereotypes but by specific findings.

Diabetes reporting as a cause of death: results from the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE

To determine the frequency of reporting of diabetes on death certificates of decedents with known diabetes, define factors associated with reporting of diabetes, and describe trends in reporting over time.

RESEARCH DESIGN AND METHODS

Data were obtained from 11,927 participants with diabetes who were enrolled in the Translating Research Into Action for Diabetes study, a multicenter prospective observational study of diabetes care in managed care. Data on decedents (n = 540) were obtained from the National Death Index. The primary dependent variable was the presence of ICD-10 codes for diabetes on the death certificate. Covariates included age at death, sex, race/ethnicity, education, income, duration of diabetes, type of diabetes, diabetes treatment, smoking status, and number of comorbidities.

RESULTS

Diabetes was recorded on 39% of death certificates and as the underlying cause of death for 10% of decedents with diabetes. Diabetes was significantly less likely to be reported on the death certificates of decedents with diabetes dying of cancer. Predictors of recording diabetes anywhere on the death certificate included longer duration of diabetes and insulin treatment. Longer duration of diabetes, insulin treatment, and fewer comorbidities were associated with recording of diabetes as the underlying cause of death.

CONCLUSIONS

Diabetes is much more likely to be reported on the death certificates of diabetic individuals who die of cardiovascular causes. Reporting of diabetes on death certificates has been stable over time. Death certificates underestimate the prevalence of diabetes among decedents and present a biased picture of the causes of death among people with diabetes.

Comparing Long-Term Survival of Patients With Multivessel Coronary Disease After CABG or PCI

Background— Randomized trials comparing coronary artery bypass graft surgery (CABG) with percutaneous coronary interventions (PCIs) for patients with multivessel coronary disease (MVD) report similar long-term survival for CABG and PCI. These studies used a highly selected population of patients and providers, and their results may not be generalizable to actual care. Our goal in this study was to compare long-term survival of MVD patients treated with CABG vs PCI in contemporary practice.

Methods and Results— From our northern New England registries of consecutive coronary revascularizations, we identified 10 198 CABG and 4295 PCI patients with MVD who may have been eligible for either procedure between 1994 and 2001. Vital status was obtained by linkage to the National Death Index. Proportional-hazards regression was used to calculate hazard ratios (HRs) for survival in CABG vs PCI patients after adjustment for comorbidities and disease characteristics. CABG patients were older; had more comorbidities, more 3-vessel disease, and lower ejection fractions; and were more completely revascularized. Adjusted long-term survival for patients with 3-vessel disease was better after CABG than PCI (HR, 0.60; P <0.01) but not for patients with 2-vessel disease (HR, 0.98; P =0.77). The survival advantage of CABG for 3-vessel disease patients was present in all patient populations, including women, diabetics, and the elderly and in the era of high stent utilization.

Conclusions— In contemporary practice, survival for patients with 3-vessel coronary disease is better after CABG than PCI, an observation that patients and physicians should carefully consider when deciding on a revascularization strategy.

Outcome of Coronary Artery Bypass Operations in Patients With Renal Insufficiency With and Without Renal Transplantation

HYPOTHESIS

Renal insufficiency (RI) is associated with an increased risk of morbidity and mortality following coronary artery bypass graft (CABG) operations, particularly among patients who are dependent on dialysis.

DESIGN AND SETTING

A retrospective analysis of data collected at a tertiary care center.

PATIENTS

One hundred eighty-four consecutive patients with RI who underwent CABG surgery between 1992 and 2004. This group consisted of 152 patients with serum creatinine levels of > or = 1.7 mg/dL (group I) and 32 kidney transplant recipients (group II). Of the patients in group I, 90 were dialysis-free (subgroup IA) and 62 were dialysis-dependent (subgroup IB).

MAIN OUTCOME MEASURES

Demographics, perioperative data, and outcomes for each of the three groups were evaluated and compared.

