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Chung M, Rajesh K, Hohri Y, Zhao Y, Wang C, Chan C, Kaku Y, Takeda K, George I, Argenziano M, Smith C, Kurlansky P, Takayama H. Adverse Technical Events During Aortic Root Replacement. Ann Thorac Surg 2024; 118:845-853. [PMID: 38936593 DOI: 10.1016/j.athoracsur.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/20/2024] [Accepted: 06/05/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Although adverse technical events during aortic root replacement (ARR) are not uncommon and are extremely challenging, there is scant literature to help surgeons prepare for such situations. We describe our experience of outstanding technical events during ARR. METHODS This is a retrospective study of 830 consecutive ARRs at a single center from 2012 to 2022. Technical events were defined as intraoperative events that led to an unplanned cardiac procedure, need for mechanical circulatory support, or additional aortic cross-clamping. Logistic regression identified factors associated with operative mortality and technical events. RESULTS Technical events occurred in 90 patients (10.8%) and were attributed to bleeding (n = 26), nonischemic ventricular dysfunction (n = 23), residual valve disease (n = 20), myocardial ischemia (n = 19), and iatrogenic dissection (n = 2). Prior sternotomy (odds ratio [OR], 2.38; 95% CI, 1.36-4.19; P = .002) and complex aortic valve disease (OR, 3.09; 95% CI, 1.09-8.75; P = .03) were associated with technical events. Patients with technical events had higher rates of operative mortality (6.7% vs 2.3%, P = .03) and all major postoperative complications. Surgical indications of dissection (OR, 13.57; 95% CI, 4.95-37.23; P < .001) and complex aortic valve disease (OR, 14.09; 95% CI, 3.67-54.02; P < .001) but not adverse technical events (OR, 2.42; 95% CI, 0.81-7.26; P = .11) were associated with operative mortality. CONCLUSIONS Adverse technical events occurred in 10.8% of ARRs and were associated with reoperative sternotomies. Technical events are associated with increased postoperative complications.
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Affiliation(s)
- Megan Chung
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Kavya Rajesh
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yu Hohri
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Chunhui Wang
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Christine Chan
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yuji Kaku
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Isaac George
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Michael Argenziano
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Craig Smith
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York.
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Wisniewski AM, Challa S, Strobel RJ, Norman AV, Yarboro LT, Yount K, Kern J, Mazzeffi M, Teman NR. Does Timing Matter? The Effect of Intensive Care Unit Arrival Timing on Elective Cardiac Surgery. Ann Thorac Surg 2024:S0003-4975(24)00681-7. [PMID: 39182555 DOI: 10.1016/j.athoracsur.2024.08.004] [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: 02/27/2024] [Revised: 07/26/2024] [Accepted: 08/06/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Due to staffing changes at scheduled intervals and decreases in essential staff in the evenings, late intensive care unit (ICU) arrivals may be at risk for suboptimal outcomes. Utilizing a regional collaborative, we sought to determine the effect of ICU arrival timing on outcomes in elective isolated coronary artery bypass. METHODS Adults undergoing elective, isolated coronary artery bypass from 17 hospitals between 2013 and 2023 were identified. Patients with missing predicted risk of mortality or missing ICU arrival time were excluded. Late ICU arrival time was defined as between 6:00 pm and 6:00 am. Hierarchical logistic regression with appropriate predicted risk scores was utilized for outcome risk adjustment. RESULTS We identified 11,638 patients, with 972 (8.4%) experiencing late ICU arrival. Late ICU arrival patients had higher predicted risk of morbidity or mortality (8.2%; [interquartile range {IQR}, 5.6%, 12.0%] vs 7.7% [IQR, 5.5%, 11.5%], P = .048) compared with early ICU arrival patients with longer median cardiopulmonary bypass times (96 minutes [IQR, 78, 119] vs 93 [IQR, 73, 116], P < .001). Late ICU arrival patients experienced more unadjusted complications including prolonged ventilation (7.7% vs 4.2%, P < .001) and operative mortality (2.0% vs 1.1%, P = .02), although no difference in failure-to-rescue (11.0% vs 10.4%, P = .84). Logistic regression with risk adjustment demonstrated late ICU arrival as a predictor of prolonged ventilation (odds ratio, 1.49 [95% CI, 1.12-1.99], P = .006). CONCLUSIONS After adjustment, late ICU arrivals experienced higher rates of prolonged ventilation, although this did not translate to failure-to-rescue.
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Affiliation(s)
- Alex M Wisniewski
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia.
| | - Sanjana Challa
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Raymond J Strobel
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Anthony V Norman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Leora T Yarboro
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kenan Yount
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - John Kern
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Nicholas R Teman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
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Haines K, Shin GJ, Truong T, Kuchibhatla M, Moore L, Rice W, Xu R, Swain S, Grisel B, Castillo-Angeles M, Agarwal S, Fernandez-Moure J. Age-Neutral Surgical Stabilization of Rib Fractures: Breaking the Ageism Barrier. J Surg Res 2024; 302:420-427. [PMID: 39153364 DOI: 10.1016/j.jss.2024.07.081] [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: 01/27/2024] [Revised: 07/10/2024] [Accepted: 07/19/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Surgical stabilization of rib fractures (SSRF) is associated with lower rates of mortality and fewer complications. This study evaluates whether the decision to undergo SSRF is associated with age, race, ethnicity, and insurance status and assesses associated clinical outcomes. METHODS This retrospective analysis included patients ≥45 y old with rib fractures who underwent SSRF in the Trauma Quality Improvement Program from 2016 to 2020. Race, ethnicity, and insurance statuses were collected. Age in years was dichotomized into two groups: 45-64 and 65+. Outcomes included ventilator-associated pneumonia, unplanned endotracheal intubation, acute respiratory distress syndrome, in-hospital mortality, failure to rescue (FTR) after major complications, and FTR after respiratory complications. Logistic regression models were fit to evaluate outcomes, controlling for gender, body mass index, Injury Severity Score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking. RESULTS Two thousand eight hundred thirty-nine patients aged 45-64 and 1828 patients aged 65+ underwent SSRF. No significant difference in clinical outcomes was noted between these groups. Analysis showed that the association of SSRF with ventilator-associated pneumonia, unplanned intubation, acute respiratory distress syndrome, in-hospital mortality, FTR after a major complication, or FTR after a respiratory complication did not vary by age (P > 0.05). Black (odds ratio [OR] 0.67; 95% confidence interval [CI]: 0.59-0.77; P < 0.001), Hispanic (OR 0.80; 95% CI: 0.71-0.91; P < 0.001), and Medicaid (OR = 0.85; 95% CI = 0.76-0.95; P = 0.005) patients were less likely to receive SSRF. CONCLUSIONS No differences in clinical outcomes were measured between adults aged 45-64 and ≥65 who underwent SSRF. Older age should not preclude patients from receiving SSRF. Further work is needed to improve underutilization in Black, Hispanic and Medicaid patients.
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Affiliation(s)
- Krista Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Gi Jung Shin
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Tracy Truong
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Maragatha Kuchibhatla
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Lauren Moore
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - William Rice
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ruidi Xu
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Sonal Swain
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Braylee Grisel
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Manuel Castillo-Angeles
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph Fernandez-Moure
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Fukuhara S, Kim KM, Yang B, Romano M, Ailawadi G, Patel HJ, Deeb GM. Reoperation following transcatheter aortic valve replacement: Insights from 10 years' experience. J Thorac Cardiovasc Surg 2024; 168:488-497.e3. [PMID: 37164056 DOI: 10.1016/j.jtcvs.2023.04.029] [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: 03/07/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Use of transcatheter aortic valve replacement (TAVR) has demonstrated dramatic growth in the past decade. This study aims to investigate implications of post-TAVR reoperation from our 10-year experience. METHODS Between 2011 and 2022, 66 post-TAVR patients underwent a reoperation, consisting of 42 (63.6%) patients with native TAVR and 24 (36.4%) patients with valve-in-valve TAVR (VIV-TAVR) after surgical aortic valve replacement. RESULTS The aggregate proportion of patients belonging to the low-/intermediate-risk group at the time of TAVR exceeded that of the high-/extreme-risk cohort in 2021. The native TAVR group received a larger TAVR valve, whereas more frequent low-risk status at the time of TAVR than the VIV-TAVR group. Concurrent procedures were highly common during reoperation and isolated surgical aortic valve replacement represented only 18.2% of the entire cohort. The native TAVR group demonstrated significantly higher TAVR explant difficulty index score (2.0 vs 1.0 points; P < .001) and operative mortality (14.2% vs 0%; P = .079) compared with the VIV-TAVR group. The 8-year cumulative incidence of reoperation was 1.9% and 14.1% (subdistribution hazard ratio, 8.0; 95% CI, 4.1-15.9; P < .001) in the native and VIV-TAVR group, respectively. Furthermore, cumulative incidence of valve reintervention, combining reoperations and redo TAVRs, was 3.3% and 19.0% (subdistribution hazard ratio, 6.2; 95% CI, 3.6-10.9; P < .001). CONCLUSIONS Low-/intermediate-risk patients are emerging as the predominant group necessitating reoperations. Native TAVR was associated with lower postimplant reintervention rates, albeit with higher reoperative technical difficulty and mortality. Conversely, VIV-TAVR was associated with higher reintervention, but demonstrated lower technical difficulty and mortality for reoperation.
