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Miles LF, Sandhu RNS, Grobler AC, Heritier S, Burgess A, Burbury KL, Story DA. Associations between non-anaemic iron deficiency and outcomes following surgery for colorectal cancer: An exploratory study of outcomes relevant to prospective observational studies. Anaesth Intensive Care 2019; 47:152-159. [DOI: 10.1177/0310057x19838899] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Iron deficiency is common in colorectal cancer. Despite perioperative guidelines advocating for the correction of non-anaemic iron deficiency prior to major surgery, the impact of this pathology on postoperative outcome is unclear. We conducted a single-centre, historical cohort study of 141 elective resections for colorectal cancer. We stratified non-anaemic patients into iron deficient and iron replete groups, and collected data on baseline characteristics, preoperative laboratory results, intraoperative events and postoperative outcomes. As this study was an exploratory work for future research, a P-value of 0.25 was considered relevant. Patients in the deficient group demonstrated lower baseline ferritin (median (interquartile range, IQR) 76 (41–141) µg/L versus 207 (140–334) µg/L, P < 0.001) and transferrin saturation (mean (standard deviation, SD) 18% (8%) versus 32% (12%), P < 0.001) than those in the replete group, and lower starting haemoglobin (mean (SD) 138 (10) g/L versus 144 (12) g/L, P = 0.01). The deficient group had increased re-admission (25% (24%) versus 4% (11%), P = 0.15) and all-cause infection (25% (24%) versus 5% (14%), P = 0.24). A decrease of two days in days alive and out of hospital at postoperative day 90 was seen in the deficient group on univariate analysis (median (IQR) 81 (75–84) versus 83 (78–84), P = 0.25). This reduced to 1.24 days in multivariate adjusted quantile regression analysis ( P = 0.22). Days alive and out of hospital at day 90, postoperative re-admission and postoperative infection may be meaningful outcome measures for future prospective observational work examining non-anaemic iron deficiency in patients undergoing major surgery for colorectal cancer.
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Affiliation(s)
- Lachlan F Miles
- Department of Anaesthesia, Austin Health, Melbourne, Australia
- Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Australia
| | | | | | - Stephane Heritier
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Adele Burgess
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - Kate L Burbury
- Division of Haematology, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - David A Story
- Department of Anaesthesia, Austin Health, Melbourne, Australia
- Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Australia
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Bell M, Eriksson LI, Svensson T, Hallqvist L, Granath F, Reilly J, Myles PS. Days at Home after Surgery: An Integrated and Efficient Outcome Measure for Clinical Trials and Quality Assurance. EClinicalMedicine 2019; 11:18-26. [PMID: 31317130 PMCID: PMC6610780 DOI: 10.1016/j.eclinm.2019.04.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Surgical audit, sometimes including public reporting, is an important foundation of high quality health care. We aimed to assess the validity of a novel outcome metric, days at home up to 30 days after surgery, as a surgical outcome measure in clinical trials and quality assurance. METHODS This was a multicentre, registry-based cohort study. We used prospectively collected hospital and national healthcare registry data obtained from patients aged 18 years or older undergoing a broad range of surgeries in Sweden over a 10-year period. The association between days at home up to 30 days after surgery and patient (older age, poorer physical status, comorbidity) and surgical (elective or non-elective, complexity, duration) risk factors, process of care outcomes (re-admissions, discharge destination), clinical outcomes (major complications, 30-day mortality) and death up to 1 year after surgery were measured. FINDINGS From January, 2005, to December, 2014, we obtained demographic and perioperative data on 636,885 patients from 21 Swedish hospitals. Mortality at 30 days and one year was 1.8% and 7.3%, respectively. The median (IQR) days at home up to 30 days after surgery was 27 (23-29), being significantly lower among high-risk patients, those recovering from more complex surgical procedures, and suffering serious postoperative complications (all p < 0.0001). Patients with 8 days or less at home up to 30 days after surgery had a nearly 7-fold higher risk of death up to 1 year postoperatively when compared with those with 29 or 30 days at home (adjusted HR 6.78 [95% CI: 6.44-7.13]). INTERPRETATION Days at home up to 30 days after surgery is a valid, easy to measure patient-centred outcome metric. It is highly sensitive to changes in surgical risk and impact of complications, and has prognostic importance; it is therefore a valuable endpoint for perioperative clinical trials and quality assurance. FUNDING Swedish National Research Council Medicine and Stockholm County Council ALF-project grant (LE), and the Australian National Health and Medical Research Council (PM).
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Affiliation(s)
- Max Bell
- Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Lars I. Eriksson
- Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Svensson
- Department of Medicine, Clinical Epidemiology Unit, Karolinska Institute, Stockholm, Sweden
| | - Linn Hallqvist
- Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Granath
- Department of Medicine, Clinical Epidemiology Unit, Karolinska Institute, Stockholm, Sweden
| | - Jennifer Reilly
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
- The Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia
| | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
- The Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia
- Corresponding author at: Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Commercial Road, Melbourne, Victoria 3004, Australia.
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103
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Webster CS. Evidence and efficacy: time to think beyond the traditional randomised controlled trial in patient safety studies. Br J Anaesth 2019; 122:723-725. [PMID: 30954239 DOI: 10.1016/j.bja.2019.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/16/2019] [Accepted: 02/22/2019] [Indexed: 12/31/2022] Open
Affiliation(s)
- Craig S Webster
- Department of Anaesthesiology and Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand.
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104
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Hannam J, Mitchell S, Cumin D, Frampton C, Merry A, Moore M, Kruger C. Haemodynamic profiles of etomidate vs propofol for induction of anaesthesia: a randomised controlled trial in patients undergoing cardiac surgery. Br J Anaesth 2019; 122:198-205. [DOI: 10.1016/j.bja.2018.09.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/28/2018] [Accepted: 09/21/2018] [Indexed: 11/25/2022] Open
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Lee H, Shi SM, Kim DH. Home Time as a Patient-Centered Outcome in Administrative Claims Data. J Am Geriatr Soc 2018; 67:347-351. [PMID: 30578532 DOI: 10.1111/jgs.15705] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 10/15/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Home time, the number of days alive and spent out of hospital and skilled nursing facility, has been proposed as a patient-centered outcome that can be readily calculated in administrative claims data. OBJECTIVES To compare home time against existing patient-centered outcome measures. DESIGN Retrospective cohort study. SETTING Community. PARTICIPANTS A total of 4594 Medicare beneficiaries 65 years or older with complete survey and claims data in the Medicare Current Beneficiary Survey 2010 to 2011. MEASUREMENTS Home time was calculated from the 2011 claims data (range, 0-365 days). The 1-year incidence of patient-centered outcomes (poor self-rated health, mobility impairment, depression, limited social activity, and difficulty in self-care) was measured. The minimum clinically important difference (MCID) was derived by contrasting the mean home time between those who experienced functional decline or death and those who did not. RESULTS The mean home time was 355.8 days (SD, 42.1 days); 84.1% had a home time of 365 days, and 5.7% had a home time of 336 days or fewer. The incidence of poor self-rated health ranged from 2% (home time, 365 days) to 21% (home time, less than 337 days). Similarly, the corresponding incidence risks were 11% to 59% for mobility impairment, 5% to 19% for depression, 17% to 67% for limited social activity, and 13% to 68% for difficulty in self-care. The risk of mobility impairment, depression, and difficulty in self-care increased steeply after home time loss of 15 days or greater. The MCID of home time was 18.6 days. CONCLUSION A loss in home time is associated with decline in several patient-centered outcome measures in community-dwelling Medicare beneficiaries. These results provide empirical evidence to promote adoption of home time and its clinical interpretation for database studies of medical interventions. J Am Geriatr Soc 67:347-351, 2019.
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Affiliation(s)
- Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sandra M Shi
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
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106
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Nazzari H, Hawkins NM, Ezekowitz J, Lauck S, Ding L, Polderman J, Yu M, Boone RH, Cheung A, Ye J, Wood D, Webb J, Toma M. The Relationship Between Heart-Failure Hospitalization and Mortality in Patients Receiving Transcatheter Aortic Valve Replacement. Can J Cardiol 2018; 35:413-421. [PMID: 30853134 DOI: 10.1016/j.cjca.2018.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Patients who have had transcatheter aortic valve replacement (TAVR) are at risk of hospitalization during the first year postprocedure. Few studies have examined the incidence of heart- failure hospitalizations (HFH) post-TAVR and the impact this has on subsequent hospitalizations and mortality. Our aim was to determine the incidence, predictors, and mortality associated with HFH post-TAVR. METHODS We used prospectively collected data for all patients who underwent TAVR between August 1, 2010, and March 31, 2015; 742 consecutive patients who underwent TAVR during the study period were included. Patients were followed for a minimum of 1 year post-TAVR. RESULTS Mean age was 80.9 ± 8.1, and 58.2% were men. Hospitalizations post-TAVR occurred in 20% of patients at 30 days and 59.7% at 1 year. Of patients hospitalized, HFH was the primary cause of hospitalization in 25.8% and 21.4% of patients at 30 days and 1 year post-TAVR, respectively. Patients with HFH at either 30 days or 1 year had higher subsequent rates of rehospitalization compared with patients who had non-HFH. Patients with HFH or non-HFH at 30 days had 1-year mortality rates of 23.1% and 21.4%, respectively, whereas those with HFH by 1 year had a higher 1-year rate of mortality compared with patients who had non-HFHs (25% vs 10.9%, P < 0.001). CONCLUSIONS HF accounts for a quarter of all hospitalizations post-TAVR and is associated with higher rates of subsequent rehospitalization and death compared with those who had non-HFH. Understanding predictors of readmissions post-TAVR will allow for better risk stratification and improve outcomes in patients receiving TAVR.