RESULTS

Fifty-four percent of the patients were in New York Heart Association classes III and IV, 36% had unstable angina, and 21% had left main coronary disease. The mean ejection fraction was 38%. The median postoperative length of stay in the hospital was 10 days. Of the patients in group IB, 8% required reexploration for bleeding compared to 3% in groups IA and II (p < 0.05). Dialysis was needed postoperatively in five patients in group IA and two patients in group II (5.7%). The raw operative mortality rate was 7.6% and was higher in group IB (9.7%) compared to groups IA and II (6.7% and 6.2%, respectively; p < 0.05). The actuarial 5-year survival rate was higher in group II compared to group I (79% vs 59%, respectively; p < 0.05). The difference in survival rates was more apparent between groups II and IB (79% vs 57%, respectively; p < 0.005).

CONCLUSIONS

CABG is associated with an increased rate of perioperative complications and mortality in patients with RI. Dialysis dependence is a major risk factor for patients undergoing CABG surgery. However, with acceptable surgical results, dialysis patients should not be denied CABG surgery. A survival advantage is demonstrated among patients with previous kidney transplants compared to those patients who are dependent on dialysis.

EuroSCORE Predicts Long-Term Mortality After Heart Valve Surgery

BACKGROUND

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is the most rigorously evaluated scoring system in cardiac surgery. We sought to evaluate the performance of EuroSCORE in the prediction of long-term mortality in patients undergoing heart valve surgery.

METHODS

Medical records of patients with isolated or combined heart valve surgery, who were discharged alive (n = 1035), were retrospectively reviewed. Their operative surgical risks were calculated according to EuroSCORE model (standard and logistic). Long-term survival data (mean follow-up 4.5 +/- 3.1 years) were obtained from the National Death Index. Kaplan-Meier curves of the quartiles of standard and logistic EuroSCORE were plotted.

RESULTS

The estimated 5-year survival rates of the quartiles in the standard and logistic EuroSCORE model were: 90.0% +/- 2.3%, 85.1% +/- 2.3%, 64.8% +/- 3.3%, and 55.1% +/- 3.7% (p < 0.0001, log-rank test with adjustment for trend) and 90.4% +/- 2.2%, 86.4% +/- 2.5%, 66.9% +/- 3.3%, and 56.1% +/- 3.3% (p < 0.0001, log-rank test with adjustment for trend) respectively. The odds of death in the highest-risk quartile were 7.46- and 7.82-fold higher than the odds of death in the lowest-risk quartile for standard and logistic EuroSCORE respectively.

CONCLUSIONS

EuroSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also long-term mortality in the whole context of heart valve surgery. This outcome can be predicted using the standard EuroSCORE, which is very simple and easy in its calculation.

Risk Factors for Sepsis and Endocarditis and Long-Term Survival Following Coronary Artery Bypass Grafting

We sought to determine risk factors for sepsis and/or endocarditis (S/E) and to identify their impact on long-term survival after coronary artery bypass grafting (CABG). We studied 3760 consecutive patients who underwent isolated CABG from 1992 to 2002. Patients with CABG without S/E were compared with those who developed S/E. Long-term survival data (mean follow-up 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for S/E was determined by logistic regression analysis and each patient with S/E was matched to one patient without S/E. Thirty-six patients (0.96%) developed S/E. Independent predictors for S/E were increased age (odds ratio [OR] 1.05 per year, 95% Confidence interval [95% CI] 1.00-1.09; p = 0.040) and the development of other major complications after CABG such as deep sternal wound infection (OR 30.80, 95% CI 9.50-99.82; p < 0.001), gastrointestinal complications (OR 19.48, 95% CI 7.14-53.18; p < 0.001), renal failure (OR 15.18, 95% CI 4.42-52.06; p < 0.001), intraoperative stroke (OR 13.11, 95% CI 4.81-35.69; p < 0.001) and respiratory failure (OR 12.95, 95% CI 5.69-29.45; p < 0.001). After adjustment for pre-, intra- and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with S/E was 3.33 (95% CI 2.17-5.10; p < 0.001). There was no difference in 30-day mortality between matched groups (25.0% vs. 19.4% in patients without S/E, p = 0.778), however patients without S/E had better 5-year survival rate (52.7 +/- 8.7% vs. 16.2 +/- 6.2%; p = 0.0004). We have identified risk factors for S/E following CABG and we found that there was increased mortality in patients with S/E during a 10-year follow-up period.