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Affiliation(s)
- Shinichi Fukuhara
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
| | - Karen M Kim
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - G Michael Deeb
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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Le NK, Mallick S, Chervu N, Butterfield J, Joachim K, Charland N, Coaston T, Vadlakonda A, Benharash P. Clinical and financial outcomes associated with the utilization of right internal mammary artery versus radial artery in multivessel coronary artery bypass grafting. Surgery 2024; 176:267-273. [PMID: 38782703 DOI: 10.1016/j.surg.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/30/2024] [Accepted: 04/06/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Multi-arterial coronary bypass grafting with the left internal mammary artery as a conduit has been shown to offer superior long-term survival compared to single-arterial coronary bypass grafting. Nevertheless, the selection of a secondary conduit between the right internal mammary artery and the radial artery remains controversial. Using a national cohort, we examined the relationships between the right internal mammary artery and the radial artery with acute clinical and financial outcomes. METHODS Adults undergoing on-pump multivessel coronary bypass grafting with left internal mammary artery as the first arterial conduit were identified in the 2016 to 2020 Nationwide Readmissions Database. Patients receiving either the right internal mammary artery or the radial artery, but not both, were included in the analysis. Multivariable regression models were fitted to examine the association between the conduits and in-hospital mortality, as well as additional secondary outcomes. RESULTS Of an estimated 49,798 patients undergoing multi-arterial coronary bypass grafting, 29,729 (59.7%) comprised the radial artery cohort. During the study period, the proportion of multi-arterial coronary bypass grafting utilizing the radial artery increased from 51.3% to 65.2% (nptrend <0.001). Following adjustment, the radial artery was associated with reduced odds of in-hospital mortality (adjusted odds ratio 0.44), prolonged mechanical ventilation (adjusted odds ratio 0.78), infectious complications (adjusted odds ratio 0.69), and 30-day nonelective readmission (adjusted odds ratio 0.77, all P < .05). CONCLUSION Despite no definite endorsement from surgical societies, the radial artery is increasingly utilized as a secondary conduit in multi-arterial coronary bypass grafting. Compared to the right internal mammary artery, the radial artery was associated with lower odds of in-hospital mortality, complications, and reduced healthcare expenditures. These results suggest that whenever feasible, the radial artery should be the favored conduit over the right internal mammary artery. Nevertheless, future studies examining long-term outcomes associated with these vessels remain necessary.
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Affiliation(s)
- Nguyen K Le
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA; David Geffen School of Medicine, UCLA, Los Angeles, CA. https://twitter.com/NguyenKLe18
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, UCLA, Los Angeles, CA
| | - Jaron Butterfield
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, UCLA, Los Angeles, CA
| | - Kole Joachim
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA; David Geffen School of Medicine, UCLA, Los Angeles, CA
| | - Nicole Charland
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA; David Geffen School of Medicine, UCLA, Los Angeles, CA
| | - Troy Coaston
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA; David Geffen School of Medicine, UCLA, Los Angeles, CA
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA; David Geffen School of Medicine, UCLA, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, UCLA, Los Angeles, CA.
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Balian J, Cho NY, Vadlakonda A, Kwon OJ, Porter G, Mallick S, Benharash P. Failure to rescue following emergency general surgery: A national analysis. Surg Open Sci 2024; 20:77-81. [PMID: 38973813 PMCID: PMC11225886 DOI: 10.1016/j.sopen.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/24/2024] [Indexed: 07/09/2024] Open
Abstract
Background Failure to rescue (FTR) is increasingly recognized as a quality metric but remains understudied in emergency general surgery (EGS). We sought to identify patient and operative factors associated with FTR to better inform standardized metrics to mitigate this potentially preventable event. Methods All adult (≥18 years) non-elective hospitalizations for large bowel resection, small bowel resection, repair of perforated ulcer, laparotomy and lysis of adhesions were identified in the 2016-2020 National Readmissions Database. Patients undergoing trauma-related operations or procedures ≤2 days of admission were excluded. FTR was defined as in-hospital death following acute kidney injury requiring dialysis (AKI), myocardial infarction, pneumonia, respiratory failure, sepsis, stroke, or thromboembolism. Multilevel mixed-effect models were developed to assess factors linked with FTR. Results Among 826,548 EGS operations satisfying inclusion criteria, 298,062 (36.1 %) developed at least one MAE. Of those experiencing MAE, 43,477 (14.6 %) ultimately did not survive to discharge (FTR). Following adjustment for fixed hospital level effects, only 3.5 % of the variance in FTR was attributable to center-level differences. Relative to private insurance and the highest income quartile, Medicaid insurance (AOR 1.33; 95%CI, 1.23-1.43) and the lowest income quartile (AOR 1.22; 95%CI, 1.17-1.29) were linked with increased odds of FTR.A subset analysis stratified complication-specific rates of FTR by insurance status. Relative to private insurance, Medicaid coverage and uninsured status were linked with greater odds of FTR following perioperative sepsis, pneumonia, and AKI. Conclusion Our findings underscore the need for increased screening and vigilance following perioperative complications to mitigate disparities in patient outcomes following high-risk EGS.
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Affiliation(s)
- Jeffrey Balian
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nam Yong Cho
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Oh. Jin Kwon
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Giselle Porter
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Saad Mallick
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Diaz-Castrillon CE, Serna-Gallegos D, Arnaoutakis G, Szeto WY, Pompeu Sá M, Sezer A, Sultan I. The burden of major complications on failure to rescue after surgery for acute type A aortic dissection: Analysis of more than 19,000 patients. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00615-9. [PMID: 39009336 DOI: 10.1016/j.jtcvs.2024.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/24/2024] [Accepted: 07/04/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND The relationship between the number and type of postoperative complications and mortality in the setting for surgery for acute type A aortic dissection (ATAAD) remains underexplored despite its critical role in the failure-to-rescue (FTR) metric. METHODS This retrospective study used data from the Society of Thoracic Surgeons Adult Cardiac Surgical Database on ATAAD surgeries performed between January 2018 and December 2022. Patients were categorized based on their number of major complications. The primary outcome was FTR. We used multilevel regression and classification and regression tree models. RESULTS We included 19,243 patients (33% females), with a median age of 61 years. Regarding complications, 47.7% of patients had 0, 20.2% had 1, 12.7% had 2, and 19.4% experienced 3 or more. The most frequently reported complications were prolonged mechanical ventilation (30.3%), unplanned reoperation (19.5%), and renal failure (17.2%). Cardiac arrest occurred in 7.1% of cases. FTR increased from 13% in patients with 1 complication to >30% in those with 4 or more complications. Cardiac arrest (adjusted odds ratio [aOR], 10.9) and renal failure (aOR, 5.3) had the highest odds for mortality, followed by limb ischemia (aOR, 2.7), stroke (aOR, 2.6), and gastrointestinal complications (aOR, 2.4). Hospitals in the top performance quartile consistently showed lower FTR rates across all levels of complication. CONCLUSIONS The study validates a dose-response association between postoperative complications and mortality in patients undergoing surgery for ATAAD. Top-performing hospitals consistently show lower FTR rates independent of the number of complications. Future research should focus on the timing of complications and interventions to reduce the burden of complications.
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Affiliation(s)
- Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - George Arnaoutakis
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin, Austin, Tex
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ahmet Sezer
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Strobel RJ, Young AM, Rotar EP, Kaplan EF, Hawkins RB, Norman AV, Ahmad RM, Joseph M, Quader M, Rich JB, Speir AM, Yarboro LT, Mehaffey JH, Teman NR. Center case volume is associated with Society of Thoracic Surgeons-defined failure to rescue in cardiac surgery. J Thorac Cardiovasc Surg 2024; 168:165-174.e2. [PMID: 37211243 PMCID: PMC10657908 DOI: 10.1016/j.jtcvs.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/17/2023] [Accepted: 05/03/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Our understanding of the impact of a center's case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR. METHODS Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year. RESULTS A total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly greater center-level major complication rates but lower mortality and FTR rates (all P values < .01). Observed-to-expected FTR was significantly associated with case volume (P = .040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P = .001). CONCLUSIONS Increasing center case volume is significantly associated with improved FTR rates. Assessment of low-volume centers' FTR performance represents an opportunity for quality improvement.