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Affiliation(s)
- Hamed Nazzari
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nathaniel M Hawkins
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Justin Ezekowitz
- Department of Medicine and the Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Sandra Lauck
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lillian Ding
- Cardiac Services British Columbia, Vancouver, British Columbia, Canada
| | - Jopie Polderman
- Cardiac Services British Columbia, Vancouver, British Columbia, Canada
| | - Maggie Yu
- Cardiac Services British Columbia, Vancouver, British Columbia, Canada
| | - Robert H Boone
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anson Cheung
- Division of Cardiovascular Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jian Ye
- Division of Cardiovascular Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Wood
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Webb
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mustafa Toma
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
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107
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Neeland IJ, Das SR, Simon DN, Diercks DB, Alexander KP, Wang TY, de Lemos JA. The obesity paradox, extreme obesity, and long-term outcomes in older adults with ST-segment elevation myocardial infarction: results from the NCDR. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 3:183-191. [PMID: 28838094 DOI: 10.1093/ehjqcco/qcx010] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/28/2017] [Indexed: 11/13/2022]
Abstract
Aims To investigate the obesity paradox and association of extreme obesity with long-term outcomes among older ST-segment elevation myocardial infarction (STEMI) patients. Methods and results Nineteen thousand four hundred and ninety-nine patients ≥65 years with STEMI surviving to hospital discharge in NCDR ACTION Registry-GWTG linked to Centers for Medicare and Medicaid Services outcomes between 2007 and 2012 were stratified by body mass index (BMI) (kg/m2) into normal weight (18.5-24.9), overweight (25-29.9), class I (30-34.9), class II (35-39.9), and class III/extreme obese (≥40) categories. Multivariable-adjusted associations were evaluated between BMI categories and mortality by Cox proportional hazards models, and days alive and out of hospital (DAOH) by generalized estimating equations, within 3 years after discharge. Seventy percent of patients were overweight/obese and 3% extremely obese. Normal weight patients were older and more likely to smoke; while extremely obese patients were younger and more likely to be female and black, with lower socioeconomic status and more comorbidity (P ≤ 0.001). A U-shaped association was observed between BMI categories and mortality: patients with class I obesity were at lowest risk, while normal weight [hazard ratio (HR) 1.30, 95% confidence interval (CI) 1.15-1.47] and extremely obese patients (HR 1.33, 95% CI 1.02-1.74) had higher mortality. Normal weight [odds ratio (OR) 0.79, 95% CI 0.68-0.90] and extremely obese (OR 0.73, 95% CI 0.54-0.99) individuals also had lower odds of DAOH. Conclusion Mild obesity is associated with lower long-term risk in older STEMI patients, while normal weight and extreme obesity are associated with worse outcomes. These findings highlight hazards faced by an increasing number of older individuals with normal weight or extreme obesity and cardiovascular disease.
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Affiliation(s)
- Ian J Neeland
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, 75390 Texas, USA
| | - Sandeep R Das
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, 75390 Texas, USA
| | - DaJuanicia N Simon
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, 27705 North Carolina, USA
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, 75390 Texas, USA
| | - Karen P Alexander
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, 27705 North Carolina, USA
| | - Tracy Y Wang
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, 27705 North Carolina, USA
| | - James A de Lemos
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, 75390 Texas, USA
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108
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Myles PS, Dieleman JM, Forbes A, Heritier S, Smith JA. Dexamethasone for Cardiac Surgery trial (DECS-II): Rationale and a novel, practice preference-randomized consent design. Am Heart J 2018; 204:52-57. [PMID: 30081275 DOI: 10.1016/j.ahj.2018.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 06/14/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Numerous studies have investigated high-dose corticosteroids in cardiac surgery, but with mixed results leading to ongoing variations in practice around the world. DECS-II is a study comparing high-dose dexamethasone with placebo in patients undergoing cardiac surgery. METHODS We discuss the rationale for conducting DECS-II, a 2800-patient, pragmatic, multicenter, assessor-blinded, randomized trial in cardiac surgery, and the features of the DECS-II study design (objectives, end points, target population, based on practice preference with post-randomization consent, treatments, patient follow-up and analysis). CONCLUSIONS The DECS-II trial will use a novel, efficient trial design to evaluate whether high-dose dexamethasone has a patient-centered benefit of enhancing recovery and increasing the number of days at home after cardiac surgery.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Department of Anaesthesia and Perioperative Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Epidemiology, Monash University; Melbourne, Victoria, Australia.
| | - Jan M Dieleman
- Department of Anaesthesia, University Medical Center, Utrecht, The Netherlands
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, School of Public Health and Epidemiology, Monash University; Melbourne, Victoria, Australia
| | - Stephane Heritier
- Department of Epidemiology and Preventive Medicine, School of Public Health and Epidemiology, Monash University; Melbourne, Victoria, Australia
| | - Julian A Smith
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, Victoria, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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109
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Huynh Q, Venn AJ, Marwick TH. Socioeconomic Disadvantage and Days at Home After Hospital Discharge of Patients with Heart Failure. Am J Cardiol 2018; 122:616-624. [PMID: 29960665 DOI: 10.1016/j.amjcard.2018.04.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 04/24/2018] [Accepted: 04/30/2018] [Indexed: 10/28/2022]
Abstract
The risk of heart failure (HF) readmission may be reduced by disease management programs, but the resource-intensive nature of these requires targeting to the greatest need. As socioeconomic status (SES) is related to other health outcomes, we sought whether regional markers of SES were associated with days at home (alive and out of hospital) after discharge. This study used statewide data of 1,391 HF patients who had their first ever HF admission to a public hospital in Tasmania (Australia) during 2009 to 2012. Measurements of residential SES included four indexes and a remoteness index generated by the Australian Bureau of Statistics. The primary outcome was days at home. Secondary outcomes included 30- and 90-day readmission or death, number of readmissions, and days to first readmission. Our HF patients had a median of 352 days at home [interquartile range 167, 361]. All four SES indexes and the remoteness index (p <0.001) were adversely associated with days at home, independent of other clinical and nonclinical factors. Findings for readmission at 30 and 90 days of discharge were inconsistent; the index of Relative Socioeconomic Advantage and Disadvantage (but not other SES indexes) was independently associated with 30-day readmission (odds ratio 1.58, p = 0.008) and remoteness index was significantly associated with 90-day readmission (odds ratio = 1.99, p = 0.009). Analyzing days to first readmission did not show any significant differences among categories of SES (log-rank test p = 0.81) or remoteness index (log-rank test p = 0.47). Thus, residential SES is associated with adverse outcome in HF, and might be useful in planning services to reduce HF readmission.
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Catto JWF, Khetrapal P, Ambler G, Sarpong R, Khan MS, Tan M, Feber A, Dixon S, Goodwin L, Williams NR, McGrath J, Rowe E, Koupparis A, Brew-Graves C, Kelly JD. Robot-assisted radical cystectomy with intracorporeal urinary diversion versus open radical cystectomy (iROC): protocol for a randomised controlled trial with internal feasibility study. BMJ Open 2018; 8:e020500. [PMID: 30093510 PMCID: PMC6089318 DOI: 10.1136/bmjopen-2017-020500] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Bladder cancer (BC) is a common malignancy and one of the most expensive to manage. Radical cystectomy (RC) with pelvic lymphadenectomy is a gold standard treatment for high-risk BC. Reductions in morbidity and mortality from RC may be achieved through robot-assisted RC (RARC). Prospective comparisons between open RC (ORC) and RARC have been limited by sample size, use of extracorporeal reconstruction and use of outcomes important for ORC. Conversely, while RARC is gaining in popularity, there is little evidence to suggest it is superior to ORC. We are undertaking a prospective randomised controlled trial (RCT) to compare RARC with intracorporeal reconstruction (iRARC) and ORC using multimodal outcomes to explore qualitative and quantitative recovery after surgery. METHODS AND ANALYSIS: iROC is a multicentre prospective RCT in English National Health Service (NHS) cancer centres. We will randomise 320 patients undergoing RC to either iRARC or ORC. Treatment allocation will occur after trial entry and consent. The primary outcome is days alive and out of hospital within the first 90 days from surgery. Secondary outcomes will measure functional recovery (activity trackers, chair-to-stand tests and health related quality of life (HRQOL) questionnaires), morbidity (complications and readmissions), cost-effectiveness (using EuroQol-5 Domain-5 levels (EQ-5D-5L) and unit costs) and surgeon fatigue. Patients will be analysed according to intention to treat. The primary outcome will be transformed and analysed using regression. All statistical assumptions will be investigated. Secondary outcomes will be analysed using appropriate regression methods. An internal feasibility study of the first 30 patients will evaluate recruitment rates, acceptance of randomised treatment choice, compliance outcome collection and to revise our sample size. ETHICS AND DISSEMINATION The study has ethical approval (REC reference 16/NE/0418). Findings will be made available to patients, clinicians, funders and the NHS through peer-reviewed publications, social media and patient support groups. TRIAL REGISTRATION NUMBERS ISRCTN13680280 and NCT03049410.