Comparing strategies for United States veterans' mortality ascertainment

Background

We aimed to determine optimal strategies for complete mortality ascertainment comparing death certificates and United States (US) Veterans Administration (VA) records.

Methods

We constructed a cohort of California veterans who died in fiscal year (FY) 2000 and used VA services the year before death. We determined decedent status using California death certificates linked to VA utilization data and the VA Beneficiary Identification and Records Locator System (BIRLS) death file. We compared the characteristics of decedents who would not have been identified by either single source (e.g., VA BIRLS alone or California death certificates alone) with the rest of the cohort.

Results

A total of 8,813 veteran decedents were identified from both VA decedent files and death certificates. Of all decedents, 5,698 / 8,813 (65%) veterans were identified in both source files, but 2,426 / 8,813 (28%) decedents were not identified in VA BIRLS, and 689 / 8,813 (8%) were not identified in death certificates. Compared to the rest of the cohort, decedents whose mortality status was ascertained through either single source differed by race / ethnicity, marital status, and California residence. Clinically, veterans identified from either single source had less comorbidity and were less likely to have been users of VA inpatient or long term care, but equally or more likely to have been users of VA outpatient services.

Conclusion

As single sources, VA decedent files and death certificates each provided an incomplete record, and death ascertainment was improved by using both source files. Potential bias may vary depending on analytic interest.

Perioperative Stroke and Long-Term Survival After Coronary Bypass Graft Surgery

BACKGROUND

Stroke is a devastating complication of coronary artery bypass graft (CABG) surgery. In-hospital outcomes have been described, yet the long-term effect of stroke on mortality following CABG surgery has not been well studied.

METHODS

We examined the survival of 35,733 consecutive patients undergoing isolated CABG surgery in northern New England from 1992 through 2001. Stroke was defined as a new fixed neurologic defect that persisted at least 24 hours after surgery. Patient records were linked to the National Death Index to assess mortality. There were 147,931 person years of follow-up and 5,705 deaths. Cox proportional hazard regression was used to calculate the adjusted hazard ratios (HR) and 95% confidence intervals (95% CI). We identified the 5-year survival stratified by primary stroke mechanism, the patient's functional impact, and discharge location among a subset of patients who had strokes between 1992 and 2000.

RESULTS

Perioperative stroke occurred in 575 patients (1.61%). Patients who had strokes had more comorbidities. After adjustments for differences in baseline patient and clinical characteristics, patients who had perioperative stroke were at a significantly increased risk for death (HR, 3.20; 95% CI, 2.80 to 3.66; p < 0.0001). Survival for patients with stroke at 1, 5, and 10 years was 83.0%, 58.7%, and 26.9%, respectively. Five-year survival decreased among patients who had major functional limitations before discharge, among those who had hypoperfusion strokes, and among patients who were discharged to locations other than home or rehabilitation facilities.

CONCLUSIONS

Perioperative stroke is associated with a very substantial increased risk of postoperative death among CABG surgery patients. The greatest risk of death was noted within the first year after surgery. Survival after 1 year approximates that of patients who did not suffer a stroke.

The Impact of Deep Sternal Wound Infection on Long-term Survival After Coronary Artery Bypass Grafting

OBJECTIVES

To identify the impact of deep sternal wound infection (DSWI) on long-term survival after coronary artery bypass grafting (CABG).

BACKGROUND

DSWI following CABG is an infrequent, yet devastating complication with increased morbidity and mortality. However, little has been published regarding the impact of DSWI on long-term mortality.

METHODS

We studied 3,760 consecutive patients who underwent isolated CABG between 1992 and 2002. Patients with CABG and no DSWI were compared with those in whom DSWI developed. Long-term survival data (mean follow-up, 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for DSWI was determined by logistic regression analysis, and each patient with DSWI was then matched to 10 patients without DSWI.