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Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Andrew M Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Evan P Rotar
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Emily F Kaplan
- University of Virginia School of Medicine, Charlottesville, Va
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Anthony V Norman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Raza M Ahmad
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Mark Joseph
- Carilion Clinic Cardiothoracic Surgery/Virginia Tech Carilion School of Medicine, Roanoke, Va
| | - Mohammed Quader
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Va
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alan M Speir
- Cardiac Surgery, Inova Fairfax Hospital, Fairfax, Va
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
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Mallick S, Chervu NL, Balian J, Charland N, Valenzuela AR, Sakowitz S, Benharash P. Association of hospital volume and operative approach with clinical and financial outcomes of elective esophagectomy in the United States. PLoS One 2024; 19:e0303586. [PMID: 38875301 PMCID: PMC11178205 DOI: 10.1371/journal.pone.0303586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 04/16/2024] [Indexed: 06/16/2024] Open
Abstract
INTRODUCTION Literature regarding the impact of esophagectomy approach on hospitalizations costs and short-term outcomes is limited. Moreover, few have examined how institutional MIS experience affects costs. We thus examined utilization trends, costs, and short-term outcomes of open and minimally invasive (MIS) esophagectomy as well as assessing the relationship between institutional MIS volume and hospitalization costs. METHODS All adults undergoing elective esophagectomy were identified from the 2016-2020 Nationwide Readmissions Database. Multiple regression models were used to assess approach with costs, in-hospital mortality, and major complications. Additionally, annual hospital MIS esophagectomy volume was modeled as a restricted cubic spline against costs. Institutions performing > 16 cases/year corresponding with the inflection point were categorized as high-volume hospitals (HVH). We subsequently examined the association of HVH status with costs, in-hospital mortality, and major complications in patients undergoing minimally invasive esophagectomy. RESULTS Of an estimated 29,116 patients meeting inclusion, 10,876 (37.4%) underwent MIS esophagectomy. MIS approaches were associated with $10,600 in increased incremental costs (95% CI 8,800-12,500), but lower odds of in-hospital mortality (AOR 0.76; 95% CI 0.61-0.96) or major complications (AOR 0.68; 95% CI 0.60, 0.77). Moreover, HVH status was associated with decreased adjusted costs, as well as lower odds of postoperative complications for patients undergoing MIS operations. CONCLUSION In this nationwide study, MIS esophagectomy was associated with increased hospitalization costs, but improved short-term outcomes. In MIS operations, cost differences were mitigated by volume, as HVH status was linked with decreased costs in the setting of decreased odds of complications. Centralization of care to HVH centers should be considered as MIS approaches are increasingly utilized.
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Affiliation(s)
- Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Nikhil L Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, UCLA, Los Angeles, CA, United States of America
| | - Jeffrey Balian
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Nicole Charland
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Alberto R Valenzuela
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, UCLA, Los Angeles, CA, United States of America
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Le NK, Chervu N, Mallick S, Vadlakonda A, Kim S, Curry J, Benharash P. Mortality and resource utilization in surgical versus transcatheter repeat mitral valve replacement: A national analysis. PLoS One 2024; 19:e0301939. [PMID: 38781278 PMCID: PMC11115312 DOI: 10.1371/journal.pone.0301939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/25/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Transcatheter mitral valve replacement (TMVR) has garnered interest as a viable alternative to the traditional surgical mitral valve replacement (SMVR) for high-risk patients requiring redo operations. This study aims to evaluate the association of TMVR with selected clinical and financial outcomes. METHODS Adults undergoing isolated redo mitral valve replacement were identified in the 2016-2020 Nationwide Readmissions Database and categorized into TMVR or SMVR cohorts. Various regression models were developed to assess the association between TMVR and in-hospital mortality, as well as additional secondary outcomes. Transseptal and transapical catheter-based approaches were also compared in relation to study endpoints. RESULTS Of an estimated 7,725 patients, 2,941 (38.1%) underwent TMVR. During the study period, the proportion of TMVR for redo operations increased from 17.8% to 46.7% (nptrend<0.001). Following adjustment, TMVR was associated with similar odds of in-hospital mortality (AOR 0.82, p = 0.48), but lower odds of stroke (AOR 0.44, p = 0.001), prolonged ventilation (AOR 0.43, p<0.001), acute kidney injury (AOR 0.61, p<0.001), and reoperation (AOR 0.29, p = 0.02). TMVR was additionally correlated with shorter postoperative length of stay (pLOS; β -0.98, p<0.001) and reduced costs (β -$10,100, p = 0.002). Additional analysis demonstrated that the transseptal approach had lower adjusted mortality (AOR 0.44, p = 0.02), shorter adjusted pLOS (β -0.43, p<0.001), but higher overall costs (β $5,200, p = 0.04), compared to transapical. CONCLUSIONS In this retrospective cohort study, we noted TMVR to yield similar odds of in-hospital mortality as SMVR, but fewer complications and reduced healthcare expenditures. Moreover, transseptal approaches were associated with lower adjusted mortality, shorter pLOS, but higher cost, relative to the transapical. Our findings suggest that TMVR represent a cost-effective and safe treatment modality for patients requiring redo mitral valve procedures. Nevertheless, future studies examining long-term outcomes associated with SMVR and TMVR in redo mitral valve operations, are needed.
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Affiliation(s)
- Nguyen K. Le
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, United States of America
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, United States of America
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, United States of America
| | - Shineui Kim
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, United States of America
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, United States of America
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11
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Strobel RJ, Money DT, Young AM, Wisniewski AM, Norman AV, Ahmad RM, Kaplan EF, Joseph M, Quader M, Mazzeffi M, Yarboro LT, Teman NR. Extracorporeal Life Support Organization Center of Excellence recognition is associated with improved failure to rescue after cardiac arrest. J Thorac Cardiovasc Surg 2024; 167:1866-1877.e1. [PMID: 37156364 PMCID: PMC10626046 DOI: 10.1016/j.jtcvs.2023.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/17/2023] [Accepted: 04/22/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE The influence of Extracorporeal Life Support Organization (ELSO) center of excellence (CoE) recognition on failure to rescue after cardiac surgery is unknown. We hypothesized that ELSO CoE would be associated with improved failure to rescue. METHODS Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. Patients were stratified by whether or not their operation was performed at an ELSO CoE. Hierarchical logistic regression analyzed the association between ELSO CoE recognition and failure to rescue. RESULTS A total of 43,641 patients were included across 17 centers. In total, 807 developed cardiac arrest with 444 (55%) experiencing failure to rescue after cardiac arrest. Three centers received ELSO CoE recognition, and accounted for 4238 patients (9.71%). Before adjustment, operative mortality was equivalent between ELSO CoE and non-ELSO CoE centers (2.08% vs 2.36%; P = .25), as was the rate of any complication (34.5% vs 33.8%; P = .35) and cardiac arrest (1.49% vs 1.89%; P = .07). After adjustment, patients undergoing surgery at an ELSO CoE facility were observed to have 44% decreased odds of failure to rescue after cardiac arrest, relative to patients at non-ELSO CoE facility (odds ratio, 0.56; 95% CI, 0.316-0.993; P = .047). CONCLUSIONS ELSO CoE status is associated with improved failure to rescue following cardiac arrest for patients undergoing cardiac surgery. These findings highlight the important role that comprehensive quality programs serve in improving perioperative outcomes in cardiac surgery.
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Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Dustin T Money
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Andrew M Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Alex M Wisniewski
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Anthony V Norman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Raza M Ahmad
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Emily F Kaplan
- School of Medicine, University of Virginia, Charlottesville, Va
| | - Mark Joseph
- Carilion Clinic Cardiothoracic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Va
| | - Mohammed Quader
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Va
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
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Kim K, Jung SH, Kim HR, Yoo JS, Kim JB, Chung CH. Cardiovascular outcomes in solid organ transplant recipients undergoing cardiac surgery: A matched pair analysis. Clin Transplant 2024; 38:e15304. [PMID: 38591111 DOI: 10.1111/ctr.15304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 03/07/2024] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION This study aimed to compare postoperative outcomes after cardiac surgery in solid-organ transplant recipients and nontransplant patients. METHODS We performed a retrospective analysis of 78 consecutive transplant recipients who underwent cardiac surgery at Asan Medical Center between 2000 and 2022 and were matched with 312 nontransplant patients who underwent cardiac surgery at a 1:4 ratio. The outcomes included 30-day mortality, all-cause death, cardiac death, readmission, and cardiac readmission. RESULTS There was no significant difference in baseline characteristics between the two groups. The most common type of cardiac surgery performed in solid organ transplant recipients was isolated valve surgery, followed by isolated CABG. The 30-day mortality was not significantly different between transplant recipients and nontransplant patients (3.9% vs. 3.5%; P > .99). Solid organ transplant recipients showed a higher all-cause mortality compared to nontransplant patients (29.1% vs. 14.3% at 5 years; P = .001); however, there was no significant difference in cardiac death between the two groups (2.6% vs. 3.2% at 5 years; P = .80). In addition, the readmission and cardiac readmission rates showed comparable findings to that of mortality. CONCLUSION Cardiac surgery can be performed safely in solid organ transplant recipients, with postoperative cardiovascular outcomes comparable to those observed in nontransplant patients.
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Affiliation(s)
- Kitae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hong Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Verma A, Williamson CG, Bakhtiyar SS, Hadaya J, Hekking T, Kronen E, Si MS, Benharash P. Center-Level Variation in Failure to Rescue After Pediatric Cardiac Surgery. Ann Thorac Surg 2024; 117:552-559. [PMID: 37182822 DOI: 10.1016/j.athoracsur.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 04/17/2023] [Accepted: 05/01/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Although failure to rescue (FTR) is increasingly recognized as a quality metric, studies in congenital cardiac surgery remain sparse. Within a national cohort of children undergoing cardiac operations, we characterized the presence of center-level variation in FTR and hypothesized a strong association with mortality but not complications. METHODS All children undergoing congenital cardiac operations were identified in the 2013 to 2019 Nationwide Readmissions Database. FTR was defined as in-hospital death after cardiac arrest, ventricular tachycardia/fibrillation, prolonged mechanical ventilation, pneumonia, stroke, venous thromboembolism, or sepsis, among other complications. Hierarchical models were used to generate hospital-specific, risk-adjusted rates of mortality, complications, and FTR. Centers in the highest decile of FTR were identified and compared with others. RESULTS Of an estimated 74,070 patients, 1.9% died before discharge, at least 1 perioperative complication developed in 43.0%, and 4.1% experienced FTR. After multilevel modeling, decreasing age, nonelective admission, and increasing operative complexity were associated with greater odds of FTR. Variations in overall mortality and FTR exhibited a strong, positive relationship (r = 0.97), whereas mortality and complications had a negligible association (r = -0.02). Compared with others, patients at centers with high rates of FTR had similar distributions of age, sex, chronic conditions, and operative complexity. CONCLUSIONS In the present study, center-level variations in mortality were more strongly explained by differences in FTR than complications. Our findings suggest the utility of FTR as a quality metric for congenital heart surgery, although further study is needed to develop a widely accepted definition and appropriate risk-adjustment models.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Tyson Hekking
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Elsa Kronen
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Ming-Sing Si
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California.
