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Imburgio S, Hazaveh S, Klei L, Arcidiacono AM, Sen S, Messenger J, Pyo R, Kiss D, Saybolt M, Jamal S, Sealove B, Heaton J. Temporal trends in outcomes following inpatient transcatheter aortic valve replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00146-5. [PMID: 38584082 DOI: 10.1016/j.carrev.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 03/22/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024]
Abstract
INTRODUCTION Despite the growing adoption of transcatheter aortic valve replacement (TAVR), there remains a lack of clinical data evaluating procedural safety and discharge practices. AIMS This study aims to investigate if there have been improvements in postoperative clinical outcomes following TAVR. METHODS In this large-scale, retrospective cohort study, patients who underwent TAVR as an inpatient were identified from 2016 to 2020 using the National Readmissions Database. The primary outcome was temporal trends in the rates of discharge to home. Secondary endpoints assessed annual discharge survival rates, 30-day readmissions, length of stay, and periprocedural cardiac arrest rates. RESULTS Over the 5-year study period, a total of 31,621 inpatient TAVR procedures were identified. Of these, 79.2 % of patients were successfully discharged home with home disposition increasing year-over-year from 74.5 % in 2016 to 85.9 % in 2020 (Odds ratio: 2.01; 95 % CI 1.62-2.48, p < 0.001). The mean annual discharge survival rate was 97.7 % which did not change significantly over the 5-year study period (p = 0.551). From 2016 to 2020, 30-day readmissions decreased from 14.0 % to 10.3 %, respectively (p = 0.028). Perioperative cardiac arrest occurred in 1.8 % (n = 579) of cases with rates remaining unchanged during the study (p = 0.674). CONCLUSION Most TAVR patients are successfully discharged alive and home, with decreasing 30-day readmissions observed over recent years. This data suggests potential improvements in preoperative planning, procedural safety, and postoperative care. Despite perioperative cardiac arrest being associated with high mortality, it remains a relatively rare complication of TAVR.
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Affiliation(s)
- Steven Imburgio
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, United States of America.
| | - Sara Hazaveh
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, United States of America
| | - Lauren Klei
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, United States of America
| | - Anne Marie Arcidiacono
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, United States of America
| | - Shuvendu Sen
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, United States of America
| | - John Messenger
- University of Colorado Hospital, Department of Cardiology, 12605 E 16th Ave, Aurora, CO 80045, United States of America
| | - Robert Pyo
- Stony Brook University Hospital, Department of Cardiology, 101 Nicolls Rd, Stony Brook, NY 11794, United States of America
| | - Daniel Kiss
- Jersey Shore University Medical Center, Department of Cardiology, 1945 NJ-33, Neptune City, NJ 07753, United States of America
| | - Matthew Saybolt
- Jersey Shore University Medical Center, Department of Cardiology, 1945 NJ-33, Neptune City, NJ 07753, United States of America
| | - Sameer Jamal
- Hackensack University Medical Center, Department of Cardiology, 30 Prospect Ave, Hackensack, NJ 07601, United States of America
| | - Brett Sealove
- Jersey Shore University Medical Center, Department of Cardiology, 1945 NJ-33, Neptune City, NJ 07753, United States of America
| | - Joseph Heaton
- Jersey Shore University Medical Center, Department of Medicine, 1945 NJ-33, Neptune City, NJ 07753, United States of America
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Jain S, Rosenbaum PR, Reiter JG, Ramadan OI, Hill AS, Silber JH, Fleisher LA. Assessing the Ambulatory Surgery Center Volume-Outcome Association. JAMA Surg 2024; 159:397-403. [PMID: 38265816 PMCID: PMC10809135 DOI: 10.1001/jamasurg.2023.7161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/01/2023] [Indexed: 01/25/2024]
Abstract
Importance In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US. Objective To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity. Design, Setting, and Participants This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019. Main Outcomes and Measures Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures). Results Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity. Conclusions and Relevance In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.
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Affiliation(s)
- Siddharth Jain
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Paul R. Rosenbaum
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Statistics and Data Science, The Wharton School, The University of Pennsylvania, Philadelphia
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Omar I. Ramadan
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Surgery, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
| | - Jeffrey H. Silber
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- The Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia
| | - Lee A. Fleisher
- The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia
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Bansal K, Pawar S, Gupta T, Gilani F, Khera S, Kolte D. Association Between Hospital Volume and 30-Day Readmissions After Transcatheter Mitral Valve Edge-to-Edge Repair. Am J Cardiol 2023; 203:149-156. [PMID: 37499594 DOI: 10.1016/j.amjcard.2023.06.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023]
Abstract
Data on the association between hospital procedural volume and 30-day readmissions after mitral valve transcatheter edge-to-edge repair (mTEER) are limited. We used the 2019 Nationwide Readmissions Database to identify hospitals that performed at least 5 mTEERs. Hospitals were categorized based on tertiles of annual mTEER volume as low-volume (5 to 13), medium-volume (14 to 28), and high-volume (29 to 171). Multivariable hierarchical logistic regression models and restricted cubic spline analyses were used to examine the association between hospital mTEER volume and 30-day readmissions. Median (interquartile range) annual hospital mTEER volume was 20 (11.5 to 34). Of 234 hospitals included in the study, 77 (32.9%), 77 (32.9%), and 80 (34.2%) were categorized as low-volume, medium-volume, and high-volume. Of 5,574 index mTEER procedures included in this study, 634 (11.4%), 1,353 (24.3%), and 3,587 (64.3%) were performed at low-volume, medium-volume, and high-volume centers, respectively. In the overall study cohort, rates of 30-day all-cause readmissions after mTEER were 13.2%. In multivariable analyses, there was no significant association between hospital mTEER volume (as a categorical variable) and 30-day all-cause or cause-specific (cardiac, non-cardiac, heart failure) readmissions. Similarly, no significant relation was observed between hospital mTEER volume as a continuous variable and 30-day all-cause or cause-specific readmissions in restricted cubic spline analysis. In conclusion, in a nationally representative sample of 234 hospitals with >5,500 mTEER procedures, we found no association between annual hospital mTEER volume and 30-day all-cause or cause-specific readmissions.
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Affiliation(s)
- Kannu Bansal
- Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Shubhadarshini Pawar
- Department of Medicine, Shree Vighanaharta Superspeciality Hospital, Dhule, India
| | - Tanush Gupta
- Division of Cardiology, Department of Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Fahad Gilani
- Division of Cardiovascular Medicine, Catholic Medical Center, Manchester, New Hampshire
| | - Sahil Khera
- Division of Interventional Cardiology, Mount Sinai Hospital, New York, New York
| | - Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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Aranda-Michel E, Kilner D, Toma C, Serna-Gallegos D, Yousef S, Brown J, Diaz-Castrillon CE, Makani A, Sultan I. A Readmission Risk Score for Transcatheter Aortic Valve Replacement: An Analysis of 200,000 Patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 53:8-12. [PMID: 36907697 DOI: 10.1016/j.carrev.2023.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE The objective of this study was to leverage a national database of TAVR procedures to create a risk model for 30-day readmissions. METHODS The National Readmissions Database was reviewed for all TAVR procedures from 2011 to 2018. Previous ICD coding paradigms created comorbidity and complication variables from the index admission. Univariate analysis included any variables with a P-value of ≤0.2. A bootstrapped mixed-effects logistic regression was run using the hospital ID as a random effect variable. By bootstrapping, a more robust estimate of the variables' effect can be generated, reducing the risk of model overfitting. The odds ratio of variables with a P-value <0.1 was turned into a risk score following the Johnson scoring method. A mixed-effect logistic regression was run using the total risk score, and a calibration plot of the observed to expected readmission was generated. RESULTS A total of 237,507 TAVRs were identified, with an in-hospital mortality of 2.2 %. A total of 17.4 % % of TAVR patients were readmitted within 30 days. The median age was 82 with 46 % of the population being women. The risk score values ranged from -3 to 37 corresponding to a predicted readmission risk between 4.6 % and 80.4 %, respectively. Discharge to a short-term facility and being a resident of the hospital state were the most significant predictors of readmission. The calibration plot shows good agreement between the observed and expected readmission rates with an underestimation at higher probabilities. CONCLUSION The readmission risk model agrees with the observed readmissions throughout the study period. The most significant risk factors were being a resident of the hospital state and discharge to a short-term facility. This suggests that using this risk score in conjunction with enhanced post-operative care in these patients could reduce readmissions and associated hospital costs, improving outcomes.
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Affiliation(s)
- Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - Dustin Kilner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - James Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America
| | - Amber Makani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, PA, United States of America; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
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Yesantharao PS, Etchill EW, Zhou AL, Ong CS, Metkus TS, Canner JK, Alejo DE, Aliu O, Czarny MJ, Hasan RK, Resar JR, Schena S. The impact of a statewide payment reform on transcatheter aortic valve replacement (TAVR) utilization and readmissions. Catheter Cardiovasc Interv 2023; 101:1193-1202. [PMID: 37102376 DOI: 10.1002/ccd.30670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/07/2023] [Accepted: 04/15/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries. METHODS This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions. RESULTS During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1). CONCLUSIONS Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.
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Affiliation(s)
- Pooja S Yesantharao
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eric W Etchill
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alice L Zhou
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Chin Siang Ong
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Thomas S Metkus
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joseph K Canner
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Diane E Alejo
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Oluseyi Aliu
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Matthew J Czarny
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Rani K Hasan
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jon R Resar
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Stefano Schena
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Medical College of Wisconsin, Milwaukee, Wisconsin, 53226, USA
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Hasan I, Brown JA, Aranda-Michel E, Serna-Gallegos D, Gada H, Kliner D, Toma C, Sanon S, Wang Y, Sultan I. Outcomes of transcatheter aortic valve replacement at teaching versus nonteaching hospitals. J Card Surg 2022; 37:3550-3555. [PMID: 36073067 DOI: 10.1111/jocs.16833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/11/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Prior studies have demonstrated that outcomes of invasive cardiac interventions may vary by hospital teaching status and volume. As transcatheter aortic valve replacement (TAVR) rapidly expands from teaching to nonteaching hospitals across the country, the clinical impact of hospital teaching status has not been clearly established. This study aimed to compare TAVR outcomes between nonteaching and teaching hospitals. METHODS An observational study was conducted using the Nationwide Readmission Database (NRD). Patients undergoing TAVR from 2011 to 2018 were included. Data was analyzed using multivariable logistic regression to determine outcomes of 30-day mortality and readmission between nonteaching and teaching hospitals. RESULTS A total of 235,321 patients underwent TAVR during the study period. Patients undergoing TAVR at teaching hospitals presented with a higher frequency of baseline comorbidities compared to nonteaching hospitals. Postprocedure complications such as myocardial infarction, arrhythmia, pneumonia, acute kidney injury, sepsis, stroke, and hemorrhage occurred more often at teaching centers (p < 0.001); translating to a higher rate of in-hospital mortality (2.27% vs. 1.99%, p = 0.006) and hospital cost ($48,300 vs. $44,900, p < 0.001) in teaching versus nonteaching hospitals. After adjusting for baseline characteristics and postoperative morbidity, in-hospital mortality (p = 0.095) and readmission rate (p = 0.420) on multivariable analysis were not statistically different between centers. CONCLUSION With the evolution and expansion of TAVR to nonteaching centers, mortality, and readmission rates are not significantly different between nonteaching and teaching hospitals. Higher unadjusted in-hospital mortality at teaching centers suggest these centers more often treat high risk patients with associated increased complications.