RESULTS

DSWI developed in 40 of 3,760 patients (1.1%). Independent predictors for DSWI were diabetes (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.7 to 11.6; p < 0.001), hemodynamic instability preoperatively (OR, 4.0; 95% CI, 1.2 to 13.9; p = 0.026), preoperative renal failure on dialysis (OR, 3.4; 95% CI, 1.0 to 13.6; p = 0.049), use of bilateral internal thoracic arteries (OR, 2.6; 95% CI, 1.3 to 5.3; p = 0.010), and sepsis and/or endocarditis after CABG (OR, 29.9; 95% CI, 11.7 to 76.4; p < 0.001). Patients with DSWI had prolonged length of stay (35.0 days vs 16.4 days; p < 0.001); however, there was no difference in early mortality between matched groups. After adjustment for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 2.44 (95% CI, 1.51 to 3.92; p < 0.001). Patients without DSWI had a better 5-year survival rate (72.8 +/- 2.4% vs 50.8.6 +/- 8.5% [mean +/- SE]; p = 0.0007 between matched groups).

CONCLUSIONS

We found that DSWI following CABG was associated with increased long-term mortality during a 10-year follow-up study.

The cost effectiveness of health insurance

BACKGROUND

Although studies have examined both the adverse consequences of lacking health insurance and the costs of insuring the uninsured, there are no estimates of the value of providing health insurance to those currently uninsured.

OBJECTIVE

To examine the value associated with providing insurance to those currently uninsured through an incremental cost-effectiveness analysis.

METHODS

People aged 25 to 64 in both the National Health Interview Survey (with 2-year mortality follow-up) and the Medical Expenditure Panel Survey were examined to estimate the contribution of sociodemographic, health, and health behavior characteristics on insured persons' quality-adjusted life years (QALYs) and healthcare costs. Parameter estimates from these regression models were used to predict QALYs and costs associated with insuring the uninsured, given their characteristics for 1996. Markov decision-analysis modeling was then employed to calculate incremental cost-effectiveness ratios.

RESULTS

The incremental cost-effectiveness of insurance for the average 25-year-old adult (through age 64) is approximately $35,000 per QALY gained (range $21,000 to $48,000). The incremental cost-effectiveness ratio becomes more favorable as people approach age 65.

CONCLUSIONS

The additional health care purchased with health insurance provides gains in quality-adjusted life at costs that compare favorably to those of other programs and medical interventions society now chooses to fund.

Long-Term Mortality of Patients With Acute Myocardial Infarction in the United States and Canada

BACKGROUND

In a previous substudy of the GUSTO-I trial, we observed better functional and quality-of-life outcomes among patients in the United States (US patients) compared with patients in Canada. Rates of invasive therapy were significantly higher in the United States and were associated with a small mortality benefit (0.4%, adjusted P=0.02). We sought to determine whether Canadian-US differences in practice patterns in GUSTO-I had an impact on 5-year mortality.

METHODS AND RESULTS

Mortality data for 23,105 US and 2898 Canadian patients enrolled in GUSTO-I were obtained from national mortality databases. Median follow-up was 5.46 years in the US and 5.33 years in the Canadian cohort. Five-year mortality rate was 19.6% among US and 21.4% among Canadian patients (P=0.02). After baseline adjustment, enrollment in Canada was associated with a higher hazard of death (1.17; 95% confidence interval, 1.07 to 1.28, P=0.001). Revascularization rates during the index hospitalization in the United States were almost 3 times those in Canada: 30.5% versus 11.4% for angioplasty and 13.1% versus 4.0% for bypass surgery (P<0.01 for both). After accounting for revascularization status as a time-dependent covariate, country was no longer a significant predictor of long-term mortality. These results were confirmed in a propensity-matched analysis.

CONCLUSIONS

Our results suggest, for the first time, that the more conservative pattern of care with regard to early revascularization in Canada for ST-segment elevation acute myocardial infarction may have a detrimental effect on long-term survival. Our results have important policy implications for cardiac care in countries and healthcare systems wherein use of invasive procedures is similarly conservative.

