Impact of Hospital Volume on Outcomes of Endovascular Stenting for Adult Aortic Coarctation

Association of occlusion time with successful endovascular recanalization in patients with symptomatic chronic intracranial total occlusion

OBJECTIVE

Endovascular treatment is one of the choices for symptomatic chronic intracranial total occlusion (CITO); however, its safety and efficacy remain unclear. The present study was performed to evaluate the safety and long-term outcome of endovascular treatment for CITO at a high-volume stroke center.

METHODS

Data about patients with symptomatic CITO who received endovascular treatment were retrospectively collected. Technique success was regarded as ≤ 30% residual stenosis. Periprocedural complications within 30 days were used to evaluate safety. Baseline characteristics and lesion features were compared between patients with successful recanalization and those with recanalization failure. Stroke recurrence and in-stent restenosis (ISR) of the culprit arteries during follow-up were used to evaluate long-term efficacy.

RESULTS

From June 2012 to September 2019, 117 patients (mean ± SD age 55.8 ± 9.6 years) were included. The successful recanalization rate was 82.9% (97/117 patients). The combined rate of periprocedural stroke, myocardial infarction, and death was 8.5% (10/117). Compared with patients with successful recanalization, patients with recanalization failure had longer occlusion time and longer lesion length (27.0 mm vs 15.4 mm, p = 0.001). In the median 23.0-month clinical follow-up period, recurrent stroke occurred in 12.6% (11/87) of patients with successful recanalization. In the median 5-month imaging follow-up period, ISR was detected in 26.6% (21/79) of patients.

CONCLUSIONS

Endovascular treatment was relatively safe for patients with symptomatic CITO. Shorter occlusion time and shorter lesion length may be associated with higher recanalization rate. The rates of stroke recurrence and symptomatic ISR were acceptable but need to be confirmed in future studies.

Endovascular Stent Repair of Aortic Coarctation in a Developing Country: A Single-Center Experience

BACKGROUND/PURPOSE

CoA remains one of the most common congenital heart diseases and is associated with significant morbidity and mortality and if untreated. We aim to evaluate the safety, feasibility, and outcomes of endovascular stenting of Coarctation of the aorta (CoA) in a developing country with limited resources and compare it to available benchmarks.

MATERIALS/METHODS

A retrospectively review of all patients who underwent endovascular stent repair of aortic coarctation at our tertiary center since 2009 was done.

RESULTS

18 patients were identified, sixteen had native CoA, while two had recurrent CoA. mean age at the time of procedure was 21.2 ± 9.8 years (range 10-45 years), and 12(66%) patients were males. The mean follow-up duration was 4 ± 2.8 years. Post stenting, the average ascending-to-descending aorta systolic gradient decreased by 42.9 ± 20.4 mmHg (p < 0.001). After the intervention, 13(72.2%) patients achieved normal BP while 5(27.8%) had residual hypertension. Fourteen patients received bare-metal stents, and four had covered stents. Attempted stent implantation was successful in all patients. Our procedural success rate was 94%. On follow-up, no dissections or aneurysmal changes were detected, four patients underwent re-expansion of the stent, one patient with suboptimal stenting result required surgery 6 months after stenting, and two patients had minor post-operative complications.

CONCLUSIONS

Endovascular stenting for de-novo or recurrent CoA in children and adults at a tertiary center in a developing country is feasible and safe with outcomes comparable to developed countries. A multidisciplinary team approach is paramount in achieving good results and low complication rates in limited-resource settings.

Mortality Among Neutropenic Cancer Patients Within the United States: The Association With Hospital Volume

PURPOSE

Neutropenia is a serious complication of chemotherapy in patients with solid tumors. The influence of hospital volume on outcomes in patients with neutropenia has been little investigated. We hypothesized that large-volume hospitals would have reduced mortality rates for neutropenic patients compared with small-volume institutions.

METHODS

We used the Nationwide Inpatient Sample database of the Healthcare Cost and Utilization Project, for the years 2007-2011. All adult inpatient episodes with a diagnosis of both neutropenia and solid-tumor malignancy were included. Hospital volume was defined as the number of neutropenic cancer episodes per institution per year. Mortality was defined as death during admission. A multilevel mixed-effects logistic regression model was applied.