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Affiliation(s)
- Irsa Hasan
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James A Brown
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Edgar Aranda-Michel
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hemal Gada
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Saurabh Sanon
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Cohen BD, Aminpour N, Wang H, Sellke FW, Al-Refaie WB, Ehsan A. Did ethno-racial disparities in access to transcatheter aortic valve replacement change over time? JTCVS OPEN 2022; 12:71-83. [PMID: 36590742 PMCID: PMC9801242 DOI: 10.1016/j.xjon.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/25/2022] [Accepted: 07/01/2022] [Indexed: 01/04/2023]
Abstract
Objective In this study we sought to evaluate whether disparate use of transcatheter aortic valve replacement (TAVR) among non-White patients has decreased over time, and if unequal access to TAVR is driven by unequal access to high-volume hospitals. Methods From 2013 to 2017, we used the State Inpatient Database across 8 states (Ariz, Colo, Fla, Md, NC, NM, Nev, Wash) to identify 51,232 Medicare beneficiaries who underwent TAVR versus surgical aortic valve replacement. Hospitals were categorized as low- (<50 per year), medium- (50-100 per year), or high-volume (>100 per year) according to total valve procedures (TAVR + surgical aortic valve replacement). Multivariable logistic regression models with interactions were performed to determine the effect of race, time, and hospital volume on the utilization of TAVR. Results Non-White patients were less likely to receive TAVR than White patients (odds ratio [OR], 0.77; 95% CI, 0.71-0.83). However, utilization of TAVR increased over time (OR, 1.73; 95% CI, 1.73-1.80) for the total population, with non-White patients' TAVR use growing faster than for White patients (OR, 1.06; 95% CI, 1.00-1.12), time × race interaction, P = .034. Further, an adjusted volume-stratified time trend analysis showed that utilization of TAVR at high volume hospitals increased faster for non-White patients versus White patients by 8.6% per year (OR, 1.09; 95% CI, 1.01-1.16) whereas use at low- and medium-volume hospitals did not contribute to any decreasing utilization gap. Conclusions This analysis shows initial low rates of TAVR utilization among non-White patients followed by accelerated use over time, relative to White patients. This narrowing gap was driven by increased TAVR utilization by non-White patients at high-volume hospitals.
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Affiliation(s)
- Brian D. Cohen
- Department of Surgery, MedStar Georgetown/Washington Hospital Center, Washington, DC
| | | | - Haijun Wang
- MedStar Health Research Institute, Hyattsville, Md
| | - Frank W. Sellke
- Division of Cardiothoracic Surgery, Brown University Medical School/Rhode Island Hospital, Providence, RI
| | - Waddah B. Al-Refaie
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC,Address for reprints: Waddah B. Al-Refaie, MD, FACS, MedStar Georgetown University Hospital, MedStar-Georgetown Surgical Outcomes Research Center, Georgetown Lombardi Comprehensive Cancer Center, 3800 Reservoir Rd NW, PHC Building, 4th Floor, Washington, DC 20007.
| | - Afshin Ehsan
- Division of Cardiothoracic Surgery, Brown University Medical School/Rhode Island Hospital, Providence, RI
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Zahid S, Din MTU, Khan MZ, Rai D, Ullah W, Sanchez-Nadales A, Elkhapery A, Khan MU, Goldsweig AM, Singla A, Fonarrow G, Balla S. Trends, Predictors, and Outcomes of 30-Day Readmission With Heart Failure After Transcatheter Aortic Valve Replacement: Insights From the US Nationwide Readmission Database. J Am Heart Assoc 2022; 11:e024890. [PMID: 35929464 PMCID: PMC9496292 DOI: 10.1161/jaha.121.024890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Data on trends, predictors, and outcomes of heart failure (HF) readmissions after transcatheter aortic valve replacement (TAVR) remain limited. Moreover, the relationship between hospital TAVR discharge volume and HF readmission outcomes has not been established. METHODS AND RESULTS The Nationwide Readmission Database was used to identify 30‐day readmissions for HF after TAVR from October 1, 2015, to November 30, 2018, using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) codes. A total of 167 345 weighted discharges following TAVR were identified. The all‐cause readmission rate within 30 days of discharge was 11.4% (19 016). Of all the causes of 30‐day rehospitalizations, HF comprised 31.4% (5962) of all causes. The 30‐day readmission rate for HF did not show a significant decline during the study period (Ptrend=0.06); however, all‐cause readmission rates decreased significantly (Ptrend=0.03). HF readmissions were comparable between high‐ and low‐volume TAVR centers. Charlson Comorbidity Index >8, length of stay >4 days during the index hospitalization, chronic obstructive pulmonary disease, atrial fibrillation, chronic HF, preexisting pacemaker, complete heart block during index hospitalization, paravalvular regurgitation, chronic kidney disease, and end‐stage renal disease were independent predictors of 30‐day HF readmission after TAVR. HF readmissions were associated with higher mortality rates when compared with non‐HF readmissions (4.9% versus 3.3%; P<0.01). Each HF readmission within 30 days was associated with an average increased cost of $13 000 more than for each non‐HF readmission. CONCLUSIONS During the study period from 2015 to 2018, 30‐day HF readmissions after TAVR remained steady despite all‐cause readmissions decreasing significantly. All‐cause readmission mortality and HF readmission mortality also showed a nonsignificant downtrend. HF readmissions were comparable across low‐, medium‐, and high‐volume TAVR centers. HF readmission was associated with increased mortality and resource use attributed to the increased costs of care compared with non‐HF readmission. Further studies are needed to identify strategies to decrease the burden of HF readmissions and related mortality after TAVR.
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Affiliation(s)
- Salman Zahid
- Department of Medicine Rochester General Hospital Rochester NY
| | | | - Muhammad Zia Khan
- Division of Cardiology West Virginia University Heart & Vascular Institute Morgantown WV
| | - Devesh Rai
- Department of Medicine Rochester General Hospital Rochester NY
| | - Waqas Ullah
- Department of Cardiovascular Medicine Jefferson University Hospitals Philadelphia PA
| | | | - Ahmed Elkhapery
- Department of Medicine Rochester General Hospital Rochester NY
| | - Muhammad Usman Khan
- Division of Cardiology West Virginia University Heart & Vascular Institute Morgantown WV
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine University of Nebraska Medical Center Omaha NE
| | | | - Greg Fonarrow
- Division of Cardiovascular Medicine University of California Los Angeles Los Angeles CA
| | - Sudarshan Balla
- Division of Cardiology West Virginia University Heart & Vascular Institute Morgantown WV
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Zhang R, Liu G, Pan Y, Zhou M, Wang Y. Association between hospital volume, processes of care and outcomes after acute ischaemic stroke: a prospective observational study. BMJ Open 2022; 12:e060015. [PMID: 35680259 PMCID: PMC9185595 DOI: 10.1136/bmjopen-2021-060015] [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: 11/03/2022] Open
Abstract
OBJECTIVES There is uncertainty with respect to the hospital volume and clinical outcomes for patients with stroke. This study aimed to assess the association between hospital volume, processes of care and outcomes after ischaemic stroke. DESIGN A multicentre prospective cohort study. SETTING Two hundred and seventeen secondary or tertiary public hospitals from China. PARTICIPANTS A total of 17 550 patients within 7 days of acute ischaemic stroke were included. MAIN OUTCOME MEASURES The outcomes included all-cause mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. The patients were divided into four groups based on quartiles of the hospital volume. We compared the difference in the process of care across the groups and estimated the effects of hospital volume on mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. Restricted cubic splines were used to illustrate the association between hospital volume and clinical outcomes. RESULTS There were no significant differences in the process of care across the four groups. When adjusted for confounders, the effect of hospital volume on mortality, recurrent stroke and combined vascular events was not significant. However, compared with the highest quartile, the patients in the lowest quartile of hospital volume tend to have poor outcome at 1 year (OR=1.29, 95% CI 1.01 to 1.64, p=0.0393). The restricted cubic spline analyses suggested a non-linear relationship between hospital volume and 1-year combined vascular events and poor outcome at 3 months and 1 year. CONCLUSIONS We found no significant associations between hospital volume, processes of care at the hospital, and mortality, recurrent stroke, and combined vascular events in patients with ischaemic stroke. However, hospital volume may be associated with poor outcome at 1 year.
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Affiliation(s)
- Runhua Zhang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Maigeng Zhou
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Statistics, China National Clinical Research Center for Neurological Diseases, Beijing, China
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10
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Saji M, Kumamaru H, Kohsaka S, Higuchi R, Izumi Y, Takamisawa I, Tobaru T, Shimokawa T, Takanashi S, Shimizu H, Takayama M. Non-cardiovascular readmissions after transcatheter aortic valve replacement: Insights from a Japanese nationwide registry of transcatheter valve therapies. J Cardiol 2022; 80:197-203. [DOI: 10.1016/j.jjcc.2022.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/12/2022] [Accepted: 03/11/2022] [Indexed: 11/25/2022]
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11
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Trends in 30-Day and 90-Day Readmission Rates After Transcatheter Aortic Valve Implantation. Am J Cardiol 2022; 167:167-170. [PMID: 35063274 DOI: 10.1016/j.amjcard.2021.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022]
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12
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Mentias A, Keshvani N, Desai MY, Kumbhani DJ, Sarrazin MV, Gao Y, Kapadia S, Peterson ED, Mack M, Girotra S, Pandey A. Risk-Adjusted, 30-Day Home Time After Transcatheter Aortic Valve Replacement as a Hospital-Level Performance Metric. J Am Coll Cardiol 2022; 79:132-144. [PMID: 35027108 PMCID: PMC10535368 DOI: 10.1016/j.jacc.2021.10.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patient-centric measures of hospital performance for transcatheter aortic valve replacement (TAVR) are needed. OBJECTIVES This study evaluated 30-day, risk-adjusted home time as a hospital performance metric for patients who underwent TAVR. METHODS This study identified 160,792 Medicare beneficiaries who underwent elective TAVR from 2015 to 2019. Home time was calculated for each patient as the number of days alive and spent outside the hospital, skilled nursing facility (SNF), and long-term acute care facility for 30 days after the TAVR procedure date. Correlations between risk-adjusted, 30-day home time and other metrics (30-day, risk-adjusted readmission rate [RSRR], 30-day, risk-adjusted mortality rate [RSMR], and annual TAVR volume) were estimated using Pearson's correlation. Meaningful upward or downward reclassification (≥2 quartile ranks) in hospital performance based on quartiles of risk-adjusted, 30-day home time compared with quartiles of other measures were assessed. RESULTS Median risk-adjusted, 30-day home time was 27.4 days (interquartile range [IQR]: 26.3-28.5 days). The largest proportion of days lost from 30-day home time was hospital stay after TAVR and SNF stay. An inverse correlation was observed between hospital-level, risk-adjusted, 30-day home time and 30-day RSRR (r = -0.465; P < 0.001) and 30-day RSMR (r = -0.3996; P < 0.001). The use of the 30-day, risk-adjusted home time was associated with reclassification in hospital performance rank hospitals compared with other metrics (9.1% up-classified, 11.2% down-classified vs RSRR; 9.1% up-classified, 10.3% down-classified vs RSMR; and 20.1% up-classified, 19.3% down-classified vs annual TAVR volume). CONCLUSIONS Risk-adjusted, 30-day home time represents a novel patient-centered performance metric for TAVR hospitals that may provide a complimentary assessment to currently used metrics.