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14
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Strobel RJ, Kaplan EF, Young AM, Rotar EP, Mehaffey JH, Hawkins RB, Joseph M, Quader MA, Yarboro LT, Teman NR. Socioeconomic distress is associated with failure to rescue in cardiac surgery. J Thorac Cardiovasc Surg 2024; 167:1100-1114.e1. [PMID: 36031426 PMCID: PMC9852359 DOI: 10.1016/j.jtcvs.2022.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/06/2022] [Accepted: 07/10/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The influence of socioeconomic determinants of health on failure to rescue (mortality after a postoperative complication) after cardiac surgery is unknown. We hypothesized that increasing Distressed Communities Index, a comprehensive socioeconomic ranking by ZIP code, would be associated with higher failure to rescue. METHODS Patients undergoing Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) who developed a failure to rescue complication were included. After excluding patients with missing ZIP code or Society of Thoracic Surgeons predicted risk of mortality, patients were stratified by Distressed Communities Index scores (0-no distress, 100-severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. The upper 2 quintiles of distress (Distressed Communities Index >60) were compared to all other patients. Hierarchical logistic regression analyzed the association between Distressed Communities Index and failure to rescue. RESULTS A total of 4004 patients developed 1 or more of the defined complications across 17 centers. Of these, 582 (14.5%) experienced failure to rescue. High socioeconomic distress (Distressed Communities Index >60) was identified among 1272 patients (31.8%). Before adjustment, failure to rescue occurred more frequently among those from socioeconomically distressed communities (Distressed Communities Index >60; 16.9% vs 13.4%, P = .004). After adjustment, residing in a socioeconomically distressed community was associated with 24% increased odds of failure to rescue (odds ratio, 1.24; confidence interval, 1.003-1.54; P = .044). CONCLUSIONS Increasing Distressed Communities Index, a measure of poor socioeconomic status, is associated with greater risk-adjusted likelihood of failure to rescue after cardiac surgery. These findings highlight that current quality metrics do not account for socioeconomic status, and as such underrepresent procedural risk for these vulnerable patients.
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Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Emily F Kaplan
- School of Medicine, University of Virginia, Charlottesville, Va
| | - Andrew M Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Evan P Rotar
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Robert B Hawkins
- Virginia Cardiac Services Quality Initiative, South Riding, Va; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Mark Joseph
- Virginia Cardiac Services Quality Initiative, South Riding, Va; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Va
| | - Mohammed A Quader
- Virginia Cardiac Services Quality Initiative, South Riding, Va; Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Va
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va.
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Lobdell KW, Grant MC, Salenger R. Temporary mechanical circulatory support & enhancing recovery after cardiac surgery. Curr Opin Anaesthesiol 2024; 37:16-23. [PMID: 38085881 DOI: 10.1097/aco.0000000000001332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery. RECENT FINDINGS Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing. SUMMARY Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.
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Affiliation(s)
- Kevin W Lobdell
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina
| | - Michael C Grant
- Johns Hopkins University School of Medicine, Anesthesiology and Critical Care Medicine, Baltimore
| | - Rawn Salenger
- University of Maryland School of Medicine, Department of Surgery, Towson, Maryland, USA
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16
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Romo Valenzuela A, Chervu NL, Roca Y, Sanaiha Y, Mallick S, Benharash P. Socioeconomic disparities in risk of financial toxicity following elective cardiac operations in the United States. PLoS One 2024; 19:e0292210. [PMID: 38295038 PMCID: PMC10830059 DOI: 10.1371/journal.pone.0292210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/13/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND While insurance reimbursements allay a portion of costs associated with cardiac operations, uncovered and additional fees are absorbed by patients. An examination of financial toxicity (FT), defined as the burden of patient medical expenses on quality of life, is warranted. Therefore, the present study used a nationally representative database to demonstrate the association between insurance status and risk of financial toxicity (FT) among patients undergoing major cardiac operations. METHODS Adults admitted for elective coronary artery bypass grafting (CABG) and isolated or concomitant valve operations were assessed using the 2016-2019 National Inpatient Sample. FT risk was defined as out-of-pocket expenditure >40% of post-subsistence income. Regression models were developed to determine factors associated with FT risk in insured and uninsured populations. To demonstrate the association between insurance status and risk of FT among patients undergoing major cardiac operations. RESULTS Of an estimated 567,865 patients, 15.6% were at risk of FT. A greater proportion of uninsured patients were at risk of FT (81.3 vs. 14.8%, p<0.001), compared to insured. After adjustment, FT risk among insured patients was not affected by non-income factors. However, Hispanic race (Adjusted Odds Ratio [AOR] 1.60), length of stay (AOR 1.17/day), and combined CABG-valve operations (AOR 2.31, all p<0.05) were associated with increased risk of FT in the uninsured. CONCLUSION Uninsured patients demonstrated higher FT risk after undergoing major cardiac operation. Hispanic race, longer lengths of stay, and combined CABG-valve operations were independently associated with increased risk of FT amongst the uninsured. Conversely, non-income factors did not impact FT risk in the insured cohort. Culturally-informed reimbursement strategies are necessary to reduce disparities in already financially disadvantaged populations.
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Affiliation(s)
- Alberto Romo Valenzuela
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Nikhil L. Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Yvonne Roca
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
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Kim Y, Weissler EH, Long CA, Williams ZF, Southerland KW, Mohapatra A. Failure-to-Salvage After Femoropopliteal Bypass Surgery is Associated With Nonmodifiable Risk Factors. J Surg Res 2024; 293:357-363. [PMID: 37806222 DOI: 10.1016/j.jss.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/15/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Bypass graft failure and major amputation are among the worst complications after femoropopliteal bypass surgery. In this large multicenter analysis, we examined our incidence and risk factors for failure-to-salvage (FTS) following either bypass surgery or bypass graft failure. METHODS A regional multicenter database was retrospectively queried for all femoropopliteal bypass procedures performed between 2002 and 2021. Re-do bypasses were excluded. The primary outcome was FTS, defined as major ipsilateral limb amputation within 90 d following index bypass surgery or bypass graft failure. Bypass graft failure was defined as critical stenosis or occlusion of the bypass graft requiring reintervention. Graft rescue was defined as bypass graft failure without subsequent major ipsilateral limb amputation within 90 d. Multivariable logistic regression analysis was utilized to identify factors associated with bypass graft failure and FTS. RESULTS Over the study period, 1315 femoropopliteal bypass procedures were performed across five hospitals. There were 25 major amputations within 90 d of initial bypass. Bypass graft failure was diagnosed in an additional 503 (38.3%) patients. Mean time to graft failure was 619 d. On multivariable analysis, bypass for tissue loss (adjusted odds ratio [aOR] 1.38 [95% confidence interval (CI) 1.03-1.83], P = 0.03) was associated with graft failure. Of patients with graft failure, 33 had major amputation, leading to an overall FTS incidence of 4.4% (n = 58) over a mean follow-up period of 3.4 y. Patient demographics, medical comorbidities, and bypass conduits were similar between the FTS and graft rescue groups (n = NS each). The FTS group more frequently underwent bypass for tissue loss (51.7% versus 29.8%, P = 0.002), and an infrageniculate bypass target was more frequently utilized in FTS compared to graft rescue patients (81.0% versus 60.4%, P = 0.002). Anticoagulation (34.5% in FTS versus 37.7% in rescue) and dual antiplatelet therapy (15.5% versus 22.1%, respectively) were similar between groups (P = NS each). On multivariable analysis, factors associated with FTS included infrageniculate target (aOR 2.42 [95% CI 1.22-4.08], P = 0.01), black race (aOR 2.47 [95% CI 1.04-5.84], P = 0.04), and bypass for tissue loss (aOR 4.75 [95% CI 1.41-16.0], P = 0.01). Anticoagulation and dual antiplatelet therapy were not associated with loss of graft patency or FTS. CONCLUSIONS Failure-to-salvage after femoropopliteal bypass surgery is associated with nonmodifiable factors, and may represent progression of underlying disease. These data may help inform vascular surgeons in counseling patients with failing bypass grafts. Further investigation of care delivery factors improving likelihood of graft salvage may be warranted.