Survival in patients with peripheral vascular disease after percutaneous coronary intervention and coronary artery bypass graft surgery

BACKGROUND

Patients with peripheral vascular disease (PVD) undergoing coronary revascularization have high rates of adverse outcomes. Whether there are important differences in outcomes for surgical versus percutaneous coronary revascularization is unknown. The objective of this study was to compare survival in patients with PVD who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) surgery for multivessel coronary artery disease.

METHODS

In-hospital data were collected on 1,305 consecutive patients undergoing coronary revascularization (PCI, n = 341; CABG, n = 964) in northern New England from 1994 to 1996. Patient records were linked to the National Death Index to assess survival out to 3 years (mean 1.2 years). Logistic and Cox proportional hazards regression were used to calculate risk-adjusted odds ratios and hazard ratios.

RESULTS

Compared with CABG patients, those undergoing PCI were more often women, had more renal failure, more prior coronary revascularizations, were more likely to have two-vessel coronary artery disease and were more likely to undergo the procedure emergently. They were less likely to have a history of heart failure. After adjusting for differences in baseline characteristics, patients undergoing CABG had better intermediate survival than did PCI patients (hazard ratio 0.68; 95% confidence interval, 0.46 to 1.00; p = 0.05).

CONCLUSIONS

Patients with multivessel coronary artery disease and PVD undergoing CABG surgery have better intermediate survival out to 3 years than similar patients undergoing PCI. This information may be useful in counseling patients with PVD requiring coronary revascularization.

WBC Count and the Risk of Cancer Mortality in a National Sample of U.S. Adults: Results from the Second National Health and Nutrition Examination Survey Mortality Study

Inflammation has been shown to be a risk factor for several chronic diseases. Few epidemiologic studies have examined the relationship between markers of inflammation and cancer. The current study included 7,674 Second National Health and Nutrition Examination Survey (NHANES II) participants, 30 to 74 years of age, between 1976 and 1980. Mortality follow-up through December 31, 1992 was assessed using the National Death Index and Social Security Administration Death Master File. A graded association between higher WBC and higher risk of total cancer mortality was observed [highest versus lowest quartile (relative risk [RR] 2.23; 95% confidence interval [CI], 1.53-3.23)] after adjusting for age, sex, and race. After further adjustment for smoking, physical activity, body mass index, alcohol intake, education, hematocrit, and diabetes, WBC remained significantly associated (P trend = 0.03) with total cancer mortality [highest versus lowest quartile (RR 1.66; 95% CI, 1.08-2.56)]. In stratified analyses, increased WBC was associated with higher risk of non-lung cancer (P trend = 0.04), but not lung cancer (P trend = 0.18). Among never smokers, a 1 SD increase in WBC (2.2 × 109 cells/L) was associated with greater risk of total (RR 1.32; 95% CI, 1.05-1.67) and non-lung (RR 1.30; 95% CI, 1.03-1.63) cancer mortality. These findings support the hypothesis that inflammation is an independent risk factor for cancer mortality. Additional studies are needed to determine whether circulating levels of inflammatory markers are associated with increased risk of incident cancer.

European system for cardiac operative risk evaluation predicts long-term survival in patients with coronary artery bypass grafting

OBJECTIVE

To evaluate the accuracy of predicting long-term mortality in patients with coronary artery bypass grafting (CABG) by using the European system for cardiac operative risk evaluation (EuroSCORE).

METHODS

Medical records of patients with CABG (n=3760) between January 1992 and March 2002 were retrospectively reviewed and their predicted surgical risk was calculated according to the standard (study A) and logistic (study B) EuroSCORE. In study A the patients were divided into six groups: 0-2 (n=610), 3-5 (n=1479), 6-8 (n=1099), 9-11 (n=452), 12-14 (n=103) and >14 (n=17). In study B the patients were divided into seven groups: 0.00-2.00 (n=447), 2.01-5.00 (n=1190), 5.01-10.00 (n=890), 10.01-20.00 (n=686), 20.01-30.00 (n=234), 30.01-60.00 (n=254) and >60.00 (n=59). Long-term survival was obtained by the National Death Index and Kaplan-Meier curves were constructed and compared employing the log-rank test. Multivariate Cox regression analysis was performed in order to control for pre, intra and postoperative factors and adjusted hazard ratios were calculated for standard and logistic EuroSCORE groups. The receiver operating characteristic (ROC) curves were plotted to assess the discrimination ability of the EuroSCORE.