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Affiliation(s)
- Amgad Mentias
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Milind Y Desai
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Dharam J Kumbhani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mary Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA; Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Yubo Gao
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA; Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Samir Kapadia
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Eric D Peterson
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Michael Mack
- Division of Cardiology, Baylor Scott and White Health, Plano, Texas, USA
| | - Saket Girotra
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA; Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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All-cause readmission after transcatheter aortic valve replacement in a community hospital - Long term follow-up: Readmissions after aortic valve replacement. Am J Med Sci 2021; 363:420-427. [PMID: 34752740 DOI: 10.1016/j.amjms.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/19/2021] [Accepted: 09/28/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Post-procedure readmissions are associated with lower quality of life and increased economic burden. The study aimed to identify predictors for long-term all-cause readmissions in patients who underwent transcatheter aortic valve replacement (TAVR) in a community hospital. METHODS A Historical cohort study of all adults who underwent TAVR at Cape-Cod hospital between June 2015 and December 2017 was performed and data on readmissions was collected up-to May 2020 (median follow up of 3.3 years). Pre-procedure, procedure and in-hospital post-procedure parameters were collected. Readmission rate was evaluated, and univariate and multivariable analyses were applied to identify predictors for readmission. RESULTS The study included 262 patients (mean age 83.7±7.9 years, 59.9% males). The median Society of Thoracic Surgeons (STS) probability of mortality (PROM) score was 4.9 (IQR, 3.1-7.9). Overall, 120 patients were readmitted. Ten percent were readmitted within 1-month, 20.8% within 3-months, 32.0% within 6-months and 44.5% within 1-year. New readmissions after 1-year were rare. STS PROM 5% or above (HR 1.50, p=0.039), pre-procedure anemia (HR 1.63, p=0.034), severely decreased pre-procedure renal function (HR 1.93, p=0.040) and procedural complication (HR 1.65, p=0.013) were independent predictors for all-cause readmission. CONCLUSIONS Elevated procedural risk, anemia, renal dysfunction and procedural complication are important predictors for readmission. Pre-procedure and ongoing treatment of the patient's background diseases and completion of treatment for complications prior to discharge may contribute to a reduction in the rate of readmissions.
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Thompson MP, Hou H, Brescia AA, Pagani FD, Sukul D, McCullough JS, Likosky DS. Center Variability in Medicare Claims-Based Publicly Reported Transcatheter Aortic Valve Replacement Outcome Measures. J Am Heart Assoc 2021; 10:e021629. [PMID: 34689581 PMCID: PMC8751838 DOI: 10.1161/jaha.121.021629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Public reporting of transcatheter aortic valve replacement (TAVR) claims–based outcome measures is used to identify high‐ and low‐performing centers. Whether claims‐based TAVR outcomes can reliably be used for center‐level comparisons is unknown. In this study, we sought to evaluate center variability in claims‐based TAVR outcomes used in public reporting. Methods and Results The study sample included 119 554 Medicare beneficiaries undergoing TAVR between January 2014 and October 2018 based on procedure codes in 100% Medicare inpatient claims. Multivariable hierarchical logistic regression was used to estimate center‐specific adjusted rates and reliability (R) of 30‐day mortality, discharge not to home/self‐care, 30‐day stroke, and 30‐day readmission. Reliability was defined as the ratio of between‐hospital variation to the sum of the between‐ and within‐hospital variation. The median (interquartile range [IQR]) center‐level adjusted outcome rates were 3.1% (2.9%–3.4%) for 30‐day mortality, 41.4% (31.3%–53.4%) for discharge not to home, 2.5% (2.3%–2.7%) for 30‐day stroke, and 14.9% (14.4%–15.5%) for 30‐day readmission. Median reliability was highest for the discharge not to home measure (R=0.95; IQR, 0.94–0.97), followed by the 30‐day stroke (R=0.92; IQR, 0.87–0.94), 30‐day mortality (R=0.86; IQR, 0.81–0.91), and 30‐day readmission measures (R=0.42; IQR, 0.35–0.51). Across outcomes, there was an inverse relationship between center volume and measure reliability. Conclusions Claims‐based TAVR outcome measures for mortality, discharge not to home, and stroke were reliable measures for center‐level comparisons, but readmission measures were unreliable. Stakeholders should consider these findings when evaluating claims‐based measures to compare center‐level TAVR performance.
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Affiliation(s)
- Michael P Thompson
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI.,Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Hechuan Hou
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI
| | - Alexander A Brescia
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI.,Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Francis D Pagani
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI.,Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Devraj Sukul
- Division of Cardiovascular Medicine Department of General Internal Medicine Michigan Medicine Ann Arbor MI
| | - Jeffrey S McCullough
- Department of Health Management and Policy School of Public Health University of Michigan Ann Arbor MI
| | - Donald S Likosky
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI.,Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
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Elbadawi A, Mahta D, Elgendy IY, Dang AT, Mahmoud M, Iskandar M, Kaple R, Al-Azizi K, Szerlip M, Kayani W, Barker CM, Jneid H. Trends in utilization, outcomes, and readmissions after transcatheter mitral valve replacement. Catheter Cardiovasc Interv 2021; 99:906-914. [PMID: 34569695 DOI: 10.1002/ccd.29963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 08/24/2021] [Accepted: 09/18/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is a paucity of real-world data regarding the temporal trends and outcomes of trans-septal transcatheter mitral valve replacement (TS-TMVR) in the United States (US). METHODS We queried the Nationwide Readmissions Database (October 2015 to December 2018) for patients undergoing TS-TMVR procedures. We reported the temporal trends in the utilization, in-hospital outcomes and 30-day readmissions after TS-TMVR. The main study outcome was in-hospital mortality. RESULTS There was an increase in the number of TS-TMVR procedures over time (48 in 2015 vs. 978 in 2018, Ptrend < 0.001), with a notable increase in the proportion of women (Ptrend = 0.04) and the prevalence of diabetes (Ptrend = 0.03). There was an increase in the number of centers performing TS-TMVR (21 in 2015 vs. 164 in 2018, Ptrend < 0.001). The overall in-hospital mortality was 7.2% with no change over time (6.3% in 2015 vs. to 5.2% in 2018, Ptrend = 0.67). There was no change in the frequency of in-hospital complications after TS-TMVR; however, the median length of stay has decreased over time. The overall 30-day readmission rate was 17.8%, with no change during the study years. The most frequent cause for 30-day readmission after TS-TMVR was acute heart failure followed by bleeding and infection-related complications. Prior coagulopathy and small-sized hospitals were independently associated with higher in-hospital mortality and 30-day readmissions. CONCLUSION This nationwide observational analysis of real-world data showed an increase in the number of TS-TMVR procedures over time, which is now performed at a greater number of centers. There was no change in the rate of in-hospital mortality, complications or 30-day readmissions; but a significant reduction in the length of hospital stay over time was noted. As the number of TS-TMVR continue to expand, these data provide a perspective on the early experience with this procedure.
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Affiliation(s)
- Ayman Elbadawi
- Section of Cardiology, Baylor School of Medicine, Houston, Texas, USA
| | - Dhruv Mahta
- Section of Cardiology, Baylor School of Medicine, Houston, Texas, USA
| | - Islam Y Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Alexander T Dang
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mona Mahmoud
- Department of Internal Medicine, Central Michigan University Health, Saginaw, Michigan, USA
| | - Mina Iskandar
- Department of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Ryan Kaple
- Department of Cardiovascular Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Karim Al-Azizi
- Cardiovascular Research Department, Baylor Scott and White the Heart Hospital, Plano, Texas, USA
| | - Molly Szerlip
- Cardiovascular Research Department, Baylor Scott and White the Heart Hospital, Plano, Texas, USA
| | - Waleed Kayani
- Section of Cardiology, Baylor School of Medicine, Houston, Texas, USA
| | - Colin M Barker
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hani Jneid
- Section of Cardiology, Baylor School of Medicine, Houston, Texas, USA
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Senussi MH, Schindler J, Sultan I, Masri A, Navid F, Kliner D, Kilic A, Sharbaugh MS, Barakat A, Althouse AD, Lee JS, Gleason TG, Mulukutla SR. Long term mortality and readmissions after transcatheter aortic valve replacement. Cardiovasc Diagn Ther 2021; 11:1002-1012. [PMID: 34527523 DOI: 10.21037/cdt-20-916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/14/2021] [Indexed: 11/06/2022]
Abstract
Background Readmissions following transcatheter aortic valve replacement (TAVR) are common but detailed analysis of cardiac and non-cardiac inpatient readmissions beyond thirty days to different levels of care are limited. Methods Our study population was 1,037 consecutive patients who underwent TAVR between 2011-2017 within a multi-hospital quaternary health system. A retrospective chart review was performed and readmissions were adjudicated and classified based on primary readmission diagnosis (cardiac versus noncardiac) and level of care [intensive care unit (ICU) admission vs. non-ICU admission]. Incidence, causes, and outcomes of readmissions to up to three years post procedure were evaluated. Results Of the 1,017 patients who survived their index hospitalization, there were readmissions due to noncardiac causes in 350 (34.4%) and cardiac causes in 208 (20.5%) during a mean 1.96 years of follow-up. The most common non-cardiac causes of readmission were sepsis/infection (14.3%), gastrointestinal (8.3%), and respiratory (4.8%), whereas heart failure (14.0%) and arrhythmias (4.6%) were the most common cardiac causes of readmission. A total of 191 (18.8%) patients were readmitted to the ICU and 372 patients (36.6%) were non-ICU readmissions. The risk of a noncardiac readmission was highest in the period immediately following TAVR (~4.5% per month) with an early high hazard phase that gradually declined over months. However, the risk of cardiac readmission remained stable at ~1% per month throughout. TAVR patients that were readmitted for any cause had markedly increased mortality; this was especially true for patients readmitted to an ICU. Conclusions In TAVR patients who survived their index hospitalization, non-cardiac readmissions were more prevalent than cardiac. The risk of readmission and subsequent mortality was highest immediately post-procedure and declined thereafter. Readmission to ICU portends the highest risk of subsequent death in this cohort. Patient baseline co-morbidities are an important consideration for TAVR patients and play a significant role in readmissions and outcomes.
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Affiliation(s)
- Mourad H Senussi
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John Schindler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ahmad Masri
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Forozan Navid
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arman Kilic
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael S Sharbaugh
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amr Barakat
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew D Althouse
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joon S Lee
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Thomas G Gleason
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Suresh R Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Gandjian M, Williamson C, Sanaiha Y, Hadaya J, Tran Z, Kim ST, Revels S, Benharash P. Continued Relevance of Minimum Volume Standards for Elective Esophagectomy: A National Perspective. Ann Thorac Surg 2021; 114:426-433. [PMID: 34437854 DOI: 10.1016/j.athoracsur.2021.07.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/11/2021] [Accepted: 07/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite minimum volume recommendations, the majority of esophagectomies are performed at centers with fewer than 20 annual cases. The present study examined the impact of institutional esophagectomy volume on in-hospital mortality, complications and resource use following esophageal resection. METHODS The 2010-2018 Nationwide Readmissions Database was queried to identify all adult patients undergoing esophagectomy for malignancy. Hospitals were categorized as high-volume (HVH) if performing at least 20 esophagectomies annually, and low-volume (LVH) if fewer. Multivariable models were developed to study the impact of volume on outcomes of interest which included in-hospital mortality, complications, duration of hospitalization (LOS), inflation adjusted costs, readmissions, and non-home discharge. RESULTS Of an estimated 23,176 hospitalizations, 45.6% occurred at HVH. Incidence of esophagectomy increased significantly along with median institutional case load over the study period, while the proportion on hospitals considered HVH remained steady at approximately 7.4%. After adjusting for relevant patient and hospital characteristics, HVH was associated with decreased mortality (AOR=0.65), LOS (β=-1.83 days), pneumonia (AOR=0.69), prolonged ventilation (AOR=0.50), sepsis (AOR=0.80), and tracheostomy (AOR=0.66), but increased odds of non-home discharge (AOR=1.56, all P<0.01), with LVH as reference. CONCLUSIONS Many clinical outcomes of esophagectomy are improved with no increment in costs when performed at centers with an annual caseload of at least 20, as recommended by patient advocacy organizations. These findings suggest that centralization of esophageal resections to high-volume centers may be congruent with value-based care models.