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Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina.
| | - E Hope Weissler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Zachary F Williams
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Kevin W Southerland
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
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Bauer TM, Pienta M, Wu X, Lehr EJ, Whitman GJ, Kramer RS, Brevig J, Pagani FD, Likosky DS. Interhospital variability in failure to rescue rates following aortic valve surgery. JTCVS OPEN 2023; 16:123-138. [PMID: 38204724 PMCID: PMC10774948 DOI: 10.1016/j.xjon.2023.08.010] [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: 05/06/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 01/12/2024]
Abstract
Objective This study evaluated interhospital variability and determinants of failure-to-rescue for patients undergoing surgical aortic valve replacement. Methods An observational study was conducted among 28,842 patients undergoing aortic valve replacement with or without coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals participating in the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Postoperative complications were defined as major (stroke, renal failure, reoperation, prolonged ventilation, sternal infection) and overall (major plus 14 other morbidities). Hospital terciles of observed to expected (O/E) mortality were compared on crude rates of major and overall complications, operative mortality, and failure to rescue (among major and overall complications). The correlation between hospital observed and expected failure-to-rescue rates was assessed. Results Median Society of Thoracic Surgeons Adult Cardiac Surgery Database predicted mortality risk was similar across hospital O:E mortality terciles (P = .10). As expected, mortality rates significantly increased across terciles (low O/E tercile: 1.6%, high O/E tercile: 4.7%; P < .001). Failure-to-rescue rates increased substantially across hospital mortality terciles among patients with major (low tercile, 8.8% and high tercile, 20.8%) and overall (low tercile, 3.0% and high tercile, 8.9%) complications. Hospital-level expected failure to rescue had a higher correlation with observed complications for overall complications (R2 = 0.71) compared with Society of Thoracic Surgeons major complications (R2 = 0.24). Conclusions Considerable interhospital variation exists in failure-to-rescue rates following aortic valve replacement. Hospitals in the low O/E mortality tercile experience failure to rescue nearly one-third less than those in the high O/E mortality tercile. Efforts to advance quality will benefit from identifying and disseminating optimal rescue strategies in this patient population.
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Affiliation(s)
- Tyler M. Bauer
- Department of Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Michael Pienta
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Eric J. Lehr
- Department of Cardiac Surgery, Swedish Heart and Vascular Institute, Swedish Medical Center, Seattle, Wash
| | | | - Robert S. Kramer
- Division of Cardiothoracic Surgery, Maine Medical Center, Portland, Maine
| | - James Brevig
- Providence St Joseph Heart Institute, Renton, Wash
- Providence Regional Medical Center, Everett, Wash
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Wang Y, Kapula N, Yang CFJ, Manapat P, Elliott IA, Guenthart BA, Lui NS, Backhus LM, Berry MF, Shrager JB, Liou DZ. Comparison of failure to rescue in younger versus elderly patients following lung cancer resection. JTCVS OPEN 2023; 16:855-872. [PMID: 38204720 PMCID: PMC10774945 DOI: 10.1016/j.xjon.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/14/2023] [Accepted: 08/02/2023] [Indexed: 01/12/2024]
Abstract
Objective Failure to rescue (FTR), defined as in-hospital death following a major complication, has been increasingly studied in patients who undergo cardiothoracic surgery. This study tested the hypothesis that elderly patients undergoing lung cancer resection have greater rates of FTR compared with younger patients. Methods Patients who underwent surgery for primary lung cancer between 2011 and 2020 and had at least 1 major postoperative complication were identified using the National Surgical Quality Improvement Program database. Patients who died following complications (FTR) were compared with those who survived in an elderly (80+ years) and younger (<80 years) cohort. Results Of the 2823 study patients, the younger cohort comprised 2497 patients (FTR: n = 139 [5.6%]), whereas the elderly cohort comprised 326 patients (FTR: n = 39 [12.0%]). Pneumonia was the most common complication in younger (877/2497, 35.1%) and elderly patients (118/326, 36.2%) but was not associated with FTR on adjusted analysis. Increasing age was associated with FTR (adjusted odds ratio [AOR], 1.55 per decade, P < .001), whereas unplanned reoperation was associated with reduced risk (AOR, 0.55, P = .01). Within the elderly cohort, surgery conducted by a thoracic surgeon was associated with lower FTR risk (AOR, 0.29, P = .028). Conclusions FTR following lung cancer resection was more frequent with increasing age. Pneumonia was the most common complication but not a predictor of FTR. Unplanned reoperation was associated with reduced FTR, as was treatment by a thoracic surgeon for elderly patients. Surgical therapy for complications after lung cancer resection and elderly patients managed by a thoracic specialist may mitigate the risk of death following an adverse postoperative event.
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Affiliation(s)
- Yoyo Wang
- University of Michigan Medical School, Ann Arbor, Mich
| | - Ntemena Kapula
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Chi-Fu J. Yang
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Pooja Manapat
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Irmina A. Elliott
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Brandon A. Guenthart
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Natalie S. Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Leah M. Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Mark F. Berry
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Joseph B. Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Douglas Z. Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
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Strobel RJ, Kaplan EF, Young AM, Wisniewski AM, Ising MS, Chaudry B, Speir A, Quader M, Mehaffey JH, Beller JP, Teman NR. The Society of Thoracic Surgeons Definition of Failure to Rescue Should Consider Including Cardiac Arrest. Ann Thorac Surg 2023; 116:1301-1308. [PMID: 37271448 PMCID: PMC10693650 DOI: 10.1016/j.athoracsur.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/28/2023] [Accepted: 04/04/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Failure to rescue (FTR) is a new quality measure in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. The STS defines FTR as death after permanent stroke, renal failure, reoperation, or prolonged ventilation. Our objective was to assess whether cardiac arrest should be included in this definition. METHODS Patients undergoing an STS index operation in a regional collaborative (2011-2021) were included. The performance of the STS definition of FTR was compared with a definition that included the STS complications plus cardiac arrest (STS+). Centers were grouped into FTR rate terciles using the STS and STS+ definitions of FTR, and changes in their relative performance rating were assessed. RESULTS A total of 43,641 patients were included across 17 centers. Cardiac arrest was the most lethal complication: 55.0% of patients who experienced cardiac arrest died. FTR after any complication (13 total) occurred among 884 patients. The STS definition of FTR accounted for 83% (735 of 884) of all FTR. The addition of cardiac arrest to the STS definition significantly increased the proportion of overall FTR accounted for (92.2% [815 of 884]; P < .001). Choice of FTR definition led to substantial differences in center-level relative performance rating by FTR rate. CONCLUSIONS Mortality after cardiac arrest is not completely captured by the STS definition of FTR and represents an important source of potentially preventable death after cardiac surgery. Future quality improvement efforts using the STS definition of FTR should account for this.
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Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Emily F Kaplan
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Andrew M Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Alex M Wisniewski
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mickey S Ising
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Bakhtiar Chaudry
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Alan Speir
- Cardiac Surgery, Inova Fairfax Hospital, Fairfax, Virginia
| | - Mohammed Quader
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Jared P Beller
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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Kurlansky PA. Failure to Rescue in Cardiac Surgery: Where Do We Go From Here? Ann Thorac Surg 2023; 116:1309-1310. [PMID: 37285949 DOI: 10.1016/j.athoracsur.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/13/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Paul A Kurlansky
- Department of Surgery, Columbia University Irving Medical Center, Neurological Institute 554, 710 W 168th St, New York, NY 10032.
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James L, Iribarne A. Failure to Rescue in Cardiac Surgery: A Need for Improved Reporting. Ann Thorac Surg 2023; 116:1318-1319. [PMID: 37230273 DOI: 10.1016/j.athoracsur.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/13/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Les James
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Alexander Iribarne
- Department of Cardiothoracic Surgery, Staten Island University Hospital, 501 Seaview Ave, Ste 202, Staten Island, NY 10305.
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Young AM, Strobel RJ, Kaplan E, Norman AV, Ahmad R, Kern J, Yarboro L, Yount K, Hulse M, Teman NR. Delirium is associated with failure to rescue after cardiac surgery. JTCVS OPEN 2023; 16:464-476. [PMID: 38204716 PMCID: PMC10775056 DOI: 10.1016/j.xjon.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/17/2023] [Accepted: 08/28/2023] [Indexed: 01/12/2024]
Abstract
Objective Postoperative delirium after cardiac surgery is associated with long-term cognitive decline and mortality. We investigated whether increased ICU Confusion Assessment Method scores were associated with greater 30-day mortality and failure to rescue after cardiac surgery. Methods We studied 4030 patients who underwent a Society of Thoracic Surgeons index operation at the University of Virginia Health System from 2011 to 2021. We obtained all ICU Confusion Assessment Method scores recorded during patients' admission and summarized scores for the first 7 postoperative days. Univariate and multivariable logistic regression analyzed the association between ICU Confusion Assessment Method score/delirium presence and postoperative complications, operative mortality, and failure to rescue. Results Any episode of ICU Confusion Assessment Method screen-positive delirium and nearly all components of the score were associated with increased 30-day mortality on univariate analysis. We found that a single episode of delirium was associated with increased mortality. Feature 2 (inattention) had the strongest association with poorer outcomes, including failure to rescue in our analysis, as were patients with higher peak Richmond Agitation Sedation Scale scores. Patients with higher mean Richmond Agitation Sedation Scale scores had an association with decreased failure to rescue. Conclusions A single episode of delirium, as measured using ICU Confusion Assessment Method scores, is associated with increased mortality. Inattention and higher peak Richmond Agitation Sedation Scale scores were associated with failure to rescue. Screening may clarify diagnosing delirium and assessing its implications on mortality and failure to rescue. Our findings suggest the importance of identifying and managing risk factors for delirium to improve patient outcomes and reduce mortality and failure to rescue rates.