RESULTS

In study A there were differences among the six groups in 30-day mortality (0.7%, 1.0%, 3.1%, 4.6%, 13.6% and 23.5%; P<0.001), in major complications (8.5%, 10.4%, 16.2%, 20.4%, 31.1% and 35.3%; P<0.001) as well as in actuarial long-term survival (86.2%, 79.6%, 53.6%, 37.9%, 24.9% and 0% from EuroSCORE 0-2 to >14; P<0.001). In study B there were differences among the seven groups in 30-day mortality (0.9%, 1.1%, 1.2%, 3.6%, 3.4%, 8.7% and 15.3%; P<0.001), major complications (8.5%, 10.1%, 12.1%, 18.4%, 16.2%, 26.0% and 30.5%; P<0.001) as well as in actuarial long-term survival (89.5%, 79.9%, 66.9%, 51.0%, 40.3%, 38.4% and 13.7% from EuroSCORE 0.00-2.00 to >60.00; P<0.001). Multivariate Cox regression analysis confirmed that EuroSCORE (standard or logistic) was a statistically significant predictor for long-term mortality, while the area under the ROC curve was 0.72 for either standard or logistic EuroSCORE.

CONCLUSION

The predicted surgical risk in CABG patients as calculated by standard or logistic EuroSCORE is a strong predictor for long-term survival in addition to predicting operative survival for which it was originally designed.

Is off-pump revascularization better for patients with non-dialysis-dependent renal insufficiency?

BACKGROUND

Renal dysfunction is a well-recognized complication following coronary artery bypass grafting (CABG). Coronary revascularization without cardiopulmonary bypass (CPB) has been shown to minimize renal injury in patients with normal preoperative renal function who undergo elective procedures. The purpose of this study was to define the effect of an off-pump revascularization strategy on the incidence of postoperative renal failure and survival of patients with preexisting renal dysfunction.

METHODS

From January 1, 1999, to December 1, 2002, a total of 371 patients were identified as having a preoperative creatinine concentration greater than or equal to 1.5 mg/dL. This number included 291 patients who did not need hemodialysis or peritoneal dialysis to support renal function. These patients were subdivided into those undergoing traditional CABG with CPB (103 patients) and those undergoing off-pump revascularization (188 patients) whose demographic, operative, and outcome information was retrospectively reviewed and compared.

RESULTS

The off-pump cohort was older than the on-pump cohort (70 +/- 9.6 versus 66 +/- 10.9 years; P =.002), had a lower prevalence of previous myocardial infarction (35% versus 50%; P =.008), and had a modestly higher mean left ventricular ejection fraction (0.47 +/- 0.01 versus 0.43 +/- 0.01; P =.017). Otherwise the groups were well matched. The mean preoperative serum creatinine and creatinine clearance values were not significantly different (1.8 +/- 0.5 versus 1.9 +/- 0.6 mg/dL [ P =.372] and 45.1 +/- 15.5 versus 46.8 +/- 17.2 mL/min [ P =.376] for the off-pump and on-pump cohorts, respectively). There was a significant reduction in postoperative renal failure (17% versus 9% of patients; P =.020) and need for new dialysis (10% versus 3% of patients; P =.022) when CPB was eliminated. Intermediate-term survival analysis revealed a survival benefit for the off-pump group (70% versus 57%) at 42 months, although this value did not reach statistical significance ( P =.143).

CONCLUSION

The results of this study suggested that patients with preoperative non-dialysis-dependent renal insufficiency have more favorable outcome when revascularization is done off pump. Avoidance of CPB results in (1) a reduction in the incidence of postoperative renal failure; (2) a reduction in the need for new dialysis; and (3) improved in-hospital and midterm survival.