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Affiliation(s)
- Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Samuel T Kim
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sha'shonda Revels
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
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Kolte D, Kennedy K, Wasfy JH, Jena AB, Elmariah S. Hospital Variation in 30-Day Readmissions Following Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2021; 10:e021350. [PMID: 33938233 PMCID: PMC8200708 DOI: 10.1161/jaha.120.021350] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Data on hospital variation in 30-day readmission rates after transcatheter aortic valve replacement (TAVR) are limited. Further, whether such variation is explained by differences in hospital characteristics and hospital practice patterns remains unknown. Methods and Results We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TAVRs. Hierarchical logistic regression models were used to examine between-hospital variation in 30-day all-cause risk-standardized readmission rate (RSRR) after TAVR and to explore reasons underlying hospital variation in 30-day RSRR. The study included 27 091 index TAVRs performed across 325 hospitals. The median (interquartile range) hospital-level 30-day RSRR was 11.9% (11.1%-12.8%) ranging from 8.8% to 16.5%. After adjusting for differences in patient characteristics, there was significant between-hospital variation in 30-day RSRR (hospital odds ratio, 1.59; 95% CI, 1.39-1.77). Differences in length of stay and discharge disposition accounted for 15% of the between-hospital variance in RSRRs. There was no significant association between hospital characteristics and 30-day readmission rates after TAVR. There was statistically significant but weak correlation between 30-day RSRR after TAVR and that after surgical aortic valve replacement, percutaneous coronary intervention, acute myocardial infarction, heart failure, and pneumonia (r=0.132-0.298; P<0.001 for all). Causes of 30-day readmission varied across hospitals, with noncardiac readmissions being more common at the bottom 5% hospitals (ie, those with the highest RSRRs). Conclusions There is significant variation in 30-day RSRR after TAVR across hospitals that is not entirely explained by differences in patient or hospital characteristics as well as hospital-wide practice patterns. Noncardiac readmissions are more common in hospitals with the highest RSRRs.
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Affiliation(s)
- Dhaval Kolte
- Cardiology Division Department of Medicine Massachusetts General HospitalHarvard Medical School Boston MA
| | - Kevin Kennedy
- Saint Luke's Mid America Heart Institute Kansas City MO
| | - Jason H Wasfy
- Cardiology Division Department of Medicine Massachusetts General HospitalHarvard Medical School Boston MA
| | - Anupam B Jena
- Department of Health Care Policy Harvard Medical School and Department of Medicine Massachusetts General Hospital Boston MA
| | - Sammy Elmariah
- Cardiology Division Department of Medicine Massachusetts General HospitalHarvard Medical School Boston MA
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Kolte D, Butala NM, Kennedy KF, Wasfy JH, Jena AB, Sakhuja R, Langer N, Melnitchouk S, Sundt TM, Passeri JJ, Palacios IF, Inglessis I, Elmariah S. Association between hospital cardiovascular procedural volumes and transcatheter mitral valve repair outcomes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:27-33. [PMID: 33903039 DOI: 10.1016/j.carrev.2021.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/17/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Cardiovascular procedural volumes can serve as metrics of hospital infrastructure and quality, and are the basis for thresholds for initiating transcatheter mitral valve repair (TMVr) programs. Whether hospital volumes of TMVr, surgical mitral valve replacement or repair (SMVRr), and percutaneous coronary intervention (PCI) are indicators of TMVr quality of care is not known. METHODS We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TMVr procedures. Hospitals were divided into quartiles of TMVr volume. Associations of hospital TMVr, SMVRr, and PCI volumes, as well as SMVRr and PCI outcomes with TMVr outcomes were examined. Outcomes studied were risk-standardized in-hospital mortality rate (RSMR) and 30-day readmission rate (RSRR). RESULTS The study included 3404 TMVr procedures performed across 150 hospitals in the US. The median hospital TMVr volume was 17 (IQR 10, 28). The mean hospital-level RSMR and RSRR for TMVr were 3.0% (95% CI 2.5%, 3.4%) and 14.8% (95% CI 14.5%, 15.0%), respectively. There was no significant association between hospital TMVr volume (as quartiles or as a continuous variable) and TMVr RSMR or RSRR (P > 0.05). Similarly, there was weak or no correlation between hospital SMVRr and PCI volumes and outcomes with TMVr RSMR or RSRR (Pearson correlation coefficients, r = -0.199 to 0.269). CONCLUSION In this study, we found no relationship between hospital TMVr, SMVRr, and PCI volume and TMVr outcomes. Further studies are needed to determine more appropriate structure and process measures to assess the performance of established and new TMVr centers.
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Affiliation(s)
- Dhaval Kolte
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Neel M Butala
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Rahul Sakhuja
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nathaniel Langer
- Cardiac Surgery Division, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Serguei Melnitchouk
- Cardiac Surgery Division, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thoralf M Sundt
- Cardiac Surgery Division, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan J Passeri
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Igor F Palacios
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ignacio Inglessis
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sammy Elmariah
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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20
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Ando T, Ashraf S, Kuno T, Briasoulis A, Takagi H, Grines C, Malik A. Hospital variation of 30-day readmission rate following transcatheter aortic valve implantation. Heart 2021; 108:219-224. [PMID: 33627399 DOI: 10.1136/heartjnl-2020-318583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Thirty-day readmission rate is one of the hospital quality metrics. Outcomes of transcatheter aortic valve implantation (TAVI) have improved significantly, but it remains unclear whether hospital-level variance in 30-day readmission rate exists in the contemporary TAVI era. METHODS From the 2017 US Nationwide Readmission Database, endovascular TAVI were identified. The unadjusted 30-day readmission rate and 30-day risk-standardised readmission rate (RSRR) were calculated and we then conducted model testing to determine the relative contribution of hospital characteristics, patient-level covariates and economic status to the variation in readmission rates observed between the hospitals. RESULTS A total of 44 899 TAVI from 338 hospitals were identified. The range of unadjusted 30-day readmission rate and 30-day RSRR was 2.0%-33.3% and 9.4%-15.3%, respectively. Median 30-day RSRR was 11.8% and there was a significant hospital-level variation (median OR 1.22, 95% CI 1.16 to 1.32, p<0.01) and this was similar in both readmissions caused due to major cardiac and non-cardiac conditions. Patient, hospital and economic factors accounted for 9.6%, 1.9% and 3.8% of the variability in hospital readmission rate, respectively. CONCLUSIONS There was significant hospital-level variation in 30-day RSRR following TAVI. Further measures are required to mitigate this variance in the readmission rate.
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Affiliation(s)
- Tomo Ando
- Division of Cardiology, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Said Ashraf
- Division of Interventional Cardiology, New York University Langone Medical Center, New York City, New York, USA
| | - Toshiki Kuno
- Department of Internal Medicine, Mount Sinai Beth Israel Hospital, New York City, New York, USA
| | | | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Cindy Grines
- Division of Interventional Cardiology, Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA
| | - Aaqib Malik
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
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21
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Kir D, Shapero K, Chatterjee S, Grimshaw A, Oddleifson A, Spatz ES, Goldsweig AM, Desai NR. Effect of institutional transcatheter aortic valve replacement volume on mortality: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2021; 98:E453-E461. [PMID: 33565695 DOI: 10.1002/ccd.29502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 08/20/2020] [Accepted: 01/11/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE We sought to conduct a systematic review and network meta-analysis to examine the association between institutional transcatheter aortic valve replacement (TAVR) volume and all-cause mortality. BACKGROUND Since inception in 2011, there has been an exponential increase in the number of TAVR centers across the world. Multiple studies have questioned if a relationship exists between institutional TAVR volume and patient outcomes. METHODS We performed a systematic literature search for relevant articles using a combination of free text terms in the title/abstract related to volume, TAVR, and patient outcomes. Two reviewers independently screened all titles/abstracts for eligibility based on pre-specified criteria. All-cause mortality data was pooled from eligible studies and centers were categorized as low-(30-50 cases), intermediate-, or high-volume (75-130 cases) based on their annual TAVR volumes. RESULTS Our search yielded an initial list of 11,153 citations, 120 full text studies were reviewed and 7 studies met all inclusion and exclusion criteria, yielding a total of 1,93,498 TAVRs. Categorized according to center's annual volume; 25,062 TAVRs were performed in low-, 77,093 in intermediate- and 91,343 in high-volume centers. Network meta-analysis showed a relative reduction in mortality rates of 37%, 23% and 19%, for high volume versus low volume centers, high volume versus intermediate volume centers and intermediate versus low volume centers, respectively. CONCLUSIONS Existing research clearly shows an inverse relationship between annual TAVR procedural volume and all-cause mortality. We need to focus on development of strong referral networks and consolidation rather than expansion of existing TAVR centers to improve patient outcomes, while ensuring adequate access-to-care.
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Affiliation(s)
- Devika Kir
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.,Department of Cardiology, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Kayle Shapero
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Saurav Chatterjee
- Hofmann Heart and Vascular Institute, Saint Francis Hospital and Medical Center, Hartford, Connecticut
| | - Alyssa Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut
| | - August Oddleifson
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Erica S Spatz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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22
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Ramos MC, Barreto JOM, Shimizu HE, de Moraes APG, da Silva EN. Regionalization for health improvement: A systematic review. PLoS One 2020; 15:e0244078. [PMID: 33351841 PMCID: PMC7755212 DOI: 10.1371/journal.pone.0244078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/02/2020] [Indexed: 12/20/2022] Open
Abstract
Regionalization is the integrated organization of a healthcare system, wherein regional structures are responsible for providing and administrating health services in a specific region. This method was adopted by several countries to improve the quality of provided care and to properly utilize available resources. Thus, a systematic review was conducted to verify effective interventions to improve health and management indicators within the health services regionalization. The protocol was registered in PROSPERO (CRD42016042314). We performed a systematic search in databases during February and March 2017 which was updated in October 2020. There was no language or date restriction. We included experimental and observational studies with interventions focused on regionalization-related actions, measures or policies aimed at decentralizing and organizing health offerings, rationalizing scarce capital and human resources, coordinating health services. A methodological assessment of the studies was performed using instruments from the Joanna Briggs Institute and GRADE was also used to assess outcomes. Thirty-nine articles fulfilled the eligibility criteria and sixteen interventions were identified that indicated different degrees of recommendations for improving the management of health system regionalization. The results showed that regionalization was effective under administrative decentralization and for rationalization of resources. The most investigated intervention was the strategy of concentrating procedures in high-volume hospitals, which showed positive outcomes, especially with the reduction of hospitalization days and in-hospital mortality rates. When implementing regionalization, it must be noted that it involves changes in current standards of health practice and in the distribution of health resources, especially for specialized services.