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Affiliation(s)
- Andrew M. Young
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Raymond J. Strobel
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Emily Kaplan
- School of Medicine, University of Virginia, Charlottesville, Va
| | - Anthony V. Norman
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Raza Ahmad
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - John Kern
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Leora Yarboro
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Kenan Yount
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Matthew Hulse
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - Nicholas R. Teman
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
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Verma A, Bakhtiyar SS, Chervu N, Hadaya J, Kronen E, Sanaiha Y, Benharash P. Center-Level Variation in Failure to Rescue After Elective Adult Cardiac Surgery. Ann Thorac Surg 2023; 116:1311-1318. [PMID: 37031769 DOI: 10.1016/j.athoracsur.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND There has been increasing emphasis on evaluation of failure to rescue (FTR) after major inpatient operations. The present study characterized center-level variation in FTR within a national cohort of patients undergoing elective cardiac operations. METHODS All adults undergoing elective coronary artery bypass grafting and/or valve operations were identified in the 2016-2019 Nationwide Readmissions Database. FTR was defined as in-hospital death after prolonged mechanical ventilation, stroke, reoperation, acute kidney injury requiring dialysis, sepsis, cardiac arrest or pulmonary embolism. Multi-level, mixed-effects regressions were used to model mortality, complications, and FTR. Centers with high hospital-specific rates of FTR (≥95th percentile) were identified and compared to others. RESULTS Of an estimated 454,506 patients included for analysis, 32,537 (7.2%) developed at least 1 complication, and 7669 (1.7%) died before discharge. Overall, 5370 (16.5%) patients experienced FTR. Compared with those who developed ≥1 complication but survived to discharge, FTR patients were significantly older, more commonly female, and had a greater burden of comorbidities as measured by the Elixhauser Comorbidity Index. Risk-adjusted, hospital-specific rates of mortality and FTR were moderately correlated (r = 0.64), mortality and complications were weakly associated (r = 0.16), and complications and FTR exhibited a very weak relationship (r = -0.02). Relative to others, centers with high rates of FTR had lower annual cardiac surgical volume (median 61 [interquartile range 33-133] vs 80 [interquartile range 43-149] cases/y, P = .019). CONCLUSIONS The present findings affirm prior work demonstrating a close link between variation in FTR and mortality, but not complications. Further study is necessary to delineate modifiable care pathways that mitigate FTR.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California; Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado; Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
| | - Elsa Kronen
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California.
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Shahian DM. Failure to Rescue: From What? Ann Thorac Surg 2023; 116:1308-1309. [PMID: 37285947 DOI: 10.1016/j.athoracsur.2023.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 06/09/2023]
Affiliation(s)
- David M Shahian
- Division of Cardiac Surgery, Department of Surgery, and Center for Quality and Safety, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114.
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Escalante GO, Sun J, Schnell S, Guderian E, Mack CA, Argenziano M, Kurlansky P. Hospital characteristics associated with failure to rescue in cardiac surgery. JTCVS OPEN 2023; 16:509-521. [PMID: 38204725 PMCID: PMC10775121 DOI: 10.1016/j.xjon.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 01/12/2024]
Abstract
Objective The study objective was to examine the association between hospital processes of care and failure to rescue in a diverse, multi-institutional cardiac surgery network. Methods Failure to rescue was defined as an operative mortality after 1 or more of 4 complications: prolonged ventilation, stroke, renal failure, and unplanned reoperation. Society of Thoracic Surgeons data from 20,950 consecutive patients in the Columbia HeartSource network who underwent 1 of 7 cardiac operations-coronary artery bypass grafting, aortic valve replacement ± coronary artery bypass grafting, mitral valve repair or replacement ± coronary artery bypass grafting-were analyzed to calculate failure to rescue rates. Hospital-specific characteristics were ascertained by survey method. Multivariable mixed-effects logistic models assessed the association of these hospital characteristics with failure to rescue while adjusting for patient-related factors known to be associated with mortality. Results Failure to rescue rates at affiliate hospitals ranged from 5.45% to 21.74% (median, 12.5%; interquartile range, 6.9%). When controlling for Society of Thoracic Surgeons-predicted risk of mortality with hospital as a random effect, 4 hospital characteristics were found to be associated with lower failure to rescue rates; the presence of cardiac-trained anesthesiologists (odds ratio, 0.41; CI, 0.31-0.55, P < .001), availability of extracorporeal membrane oxygenation mechanical circulatory support (odds ratio, 0.41; CI, 0.31-0.54, P < .001), ratio of intensive care unit beds to intensivists (odds ratio, 0.87; CI, 0.76-0.99, P = .039), and total number of intensive care unit beds (odds ratio, 0.97; CI, 0.96-0.99, P = .002). Conclusions In a diverse multi-institutional cardiac surgical network, we were able to identify specific hospital processes of care associated with failure to rescue, even when adjusting for patient-related predictors of operative mortality.
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Affiliation(s)
| | - Jocelyn Sun
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University New York, New York, NY
| | - Susan Schnell
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
| | - Emily Guderian
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
| | - Charles A. Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Michael Argenziano
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University New York, New York, NY
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University New York, New York, NY
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
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Roy JM, Segura AC, Rumalla K, Skandalakis GP, Covell MM, Bowers CA. A Predictive Model of Failure to Rescue After Thoracolumbar Fusion. Neurospine 2023; 20:1337-1345. [PMID: 38171301 PMCID: PMC10762394 DOI: 10.14245/ns.2346840.420] [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: 08/15/2023] [Revised: 09/30/2023] [Accepted: 10/01/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Although failure to rescue (FTR) has been utilized as a quality-improvement metric in several surgical specialties, its current utilization in spine surgery is limited. Our study aims to identify the patient characteristics that are independent predictors of FTR among thoracolumbar fusion (TLF) patients. METHODS Patients who underwent TLF were identified using relevant diagnostic and procedural codes from the National Surgical Quality Improvement Program (NSQIP) database from 2011-2020. Frailty was assessed using the risk analysis index (RAI). FTR was defined as death, within 30 days, following a major complication. Univariate and multivariable analyses were used to compare baseline characteristics and early postoperative sequelae across FTR and non-FTR cohorts. Receiver operating characteristic (ROC) curve analysis was used to assess the discriminatory accuracy of the frailty-driven predictive model for FTR. RESULTS The study cohort (N = 15,749) had a median age of 66 years (interquartile range, 15 years). Increasing frailty, as measured by the RAI, was associated with an increased likelihood of FTR: odds ratio (95% confidence interval [CI]) is RAI 21-25, 1.3 [0.8-2.2]; RAI 26-30, 4.0 [2.4-6.6]; RAI 31-35, 7.0 [3.8-12.7]; RAI 36-40, 10.0 [4.9-20.2]; RAI 41- 45, 21.5 [9.1-50.6]; RAI ≥ 46, 45.8 [14.8-141.5]. The frailty-driven predictive model for FTR demonstrated outstanding discriminatory accuracy (C-statistic = 0.92; CI, 0.89-0.95). CONCLUSION Baseline frailty, as stratified by type of postoperative complication, predicts FTR with outstanding discriminatory accuracy in TLF patients. This frailty-driven model may inform patients and clinicians of FTR risk following TLF and help guide postoperative care after a major complication.
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Affiliation(s)
- Joanna M. Roy
- Topiwala National Medical College, Mumbai, India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
| | - Aaron C. Segura
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Kranti Rumalla
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Georgios P. Skandalakis
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Michael M. Covell
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
- School of Medicine, Georgetown University, Washington, DC, USA
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Mohammadi S, Babaki S, Kalavrouiotis D. Commentary: Failure to rescue or failure to measure? J Thorac Cardiovasc Surg 2023; 166:1166-1167. [PMID: 35545452 DOI: 10.1016/j.jtcvs.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/03/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Siamak Mohammadi
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada.