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Affiliation(s)
- James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Pramit Khetrapal
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Rachael Sarpong
- Surgical and Interventional Trials Unit (SITU), Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Melanie Tan
- Surgical and Interventional Trials Unit (SITU), Division of Surgery and Interventional Science, University College London, London, UK
| | - Andrew Feber
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Simon Dixon
- Health Economics and Decision Science, NIHR Research Design Service Yorkshire and the Humber, University of Sheffield, Sheffield, UK
| | - Louise Goodwin
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Norman R Williams
- Surgical and Interventional Trials Unit (SITU), Division of Surgery and Interventional Science, University College London, London, UK
| | - John McGrath
- Department of Urology, Royal Devon and Exeter NHS Trust, Exeter, UK
| | - Edward Rowe
- Department of Urology, North Bristol NHS Trust, Bristol, UK
| | | | - Chris Brew-Graves
- Surgical and Interventional Trials Unit (SITU), Division of Surgery and Interventional Science, University College London, London, UK
| | - John D Kelly
- Division of Surgery and Interventional Science, University College London, London, UK
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Jones DA, Whittaker P, Rathod KS, Richards AJ, Andiapen M, Antoniou S, Mathur A, Ahluwalia A. Sodium Nitrite-Mediated Cardioprotection in Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: A Cost-Effectiveness Analysis. J Cardiovasc Pharmacol Ther 2018; 24:113-119. [PMID: 30081658 DOI: 10.1177/1074248418784940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES In the follow-up of patients in a trial of intracoronary sodium nitrite given during primary percutaneous coronary intervention (PCI) after acute myocardial infarction (AMI), we found a reduction in the incidence of major adverse cardiac events (MACEs). Specifically, MACE rates were 5.2% versus 25.0% with placebo at 3 years ( P = .013). Such MACE reductions should also be associated with economic benefit. Thus, we assessed the cost utility of sodium nitrite therapy versus standard primary PCI only. METHODS AND RESULTS We developed a model to simulate costs and quality-adjusted life years (QALYs) over the first 36 months after ST-Segment Elevation Myocardial Infarction (STEMI). Decision tree analysis was used to assess different potential cardiovascular outcomes after STEMI for patients in both treatment groups. Model inputs were derived from the NITRITE-AMI study. Cost of comparative treatments and follow-up in relation to cardiovascular events was calculated from the United Kingdom National Health Service perspective. Higher procedural costs for nitrite treatment were offset by lower costs for repeat revascularization, myocardial infarction, and hospitalization for heart failure compared to primary PCI plus placebo. Nitrite treatment was associated with higher utility values (0.91 ± 0.19 vs 0.82 ± 0.30, P = .041). The calculated incremental cost-effectiveness ratio of £2177 per QALY indicates a cost-effective strategy. Furthermore, positive results were maintained when input parameters varied, indicating the robustness of our model. In fact, based on the difference in utility values, the cost of nitrite could increase by 4-fold (£2006 per vial) and remain cost-effective. CONCLUSION This first analysis of sodium nitrite as a cardioprotective treatment demonstrates cost-effectiveness. Although more comparative analysis and assessment of longer follow-up times are required, our data indicate the considerable potential of nitrite-mediated cardioprotection.
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Affiliation(s)
- Daniel A Jones
- 1 Barts NIHR Biomedical Research Centre, Barts and The London Medical School, Queen Mary University, London, United Kingdom.,2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom.,3 Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Peter Whittaker
- 3 Department of Health Policy, London School of Economics and Political Science, London, United Kingdom.,4 Department of Emergency Medicine, Cardiovascular Research Institute, Wayne State University, Detroit, MI, USA
| | - Krishnaraj S Rathod
- 1 Barts NIHR Biomedical Research Centre, Barts and The London Medical School, Queen Mary University, London, United Kingdom.,2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Amy J Richards
- 2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Mervyn Andiapen
- 2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Sotiris Antoniou
- 2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Anthony Mathur
- 1 Barts NIHR Biomedical Research Centre, Barts and The London Medical School, Queen Mary University, London, United Kingdom.,2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Amrita Ahluwalia
- 1 Barts NIHR Biomedical Research Centre, Barts and The London Medical School, Queen Mary University, London, United Kingdom.,2 Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
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Left Ventricular Device Implantation Impacts on Hospitalisation Rates, Length of Stay and Out of Hospital Time. Heart Lung Circ 2018; 27:708-715. [DOI: 10.1016/j.hlc.2017.06.717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/15/2017] [Accepted: 06/02/2017] [Indexed: 11/23/2022]
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Bittermann T, Hubbard RA, Serper M, Lewis JD, Hohmann SF, VanWagner LB, Goldberg DS. Healthcare utilization after liver transplantation is highly variable among both centers and recipients. Am J Transplant 2018; 18:1197-1205. [PMID: 29024364 PMCID: PMC5895535 DOI: 10.1111/ajt.14539] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 01/25/2023]
Abstract
The relationship between healthcare utilization before and after liver transplantation (LT), and its association with center characteristics, is incompletely understood. This was a retrospective cohort study of 34 402 adult LTs between 2002 and 2013 using Vizient inpatient claims data linked to the United Network for Organ Sharing (UNOS) database. Multivariable mixed-effects linear regression models evaluated the association between hospitalization 90 days pre-LT and the number of days alive and out of the hospital (DAOH) 1 year post-LT. Of those patients alive at LT discharge, 24.7% spent ≥30 days hospitalized during the first year. Hospitalization in the 90 days pre-LT was inversely associated with DAOH (β = -3.4 DAOH/week hospitalized pre-LT; P = .002). Centers with >30% of their liver transplant recipients hospitalized ≥30 days in the first LT year were typically smaller volume and/or transplanting higher risk recipients (Model for End-Stage Liver Disease [MELD] score ≥35, inpatient or ventilated pre-LT). In conclusion, pre-LT hospitalization predicts 1-year post-LT hospitalization independent of MELD score at the patient-level, whereas center-specific post-LT healthcare utilization is associated with certain center behaviors and selection practices.
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Affiliation(s)
- T Bittermann
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - R A Hubbard
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - M Serper
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - J D Lewis
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - S F Hohmann
- Center for Advanced Analytics, Vizient, Chicago, IL, USA
| | - L B VanWagner
- Division of Gastroenterology & Hepatology and Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - D S Goldberg
- Division of Gastroenterology & Hepatology, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
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Buggy DJ, Freeman J, Johnson MZ, Leslie K, Riedel B, Sessler DI, Kurz A, Gottumukkala V, Short T, Pace N, Myles PS. Systematic review and consensus definitions for standardised endpoints in perioperative medicine: postoperative cancer outcomes. Br J Anaesth 2018; 121:38-44. [PMID: 29935592 DOI: 10.1016/j.bja.2018.03.020] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/22/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND The Standardising Endpoints for Perioperative Medicine group was established to derive an appropriate set of endpoints for use in clinical trials related to anaesthesia and perioperative medicine. Anaesthetic or analgesic technique during cancer surgery with curative intent may influence the risk of recurrence or metastasis. However, given the current equipoise in the existing literature, prospective, randomised, controlled trials are necessary to test this hypothesis. As such, a cancer subgroup was formed to derive endpoints related to research in onco-anaesthesia based on a current evidence base, international consensus and expert guidance. METHODS We undertook a systematic review to identify measures of oncological outcome used in the oncological, surgical, and wider literature. A multiround Delphi consensus process that included up to 89 clinician-researchers was then used to refine a recommended list of endpoints. RESULTS We identified 90 studies in a literature search, which were the basis for a preliminary list of nine outcome measures and their definitions. A further two were added during the Delphi process. Response rates for Delphi rounds one, two, and three were 88% (n=9), 82% (n=73), and 100% (n=10), respectively. A final list of 10 defined endpoints was refined and developed, of which six secured approval by ≥70% of the group: cancer health related quality of life, days alive and out of hospital at 90 days, time to tumour progression, disease-free survival, cancer-specific survival, and overall survival (and 5-yr overall survival). CONCLUSION Standardised endpoints in clinical outcomes studies will support benchmarking and pooling (meta-analysis) of trials. It is therefore recommended that one or more of these consensus-derived endpoints should be considered for inclusion in clinical trials evaluating a causal effect of anaesthesia-analgesia technique on oncological outcomes.