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Affiliation(s)
- Maíra Catharina Ramos
- Faculty of Health Sciences, University of Brasilia, Brasília, Brazil
- Oswaldo Cruz Foundation, Brasília, Brazil
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23
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Apostolidou E, Kolte D, Kennedy KF, Beale CE, Abbott JD, Ehsan A, Gurm HS, Carson JL, Mamdani S, Aronow HD. Institutional Red Blood Cell Transfusion Rates Are Correlated Following Endovascular and Surgical Cardiovascular Procedures: Evidence That Local Culture Influences Transfusion Decisions. J Am Heart Assoc 2020; 9:e016232. [PMID: 33140685 PMCID: PMC7763716 DOI: 10.1161/jaha.119.016232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The relationship between local hospital culture and transfusion rates following endovascular and surgical cardiovascular procedures has not been well studied. Methods and Results Patients undergoing coronary revascularization, aortic valve replacement, lower extremity peripheral vascular intervention, or carotid artery revascularization from up to 852 US hospitals in the Nationwide Readmissions Database were identified. Crude and risk‐standardized red blood cell transfusion rates were determined for each procedure. Pearson correlation coefficients were calculated between respective procedural transfusion rates. Median odds ratios were estimated to reflect between‐hospital variability in red blood cell transfusion rates following the same procedure for a given patient. There was wide variation in red blood cell transfusion rates across different procedures, from 2% following carotid endarterectomy to 29% following surgical aortic valve replacement. For surgical and endovascular modalities, transfusion rates at the same hospital were highly correlated for aortic valve replacement (r=0.67; P<0.001), moderately correlated for coronary revascularization (r=0.56; P<0.001) and peripheral vascular intervention (r=0.51; P<0.001), and weakly correlated for carotid artery revascularization (r=0.19, P<0.001). Median odds ratios were all >2, highest for coronary artery bypass graft surgery and surgical aortic valve replacement, indicating substantial site variation in transfusion rates. Conclusions After adjustment for patient‐related factors, wide variation in red blood cell transfusion rates remained across surgical and endovascular procedures employed for the same cardiovascular condition. Transfusion rates following these procedures are highly correlated at individual hospitals and vary widely across hospitals. In aggregate, these findings suggest that local institutional culture significantly influences the decision to transfuse following invasive cardiovascular procedures and highlight the need for randomized data to inform such decisions.
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Affiliation(s)
- Eirini Apostolidou
- Division of Cardiology Alpert Medical School of Brown University Providence RI
| | - Dhaval Kolte
- Division of Cardiology Massachusetts General Hospital and Harvard Medical School Boston MA
| | - Kevin F Kennedy
- Statistical Consultant to the Cardiovascular Institute Kansas City MO
| | | | - J Dawn Abbott
- Division of Cardiology Alpert Medical School of Brown University Providence RI
| | - Afshin Ehsan
- Division of Cardiothoracic Surgery Alpert Medical School of Brown University Providence RI
| | | | - Jeffrey L Carson
- Division of Internal Medicine Robert Wood Johnson University Hospital New Brunswick NJ
| | - Shafiq Mamdani
- Division of Cardiology Alpert Medical School of Brown University Providence RI
| | - Herbert D Aronow
- Division of Cardiology Alpert Medical School of Brown University Providence RI
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24
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Khoury H, Ragalie W, Sanaiha Y, Boutros H, Rudasill S, Shemin RJ, Benharash P. Readmission After Surgical Aortic Valve Replacement in the United States. Ann Thorac Surg 2020; 110:849-855. [DOI: 10.1016/j.athoracsur.2019.11.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 11/05/2019] [Accepted: 11/27/2019] [Indexed: 12/01/2022]
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25
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Isogai T, Saad AM, Ahuja KR, Shekhar S, Abdelfattah OM, Gad MM, Svensson LG, Krishnaswamy A, Kapadia SR. Short‐term outcomes of transcatheter aortic valve replacement for pure native aortic regurgitation in the United States. Catheter Cardiovasc Interv 2020; 97:477-485. [DOI: 10.1002/ccd.29189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/17/2020] [Accepted: 07/19/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Toshiaki Isogai
- Department of Cardiovascular Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland Ohio USA
| | - Anas M. Saad
- Department of Cardiovascular Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland Ohio USA
| | - Keerat R. Ahuja
- Department of Cardiovascular Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland Ohio USA
| | - Shashank Shekhar
- Department of Cardiovascular Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland Ohio USA
| | - Omar M. Abdelfattah
- Department of Cardiovascular Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland Ohio USA
| | - Mohamed M. Gad
- Department of Cardiovascular Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland Ohio USA
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery Heart and Vascular Institute, Cleveland Clinic Cleveland Ohio USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland Ohio USA
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland Ohio USA
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26
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Hirji SA, Zogg CK, Vaduganathan M, Kiehm S, Percy ED, Yazdchi F, Pelletier M, Shah PB, Bhatt DL, O'Gara P, Kaneko T. Quantifying the Impact of Care Fragmentation on Outcomes After Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 128:113-119. [PMID: 32650903 DOI: 10.1016/j.amjcard.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/28/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
Abstract
The Center for Medicare & Medicaid Services has identified readmission as an important quality metric in assessing hospital performance and value of care. The aim of this study was to quantify the impact of "care fragmentation" on transcatheter aortic valve implantation (TAVI) outcomes. Readmission to nonindex hospitals was defined as any hospital other than the hospital where the TAVI was performed. In this multicenter, population-based, nationally representative study, a nationally weighted cohort of US adult patients who underwent TAVI in the National Readmission Database between 01/01/2010 and 9/31/2015 were analyzed. Patient characteristics, trends, and outcomes after 90-day nonindex readmission were evaluated. Thirty-day metric was used as a reference group for comparison. A weighted total of 51,092 patients met inclusion criteria. Overall, the 90-day readmission rate after TAVI was 27.6% (30-day reference group: 17.4%), and 42% of these readmissions were to nonindex hospitals. Noncardiac causes accounted for most nonindex readmissions, but major cardiac procedures were more likely performed at index hospitals during readmission within 90 days. Despite the high co-morbidity burden of patients readmitted to nonindex hospitals, unadjusted and risk-adjusted all-cause mortality, readmission length of stay and total hospital costs following nonindex readmission were lower compared with index readmission at 90 days. In conclusion, in this real world, nationally representative cohort of TAVI patients in the United States, care fragmentation remains prevalent and represent an enduring, residual target for future health policies. Although the impactful readmissions may be directed toward index hospitals, concerted efforts are needed to address mechanisms that increase care fragmentation.
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27
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Malik AH, Yandrapalli S, Zaid S, Shetty S, Athar A, Gupta R, Aronow WS, Goldberg JB, Cohen MB, Ahmad H, Lansman SL, Tang GHL. Impact of Frailty on Mortality, Readmissions, and Resource Utilization After TAVI. Am J Cardiol 2020; 127:120-127. [PMID: 32402487 DOI: 10.1016/j.amjcard.2020.03.047] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 12/01/2022]
Abstract
With aging population and preponderance of severe aortic stenosis occurring in elderly patients, the number of transcatheter aortic valve implantations (TAVI) performed in the elderly are growing. Frailty is common in the elderly and is known to be associated with worse outcomes. We aimed to evaluate the impact of frailty on hospital readmissions rates after TAVI. We used the 2016 Nationwide Readmission Database and categorized patients who underwent TAVI low, intermediate, and high frailty status. The primary outcome was 6-months readmission rates across the 3 frailty categories. Secondary outcomes included causes of readmissions, in-hospital mortality and cost of care. STATA 16.0 was used for survey-specific statistical tests. Of 20,504 patients who underwent TAVI, 58.9% were low-, 39.6% were intermediate-, and 1.5% were in the high-frailty group. Overall in-hospital mortality was 1.9% (n = 396), and was 0.6%, 3.3%, and 16.8% (p <0.01) with increasing frailty. Of the 20,108 patients who survived to discharge, 6,427 (32%) patients were readmitted within 6-months after TAVI. Readmission rates increased across the categories from 27.9% in low, 37.6% in intermediate and 51.1% in high frailty group (p <0.01). While cardiac causes (mostly heart failure) were the predominant readmission etiologies across frailty categories (low: 51.2%, intermediate: 34.1%, high: 27.2%), rates of infectious and injury-related readmissions increased (low: 11%, intermediate: 30%, high: 45%). Mortality during readmissions also worsened from 0.8%, 5.3%, and 8.5% (p <0.01). Over 40% of patients undergoing TAVI were of intermediate-high frailty. In conclusion, an increasing frailty was associated with significantly worse postprocedure mortality, readmissions, and related mortality.
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Affiliation(s)
- Aaqib H Malik
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York.
| | - Srikanth Yandrapalli
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Syed Zaid
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Suchith Shetty
- Department of Medicine, University of Iowa Health Care, Carver College of Medicine, Iowa
| | - Ammar Athar
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Rahul Gupta
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Joshua B Goldberg
- Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Martin B Cohen
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Hasan Ahmad
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Steven L Lansman
- Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York
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28
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Bica I, Alaa AM, Lambert C, van der Schaar M. From Real-World Patient Data to Individualized Treatment Effects Using Machine Learning: Current and Future Methods to Address Underlying Challenges. Clin Pharmacol Ther 2020; 109:87-100. [PMID: 32449163 DOI: 10.1002/cpt.1907] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 05/14/2020] [Indexed: 12/21/2022]
Abstract
Clinical decision making needs to be supported by evidence that treatments are beneficial to individual patients. Although randomized control trials (RCTs) are the gold standard for testing and introducing new drugs, due to the focus on specific questions with respect to establishing efficacy and safety vs. standard treatment, they do not provide a full characterization of the heterogeneity in the final intended treatment population. Conversely, real-world observational data, such as electronic health records (EHRs), contain large amounts of clinical information about heterogeneous patients and their response to treatments. In this paper, we introduce the main opportunities and challenges in using observational data for training machine learning methods to estimate individualized treatment effects and make treatment recommendations. We describe the modeling choices of the state-of-the-art machine learning methods for causal inference, developed for estimating treatment effects both in the cross-section and longitudinal settings. Additionally, we highlight future research directions that could lead to achieving the full potential of leveraging EHRs and machine learning for making individualized treatment recommendations. We also discuss how experimental data from RCTs and Pharmacometric and Quantitative Systems Pharmacology approaches can be used to not only improve machine learning methods, but also provide ways for validating them. These future research directions will require us to collaborate across the scientific disciplines to incorporate models based on RCTs and known disease processes, physiology, and pharmacology into these machine learning models based on EHRs to fully optimize the opportunity these data present.