RESULTS

Twenty thousand three hundred and ten hospitalizations were included in the study, from 1,869 different institutions. Median age was 62 years. The overall inpatient mortality was 2.3%, and was dependent on age (age 50-59 years-1.6% and age 80-89 years-5.3%). The median number of neutropenic inpatient episodes in each institution per year was 14 (range, 1-168). Mortality was 3.3%, 2.7%, 2.2%, 2.2%, and 1.2% for each quintile of hospital volume (from lowest to highest volume, P < .001). Likewise, the proportion discharged home was 85.7%, 90.3%, 91.5%, 92.7%, and 95.4% (P < .001). The association between hospital volume and mortality remained significant after adjustment for patient-level and hospital-level variables.

DISCUSSION

Patients with neutropenia hospitalized in large-volume institutions have a substantially lower mortality compared with those hospitalized at low-volume institutions. Further study is required to validate our findings or overcome potential biases, understand mechanism, and investigate how smaller institutions can improve outcomes.

Nationwide Trends in Hospital Outcomes and Utilization After Lower Limb Revascularization in Patients on Hemodialysis

OBJECTIVES

This study aimed to describe the temporal trends and outcomes of endovascular and surgical revascularization in a large, nationally representative sample of patients with end-stage renal disease on hemodialysis hospitalized for peripheral artery disease (PAD).

BACKGROUND

PAD is prevalent among patients with end-stage renal disease on hemodialysis and is associated with significant morbidity and mortality. There is a paucity of information on trends in endovascular and surgical revascularization and post-procedure outcomes in this population.

METHODS

We used the Nationwide Inpatient Sample (2002 to 2012) to identify hemodialysis patients undergoing endovascular or surgical procedures for PAD using diagnostic and procedural codes. We compared trends in amputation, post-procedure complications, mortality, length of stay, and costs between the 2 groups using trend tests and logistic regression.

RESULTS

There were 77,049 endovascular and 29,556 surgical procedures for PAD in hemodialysis patients. Trend analysis showed that endovascular procedures increased by nearly 3-fold, whereas there was a reciprocal decrease in surgical revascularization. Post-procedure complication rates were relatively stable in persons undergoing endovascular procedures but nearly doubled in those undergoing surgery. Surgery was associated with 1.8 times adjusted odds (95% confidence interval: 1.60 to 2.02) for complications and 1.6 times the adjusted odds for amputations (95% confidence interval: 1.40 to 1.75) but had similar mortality (adjusted odds ratio: 1.05; 95% confidence interval: 0.85 to 1.29) compared with endovascular procedures. Length of stay for endovascular procedures remained stable, whereas a decrease was seen for surgical procedures. Overall costs increased marginally for both procedures.

CONCLUSIONS

Rates of endovascular procedures have increased, whereas those of surgeries have decreased. Surgical revascularization is associated with higher odds of overall complications. Further prospective studies and clinical trials are required to analyze the relationship between the severity of PAD and the revascularization strategy chosen.

Administrative health databases for addressing emerging issues in adults with CHD: a systematic review

The need for population-based studies of adults with CHD has motivated the growing use of secondary analyses of administrative health data in a variety of jurisdictions worldwide. We aimed at systematically reviewing all studies using administrative health data sources for adult CHD research from 2006 to 2016. Using PubMed and Embase (1 January, 2006 to 1 January, 2016), we identified 2217 abstracts, from which 59 studies were included in this review. These comprised 12 different data sources from six countries. Of these, 55% originated in the United States of America, 28% in Canada, and 17% in Europe and Asia. No study was published before 2007, after which the number of publications grew exponentially. In all, 41% of the studies were cross-sectional and 25% were retrospective cohort studies with a wide variation in the availability of patient-level compared with hospitalisation-level episodes of care; 58% of studies from eight different data sources linked administrative data at a patient level; and 37% of studies reported validation procedures. Assessing resource utilisation and temporal trends of relevant epidemiological and outcome end points were the most reported objectives. The median impact factor of publication journals was 4.04, with an interquartile range of 3.15, 7.44. Although not designed for research purposes, administrative health databases have become powerful data sources for studying adult CHD populations because of their large sample sizes, comprehensive records, and long observation periods, providing a useful tool to further develop quality of care improvement programmes. Data linkage with electronic records will become important in obtaining more granular life-long adult CHD data. The health services nature of the data optimises the impact on policy and public health.

Avoidable costs of stenting for aortic coarctation in the United Kingdom: an economic model

BACKGROUND

Undesirable outcomes in health care are associated with patient harm and substantial excess costs. Coarctation of the aorta (CoA), one of the most common congenital heart diseases, can be repaired with stenting but requires monitoring and subsequent interventions to detect and treat disease recurrence and aortic wall injuries. Avoidable costs associated with stenting in patients with CoA are unknown.