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Affiliation(s)
- D J Buggy
- Department of Anaesthesia, Mater Misericordiae University Hospital, School of Medicine, University College Dublin, Ireland; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - J Freeman
- Department of Anaesthesia, Mater Misericordiae University Hospital, School of Medicine, University College Dublin, Ireland
| | - M Z Johnson
- Department of Anaesthesia, Mater Misericordiae University Hospital, School of Medicine, University College Dublin, Ireland
| | - K Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne Medical School, University of Melbourne, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and University of Melbourne, Australia
| | - D I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - A Kurz
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - V Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - T Short
- Auckland City Hospital, Auckland, New Zealand
| | - N Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - P S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
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Abdullah HR, Tan SR, Lee SJ, Bin Abd Razak HR, Seet RH, Ying H, Sethi E, Sim EY. Protocol for a single-centre prospective observational study of postoperative delirium following total joint arthroplasties among South East Asians. BMJ Open 2018; 8:e019426. [PMID: 29511014 PMCID: PMC5855196 DOI: 10.1136/bmjopen-2017-019426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Postoperative delirium is a serious and common complication in older adults following total joint arthroplasties (TJA). It is associated with increased risk of postoperative complications, mortality, length of hospital stay and postdischarge institutionalisation. Thus, it has a negative impact on the health-related quality of life of the patient and poses a large economic burden. This study aims to characterise the incidence of postoperative delirium following TJA in the South East Asian population and investigate any risk factors or associated outcomes. METHODS AND ANALYSIS This is a single-centre prospective observational study recruiting patients between 65 and 90 years old undergoing elective total knee arthroplasty or total hip arthroplasty. Exclusion criteria included patients with clinically diagnosed dementia. Preoperative and intraoperative data will be obtained prospectively. The primary outcome will be the presence of postoperative delirium assessed using the Confusion Assessment Method on postoperative days 1, 2 and 3 and day of discharge. Other secondary outcomes assessed postoperatively will include hospital outcomes, pain at rest, knee and hip function, health-related quality of life and Postoperative Morbidity Survey-defined morbidity. Data will be analysed to calculate the incidence of postoperative delirium. Potential risk factors and any associated outcomes of postoperative delirium will also be determined. ETHICS AND DISSEMINATION This study has been approved by the Singapore General Hospital Institutional Review Board (SGH IRB) (CIRB Ref: 2017/2467) and is registered on the ClinicalTrials.gov registry (Identified: NCT03260218). An informed consent form will be signed by all participants before recruitment and translators will be made available to non-English-speaking participants. The results of this study will be presented at international conferences and submitted to a peer-reviewed journal. The data collected will also be made available in a public data repository. TRIAL REGISTRATION NUMBER NCT03260218.
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Affiliation(s)
- Hairil Rizal Abdullah
- Department of Anesthesiology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | | | - Si Jia Lee
- Department of Anesthesiology, Singapore General Hospital, Singapore
| | | | | | - Hao Ying
- Health Services Research Unit, Division of Medicine, Singapore General Hospital, Singapore
| | - Ervin Sethi
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Eileen Yilin Sim
- Department of Anesthesiology, Singapore General Hospital, Singapore
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Affiliation(s)
| | - Junshan Qiu
- Division of Biometrics I, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Duolao Wang
- Liverpool School of Tropical Medicine, Liverpool, UK
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Khetrapal P, Tan WS, Lamb B, Tan M, Baker H, Thompson J, Sridhar A, Kelly JD, Briggs T. The Role of Robotics in the Invasive Management of Bladder Cancer. Curr Urol Rep 2017. [PMID: 28634646 DOI: 10.1007/s11934-017-0706-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Robot-assisted radical cystectomy (RARC) has been adopted widely in many centres, owed largely to the success of robot-assisted laparoscopic prostatectomy (RALP). It aims to replicate the oncological outcomes of open radical cystectomy (ORC), while providing a shorter recovery period. Despite this, previous RCTs have failed to show a benefit for RARC over ORC. These trials have compared extracorporeal RARC (eRARC) with ORC, which requires a further incision to mobilise the bowel for urinary reconstruction with an open technique. For intracorporeal RARC (iRARC), this urinary reconstruction is performed robotically without further incisions. There are theoretical benefits to this approach such as reduced recovery time for the bowel and reduced ileus rates, but no level 1 evidence currently exists to support this. While there has been an improvement in patient outcomes since the adoption of RARC, various other factors, such as enhanced recovery programmes and surgical learning curve, have made it difficult to attribute this solely to the robotic approach as many centres performing ORC have also shown similar improvements. In this review, we will discuss implementation of RARC as well as perioperative measures that have helped improve outcomes, offer a comparison of outcomes between ORC and RARC and highlight upcoming RCTs that may offer new evidence for or against a paradigm shift in the future of bladder cancer surgery.
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Affiliation(s)
- Pramit Khetrapal
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK. .,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK.
| | - Wei Shen Tan
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK.,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK
| | - Benjamin Lamb
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Melanie Tan
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Hilary Baker
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - James Thompson
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Ashwin Sridhar
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - John D Kelly
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK.,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK
| | - Tim Briggs
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
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Myles PS, Shulman MA, Heritier S, Wallace S, McIlroy DR, McCluskey S, Sillar I, Forbes A. Validation of days at home as an outcome measure after surgery: a prospective cohort study in Australia. BMJ Open 2017; 7:e015828. [PMID: 28821518 PMCID: PMC5629653 DOI: 10.1136/bmjopen-2017-015828] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To evaluate 'days at home up to 30 days after surgery' (DAH30) as a patient-centred outcome measure. DESIGN Prospective cohort study. DATA SOURCE Using clinical trial data (seven trials, 2109 patients) we calculated DAH30 from length of stay, readmission, discharge destination and death up to 30 days after surgery. MAIN OUTCOME The association between DAH30 and serious complications after surgery. RESULTS One or more complications occurred in 263 of 1846 (14.2%) patients, including 19 (1.0%) deaths within 30 days of surgery; 245 (11.6%) patients were discharged to a rehabilitation facility and 150 (7.1%) were readmitted to hospital within 30 days of surgery. The median DAH30 was significantly less in older patients (p<0.001), those with poorer physical functioning (p<0.001) and in those undergoing longer operations (p<0.001). Patients with serious complications had less days at home than patients without serious complications (20.5 (95% CI 19.1 to 21.9) vs 23.9 (95% CI 23.8 to 23.9) p<0.001), and had higher rates of readmission (16.0% vs 5.9%; p<0.001). After adjusting for patient age, sex, physical status and duration of surgery, the occurrence of postoperative complications was associated with fewer days at home after surgery (difference 3.0(95% CI 2.1 to 4.0) days; p<0.001). CONCLUSIONS DAH30 has construct validity and is a readily obtainable generic patient-centred outcome measure. It is a pragmatic outcome measure for perioperative clinical trials.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark A Shulman
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephane Heritier
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sophie Wallace
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - David R McIlroy
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stuart McCluskey
- Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Isabella Sillar
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Abstract
Advances in cardiovascular medicine fueled by innovative clinical trials have dramatically improved the lives of patients worldwide. Commensurate with this progress has been a decline in morbid and mortal events. Accordingly, an increased propensity to collate patient outcomes in clinical trials has emerged that combines death and nonfatal complications into a single composite event. Despite the acknowledged benefits in trial efficiency from such an approach, this method assumes uniform directionality of each component, does not distinguish the relative clinical significance of each, and counts only the first occurrence of any event in the final tally within a conventional time to first event analysis. In this article, we evaluate the criticisms that have been leveled at this approach and provide an overview of recently published phase III cardiovascular trials using primary composite end points. We then explore what to anticipate from the large cohort of as-yet unpublished clinical trials in this arena. Last, we propose a variety of novel approaches that use composite end points and suggest a path forward to enhancing their use in future clinical trials.
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Affiliation(s)
- Paul W. Armstrong
- From Canadian VIGOUR Centre, Department of Medicine (Cardiology), University of Alberta, Edmonton, Canada
| | - Cynthia M. Westerhout
- From Canadian VIGOUR Centre, Department of Medicine (Cardiology), University of Alberta, Edmonton, Canada
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120
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Affiliation(s)
- Paul M. Brown
- From the Department of Medicine, University of Alberta, Edmonton, Canada (P.M.B.); and Canadian VIGOUR Centre, Edmonton (P.M.B., J.A.E.)
| | - Justin A. Ezekowitz
- From the Department of Medicine, University of Alberta, Edmonton, Canada (P.M.B.); and Canadian VIGOUR Centre, Edmonton (P.M.B., J.A.E.)