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Affiliation(s)
- Ioana Bica
- University of Oxford, Oxford, UK.,The Alan Turing Institute, London, UK
| | - Ahmed M Alaa
- University of California - Los Angeles, Los Angeles, California, USA
| | - Craig Lambert
- Clinical Pharmacology and Safety Sciences, Research and Development, AstraZeneca, Cambridge, UK
| | - Mihaela van der Schaar
- The Alan Turing Institute, London, UK.,University of California - Los Angeles, Los Angeles, California, USA.,University of Cambridge, Cambridge, UK
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29
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Hirji SA, Shah R, Aranki S, McGurk S, Singh S, Mallidi HR, Pelletier M, Shekar P, Kaneko T. The impact of hospital size on national trends and outcomes in isolated open proximal aortic surgery. J Thorac Cardiovasc Surg 2020; 163:1269-1278.e9. [PMID: 32713639 DOI: 10.1016/j.jtcvs.2020.03.180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the impact of hospital size on national trend estimates of isolated open proximal aortic surgery for benchmarking hospital performance. METHODS Patients age >18 years who underwent isolated open proximal aortic surgery for aneurysm and dissection from 2002 to 2014 were identified using the National Inpatient Sample. Concomitant valvular, vessel revascularization, re-do procedures, endovascular, and surgery for descending and thoracoabdominal aorta were excluded. Discharges were stratified by hospital size and analyzed using trend, multivariable regression, propensity-score matching analysis. RESULTS Over a 13-year period, 53,657 isolated open proximal aortic operations were performed nationally. Although the total number of operations/year increased (∼2.9%/year increase) and overall in-hospital mortality decreased (∼4%/year; both P < .001 for trend), these did not differ by hospital size (P > .05). Large hospitals treated more sicker and older patients but had shorter length of stay and lower hospital costs (both P < .001). Even after propensity-score matching, large hospital continued to demonstrate superior in-hospital outcomes, although only statistically for major in-hospital cardiac complications compared with non-large hospitals. In our subgroup analysis of dissection versus non-dissection cohort, in-hospital mortality trends decreased only in the non-dissection cohort (P < .01) versus dissection cohort (P = .39), driven primarily by the impact of large hospitals (P < .01). CONCLUSIONS This study demonstrates increasing volume and improving outcomes of isolated open proximal aortic surgeries nationally over the last decade regardless of hospital bed size. Moreover, the resource allocation of sicker patients to larger hospital resulted shorter length of stay and hospital costs, while maintaining similar operative mortality to small- and medium-sized hospitals.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Rohan Shah
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sary Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Steve Singh
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Hari R Mallidi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Marc Pelletier
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Prem Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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30
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Ando T, Adegbala O, Uemura T, Ashraf S, Akintoye E, Pahuja M, Afonso L, Briasoulis A, Takagi H. Palliative Care in Ruptured Aortic Aneurysm in the United States: A Retrospective Analysis of Nationwide Inpatient Sample Database. Angiology 2020; 71:633-640. [DOI: 10.1177/0003319720917239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We assessed the trend of palliative care (PC) referrals and its effect on hospitalization cost and length of stay (LOS) in ruptured aortic aneurysm (rAA). The Nationwide Inpatient Sample from 2005 to 2014 was used to identify admissions with age ≥50 and rAA. A total of 54 134 rAA admissions were identified and 5019 (9.3%) had PC referrals. During the study period, PC referral rate increased from 0.97% to 15.3% ( P trend < .0001). Length of stay (1.7 vs 2.8 days, adjusted mean ratio [aMR] = 0.62, 95% confidence interval [CI]: 0.58-0.66), and cost (US$7778 vs US$13 575, aMR = 0.57, 95% CI: 0.52-0.63) were significantly lower in rAA admissions that did not undergo interventions. In the percutaneous repair group, LOS was similar but the cost was higher (US$61 759 vs US$52 260, aMR = 1.18, 95% CI: 1.05-1.30), whereas in surgical repair group, LOS was shorter (4.6 vs 5.9 days, aMR = 0.77, 95% CI: 0.73-0.82) but the cost was higher (US$59 755 vs US$52 523, aMR = 1.14, 95% CI: 1.02-1.28). Palliative care could shorten LOS and save hospitalization cost in rAA admissions not a candidate for repair. Further studies are required to investigate the variable effects of PC on rAA.
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Affiliation(s)
- Tomo Ando
- Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Oluwole Adegbala
- Englewood Hospital and Medical Center, Seton Hall University-Hackensack Meridian School of Medicine, Englewood, NJ, USA
| | - Takeshi Uemura
- University Health Partners of Hawaii, John A Burns School of Medicine, Honolulu, HI, USA
| | - Said Ashraf
- Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | | | - Mohit Pahuja
- Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Luis Afonso
- Wayne State University/Detroit Medical Center, Detroit, MI, USA
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Krishnan U, Visaria A, Banerjee S, Kim LK, Karas MG, Sobol I, Horn EM, Goyal P. Association of Hospital Volume with 30-Day Readmission Following Left Ventricular Assist Device Implantation. J Card Fail 2020; 26:349-351. [PMID: 32151635 PMCID: PMC8019493 DOI: 10.1016/j.cardfail.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Udhay Krishnan
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | | | - Samprit Banerjee
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY
| | - Luke K Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Maria G Karas
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Irina Sobol
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Parag Goyal
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY; Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY.
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Qin Y, Wei X, Han H, Wen Y, Gu K, Ruan Y, Lucas CH, Baber U, Tomey MI, He J. Association between age and readmission after percutaneous coronary intervention for acute myocardial infarction. Heart 2020; 106:1595-1603. [PMID: 32144190 DOI: 10.1136/heartjnl-2019-316103] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the association between age and the risk of 30-day unplanned readmission among adult patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). METHODS This retrospective analysis included patients from the Nationwide Readmissions Database with AMI who underwent PCI during 2013-2014. We used multivariable logistic regression model to calculate adjusted odds ratios (AORs) for risk of readmission. To examine potential non-linear association, we performed logistic regression with restricted cubic splines (RCS). RESULTS Of the 492 550 patients with AMI aged above 18 years undergoing PCI during the index hospitalisation, 48 630 (9.87%) were readmitted within 30 days. Although the crude readmission rate of younger patients (aged 18-54 years) was the lowest (7.27%), younger patients had higher risk of readmission compared with patients aged 55-64 years for all-causes (AOR 1.06 (1.01 to 1.11), p=0.0129) and specific causes, such as AMI and chest pain (both cardiac and non-specific) after adjusted for covariates. Patients aged 65-74 years were at lower risk of all-cause readmission. Older patients (age ≥75 years) had higher risk of readmission for heart failure (AOR 1.50 (1.29 to 1.74)) and infection (AOR 1.44 (1.16 to 1.79)), but lower risk for chest pain. RCS analyses showed a U-shaped relationship between age and readmission risk. CONCLUSIONS Our results suggest higher risk of readmission in younger patients for all-cause unplanned readmission after adjusted for covariates. The trends of readmission risk along with age were different for specific causes. Age-targeted initiatives are warranted to reduce preventable readmissions in patients with AMI undergoing PCI.
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Affiliation(s)
- Yingyi Qin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Xin Wei
- Department of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Hedong Han
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yumeng Wen
- Division of Nephrology, Johns Hopkins University school of medicine, Baltimore, Maryland, USA
| | - Kevin Gu
- Division of Cardiology, Department of Medicine, Mcmaster University Hospital, Hamilton, Ontario, Canada
| | - Yiming Ruan
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Claire Huang Lucas
- Department of medicine, Mount Sinai St. Luke's and West Medical Center, New York, New York, USA
| | - Usman Baber
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Matthew I Tomey
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Jia He
- Department of Health Statistics, Second Military Medical University, Shanghai, China .,Tongji University School of Medicine, Shanghai, China
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Kastenberg ZJ, Wall N, Malhotra N, Zobell S, Mammen L, Short SS, Rollins MD. The effect of multidisciplinary colorectal center development on short-term hospital readmissions for patients with anorectal malformations or Hirschsprung disease. J Pediatr Surg 2020; 55:541-544. [PMID: 31859042 DOI: 10.1016/j.jpedsurg.2019.10.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/30/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Hospital readmissions have become a quality metric for both hospital systems and individual surgeons. The medical literature is replete with studies describing readmission rates and factors contributing to readmissions following surgical procedures. Relatively little, however, has been done to define potential solutions to these problems. Over the past decade there has been a movement toward the development of multidisciplinary colorectal centers at high volume children's hospitals. We hypothesized that the development of a colorectal center at our children's hospital decreased readmissions in our colorectal surgery population. MATERIALS AND METHODS A retrospective review was performed including all patients with the diagnosis of anorectal malformation (ARM) or Hirschsprung disease (HD) at our institution between the years of 2005-2017. Patient level outcomes were compared between the cohort treated prior to (2005-2010) and the cohort treated after the development of the colorectal center (2012-2017). RESULTS A total of 354 patients were identified. One hundred seventy-eight patients (113 ARM, 65 HD) were treated prior to and 176 patients (110 ARM, 66 HD) were treated after the development of the colorectal center. Forty-five (25.3%) patients underwent neonatal repair prior to development of the center compared to 15 (8.5%) after. 111 (62.4%) patients underwent colostomy prior to the colorectal center comparted to 95 (54%) after. The rate of readmission within 120 days of discharge in the early group was 63% compared to 52% in those managed in the multidisciplinary colorectal center (p = 0.04). Conversely, the rate of emergency room visits increased from 8.4% to 27.3% (p = 0.01). The decrease in readmission rates was more pronounced in the ARM group, while the HD cohort had similar readmission rates before and after the establishment of the center. Multivariate logistic regression revealed an odds ratio of 0.59 (95% CI 0.37-0.92) for readmission following the development of the multidisciplinary colorectal center. DISCUSSION The development of a multidisciplinary colorectal center at our institution was associated with decreased hospital readmissions, but an increase in emergency department resource utilization. These findings suggest improved efficiency in patient care with the implementation of a multispecialty, patient centered approach while also identifying areas of focus for future quality improvement initiatives. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Zachary J Kastenberg
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT.
| | - Natalie Wall
- University of Utah School of Medicine, Salt Lake City, UT
| | - Neha Malhotra
- Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, UT
| | - Sarah Zobell
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT
| | - Lija Mammen
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT
| | - Scott S Short
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT
| | - Michael D Rollins
- Primary Children's Hospital, University of Utah School of Medicine, Division of Pediatric Surgery, Salt Lake City, UT
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Li YM, Mei FY, Yao YJ, Tsauo JY, Peng Y, Chen M. Causes and predictors of readmission after transcatheter aortic valve implantation : A meta-analysis and systematic review. Herz 2019; 46:1-8. [PMID: 31807789 DOI: 10.1007/s00059-019-04870-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 09/13/2019] [Accepted: 11/11/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Since readmission rate is an important clinical index to determine the quality of inpatient care and hospital performance, the aim of this study was to explain the causes and predictors of readmission following transcatheter aortic valve implantation (TAVI) at short-term and mid-term follow-up. METHODS AND RESULTS A systematic review and meta-analysis of all published articles from Embase, Pubmed/MEDLINE, and Ovid was carried out. In all, 10 studies including 52,702 patients were identified. The pooled estimate for the overall event rate was 0.15, and cardiovascular causes were the main reason for 30-day readmission (0.42, 95% confidence interval [CI]: 0.39-0.45). In addition, the pooled incidence of 1‑year readmission was 0.31, and cardiovascular events were still the main cause (0.41, 95% CI: 0.33-0.48). Patients with major and life-threatening bleeding, new permanent pacemaker implantation, and clinical heart failure were associated with a high risk for early readmission after TAVI. Moreover, an advanced (≥3) New York Heart Association classification, acute kidney injury, paravalvular leak, mitral regurgitation (≥ moderate), and major bleeding predicted unfavorable outcome to 1‑year readmission. Female gender and transfemoral TAVI was associated with a lower risk for unplanned rehospitalization. CONCLUSIONS This meta-analysis found cardiovascular factors to be the main causes for both 30-day and 1‑year rehospitalization. Heart failure represented the most common cardiovascular event at both short-term and mid-term follow-up. Several baseline characteristics and procedure-related factors were deemed unfavorable predictors of readmission. Importantly, transfemoral access and female gender were associated with a lower risk of readmission.
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Affiliation(s)
- Yi-Ming Li
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, 610041, Chengdu, China
| | - Fu-Yang Mei
- Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Yi-Jun Yao
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Jia-Yu Tsauo
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, 610041, Chengdu, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, 610041, Chengdu, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, 610041, Chengdu, China.