| | - Shervin Babaki
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada; Research Center, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouiotis
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
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Sakowitz S, Bakhtiyar SS, Vadlakonda A, Ali K, Sanaiha Y, Benharash P. Failure to rescue among octogenarians undergoing cardiac surgery in the United States. Surgery 2023; 174:893-900. [PMID: 37544816 DOI: 10.1016/j.surg.2023.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/30/2023] [Accepted: 06/18/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND A rapidly growing population, octogenarians are considered at high-risk for mortality and complications after cardiac surgery. Given the recent addition of failure to rescue as a Society of Thoracic Surgeons quality metric, a better understanding of patient and operative factors predictive of failure to rescue in this cohort is warranted. METHODS The 2010-2020 Nationwide Readmissions Database was used to identify all patients ≥80 years undergoing first-time, elective coronary artery bypass grafting or concomitant valve operations. Patients experiencing failure to rescue, defined as mortality after a major or minor complication, were classified as Failure to Rescue (others: Non-Failure to Rescue). Multivariable regression models were developed to ascertain significant perioperative factors associated with failure to rescue. RESULTS Of ∼562,794 octogenarian patients, 76,473 (13.6%) developed complications. Of these, 7,055 (9.2%) experienced failure to rescue. The incidence of failure to rescue decreased across the study time course (9.7% in 2010 to 7.6% in 2019, P = .001). After risk adjustment, age (adjusted odds ratio, 1.05/year; 95% confidence interval, 1.03-1.07), female sex (adjusted odds ratio, 1.40; 95% confidence interval, 1.27-1.53), congestive heart failure (adjusted odds ratio, 1.54; 95% confidence interval, 1.38-1.71), late-stage kidney disease (adjusted odds ratio, 2.38; 95% confidence interval, 1.79-3.17), liver disease (adjusted odds ratio, 9.59; 95% confidence interval, 8.17-11.26), and cerebrovascular disease (adjusted odds ratio, 2.42; 95% confidence interval, 2.12-2.76) were associated with failure to rescue. Relative to isolated coronary artery bypass grafting, combined coronary artery bypass grafting-valve (adjusted odds ratio, 1.67; 95% confidence interval, 1.43-1.95) and multi-valve procedures (adjusted odds ratio, 2.23; 95% confidence interval, 1.75-2.85) were linked with greater odds of failure to rescue. There was no association between failure to rescue and hospital volume. CONCLUSION Despite improvements in perioperative management, failure to rescue occurs in ∼9% of octogenarians undergoing elective cardiac operations. Although incidence has declined over the past decade, the continued prevalence of failure to rescue underscores the need for novel risk assessments and targeted interventions.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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Roy JM, Rumalla K, Skandalakis GP, Kazim SF, Schmidt MH, Bowers CA. Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? A systematic review. Neurosurg Rev 2023; 46:227. [PMID: 37672166 DOI: 10.1007/s10143-023-02137-7] [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: 06/23/2023] [Revised: 08/25/2023] [Accepted: 09/01/2023] [Indexed: 09/07/2023]
Abstract
Failure to rescue (FTR) is a standardized patient safety indicator (PSI-04) developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the ability of a healthcare team to prevent mortality following a major complication. However, FTR rates vary and are impacted by non-modifiable individual patient characteristics such as baseline frailty. This raises concerns regarding the validity of FTR as an objective quality metric, as not all patients have the same baseline frailty level, or physiological reserve, to recover from major complications. Literature from other surgical specialties has identified flaws in FTR and called for risk-adjusted metrics. Currently, knowledge of factors influencing FTR and its subsequent implementation in neurosurgical patients are limited. The present review assesses trends in FTR utilization to assess how FTR performs as an objective neurosurgery quality metric. This review then proposes how FTR may be best modified to optimize use in neurosurgical patients. A PubMed search was performed to identify articles published until August 9, 2023. Studies that reported FTR as an outcome in patients undergoing neurosurgical procedures were included. A qualitative assessment was performed using the Newcastle Ottawa Scale (NOS). The initial search revealed 1232 citations. After a title and abstract screen, followed by a full text screen, 12 studies met criteria for inclusion. These articles measured FTR across a total of 764,349 patients undergoing neurosurgical procedures. Five studies analyzed FTR with regard to hospital characteristics, and three studies utilized patient characteristics to predict FTR. All studies were considered high quality based on the NOS. Modifications in criteria to measure FTR are necessary since FTR depends on patient characteristics like frailty. This would allow for the incorporation of risk-adjusted FTR metrics that would aid in clinical decision making in neurosurgical patients.
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Affiliation(s)
- Joanna M Roy
- Topiwala National Medical College, Mumbai, India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, 87131, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA
| | - Georgios P Skandalakis
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA
| | - Meic H Schmidt
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, 87131, USA
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, 87131, USA.
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), 1 University New Mexico, MSC10 5615, Albuquerque, NM, 87131, USA.
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA.
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Chervu N, Verma A, Sakowitz S, Bakhtiyar SS, Hadaya J, Sanaiha Y, Benharash P. Association of Hospital Volume and Outcomes Following Off-Pump Coronary Artery Bypass Grafting. Heart Lung Circ 2023; 32:1128-1135. [PMID: 37541816 DOI: 10.1016/j.hlc.2023.07.002] [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: 04/12/2023] [Revised: 06/22/2023] [Accepted: 07/03/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Off-pump coronary artery bypass grafting (OPCAB) has been used to mitigate the negative systemic effects of cardiopulmonary bypass. Recent consortium and single-institution studies suggest an association between operator experience and long-term survival. We thus aimed to ascertain the relationship between institutional OPCAB volume and outcomes using a contemporary nationwide all-payer database. METHODS Adult admissions for elective isolated OPCAB were identified from the 2016-2019 Nationwide Readmissions Database. The primary outcome was major adverse events (MAE), defined as a composite of mortality, reoperation, prolonged mechanical ventilation, acute kidney injury requiring dialysis, or perioperative stroke during the index hospitalisation. Secondary outcomes included temporal trends, postoperative length of stay (pLOS), hospitalisation costs, non-home discharge, and 30-day readmission rate. High-volume hospitals (HVH) were defined to have annual caseloads >35 based on cubic spline analysis. RESULTS Of an estimated 41,154 patients, 59.9% were treated at HVH. The proportion of coronary artery bypass grafting operations that were OPCAB significantly decreased from 21.1% in 2016 to 18.3% in 2019. After adjustment, HVH status was associated with lower adjusted odds of MAE (adjusted odds ratio [AOR] 0.78, 95% confidence interval [CI] 0.70-0.88), compared to others. HVH were also associated with shorter pLOS (β -0.10, 95% -0.13, -0.07), reduced costs (β -US$4,900, - US$6,300, - US$3,600), non-home discharge (AOR 0.54, 95% CI 0.45-0.64), and 30-day readmission (AOR 0.86, 95% CI 0.77-0.96). CONCLUSIONS Our results suggest that OPCAB requires a distinct set of surgical expertise and institutional aptitude. As a result, centralisation of care to centres of excellence should be considered.
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Affiliation(s)
- Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, USA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, USA.
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Lobdell KW, Crotwell S, Watts LT, LeNoir B, Frederick J, Skipper ER, Russell GB, Habib R, Maxey T, Rose GA. Remote monitoring following adult cardiac surgery: A paradigm shift? JTCVS OPEN 2023; 15:300-310. [PMID: 37808027 PMCID: PMC10556943 DOI: 10.1016/j.xjon.2023.07.003] [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: 02/24/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 10/10/2023]
Abstract
Background The Perfect Care (PC) initiative engages, educates, and enrolls adult cardiac surgery patients into a transformational program that includes an app for appointment scheduling, tracking biometric data and patient-reported outcomes, audiovisual visits, and messaging, paired with a digital health kit (consisting of a fitness tracker, scale, and sphygmomanometer). PC aims to reduce postoperative length of stay (LOS) as well as 30-day readmission and mortality. Methods This was a retrospective review of patients who underwent coronary artery bypass (CAB), valve, or combined CAB and valve procedures at either of the 2 participating hospitals between April 2018 and March 2022. Patients who participated in the PC quality improvement initiative were compared to propensity-matched controls (1:1 matching). The evaluation focused on postoperative LOS and a novel composite measure comprising 30-day readmission and mortality. Results Remote monitoring (PC) was associated with a shorter postoperative LOS, lower combined rate of 30-day readmission and mortality, and less variation compared to matched non-PC controls. Conclusions Integrated improvements in postoperative remote monitoring of adult cardiac surgery patients may reduce time in the hospital and post-acute care facilities. Future prioritized efforts include the development of additional, personalized biometric monitoring devices, use of biometric data to augment risk assessment, and investigation of the value of remote monitoring on various patient risk profiles to address potential disparities in care.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Thomas Maxey
- Sanger Heart & Vascular Institute, Charlotte, NC
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Tam DY, Fremes SE. Commentary: Who benefits from public reporting of outcomes in coronary surgery? J Thorac Cardiovasc Surg 2023; 166:816-818. [PMID: 35221027 DOI: 10.1016/j.jtcvs.2022.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Derrick Y Tam
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Shahian DM. Measuring and reporting cardiac surgery quality: A continuing evolution. J Thorac Cardiovasc Surg 2023; 166:819-825. [PMID: 35428459 DOI: 10.1016/j.jtcvs.2022.02.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 11/18/2022]
Affiliation(s)
- David M Shahian
- Division of Cardiac Surgery, Department of Surgery, and Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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Magouliotis DE, Xanthopoulos A, Zotos PA, Arjomandi Rad A, Tatsios E, Bareka M, Briasoulis A, Triposkiadis F, Skoularigis J, Athanasiou T. The Emerging Role of "Failure to Rescue" as the Primary Quality Metric for Cardiovascular Surgery and Critical Care. J Clin Med 2023; 12:4876. [PMID: 37510991 PMCID: PMC10381557 DOI: 10.3390/jcm12144876] [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: 06/05/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
We conducted a thorough literature review on the emerging role of failure to rescue (FTR) as a quality metric for cardiovascular surgery and critical care. For this purpose, we identified all original research studies assessing the implementation of FTR in cardiovascular surgery and critical care from 1992 to 2023. All included studies were evaluated for their quality. Although all studies defined FTR as mortality after a surgical complication, a high heterogeneity has been reported among studies regarding the included complications. There are certain factors that affect the FTR, divided into hospital- and patient-related factors. The identification of these factors allowed us to build a stepwise roadmap to reduce the FTR rate. Recently, FTR has further evolved as a metric to assess morbidity instead of mortality, while being also evaluated in the context of interventional cardiology. All these advances are further discussed in the current review, thus providing all the necessary information to surgeons, anesthesiologists, and physicians willing to implement FTR as a metric of quality in their establishment.