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Decook L, Chang YH, Slack J, Gastineau D, Leis J, Noel P, Palmer J, Sproat L, Sorror M, Khera N. Association of hematopoietic cell transplantation-specific comorbidity index with resource utilization after allogeneic transplantation. Bone Marrow Transplant 2017; 52:998-1002. [DOI: 10.1038/bmt.2017.70] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/02/2017] [Accepted: 03/06/2017] [Indexed: 11/09/2022]
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Chau M, Richards T, Evans C, Butcher A, Collier T, Klein A. The UK Cardiac and Vascular Surgery Interventional Anaemia Response (CAVIAR) Study: protocol for an observational cohort study to determine the impact and effect of preoperative anaemia management in cardiac and vascular surgical patients. BMJ Open 2017; 7:e014872. [PMID: 28420664 PMCID: PMC5775454 DOI: 10.1136/bmjopen-2016-014872] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Preoperative anaemia is linked to poor postsurgical outcome, longer hospital stays, greater risk of complications and mortality. Currently in the UK, some sites have developed anaemia clinics or pathways that use intravenous iron to correct iron deficiency anaemia prior to surgery as their standard of care. Although intravenous iron has been observed to be effective in a variety of patient settings, there is insufficient evidence in its use in cardiac and vascular patients. The aim of this study is to observe the impact and effect of anaemia and its management in patients undergoing cardiac and vascular surgery. In addition, the UK Cardiac and Vascular Surgery Interventional Anaemia Response (CAVIAR) Study is also a feasibility study with the aim to establish anaemia management pathways in the preoperative setting to inform the design of future randomised controlled trials. METHODS AND ANALYSIS The UK CAVIAR Study is a multicentre, stepped, observational study, in patients awaiting major cardiac or vascular surgery. We will be examining different haematological variables (especially hepcidin), functional capacity and patient outcome. Patients will be compared based on their anaemia status, whether they received intravenous iron in accordance to their hospital's preoperative pathway, and their disease group. The primary outcomes are the change in haemoglobin levels from baseline (before treatment) to before surgery; and the number of successful patients recruited and consented (feasibility). The secondary outcomes will include changes in biomarkers of iron deficiency, length of stay, quality of life and postoperative recovery. ETHICS AND DISSEMINATION The study protocol was approved by the London-Westminster Research Ethics Committee (15/LO/1569, 27 November 2015). NHS approval was also obtained with each hospital trust. The findings of the study will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER Clinical Trials registry (NCT02637102) and the ISRCTN registry (ISRCTN55032357).
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Affiliation(s)
- Marisa Chau
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Toby Richards
- Division of Surgery & Interventional Science, University College London, London, UK
| | | | - Anna Butcher
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrew Klein
- Department of Anaesthesia, Papworth Hospital, Cambridge, UK
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Brown PM, Ezekowitz JA. Composite End Points in Clinical Trials of Heart Failure Therapy. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003222. [DOI: 10.1161/circheartfailure.116.003222] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Composite end points are popular outcomes in clinical trials of heart failure therapies. For example, a global rank composite is typically analyzed using a Mann–Whitney U test, and the results are summarized by the mean of ranks and a corresponding
P
value. The mean of ranks is uninformative, and a clinically meaningful estimate of the treatment effect is needed to communicate study results and facilitate an assessment of heterogeneity (the consistency of the effect across outcomes). The probability index is intuitive for clinicians, easy to calculate, and may be applied to various composites. We suggest a simple and familiar plot to assess heterogeneity across outcomes, which should be routine when analyzing composites. We think that the probability index provides an immediate and simple solution to an overt problem.
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Affiliation(s)
- Paul M. Brown
- From the Department of Medicine, University of Alberta, Edmonton, Canada (P.M.B.); and Canadian VIGOUR Centre, Edmonton, Canada (P.M.B., J.A.E.)
| | - Justin A. Ezekowitz
- From the Department of Medicine, University of Alberta, Edmonton, Canada (P.M.B.); and Canadian VIGOUR Centre, Edmonton, Canada (P.M.B., J.A.E.)
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Brown CL, Hammill BG, Qualls LG, Curtis LH, Muir AJ. Significant Morbidity and Mortality Among Hospitalized End-Stage Liver Disease Patients in Medicare. J Pain Symptom Manage 2016; 52:412-419.e1. [PMID: 27265812 PMCID: PMC5144155 DOI: 10.1016/j.jpainsymman.2016.03.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/19/2016] [Accepted: 03/16/2016] [Indexed: 12/19/2022]
Abstract
CONTEXT For end-stage liver disease (ESLD) patients, care focuses on managing the life-threatening complications of portal hypertension, causing high resource utilization. OBJECTIVES To describe the end-of-life trajectory of hospitalized ESLD patients in Medicare. METHODS Using a 5% random sample of Medicare fee-for-service beneficiaries, we performed a retrospective cohort study, identifying hospitalized ESLD and heart failure (HF) patients (2007-2011). Index hospitalization end points included mortality, discharge to hospice, and length of stay. Postdischarge end points included all-cause mortality, rehospitalization, hospice enrollment, and days alive and out of hospital (DAOH). Follow-up was at one and three years after index hospitalization discharge. A reference cohort of decompensated HF patients was used for baseline comparison. RESULTS At one year, the ESLD cohort (n = 22,311) had 209 DAOH; decompensated HF (n = 85,397) had 252 DAOH. Among ESLD patients, inpatient mortality was 13.5%; all-cause mortality was 64.9%. For these outcomes, rates were higher in those with ESLD than HF. In the ESLD group, rehospitalization rate was 59.1% (slightly lower than the HF group), hospice enrollment rate was 36.1%, and there were higher than expected cancer rates. For hospice-enrolled patients, the median length of time spent in hospice was nine days. The HF cohort had lower hospice enrollment, but more days enrolled. CONCLUSION The results of this study show that morbidity and mortality rates associated with end of life in ESLD are substantial. There is an acute need for alternative approaches to manage the care of ESLD patients.
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Affiliation(s)
- Cristal L Brown
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bradley G Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laura G Qualls
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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Dong G, Li D, Ballerstedt S, Vandemeulebroecke M. A generalized analytic solution to the win ratio to analyze a composite endpoint considering the clinical importance order among components. Pharm Stat 2016; 15:430-7. [DOI: 10.1002/pst.1763] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | - Di Li
- Eisai Inc.; Woodcliff Lake NJ USA
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Clark AL, Johnson M, Fairhurst C, Torgerson D, Cockayne S, Rodgers S, Griffin S, Allgar V, Jones L, Nabb S, Harvey I, Squire I, Murphy J, Greenstone M. Does home oxygen therapy (HOT) in addition to standard care reduce disease severity and improve symptoms in people with chronic heart failure? A randomised trial of home oxygen therapy for patients with chronic heart failure. Health Technol Assess 2016; 19:1-120. [PMID: 26393373 DOI: 10.3310/hta19750] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Home oxygen therapy (HOT) is commonly used for patients with severe chronic heart failure (CHF) who have intractable breathlessness. There is no trial evidence to support its use. OBJECTIVES To detect whether or not there was a quality-of-life benefit from HOT given as long-term oxygen therapy (LTOT) for at least 15 hours per day in the home, including overnight hours, compared with best medical therapy (BMT) in patients with severely symptomatic CHF. DESIGN A pragmatic, two-arm, randomised controlled trial recruiting patients with severe CHF. It included a linked qualitative substudy to assess the views of patients using home oxygen, and a free-standing substudy to assess the haemodynamic effects of acute oxygen administration. SETTING Heart failure outpatient clinics in hospital or the community, in a range of urban and rural settings. PARTICIPANTS Patients had to have heart failure from any aetiology, New York Heart Association (NYHA) class III/IV symptoms, at least moderate left ventricular systolic dysfunction, and be receiving maximally tolerated medical management. Patients were excluded if they had had a cardiac resynchronisation therapy device implanted within the past 3 months, chronic obstructive pulmonary disease fulfilling the criteria for LTOT or malignant disease that would impair survival or were using a device or medication that would impede their ability to use LTOT. INTERVENTIONS Patients received BMT and were randomised (unblinded) to open-label LTOT, prescribed for 15 hours per day including overnight hours, or no oxygen therapy. MAIN OUTCOME MEASURES The primary end point was quality of life as measured by the Minnesota Living with Heart Failure (MLwHF) questionnaire score at 6 months. Secondary outcomes included assessing the effect of LTOT on patient symptoms and disease severity, and assessing its acceptability to patients and carers. RESULTS Between April 2012 and February 2014, 114 patients were randomised to receive either LTOT or BMT. The mean age was 72.3 years [standard deviation (SD) 11.3 years] and 70% were male. Ischaemic heart disease was the cause of heart failure in 84%; 95% were in NYHA class III; the mean left ventricular ejection fraction was 27.8%; and the median N-terminal pro-B-type natriuretic hormone was 2203 ng/l. The primary analysis used a covariance pattern mixed model which included patients only if they provided data for all baseline covariates adjusted for in the model and outcome data for at least one post-randomisation time point (n = 102: intervention, n = 51; control, n = 51). There was no difference in the MLwHF questionnaire score at 6 months between the two arms [at baseline the mean score was 54.0 (SD 18.4) for LTOT and 54.0 (SD 17.9) for BMT; at 6 months the mean score was 48.1 (SD 18.5) for LTOT and 49.0 (SD 20.2) for BMT; adjusted mean difference -0.10, 95% confidence interval (CI) -6.88 to 6.69; p = 0.98]. At 3 months, the adjusted mean MLwHF questionnaire score was lower in the LTOT group (-5.47, 95% CI -10.54 to -0.41; p = 0.03) and breathlessness scores improved, although the effect did not persist to 6 months. There was no effect of LTOT on any secondary measure. There was a greater number of deaths in the BMT arm (n = 12 vs. n = 6). Adherence was poor, with only 11% of patients reporting using the oxygen as prescribed. CONCLUSIONS Although the study was significantly underpowered, HOT prescribed for 15 hours per day and subsequently used for a mean of 5.4 hours per day has no impact on quality of life as measured by the MLwHF questionnaire score at 6 months. Suggestions for future research include (1) a trial of patients with severe heart failure randomised to have emergency oxygen supply in the house, supplied by cylinders rather than an oxygen concentrator, powered to detect a reduction in admissions to hospital, and (2) a study of bed-bound patients with heart failure who are in the last few weeks of life, powered to detect changes in symptom severity. TRIAL REGISTRATION Current Controlled Trials ISRCTN60260702. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 75. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Andrew L Clark