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Causes, Risk Factors, and Costs of 30-Day Readmissions After Mitral Valve Repair and Replacement. Ann Thorac Surg 2019; 108:1729-1737. [DOI: 10.1016/j.athoracsur.2019.07.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/26/2019] [Accepted: 07/09/2019] [Indexed: 12/16/2022]
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Guedeney P, Huchet F, Manigold T, Rouanet S, Balagny P, Leprince P, Lebreton G, Letocart V, Barthelemy O, Vicaut E, Montalescot G, Guerin P, Collet JP. Incidence of, risk factors for and impact of readmission for heart failure after successful transcatheter aortic valve implantation. Arch Cardiovasc Dis 2019; 112:765-772. [DOI: 10.1016/j.acvd.2019.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/31/2019] [Accepted: 09/11/2019] [Indexed: 10/25/2022]
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Doshi R, Taha M, Dave M, Desai R, Gullapalli N. Sex differences in 30-day readmission rates, etiology, and predictors after transcatheter aortic valve replacement. Indian Heart J 2019; 71:291-296. [PMID: 31779855 PMCID: PMC6890955 DOI: 10.1016/j.ihj.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/01/2019] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND The aim of this study is to analyze sex-specific readmission rates, etiology, and predictors of readmission after transcatheter aortic valve replacement (TAVR). Readmissions after TAVR are common, contributing to increased health care utilization and costs. Many factors have been discovered as predictors of readmission; however, sex-specific disparities in readmission rates are limited. METHODS Between January 2012 and September 2015, adult patients after TAVR were identified using appropriate international classifications of diseases, ninth revision, clinical modification from the National Readmission Database. Incidence of unplanned 30-days readmission rate was the primary outcome of this study. In addition, this study includes sex-specific etiology and predictors of readmissions. Multivariate logistic regression was performed to analyze adjusted readmission rates. Hierarchical 2-level logistic models were used to evaluate predictors of readmission. RESULTS Readmission rate at 30 days was 17.3%, with slightly higher readmission rates in women (OR 1.09; CI: 1.01-1.19, p < 0.001) after multivariate adjusted analysis. Noncardiac causes were responsible for most readmissions in both genders. Etiologies for readmissions such as arrhythmias, pulmonary complications, and infections were slightly higher in women, whereas heart failure and bleeding complications were higher in men. History of heart failure, atrial fibrillation, prior pacemaker, and renal failure significantly strongly predicted readmissions in both genders. CONCLUSION Women undergoing TAVR have slightly higher 30-day all-cause readmission rates. These results indicate that women require more attention compared to men to prevent 30-day readmission. In addition, risk stratification for men and women based on predictors will help identify high-risk men and women for readmissions.
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Affiliation(s)
- Rajkumar Doshi
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, NV, United States.
| | - Mohamed Taha
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, NV, United States
| | - Mihir Dave
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rupak Desai
- Division of Cardiology, Atlanta VA Medical Center, Decatur, VA, United States
| | - Nageshwara Gullapalli
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, NV, United States
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Mazer CD, Bhatt DL, Verma S. Anticoagulation Following TAVR: No Clear Answer Yet. J Am Coll Cardiol 2019; 73:22-28. [PMID: 30621947 DOI: 10.1016/j.jacc.2018.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/12/2018] [Indexed: 12/27/2022]
Affiliation(s)
- C David Mazer
- Department of Anesthesia, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Departments of Anesthesia and Physiology, University of Toronto, Toronto, Ontario, Canada.
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts. https://twitter.com/DLBHATTMD
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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Doshi R, Pisipati S, Taha M, Dave M, Shah J, Adalja D, Gullapalli N. Incidence, 30-day readmission rates and predictors of readmission after new onset atrial fibrillation who underwent transcatheter aortic valve replacement. Heart Lung 2019; 49:186-192. [PMID: 31690493 DOI: 10.1016/j.hrtlng.2019.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/27/2019] [Accepted: 10/23/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION New onset Atrial Fibrillation (NOAF) is frequently seen post transcatheter aortic valve replacement (TAVR). NOAF in the setting of TAVR has also been recognized as predictor of worse outcomes, including higher readmission rates. Data assessing the effect and predictors of NOAF on 30-day readmission rates post TAVR is limited. OBJECTIVE To assess the incidence, 30-day readmission rate and predictors of NOAF in patients who underwent TAVR. METHODS Nationwide Readmissions Database was used to identify patients who developed NOAF post-TAVR between 2012 and 2015. RESULTS A total of 24,076 patients were included in this study, of which 54% were males, and the mean age was 82.4 ± 7.2. NOAF was developed in 10,847 (45%) patients. Overall readmission rates with NOAF was 19.7% and trend in the readmissions reduced during the course of the study (21.9% to 18.7%, Ptrend < 0.001). Thirty-day readmission rate in patients who developed NOAF post-TAVR was significantly higher compared to TAVR patients without NOAF (OR 1.39; 95% CI, 1.28-1.51; p < 0.001). Similarly, rate of ischemic stroke was significantly higher among patients who developed NOAF (OR 1.22; 95% CI, 1.07-1.4; p = 0.004). Predictors of readmissions in NOAF group were mostly non-cardiac, and included age, and comorbidities with chronic liver disease, renal failure and chronic lung disease been the most common comorbidities, in that order. CONCLUSIONS Incidence of NOAF is associated with increased risk of readmissions and ischemic stroke. Future research should focus on interventions to prevent avoidable readmissions and associated morbidity and mortality.
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Affiliation(s)
- Rajkumar Doshi
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States.
| | - Sailaja Pisipati
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States
| | - Mohamed Taha
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States
| | - Mihir Dave
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States; Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jay Shah
- Department of Internal Medicine, Mercy St. Vincent Medical Center, Toledo, OH, USA
| | - Devina Adalja
- Department of General Medicine, Gotri Medical Education and Research Center, Vadodara, Gujarat, India
| | - Nageshwara Gullapalli
- Department of Internal Medicine, University of Nevada Reno School of Medicine, 1155 Mill St, W-11, Reno, NV 89502, United States
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Malik AH, Yandrapalli S, Tang GHL. Reevaluating the Use of the Nationwide Inpatient Sample to Identify Incident Cases of Atrial Fibrillation After Aortic Valve Replacement. JAMA Intern Med 2019; 179:1597-1598. [PMID: 31682689 DOI: 10.1001/jamainternmed.2019.4409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Aaqib H Malik
- Department of Medicine, New York Medical College, Westchester Medical Center, Valhalla
| | - Srikanth Yandrapalli
- Division of Cardiology, Department of Medicine, New York Medical College, Westchester Medical Center, Valhalla
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York
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Barbanti M, Webb JG, Dvir D, Prendergast BD. Residual challenges in TAVI: moving forward. EUROINTERVENTION 2019; 15:857-866. [DOI: 10.4244/eij-d-19-00788] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Mentias A, Saad M, Desai MY, Horwitz PA, Rossen JD, Panaich S, Elbadawi A, Qazi A, Sorajja P, Jneid H, Kapadia S, London B, Vaughan Sarrazin MS. Temporal Trends and Clinical Outcomes of Transcatheter Aortic Valve Replacement in Nonagenarians. J Am Heart Assoc 2019; 8:e013685. [PMID: 31668118 PMCID: PMC6898796 DOI: 10.1161/jaha.119.013685] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Contemporary outcomes of transcatheter aortic valve replacement (TAVR) in nonagenarians are unknown. Methods and Results We identified 13 544 nonagenarians (aged 90–100 years) who underwent TAVR between 2012 and 2016 using Medicare claims. Generalized estimating equations were used to study the change in short‐term outcomes among nonagenarians over time. We compared outcomes between nonagenarians and non‐nonagenarians undergoing TAVR in 2016. A mixed‐effect multivariable logistic regression was performed to determine predictors of 30‐day mortality in nonagenarians in 2016. A center was defined as a high‐volume center if it performed ≥100 TAVR procedures per year. After adjusting for changes in patients’ characteristics, risk‐adjusted 30‐day mortality declined in nonagenarians from 9.8% in 2012 to 4.4% in 2016 (P<0.001), whereas mortality for patients <90 years decreased from 6.4% to 3.5%. In 2016, 35 712 TAVR procedures were performed, of which 12.7% were in nonagenarians. Overall, in‐hospital mortality in 2016 was higher in nonagenarians compared with younger patients (2.4% versus 1.7%, P<0.05) but did not differ in analysis limited to high‐volume centers (2.2% versus 1.7%; odds ratio: 1.33; 95% CI, 0.97–1.81; P=0.07). Important predictors of 30‐day mortality in nonagenarians included in‐hospital stroke (adjusted odds ratio [aOR]: 8.67; 95% CI, 5.03–15.00), acute kidney injury (aOR: 4.11; 95% CI, 2.90–5.83), blood transfusion (aOR: 2.66; 95% CI, 1.81–3.90), respiratory complications (aOR: 2.96; 95% CI, 1.52–5.76), heart failure (aOR: 1.86; 95% CI, 1.04–3.34), coagulopathy (aOR: 1.59; 95% CI, 1.12–2.26; P<0.05 for all). Conclusions Short‐term outcomes after TAVR have improved in nonagenarians. Several procedural complications were associated with increased 30‐day mortality among nonagenarians.
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Affiliation(s)
- Amgad Mentias
- Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA
| | - Marwan Saad
- Cardiovascular Institute The Warren Alpert School of Medicine at Brown University Providence RI
| | - Milind Y Desai
- Heart and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Phillip A Horwitz
- Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA
| | - James D Rossen
- Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA
| | - Sidakpal Panaich
- Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA
| | - Ayman Elbadawi
- Division of Cardiovascular Medicine University of Texas Medical Branch Galveston TX
| | - Abdul Qazi
- Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA
| | - Paul Sorajja
- Minneapolis Heart Institute Foundation Abbott Northwestern Hospital Minneapolis MN
| | - Hani Jneid
- Division of Cardiology Baylor College of Medicine Houston TX
| | - Samir Kapadia
- Heart and Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Barry London
- Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA
| | - Mary S Vaughan Sarrazin
- Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City IA.,Comprehensive Access and Delivery Research and Evaluation Center (CADRE) Iowa City VA Medical Center Iowa City IA
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Ando T, Adegbala O, Takagi H, Afonso L, Briasoulis A. Early Invasive Versus Ischemia-Guided Strategy in Non-ST-Segment Elevation Acute Coronary Syndrome With Chronic Obstructive Pulmonary Disease: A National Inpatient Sample Analysis. Angiology 2019; 71:372-379. [PMID: 31578083 DOI: 10.1177/0003319719877096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a risk factor for non-ST-segment elevation-acute coronary syndromes (NSTE-ACS). Whether early invasive strategy (EIS) or ischemia-guided strategy (IGS) confers better outcomes in NSTE-ACS with COPD is largely unknown. Nationwide Inpatient Sample database of the United States was queried from 2010 to 2015 to identify NSTE-ACS with and without COPD. Early invasive strategy was defined as coronary angiogram with or without revascularization on admission day 0 or 1, whereas IGS included patients who did not receive EIS. Standardized morbidity ratio weight was used to calculate the adjusted odds ratio. A total of 228 175 NSTE-ACS admissions with COPD were identified of which 34.0% received EIS. In-hospital mortality was lower with EIS in patients with COPD (3.1% vs 5.5%, adjusted odds ratio 0.57, 95% confidence interval 0.50-0.63) compared to IGS, but the magnitude of mortality reduction observed in EIS in patients with COPD was less compared to non-COPD patients (P interaction = .02). Length of stay was shorter (4.2 vs 4.7 days, P < .0001) but the cost was higher (US$23 804 vs US$18 533, P < .0001) in EIS in COPD. Early invasive strategy resulted in lower in-hospital mortality and marginally shorter length of stay but higher hospitalization cost in NSTE-ACS with COPD.