METHODS

We developed an economic model to calculate potentially avoidable costs in stenting treatment of CoA in the United Kingdom over 5 years. We calculated baseline costs for the intervention and potentially avoidable complications and follow-up interventions and compared these to the costs in hypothetical scenarios with improved treatment effectiveness and complication rates.

RESULTS

Baseline costs were £16 688 ($25 182) per patient. Avoidable costs ranged from £137 ($207) per patient in a scenario assuming a 10% reduction in aortic wall injuries and reinterventions at follow-up, to £1627 ($2455) in a Best-case scenario with 100% treatment success and no complications. Overall costs in the Best-case scenario were 90.2% of overall costs at Baseline. Reintervention rate at follow-up was identified as most influential lever for overall costs. Probabilistic sensitivity analysis showed a considerable degree of uncertainty for avoidable costs with widely overlapping 95% confidence intervals.

CONCLUSIONS

Significant improvements in the treatment effectiveness and reductions in complication rates are required to realize discernible cost savings. Up to 10% of total baseline costs could be avoided in the best-case scenario. This highlights the need to pursue patient-specific treatment approaches which promise optimal outcomes.

Unwarranted Variation in the Quality of Care for Patients With Diseases of the Thoracic Aorta

BACKGROUND

Thoracic aortic disease has a high mortality. We sought to establish the contribution of unwarranted variation in care to regional differences in outcomes observed in patients with thoracic aortic disease in England.

METHODS AND RESULTS

Data from the Hospital Episode Statistics (HES) and the National Adult Cardiac Surgery Audit (NACSA) were extracted. A parallel systematic review/meta-analysis through December 2015, and structure and process questionnaire of English cardiac surgery units were also accomplished. Treatment and mortality rates were investigated. A total of 24 548 adult patients in the HES study, 8058 in the NACSA study, and 103 543 from a total of 33 studies in the systematic review were obtained. Treatment rates for thoracic aortic disease within 6 months of index admission ranged from 7.6% to 31.5% between English counties. Risk-adjusted 6-month mortality in untreated patients ranged from 19.4% to 36.3%. Regional variation persisted after adjustment for disease or patient factors. Regional cardiac units with higher case volumes treated more-complex patients and had significantly lower risk-adjusted mortality relative to low-volume units. The results of the systematic review indicated that the delivery of care by multidisciplinary teams in high-volume units resulted in better outcomes. The observational analyses and the online survey indicated that this is not how services are configured in most units in England.

CONCLUSIONS

Changes in the organization of services that address unwarranted variation in the provision of care for patients with thoracic aortic disease in England may result in more-equitable access to treatment and improved outcomes.

Effect of Center Volume on Outcomes in Hospitalized Patients With Hereditary Hemorrhagic Telangiectasia

OBJECTIVE

To determine whether hospitalized patients with hereditary hemorrhagic telangiectasia (HHT) had better outcomes at high-volume treatment centers (HVCs).

PATIENTS AND METHODS

The Nationwide Inpatient Sample (2000-2011) was used to identify HHT-related hospitalizations. Hospitals were classified based on quartiles of annual HHT discharge volume. The 75th percentile cutoff value (third quartile) was used to classify hospitals as low-volume centers (1-7 HHT discharges per year) or as HVCs (≥8 discharges per year. Demographic features, complication rates, and outcomes were compared between the 2 groups.

RESULTS

We identified 9440 hospital discharges in patients with HHT. Of these patients, 6856 (72.6%) were admitted to low-volume centers and 2584 (27.4%) to HVCs. The former were more likely to be of white race, older, and with higher income levels (P<.001 for each). The HVCs had higher rates of anemia, epistaxis, congestive heart failure, pulmonary hypertension, and cerebral and pulmonary arteriovenous malformations and lower rates of ischemic stroke and myocardial infarction. After adjusting for baseline differences in a multivariate model, patients treated at HVCs were more likely to be discharged home (odds ratio [OR]=1.35; 95% CI, 1.21-1.52; P<.001) and less likely to be discharged to short-term rehabilitation facilities (OR=0.45; 95% CI, 0.31-0.64; P<.001). Patients treated at HVCs also had a significantly lower risk of in-hospital mortality (OR=0.51; 95% CI, 0.34-0.74; P<.001).

CONCLUSION

Patients with HHT hospitalized at HVCs had better outcomes, with lower in-hospital mortality and higher home discharge rates. These findings strongly support ongoing efforts to expand access to HHT centers of excellence in the United States and worldwide.