- Hull York Medical School, Castle Hill Hospital, Cottingham, UK
| | | | - Caroline Fairhurst
- Department of Health Sciences, York Trials Unit, University of York, York, UK
| | - David Torgerson
- Department of Health Sciences, York Trials Unit, University of York, York, UK
| | - Sarah Cockayne
- Department of Health Sciences, York Trials Unit, University of York, York, UK
| | - Sara Rodgers
- Department of Health Sciences, York Trials Unit, University of York, York, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, York, UK
| | | | - Lesley Jones
- School of Social Sciences, University of Hull, Hull, UK
| | - Samantha Nabb
- Department of Sport, Health and Exercise Science, University of Hull, Hull, UK
| | - Ian Harvey
- Department of Academic Cardiology, Castle Hill Hospital, Cottingham, UK
| | - Iain Squire
- Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Jerry Murphy
- Department of Cardiology, Darlington Memorial Hospital, Darlington, UK
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Long-Term Post-Discharge Risks in Older Survivors of Myocardial Infarction With and Without Out-of-Hospital Cardiac Arrest. J Am Coll Cardiol 2016; 67:1981-90. [DOI: 10.1016/j.jacc.2016.02.044] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 11/23/2022]
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129
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Stewart S, Wiley JF, Ball J, Chan YK, Ahamed Y, Thompson DR, Carrington MJ. Impact of Nurse-Led, Multidisciplinary Home-Based Intervention on Event-Free Survival Across the Spectrum of Chronic Heart Disease: Composite Analysis of Health Outcomes in 1226 Patients From 3 Randomized Trials. Circulation 2016; 133:1867-77. [PMID: 27083509 PMCID: PMC4857795 DOI: 10.1161/circulationaha.116.020730] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/11/2016] [Indexed: 12/19/2022]
Abstract
Background— We sought to determine the overall impact of a nurse-led, multidisciplinary home-based intervention (HBI) adapted to hospitalized patients with chronic forms of heart disease of varying types. Methods and Results— Prospectively planned, combined, secondary analysis of 3 randomized trials (1226 patients) of HBI were compared with standard management. Hospitalized patients presenting with heart disease but not heart failure, atrial fibrillation but not heart failure, and heart failure, as well, were recruited. Overall, 612 and 614 patients, respectively, were allocated to a home visit 7 to 14 days postdischarge by a cardiac nurse with follow-up and multidisciplinary support according to clinical need or standard management. The primary outcome of days-alive and out-of-hospital was examined on an intention-to-treat basis. During 1371 days (interquartile range, 1112–1605) of follow-up, 218 patients died and 17 917 days of hospital stay were recorded. In comparison with standard management, HBI patients achieved significantly prolonged event-free survival (90.1% [95% confidence interval, 88.2–92.0] versus 87.2% [95% confidence interval, 85.1–89.3] days-alive and out-of-hospital; P=0.020). This reflected less all-cause mortality (adjusted hazard ratio, 0.67; 95% confidence interval, 0.50–0.88; P=0.005) and unplanned hospital stay (median, 0.22 [interquartile range, 0–1.3] versus 0.36 [0–2.1] days/100 days follow-up; P=0.011). Analyses of the differential impact of HBI on all-cause mortality showed significant interactions (characterized by U-shaped relationships) with age (P=0.005) and comorbidity (P=0.041); HBI was most effective for those aged 60 to 82 years (59%–65% of individual trial cohorts) and with a Charlson Comorbidity Index Score of 5 to 8 (36%–61%). Conclusions— These data provide further support for the application of postdischarge HBI across the full spectrum of patients being hospitalized for chronic forms of heart disease. Clinical Trial Registration— URL: http://www.anzctr.org.au. Unique identifiers: 12610000221055, 12608000022369, 12607000069459.
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Affiliation(s)
- Simon Stewart
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia.
| | - Joshua F Wiley
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Jocasta Ball
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Yih-Kai Chan
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Yasmin Ahamed
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - David R Thompson
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Melinda J Carrington
- From Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
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130
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Boriani G, Berti E, Belotti LMB, Biffi M, De Palma R, Malavasi VL, Bottoni N, Rossi L, De Maria E, Mantovan R, Zardini M, Casali E, Marconi M, Bandini A, Tomasi C, Boggian G, Barbato G, Toselli T, Zennaro M, Sassone B. Cardiac device therapy in patients with left ventricular dysfunction and heart failure: ‘real‐world’ data on long‐term outcomes (mortality, hospitalizations, days alive and out of hospital). Eur J Heart Fail 2016; 18:693-702. [DOI: 10.1002/ejhf.509] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 12/05/2015] [Accepted: 12/26/2015] [Indexed: 11/10/2022] Open
Affiliation(s)
- Giuseppe Boriani
- Institute of Cardiology, University of Bologna Azienda Ospedaliera S. Orsola‐Malpighi Bologna Italy
- Division of Cardiology, Modena University Hospital University of Modena and Reggio Emilia Modena Italy
| | - Elena Berti
- Agency for Health and Social Care of Emilia‐Romagna Bologna Italy
| | | | - Mauro Biffi
- Institute of Cardiology, University of Bologna Azienda Ospedaliera S. Orsola‐Malpighi Bologna Italy
| | - Rossana De Palma
- Agency for Health and Social Care of Emilia‐Romagna Bologna Italy
| | - Vincenzo L. Malavasi
- Division of Cardiology, Modena University Hospital University of Modena and Reggio Emilia Modena Italy
| | - Nicola Bottoni
- Division of Cardiology S. Maria Nuova Hospital Reggio Emilia Italy
| | - Luca Rossi
- Division of Cardiology G. da Saliceto Hospital Piacenza Italy
| | | | | | - Marco Zardini
- Division of Cardiology Parma University Hospital Parma Italy
| | - Edoardo Casali
- Division of Cardiology, Modena University Hospital University of Modena and Reggio Emilia Modena Italy
| | - Marco Marconi
- Division of Cardiology, Local Health Unit Rimini Italy
| | - Alberto Bandini
- Division of Cardiologia G.B. Morgagni‐L. Pierantoni Hospital Forlì Italy
| | - Corrado Tomasi
- Division of Cardiology S. Maria delle Croci Hospital Ravenna Italy
| | - Giulio Boggian
- Division of Cardiology Hospital of Bentivoglio Bologna Italy
| | | | - Tiziano Toselli
- Division of Cardiology Ferrara University Hospital Ferrara Italy
| | - Mauro Zennaro
- Division of Cardiology Baggiovara Hospital Modena Italy
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131
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Wang D, Pocock S. A win ratio approach to comparing continuous non-normal outcomes in clinical trials. Pharm Stat 2016; 15:238-45. [DOI: 10.1002/pst.1743] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 01/25/2016] [Accepted: 02/02/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Duolao Wang
- Biostatistics Unit, Department of Clinical Sciences; Liverpool School of Tropical Medicine; Pembroke Place Liverpool L3 5QA UK
| | - Stuart Pocock
- Department of Medical Statistics, Faculty of Epidemiology and Population Health; London School of Hygiene and Tropical Medicine; Keppel Street London WC1E 7HT UK
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Rahimi K, Velardo C, Triantafyllidis A, Conrad N, Shah SA, Chantler T, Mohseni H, Stoppani E, Moore F, Paton C, Emdin CA, Ernst J, Tarassenko L, Rahimi K, Velardo C, Triantafyllidis A, Conrad N, Ahmar Shah S, Chantler T, Mohseni H, Stoppani E, Moore F, Paton C, Tarassenko L, Cleland J, Emptage F, Chantler T, Farmer A, Fitzpatrick R, Hobbs R, MacMahon S, Perkins A, Rahimi K, Tarassenko L, Altmann P, Chandrasekaran B, Emdin CA, Ernst J, Foley P, Hersch F, Salimi-Khorshidi G, Noble J, Woodward M. A user-centred home monitoring and self-management system for patients with heart failure: a multicentre cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2015; 1:66-71. [PMID: 29474596 DOI: 10.1093/ehjqcco/qcv013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/03/2015] [Indexed: 11/13/2022]
Abstract
Aims Previous generations of home monitoring systems have had limited usability. We aimed to develop and evaluate a user-centred and adaptive system for health monitoring and self-management support in patients with heart failure. Methods and results Patients with heart failure were recruited from three UK centres and provided with Internet-enabled tablet computers that were wirelessly linked with sensor devices for blood pressure, heart rate, and weight monitoring. Patient observations, interviews, and concurrent analyses of the automatically collected data from their monitoring devices were used to increase the usability of the system. Of the 52 participants (median age 77 years, median follow-up 6 months [interquartile range, IQR, 3.6-9.2]), 24 (46%) had no, or very limited prior, experience with digital technologies. It took participants about 1.5 min to complete the daily monitoring tasks, and the rate of failed attempts in completing tasks was <5%. After 45 weeks of observation, participants still used the system on 4.5 days per week (confidence interval 3.2-5.7 days). Of the 46 patients who could complete the final survey, 93% considered the monitoring system as easy to use and 38% asked to keep the system for self-management support after the study was completed. Conclusion We developed a user-centred home monitoring system that enabled a wide range of heart failure patients, with differing degrees of IT literacy, to monitor their health status regularly. Despite no active medical intervention, patients felt that they benefited from the reassurance and sense of connectivity that the monitoring system provided.