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Affiliation(s)
- Tomo Ando
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Oluwole Adegbala
- Division of Internal Medicine, Englewood Hospital and Medical Center, Seton Hall University-Hackensack Meridian School of Medicine, Englewood, NJ, USA
| | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Luis Afonso
- Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI, USA
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Reddy V, Adegbala O, Ando T, Shokr M, Kumar K, Penumetcha A, Khan M. Comparison of In-Hospital Outcomes of Patients With-Versus-Without Atrial Fibrillation and Alcohol Withdrawal Syndrome. Am J Cardiol 2019; 124:1056-1058. [PMID: 31395296 DOI: 10.1016/j.amjcard.2019.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/19/2019] [Accepted: 07/02/2019] [Indexed: 11/28/2022]
Abstract
Alcohol withdrawal syndrome (AWS) has been associated with significant medical complications and length of stay. Cardiovascular effects from AWS include a physiologic tachycardia and hypertensive response. Although atrial fibrillation (AF) is one of the most common arrhythmias, the impact of a known history of AF on AWS is unclear. The purpose of our study is to assess the impact of history of AF on clinical outcomes, cost, and length of stay on AWS. The Nationwide Inpatient Sample was used to identify patients aged 18 years or older who underwent AWS with or without AF using the International Classification of Disease 9 Clinical Modification codes from January 2010 to December 2014. Outcomes were compared between those with or without AF using propensity score method-stratified morbidity ratio weighing- to adjust for baseline patient and hospital characteristics. A total of 280,451 patients with AWS of which 14,459 (5.2%) had history of AF. Patients with AF was older, less likely female, and more had higher burden of co-morbidities. In an adjusted model, in-hospital mortality (odds ratio [OR] 1.98 95% confidence interval [CI] 1.61 to 2.45), ischemic stroke (OR 1.67 95% CI 1.42 to 1.95), acute kidney injury (OR 1.36 95% CI 1.24 to 1.49), acute kidney injury requiring dialysis (OR 1.89 95% CI 1.39 to 2.50), and cost (mean ratio 1.27 95% CI 1.21 to 1.33) were higher in the AF cohort. Length of stay was shorter in patients with AF (mean ratio 0.85 95% CI 0.81 to 0.90). In conclusion, a known history of AF increased the risk of in-hospital mortality, morbidity, and hospital expense in AWS.
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Affiliation(s)
- Vivek Reddy
- Wayne State University, Department of Cardiology, Detroit, Michigan.
| | - Oluwole Adegbala
- Wayne State University, Department of Cardiology, Detroit, Michigan
| | - Tomo Ando
- Wayne State University, Department of Cardiology, Detroit, Michigan
| | - Mohamed Shokr
- Wayne State University, Department of Cardiology, Detroit, Michigan
| | - Kartik Kumar
- Wayne State University, Department of Cardiology, Detroit, Michigan
| | | | - Mazhar Khan
- Detroit Medical Center, Department of Cardiology, Detroit, Michigan
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Factors Associated With and Outcomes of Aborted Procedures During Elective Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2019; 12:1768-1777. [PMID: 31473238 DOI: 10.1016/j.jcin.2019.05.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/02/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study sought to evaluate the outcomes and factors associated with aborted procedures among patients undergoing elective transcatheter aortic valve replacement (TAVR). BACKGROUND Elective TAVR procedures can be aborted because of device limitations or aborted for other reasons, including patient and procedural factors. Little is known about 30-day outcomes and factors associated with aborted procedures and procedures aborted because of device limitations (ADs). METHODS Patients undergoing elective TAVR procedures from 2011 to 2017 in the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry were examined. The incidence of aborted procedures, both ADs and procedures aborted for other reasons (AOs), was examined. Rates of 30-day all-cause death or stroke and a composite of vascular complications and bleeding events were compared between patients with and those without aborted procedures and between patients with ADs and those with AOs. Multivariate modeling identified factors associated with aborted procedures and ADs. RESULTS Among 106,169 patients who underwent TAVR between 2011 and 2017, procedures were aborted in 1,150 (1.1%) (581 ADs and 569 AOs). Patients with aborted procedures were more likely female with peripheral artery disease and more often treated at lower volume centers compared with those with nonaborted procedures (p < 0.01 for all). The incidence of aborted procedures and ADs decreased over the study period (p < 0.01). The adjusted rates of 30-day death and stroke were greater for aborted versus nonaborted procedures (odds ratio: 5.02; 95% confidence interval: 4.13 to 6.11). Peripheral artery disease, alternative access, and low institutional TAVR volume were factors associated with aborted procedures and ADs (p < 0.05 for all). CONCLUSIONS The incidence of aborted procedures is declining, but peripheral artery disease and low institutional TAVR volume remain associated with aborted procedures. A thorough pre-procedural assessment and referral of challenging cases to high-volume centers may be strategies to minimize aborted procedures.
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Pineda AM, Harrison JK, Kleiman NS, Rihal CS, Kodali SK, Kirtane AJ, Leon MB, Sherwood MW, Manandhar P, Vemulapalli S, Beohar N. Incidence and Outcomes of Surgical Bailout During TAVR. JACC Cardiovasc Interv 2019; 12:1751-1764. [DOI: 10.1016/j.jcin.2019.04.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/11/2019] [Accepted: 04/16/2019] [Indexed: 11/26/2022]
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Debunking the July Effect in Cardiac Surgery: A National Analysis of More Than 470,000 Procedures. Ann Thorac Surg 2019; 108:929-934. [DOI: 10.1016/j.athoracsur.2019.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/03/2019] [Accepted: 06/17/2019] [Indexed: 12/24/2022]
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Khera S, Kolte D, Deo S, Kalra A, Gupta T, Abbott D, Kleiman N, Bhatt DL, Fonarow GC, Khalique OK, Kodali S, Leon MB, Elmariah S. Derivation and external validation of a simple risk tool to predict 30-day hospital readmissions after transcatheter aortic valve replacement. EUROINTERVENTION 2019; 15:155-163. [PMID: 30803938 DOI: 10.4244/eij-d-18-00954] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Patients undergoing transcatheter aortic valve replacement (TAVR) possess a higher risk of recurrent healthcare resource utilisation due to multiple comorbidities, frailty, and advanced age. We sought to devise a simple tool to identify TAVR patients at increased risk of 30-day readmission. METHODS AND RESULTS We used the Nationwide Readmissions Database from January 2013 to September 2015. Complex survey methods and hierarchical regression in R were implemented to create a prediction tool to determine probability of 30-day readmission. Boot-strapped internal validation and cross-validation were performed to assess model accuracy. External validation was performed using a single-centre data set. Of 39,305 patients who underwent endovascular TAVR, 6,380 (16.2%) were readmitted within 30 days. The final 30-day readmission risk prediction tool included the following variables: chronic kidney disease, end-stage renal disease on dialysis (ESRD), anaemia, chronic lung disease, chronic liver disease, atrial fibrillation, length of stay, acute kidney injury, and discharge disposition. ESRD (OR 2.11, 95% CI: 1.7-2.63), length of stay ≥5 days (OR 1.64, 95% CI: 1.50-1.79), and short-term hospital discharge disposition (OR 1.81, 95% CI: 1.2-2.7) were the strongest predictors. The c-statistic of the prediction model was 0.63. The c-statistic in the external validation cohort was 0.69. On internal calibration, the tool was extremely accurate in predicting readmissions up to 25%. CONCLUSIONS A simple and easy-to-use risk prediction tool utilising standard clinical parameters identifies TAVR patients at increased risk of 30-day readmission. The tool may consequently inform hospital discharge planning, optimise transitions of care, and reduce resource utilisation.
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Affiliation(s)
- Sahil Khera
- Columbia University Medical Center, New York, NY, USA
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Relation of Hospital Volume With In-Hospital and 90-Day Outcomes After Transcatheter Mitral Valve Repair Using MitraClip. Am J Cardiol 2019; 124:63-69. [PMID: 31030971 DOI: 10.1016/j.amjcard.2019.04.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/23/2019] [Accepted: 04/01/2019] [Indexed: 11/23/2022]
Abstract
MitraClip therapy has shown increasing use since it was commercially adopted among US hospitals in October 2013. However, the relation of institutional MitraClip volume with outcomes is unclear. This study sought to examine the association between hospital volume and outcomes after transcatheter mitral valve repair using the MitraClip device. Using the Nationwide Readmissions Database, we identified all patients who underwent a MitraClip procedure and categorized hospitals into tertiles based on their annual procedure volume: low (≤3 procedures/year), medium (4 to 13/year), and high (≥14/year) volume centers. Multivariable logistic and Cox regression analyses were performed to examine the impact of institutional MitraClip volume on in-hospital and 90-day outcomes, respectively. From 2014 to 2015, a total of 3,420 procedures were performed at 266 hospitals with a median annual procedural volume of 5 per hospital. Low (n = 81), medium (n = 86), and high (n = 99) volume hospitals performed 147 (4.3%), 403 (11.8%), and 2,870 (83.9%) MitraClip procedures, respectively. The low versus high hospital volume was independently associated with increased in-hospital mortality (7.8% vs 3.0%; adjusted odds ratio [aOR] 2.64; p = 0.04), acute myocardial infarction (10.2% vs 2.2%; aOR 2.93; p = 0.02), and acute respiratory failure (19.3% vs 7.7%; aOR 2.24; p = 0.02) during index admission as well as 90-day all-cause readmissions (37.8% vs 26.6%; adjusted hazard ratio 1.54; p = 0.03), and 90-day infective endocarditis (2.4% vs 0.3%; adjusted hazard ratio 10.06; p = 0.003). In conclusion, low hospital MitraClip volume is an independent determinant of worse outcomes including in-hospital mortality and 90-day readmissions.
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Hosler QP, Maltagliati AJ, Shi SM, Afilalo J, Popma JJ, Khabbaz KR, Laham RJ, Guibone K, Kim DH. A Practical Two-Stage Frailty Assessment for Older Adults Undergoing Aortic Valve Replacement. J Am Geriatr Soc 2019; 67:2031-2037. [PMID: 31211413 DOI: 10.1111/jgs.16036] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/28/2019] [Accepted: 05/21/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Despite evidence, frailty is not routinely assessed before cardiac surgery. We compared five brief frailty tests for predicting poor outcomes after aortic valve replacement and evaluated a strategy of performing comprehensive geriatric assessment (CGA) in screen-positive patients. DESIGN Prospective cohort study. SETTING A single academic center. PARTICIPANTS Patients undergoing surgical aortic valve replacement (SAVR) (n = 91; mean age = 77.8 y) or transcatheter aortic valve replacement (TAVR) (n = 137; mean age = 84.5 y) from February 2014 to June 2017. MEASUREMENTS Brief frailty tests (Fatigue, Resistance, Ambulation, Illness, and Loss of weight [FRAIL] scale; Clinical Frailty Scale; grip strength; gait speed; and chair rise) and a deficit-accumulation frailty index based on CGA (CGA-FI) were measured at baseline. A composite of death or functional decline and severe symptoms at 6 months was assessed. RESULTS The outcome occurred in 8.8% (n = 8) after SAVR and 24.8% (n = 34) after TAVR. The chair rise test showed the highest discrimination in the SAVR (C statistic = .76) and TAVR cohorts (C statistic = .63). When the chair rise test was chosen as a screening test (≥17 s for SAVR and ≥23 s for TAVR), the incidence of outcome for screen-negative patients, screen-positive patients with CGA-FI of .34 or lower, and screen-positive patients with CGA-FI higher than .34 were 1.9% (n = 1/54), 5.3% (n = 1/19), and 33.3% (n = 6/18) after SAVR, respectively, and 15.0% (n = 9/60), 14.3% (n = 3/21), and 38.3% (n = 22/56) after TAVR, respectively. Compared with routinely performing CGA, targeting CGA to screen-positive patients would result in 54 fewer CGAs, without compromising sensitivity (routine vs targeted: .75 vs .75; P = 1.00) and specificity (.84 vs .86; P = 1.00) in the SAVR cohort; and 60 fewer CGAs with lower sensitivity (.82 vs.65; P = .03) and higher specificity (.50 vs .67; P < .01) in the TAVR cohort. CONCLUSIONS The chair rise test with targeted CGA may be a practical strategy to identify older patients at high risk for mortality and poor recovery after SAVR and TAVR in whom individualized care management should be considered. J Am Geriatr Soc 67:2031-2037, 2019.
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Affiliation(s)
- Quinn P Hosler
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Sandra M Shi
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jonathan Afilalo
- Division of Cardiology and Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeffrey J Popma
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kamal R Khabbaz
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Roger J Laham
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kimberly Guibone
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
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