Use of the Social Security Administration Death Master File for ascertainment of mortality status

Objectives

Internet sources that use the Social Security Administration's (SSA) Death Master File have demonstrated high sensitivity among males for detection of mortality status in comparisons to the National Death Index, but the sensitivity has not been investigated for other demographic groups.

Methods

The authors used the SSA Death Master File to determine the mortality status of 374 decedents from the ongoing Patient Outcomes Study at Cedars-Sinai Medical Center whose deaths were confirmed by physicians using hospital records.

Results

Decedents identified by the SSA Death Master File were significantly older than those not identified. Foreign-born decedents were significantly less likely to be identified as dead than American-born decedents. Gender and marital status were not significant factors for identification by the SSA Death Master File.

Conclusion

The results of this study suggest that Internet sources may be used as an inexpensive and effective tool for determination of mortality status. However, among certain populations use of these databases alone may provide incomplete information.

Racial segregation and longevity among African Americans: an individual-level analysis

OBJECTIVE

To test the relationship between racial segregation and mortality using a multidimensional questionnaire-based measure of exposure to segregation.

DATA SOURCES

Data for this analysis come from the National Survey of Black Americans (NSBA), a national multistage probability sample of 2,107 African Americans (aged 18-101). The NSBA was conducted as a household survey. The NSBA was matched with the National Death Index (NDI).

STUDY DESIGN

Prospective cohort study, where Cox regression analysis was used to examine the effect of baseline variables on time to death over a 13-year period.

PRINCIPAL FINDINGS

Respondents who were exposed to racial segregation were significantly less likely to survive the study period after controls for age, health status, and other predictors of mortality.

CONCLUSION

The results support previous studies linking segregation with health outcomes.

Linking hospital discharge and death records—accuracy and sources of bias

BACKGROUND AND OBJECTIVE

The aim of this study was to develop and apply an automated linkage algorithm to 10 years of California hospitalization discharge abstracts and death records (1990 to 1999), evaluate linkage accuracy, and identify sources of bias.

METHODS

Among the 1,858,458 acute hospital discharge records with unique social security numbers (SSNs) from 1 representative year of discharge data (1997), which had at least 2 years of follow-up, 66,410 of 69,757 deaths occurring in the hospital (95%) and 66,998 of 1,788,701 of individuals discharged alive (3.7%) linked to death records. Linkage sensitivity and specificity were estimated as 0.9524 and 0.9998 and positive and negative predictive values as 0.994 and 0.998 (corresponding to 400 incorrect death linkages among out-of-hospital death record linkages and 3,300 unidentified record pairs among unlinked live discharges).

RESULTS

Based upon gold standard linkage rates, discharge records for those of age 1 year and older without SSNs may have 2,520 additional uncounted posthospitalization deaths at 1 year after admission. Gold standard comparison for those with SSNs showed women, the elderly, and Hispanics and non-Hispanic Blacks had more unlinked hospital death records, although absolute differences were small. The concentration of unidentified linkages among discharge records of traditionally vulnerable populations may result in understating mortality rates and other estimates (i.e., events with competing hazard of death) for these populations if SSN is differentially related to a patient's disease severity and comorbidities.

CONCLUSION

Because identification of cases of out-of-hospital deaths has improved over the past decade, observed improvements in patient survival over this time are likely to be conservative.

Assessment of mortality after long-term follow-up of patients with community-acquired pneumonia

Although studies have assessed short-term mortality among patients with community-acquired pneumonia, there is limited data on prognosis and risk factors that affect long-term mortality. The mortality among patients enrolled at 4 sites of the Pneumonia Patient Outcome Research Team cohort study who survived at least 90 days after presentation to the hospital was compared with that among age-matched control subjects. Overall, 1419 of 1555 patients survived for >90 days, with a mean follow-up period of 5.9 years. There was significantly higher long-term mortality among patients with pneumonia than among age-matched controls. Factors significantly associated with long-term mortality were age (stratified by decade), do-not-resuscitate status, poor nutritional status, pleural effusion, glucocorticoid use, nursing home residence, high school graduation level or less, male sex, preexisting comorbid illnesses, and the lack of feverishness. This study demonstrates that there is significantly higher long-term mortality among patients with pneumonia than among age-matched controls and that long-term mortality largely is not affected by acute physiologic derangements.