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Affiliation(s)
- Kazem Rahimi
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK
| | - Carmelo Velardo
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | | | - Nathalie Conrad
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK
| | - Syed Ahmar Shah
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Tracey Chantler
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK
| | - Hamid Mohseni
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK
| | - Emma Stoppani
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK
| | - Francesca Moore
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK
| | - Chris Paton
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK
| | - Connor A Emdin
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK
| | - Johanna Ernst
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK.,Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - Lionel Tarassenko
- Division of Cardiovascular Medicine, George Institute for Global Health, University of Oxford, Broad Street 34, Oxford OX1 3DB, UK
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Di Tano G, De Maria R, Gonzini L, Aspromonte N, Di Lenarda A, Feola M, Marini M, Milli M, Misuraca G, Mortara A, Oliva F, Pulignano G, Russo G, Senni M, Tavazzi L. The 30-day metric in acute heart failure revisited: data from IN-HF Outcome, an Italian nationwide cardiology registry. Eur J Heart Fail 2015; 17:1032-41. [PMID: 26018852 DOI: 10.1002/ejhf.290] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/17/2015] [Accepted: 04/27/2015] [Indexed: 11/11/2022] Open
Abstract
AIMS Unplanned readmissions early after a discharge from acute heart failure hospitalization are common and have become a reimbursement benchmark and marker of hospital quality. However, the competing risk of short-term post-discharge mortality is substantial. METHODS AND RESULTS Using data from the prospective, nationwide Registry IN-HF Outcome, we analysed the incidence and predictors of 30-day mortality or readmissions and associated days-alive-out-of-hospital (DAOH) in 1520 patients discharged alive after admission for acute heart failure. Within 30 days after discharge, 94 patients (6.2%) were readmitted (91% for cardiovascular causes; 60% recurrent heart failure) and 42 (2.8%) died, 10 of which occurred during readmission. Overall, 126 patients (8.3%) met the combined endpoint. By multivariable logistic regression, worsening chronic heart failure as clinical presentation [odds ratio (OR) 1.83, 95% confidence interval (CI) 1.21-2.77, P = 0.005), inotropes during admission (OR 2.19, 95% CI 1.40-3.43, P = 0.0006), length of stay (OR 1.02, 95% CI 1.01-1.04, P = 0.002) and renin-angiotensin system inhibitors at discharge (OR 0.52, 95%CI 0.35-0.77, P = 0.001) independently predicted 30-day all-cause mortality and/or readmission (c-statistic = 0.695). Per cent 30-day DAOH was lower in patients with in-hospital inotrope use, no renin-angiotensin system inhibitors prescription at discharge, New York Heart Association III-IV class at discharge, and correlated inversely with length of stay and age. CONCLUSION A clinical and biohumoral profile consistent with chronic advanced heart failure and end-organ damage identifies acute heart failure patients discharged home from cardiology units, who are at highest risk of early death and/or readmission. These findings have practical implications for tailoring specific follow-up.
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Affiliation(s)
| | - Renata De Maria
- CNR Clinical Physiology Institute, Cardiothoracic and Vascular Department, Azienda Ospedaliera Niguarda Ca' Granda, Milan, Italy
| | | | | | - Andrea Di Lenarda
- Cardiovascular Center, Health Authority n. 1 and University of Trieste, Trieste, Italy
| | - Mauro Feola
- Cardiovascular Rehabilitation, Heart Failure Unit, Ospedale Maggiore SS, Trinità, Fossano, Italy
| | - Marco Marini
- Cardiology Department, Ospedali Riuniti, Umberto I-Lancisi-Salesi, Ancona, Italy
| | - Massimo Milli
- Cardiology, Ospedale Santa Maria Nuova, Florence, Italy
| | | | - Andrea Mortara
- Cardiology Department, Policlinico di Monza, Monza, Italy
| | - Fabrizio Oliva
- Cardiologia 2 Heart Failure and Heart Transplant Programme, 'A. De Gasperis' Cardiothoracic and Vascular Department, Azienda Ospedaliera Niguarda Ca' Granda, Milan, Italy
| | - Giovanni Pulignano
- Heart Failure Clinic, 1st Cardiology/CCU Unit, Cardiovascular Department, San Camillo Hospital, Rome, Italy
| | - Giulia Russo
- Cardiovascular Center, Health Authority n. 1 and University of Trieste, Trieste, Italy
| | - Michele Senni
- Cardiovascular Department, Cardiology 1, Papa Giovanni XXIII Hospital, Bergamo
| | - Luigi Tavazzi
- Maria Cecilia Hospital-GVM Care&Research-E.S. Health Science Foundation, Cotignola, Italy
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Stewart S, Ball J, Horowitz JD, Marwick TH, Mahadevan G, Wong C, Abhayaratna WP, Chan YK, Esterman A, Thompson DR, Scuffham PA, Carrington MJ. Standard versus atrial fibrillation-specific management strategy (SAFETY) to reduce recurrent admission and prolong survival: pragmatic, multicentre, randomised controlled trial. Lancet 2015; 385:775-84. [PMID: 25467562 DOI: 10.1016/s0140-6736(14)61992-9] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients are increasingly being admitted with chronic atrial fibrillation, and disease-specific management might reduce recurrent admissions and prolong survival. However, evidence is scant to support the application of this therapeutic approach. We aimed to assess SAFETY--a management strategy that is specific to atrial fibrillation. METHODS We did a pragmatic, multicentre, randomised controlled trial in patients admitted with chronic, non-valvular atrial fibrillation (but not heart failure). Patients were recruited from three tertiary referral hospitals in Australia. 335 participants were randomly assigned by computer-generated schedule (stratified for rhythm or rate control) to either standard management (n=167) or the SAFETY intervention (n=168). Standard management consisted of routine primary care and hospital outpatient follow-up. The SAFETY intervention comprised a home visit and Holter monitoring 7-14 days after discharge by a cardiac nurse with prolonged follow-up and multidisciplinary support as needed. Clinical reviews were undertaken at 12 and 24 months (minimum follow-up). Coprimary outcomes were death or unplanned readmission (both all-cause), measured as event-free survival and the proportion of actual versus maximum days alive and out of hospital. Analyses were done on an intention-to-treat basis. The trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTRN 12610000221055). FINDINGS During median follow-up of 905 days (IQR 773-1050), 49 people died and 987 unplanned admissions were recorded (totalling 5530 days in hospital). 127 (76%) patients assigned to the SAFETY intervention died or had an unplanned readmission (median event-free survival 183 days [IQR 116-409]) and 137 (82%) people allocated standard management achieved a coprimary outcome (199 days [116-249]; hazard ratio 0·97, 95% CI 0·76-1·23; p=0·851). Patients assigned to the SAFETY intervention had 99·5% maximum event-free days (95% CI 99·3-99·7), equating to a median of 900 (IQR 767-1025) of 937 maximum days alive and out of hospital. By comparison, those allocated to standard management had 99·2% (95% CI 98·8-99·4) maximum event-free days, equating to a median of 860 (IQR 752-1047) of 937 maximum days alive and out of hospital (effect size 0·22, 95% CI 0·21-0·23; p=0·039). INTERPRETATION A post-discharge management programme specific to atrial fibrillation was associated with proportionately more days alive and out of hospital (but not prolonged event-free survival) relative to standard management. Disease-specific management is a possible strategy to improve poor health outcomes in patients admitted with chronic atrial fibrillation. FUNDING National Health and Medical Research Council of Australia.
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Affiliation(s)
- Simon Stewart
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia.
| | - Jocasta Ball
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - John D Horowitz
- The Queen Elizabeth Hospital and University of Adelaide, Adelaide, SA, Australia
| | | | - Gnanadevan Mahadevan
- The Queen Elizabeth Hospital and University of Adelaide, Adelaide, SA, Australia
| | - Chiew Wong
- Department of Cardiology, Footscray Hospital, Melbourne, VIC, Australia
| | - Walter P Abhayaratna
- Division of Medicine, Canberra Hospital and Australian National University, Canberra, ACT, Australia
| | - Yih K Chan
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Adrian Esterman
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - David R Thompson
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Paul A Scuffham
- Centre for Applied Health Economics, Griffith University, Brisbane, QLD, Australia
| | - Melinda J Carrington
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia
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Patel SR, Sileo A, Bello R, Gunda S, Nguyen J, Goldstein D. Heart transplantation versus continuous-flow left ventricular assist device: comprehensive cost at 1 year. J Card Fail 2014; 21:160-6. [PMID: 25433361 DOI: 10.1016/j.cardfail.2014.11.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/11/2014] [Accepted: 11/17/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND With health care reform firmly on the horizon, it is critical to understand the costs associated with new technologies such as continuous-flow left ventricular assist device (CF-LVAD) compared with well established treatments such as heart transplantation (HT). Scarce data exist describing the costs of these 2 therapies after 1 year of support. METHODS AND RESULTS The study population consisted of 20 consecutive subjects who underwent implantation of a CF-LVAD and 20 consecutive subjects who underwent HT and survived ≥1 year. Comprehensive cost calculation included all direct and indirect costs from day of operation through 365 days and were inflation adjusted to 2010 US dollars. Hospital charges were converted to costs with the use of hospital-specific cost-to-charge ratios and were analyzed by time segment as well as cost center. The total 1-year cost was higher in the CF-LVAD group, although this difference did not reach statistical significance ($369,519 [interquartile range [IQR] $321,020-$520,395] vs $329,648 [IQR $278,924-$395,456]; P = .242). In both groups, the index admission constituted >50% of the total 1-year cost and the major drivers of expense by cost center were organ/device acquisition, room and board, and professional fees. CONCLUSIONS Patients surviving to 1 year on CF-LVAD support accrued costs similar to those of HT recipients; however, the total cost, at more than one-third of a million dollars, remains high. Reduction in the postoperative length of stay offers an avenue for significant cost savings.