Prevalence of risk factors, and not gender per se, determines short- and long-term survival after coronary artery bypass surgery

OBJECTIVE

Much attention has been directed towards female gender as an independent risk factor for in-hospital mortality after coronary artery bypass grafting surgery; however, the effects of surgery are known to persist for 6 months or more. Studies that have compared postoperative survival in women and men beyond hospital discharge report disparate results with regard to the independent effect of gender per se on ultimate survival.

DESIGN

This investigation was a prospective, observational study.

SETTING

The study was a multicenter investigation involving 24 US medical centers.

PARTICIPANTS

There were 2,048 patients undergoing isolated coronary artery bypass graft surgery enrolled between September 1991 and September 1993 and after discharge.

INTERVENTIONS

There were no interventions with this prospective observational study.

MEASUREMENTS AND MAIN RESULTS

Preoperative demographic variables, medical history, and angiographic data were collected for each patient at the time of enrollment. Patients' vital status through the National Death Index up to August 31, 1998, were added to assess postoperative long-term survival. For survivorship analysis, the Kaplan-Meier product-limit method was used with Cox regression model. Survivorship analyses were performed separately and in combination on mortality within 30 days and 6 months of coronary artery bypass graft surgery and during the entire postoperative follow-up period. Among women, preoperative disease status, as expected, was more severe than that in men. Women were older (p = 0.0001) and had more comorbidity, such as congestive heart failure (p = 0.0019), diabetes (p = 0.0001), anemia, and hypertension (p = 0.0001). After surgery, unadjusted survival of 6 months and 5 years in women was worse than that in men. However, there were no gender-related differences in short- or long-term survival after adjusting for covariates in the multivariate model. Preoperative conditions, such as congestive heart failure, anemia, diabetes, and advanced age, are indicative of greater risk in both women and men for lower survival after coronary artery bypass graft surgery.

CONCLUSIONS

Disease prevalence in women, and not gender per se, affects mid- and long-term survival after cardiac surgery. Attention, therefore, should be focused on efforts to reduce or modify such disease prevalence earlier in women, which may in turn allow longer survival after surgical intervention. Differences in postoperative survival between women and men were related to the gender differences in the distribution of preoperative risk factors.

Estimated Number of Children Left Motherless by AIDS in the United States, 1978???1998

When a mother dies of AIDS, basic needs of her children may be left unmet. To estimate the number and characteristics of maternal AIDS orphans in the United States, demographic techniques were applied to data from several sources. From the national HIV/AIDS surveillance system, reporting delays were adjusted for the number of deaths among women aged 15-44 diagnosed with AIDS through 1998 and reported as deceased by December 1999. No fertility was assumed in the year preceding death. To the adjusted number of deaths the annual age- and race-specific cumulative fertility and infant mortality rates from national vital statistics were applied. A perinatal infection rate of 25% was assumed among children born through 1994, and 10% among children born after 1994. Through 1998, 51,473 women died leaving 97,376 children motherless. Of the estimated 76,661-87,0018 uninfected children, 83% were younger than 21 years when orphaned. After increasing each year, the annual number of orphaned children younger than 21 years peaked in 1995. In 1998, between 4252-4489 uninfected youth were added to 47,863-54,025 existing orphans younger than age 21. Due to declines in AIDS deaths, the annual number of children orphaned by AIDS has declined. Nevertheless, each year thousands of youth are orphaned.

Long-term prognostic implication of extracardiac vascular disease in patients undergoing percutaneous coronary intervention

Patients with extracardiac vascular disease were identified from 2,372 consecutive percutaneous coronary intervention (PCI) cases performed between 1997 and 2001. After multivariate adjustment, we found the presence of extracardiac vascular disease to be associated with a significantly higher risk for late mortality (hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.0 to 2.0, p = 0.029). When extracardiac vascular disease was separated into cerebrovascular disease and peripheral vascular disease, cerebrovascular disease was less common but was associated with a trend towards worse survival.