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Affiliation(s)
- Snehal R Patel
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | - Alan Sileo
- Department of Financial Services, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ricardo Bello
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sampath Gunda
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jenni Nguyen
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Daniel Goldstein
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Hung M, Ortmann E, Besser M, Martin-Cabrera P, Richards T, Ghosh M, Bottrill F, Collier T, Klein AA. A prospective observational cohort study to identify the causes of anaemia and association with outcome in cardiac surgical patients. Heart 2014; 101:107-12. [DOI: 10.1136/heartjnl-2014-305856] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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137
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Pettit SJ, Jackson CE, Gardner RS. Deactivation of implantable cardioverter-defibrillators at end of life. Future Cardiol 2013; 9:885-96. [PMID: 24180544 DOI: 10.2217/fca.13.81] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
It is inevitable that all patients with implantable cardioverter-defibrillators (ICDs) will die during extended follow-up. End-of-life care planning may become appropriate as a patient's condition deteriorates. There is concern about multiple futile shocks in the final hours of life, although the incidence of this problem has been estimated at only 8-16%. Despite broad consensus that ICD deactivation should be discussed as part of end-of-life care planning, the effect of ICD deactivation, in particular whether life expectancy is altered, is uncertain. Many clinicians are reluctant to discuss ICD deactivation. Many patients have misconceptions regarding ICD function and value longevity above quality of life. As such, ICD deactivation is often discussed late or not at all. The management of ICDs in patients approaching death is likely to become a major problem in the coming years. This article will discuss directions in which clinical practice might develop and areas for future research.
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Affiliation(s)
- Stephen J Pettit
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE, UK.
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Bagai A, Chen AY, Wang TY, Alexander KP, Thomas L, Ohman EM, Hochman JS, Peterson ED, Roe MT. Long-term outcomes among older patients with non-ST-segment elevation myocardial infarction complicated by cardiogenic shock. Am Heart J 2013; 166:298-305. [PMID: 23895813 DOI: 10.1016/j.ahj.2013.05.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 05/05/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cardiogenic shock complicating acute myocardial infarction (MI) in older patients is associated with a high risk of inhospital mortality; however, the long-term prognosis among these patients who survive the index hospitalization is uncertain. METHODS We evaluated 42,656 patients 65 years or older with non-ST-segment elevation MI from the CRUSADE Registry treated at 448 hospitals in the United States from 2003 to 2006 and linked to Medicare longitudinal claims data. Among patients who survived to hospital discharge, Cox proportional hazards modeling was used to compare survival between patients with and without inhospital shock. The secondary outcome of "percent days alive and out of hospital" (%DAOH) was also compared between the 2 groups. RESULTS Overall, 2,001 (4.7%) patients had shock on presentation and/or developed shock during the index hospitalization. Inhospital mortality rates among those with and without shock were 39.1% versus 4.5% (P < .001). Among the 40,036 index hospital survivors, postdischarge survival curves diverged early with lower survival (48.1% [95% CI 45.0-51.2] vs 56.5% [95% CI 56.0-57.1], P < .001) and lower %DAOH (65.5% ± 40.6% and 73.4% ± 36.8 %, P < .001) among patients with shock through 4 years. Based on the observation of parallel survival curves starting 6 months postdischarge, we performed landmark analyses and found no difference in mortality (hazard ratio 1.02, 95% CI 0.91-1.14) or %DAOH (79.7% ± 32.0% vs 81.3% ± 31.0%, P = .17) beyond 6 months between those with and without shock. CONCLUSIONS Our results highlight the time-dependent hazard of risk during the early postdischarge period for older patients with non-ST-segment elevation MI and cardiogenic shock that appears to be mitigated after 6 months, thereby lending support for the examination of new therapies designed to ameliorate this early risk.
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Zannad F, Garcia AA, Anker SD, Armstrong PW, Calvo G, Cleland JGF, Cohn JN, Dickstein K, Domanski MJ, Ekman I, Filippatos GS, Gheorghiade M, Hernandez AF, Jaarsma T, Koglin J, Konstam M, Kupfer S, Maggioni AP, Mebazaa A, Metra M, Nowack C, Pieske B, Piña IL, Pocock SJ, Ponikowski P, Rosano G, Ruilope LM, Ruschitzka F, Severin T, Solomon S, Stein K, Stockbridge NL, Stough WG, Swedberg K, Tavazzi L, Voors AA, Wasserman SM, Woehrle H, Zalewski A, McMurray JJV. Clinical outcome endpoints in heart failure trials: a European Society of Cardiology Heart Failure Association consensus document. Eur J Heart Fail 2013; 15:1082-94. [PMID: 23787718 DOI: 10.1093/eurjhf/hft095] [Citation(s) in RCA: 175] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Endpoint selection is a critically important step in clinical trial design. It poses major challenges for investigators, regulators, and study sponsors, and it also has important clinical and practical implications for physicians and patients. Clinical outcomes of interest in heart failure trials include all-cause mortality, cause-specific mortality, relevant non-fatal morbidity (e.g., all-cause and cause-specific hospitalization), composites capturing both morbidity and mortality, safety, symptoms, functional capacity, and patient-reported outcomes. Each of these endpoints has strengths and weaknesses that create controversies regarding which is most appropriate in terms of clinical importance, sensitivity, reliability, and consistency. Not surprisingly, a lack of consensus exists within the scientific community regarding the optimal endpoint(s) for both acute and chronic heart failure trials. In an effort to address these issues, the Heart Failure Association of the European Society of Cardiology (HFA-ESC) convened a group of expert heart failure clinical investigators, biostatisticians, regulators, and pharmaceutical industry scientists (Nice, France, 12-13 February 2012) to evaluate the challenges of defining heart failure endpoints in clinical trials and to develop a consensus framework. This report summarizes the group's recommendations for achieving common views on heart failure endpoints in clinical trials.
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Affiliation(s)
- Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
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Borer JS, Böhm M, Ford I, Komajda M, Tavazzi L, Sendon JL, Alings M, Lopez-de-Sa E, Swedberg K. Effect of ivabradine on recurrent hospitalization for worsening heart failure in patients with chronic systolic heart failure: the SHIFT Study. Eur Heart J 2012; 33:2813-20. [PMID: 22927555 PMCID: PMC3498004 DOI: 10.1093/eurheartj/ehs259] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 07/25/2012] [Accepted: 07/27/2012] [Indexed: 11/13/2022] Open
Abstract
AIMS We explored the effect of treatment with ivabradine, a pure heart rate-slowing agent, on recurrent hospitalizations for worsening heart failure (HF) in the SHIFT trial. METHODS AND RESULTS SHIFT was a double-blind clinical trial in which 6505 patients with moderate-to-severe HF and left ventricular systolic dysfunction, all of whom had been hospitalized for HF during the preceding year, were randomized to ivabradine or to placebo on a background of guideline-recommended HF therapy (including maximized β-blockade). In total, 1186 patients experienced at least one additional HF hospitalization during the study, 472 suffered at least two, and 218 suffered at least 3. Patients with additional HF hospitalizations had more severe disease than those without. Ivabradine was associated with fewer total HF hospitalizations [902 vs. 1211 events with placebo; incidence rate ratio, 0.75, 95% confidence interval (CI), 0.65-0.87, P = 0.0002] during the 22.9-month median follow-up. Ivabradine-treated patients evidenced lower risk for a second or third additional HF hospitalization [hazard ratio (HR): 0.66, 95% CI, 0.55-0.79, P < 0.001 and HR: 0.71, 95% CI, 0.54-0.93, P = 0.012, respectively]. Similar observations were made for all-cause and cardiovascular hospitalizations. CONCLUSION Treatment with ivabradine, on a background of guidelines-based HF therapy, is associated with a substantial reduction in the likelihood of recurrent hospitalizations for worsening HF. This benefit can be expected to improve the quality of life and to substantially reduce health-care costs.
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Affiliation(s)
- Jeffrey S Borer
- Department of Medicine, State University of New York Downstate Medical Center, Brooklyn and New York, NY 10128-1152, USA.
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