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Affiliation(s)
- Dimitrios E Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Prokopis-Andreas Zotos
- Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Arian Arjomandi Rad
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London W2 1NY, UK
| | - Evangelos Tatsios
- Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Metaxia Bareka
- Department of Anesthesiology, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Alexandros Briasoulis
- Department of Therapeutics, Faculty of Medicine, National and Kapodistrian University of Athens, 10679 Athens, Greece
| | | | - John Skoularigis
- Department of Cardiology, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London W2 1NY, UK
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Cocchieri R, van de Wetering B, Baan J, Driessen A, Riezebos R, van Tuijl S, de Mol B. The evolution of technical prerequisites and local boundary conditions for optimization of mitral valve interventions-Emphasis on skills development and institutional risk performance. Front Cardiovasc Med 2023; 10:1101337. [PMID: 37547244 PMCID: PMC10402900 DOI: 10.3389/fcvm.2023.1101337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/29/2023] [Indexed: 08/08/2023] Open
Abstract
This viewpoint report describes how the evolution of transcatheter mitral valve intervention (TMVI) is influenced by lessons learned from three evolutionary tracks: (1) the development of treatment from mitral valve surgery (MVS) to transcutaneous procedures; (2) the evolution of biomedical engineering for research and development resulting in predictable and safe clinical use; (3) the adaptation to local conditions, impact of transcatheter aortic valve replacement (TAVR) experience and creation of infrastructure for skills development and risk management. Thanks to developments in computer science and biostatistics, an increasing number of reports regarding clinical safety and effectiveness is generated. A full toolbox of techniques, devices and support technology is now available, especially in surgery. There is no doubt that the injury associated with a minimally invasive access reduces perioperative risks, but it may affect the effectiveness of the treatment due to incomplete correction. Based on literature, solutions and performance standards are formulated with an emphasis in technology and positive outcome. Despite references to Heart Team decision making, boundary conditions such as hospital infrastructure, caseload, skills training and perioperative risk management remain underexposed. The role of Biomedical Engineering is exclusively defined by the Research and Development (R&D) cycle including the impact of human factor engineering (HFE). Feasibility studies generate estimations of strengths and safety limitations. Usability testing reveals user friendliness and safety margins of clinical use. Apart from a certification requirement, this information should have an impact on the definition of necessary skills levels and consequent required training. Physicians Preference Testing (PPT) and use of a biosimulator are recommended. The example of the interaction between two Amsterdam heart centers describes the evolution of a professional ecosystem that can facilitate innovation. Adaptation to local conditions in terms of infrastructure, referrals and reimbursement, appears essential for the evolution of a complete mitral valve disease management program. Efficacy of institutional risk management performance (IRMP) and sufficient team skills should be embedded in an appropriate infrastructure that enables scale and offers complete and safe solutions for mitral valve disease. The longstanding evolution of mitral valve therapies is the result of working devices embedded in an ecosystem focused on developing skills and effective risk management actions.
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Affiliation(s)
| | | | - Jan Baan
- Amsterdam University Center, Technical University Eindhoven, Amsterdam, Netherlands
| | - Antoine Driessen
- Amsterdam University Center, Technical University Eindhoven, Amsterdam, Netherlands
| | | | | | - Bas de Mol
- LifeTec Group BV, Eindhoven, Netherlands
- Amsterdam University Center, Technical University Eindhoven, Amsterdam, Netherlands
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Pienta MJ, Cascino TM, Likosky DS, Ghaferi AA, Aaronson KD, Pagani FD, Thompson MP. Failure to rescue: A candidate quality metric for durable left ventricular assist device implantation. J Thorac Cardiovasc Surg 2023; 165:2114-2123.e5. [PMID: 34887093 PMCID: PMC9081291 DOI: 10.1016/j.jtcvs.2021.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 10/21/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Failure to rescue (FTR), defined as death after a complication, is recognized as a principal driver of variation in mortality among hospitals. We evaluated FTR as a quality metric in patients who received durable left ventricular assist devices (LVADs) using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support. METHODS Data on 13,617 patients who received primary durable LVADs from April 2012 to October 2017 at 131 hospitals that performed at least 20 implants were analyzed from the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support. Rates of major complications and FTR were compared across risk-adjusted in-hospital mortality terciles (low, medium, high) and hospital volume. Logistic regression was used to estimate expected FTR rates on the basis of patient factors for each major complication. RESULTS The overall unadjusted in-hospital mortality rate was 6.96%. Risk-adjusted in-hospital mortality rates varied 3.1-fold across terciles (low, 3.3%; high, 10.3%; P trend <.001). Rates of major complications varied 1.1-fold (low, 34.0%; high, 38.8%; P < .0001). Among patients with a major complication, 854 died in-hospital for an FTR rate of 17.7%, with 2.8-fold variation across mortality terciles (low, 8.5%; high, 23.9%; P < .0001). FTR rates were highest for renal dysfunction requiring dialysis (45.3%) and stroke (36.5%). Higher average annual LVAD volume was associated with higher rates of major complications (<10 per year, 26.7%; 10-20 per year, 34.0%; 20-30 per year, 34.0%; >30 per year, 40.1%; P trend <.0001) whereas hospitals implanting <10 per year had the highest FTR rate (<10 per year, 23.5%; 10-20 per year, 16.5%; 20-30 per year, 17.0%; >30 per year, 17.9%; P = .03). CONCLUSIONS FTR might serve as an important quality metric for durable LVAD implant procedures, and identifying strategies for successful rescue after complications might reduce hospital variations in mortality.
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Affiliation(s)
- Michael J Pienta
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
| | - Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Mich
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Amir A Ghaferi
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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Young AM, Strobel RJ, Rotar E, Norman A, Henrich M, Mehaffey JH, Brady W, Teman NR. Implementation of a non-intensive-care unit medical emergency team improves failure to rescue rates in cardiac surgery patients. J Thorac Cardiovasc Surg 2023; 165:1861-1872.e5. [PMID: 36038381 PMCID: PMC9887097 DOI: 10.1016/j.jtcvs.2022.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/22/2022] [Accepted: 07/09/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Failure to rescue (FTR) is an emerging measure in cardiac surgery, defined as mortality after a postoperative complication. We hypothesized that establishing a medical emergency team (MET) reduced rates of FTR in adults undergoing cardiac surgery. METHODS All patients (N = 11,218) undergoing a The Society of Thoracic Surgeons index operation at our center (1994-2018) were stratified by pre-MET or MET era based on the 2009 institutional implementation of a MET to respond to clinical decompensation in non-intensive-care patients. Patients missing The Society of Thoracic Surgeons predicted risk of mortality were excluded from all cohorts. Risk adjusted multivariable regression analyzed the association of postoperative complications, operative mortality, and FTR by era. Nearest neighbor propensity score matching utilizing patients' The Society of Thoracic Surgeons predicted risk of mortality was performed to create balanced control and exposure groups for secondary subgroup analysis. RESULTS In the risk-adjusted multivariable analysis, surgery during the MET era was associated with decreased mortality (odds ratio [OR], 0.51; 95% CI, 0.45-0.77; P < .001), postoperative renal failure (OR, 0.57; 95% CI, 0.46-0.70; P < .001), reoperation (OR, 0.75; 95% CI, 0.59-0.95; P = .017), and deep sternal wound infection (OR, 0.16; 95% CI, 0.04-0.45; P = .002). Surgery performed during the MET era was associated with a decreased rate of FTR in the risk-adjusted analysis (OR, 0.46; 95% CI, 0.34-0.70; P < .001). CONCLUSIONS The development of an institutional MET program was associated with a decrease in major complications and FTR. These findings support the development of MET programs to improve FTR after cardiac surgery.
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Affiliation(s)
- Andrew M Young
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - Raymond J Strobel
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - Evan Rotar
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - Anthony Norman
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - Matt Henrich
- Department of Emergency Medicine, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va
| | - William Brady
- Department of Emergency Medicine, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Cardiovascular and Thoracic Surgery, University of Virginia, Charlottesville, Va.
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Gregory AJ, Noss CD, Chun R, Gysel M, Prusinkiewicz C, Webb N, Raymond M, Cogan J, Rousseau-Saine N, Lam W, van Rensburg G, Alli A, de Vasconcelos Papa F. Perioperative Optimization of the Cardiac Surgical Patient. Can J Cardiol 2023; 39:497-514. [PMID: 36746372 DOI: 10.1016/j.cjca.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/16/2023] [Accepted: 01/29/2023] [Indexed: 02/06/2023] Open
Abstract
Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.
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Affiliation(s)
- Alexander J Gregory
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Christopher D Noss
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Rosaleen Chun
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael Gysel
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Prusinkiewicz
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Webb
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meggie Raymond
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jennifer Cogan
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Wing Lam
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Gerry van Rensburg
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmad Alli
- Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Gross CR, Adams DH, Patel P, Varghese R. Failure to Rescue: A Quality Metric for Cardiac Surgery and Cardiovascular Critical Care. Can J Cardiol 2023; 39:487-496. [PMID: 36621563 DOI: 10.1016/j.cjca.2023.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/03/2023] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Failure to rescue, defined as mortality after a surgical complication, is a widely accepted quality metric across many specialties and is becoming an important metric in cardiac surgery. The failure to rescue metric provides a target for improvements in patient outcomes after complications occur. To be used appropriately, the failure to rescue metric must be defined using a prespecified set of life-threatening and rescuable complications. Successful patient rescue requires a systematic approach of complication recognition, timely escalation of care, effective medical management, and mitigation of additional complications. This process requires contributions from cardiac surgeons, intensivists, and other specialists including cardiologists, neurologists, and anaesthesiologists. Factors that affect failure to rescue rates in cardiac surgery and cardiovascular critical care include nurse staffing ratios, intensivist coverage, advanced specialist support, hospital and surgical volume, the presence of trainees, and patient comorbidities. Strategies to improve patient rescue include working to understand the mechanisms of failure to rescue, anticipating postoperative complications, prioritizing microsystem factors, enhancing early escalation of care, and educating and empowering junior clinicians. When used appropriately, the failure to rescue quality metric can help institutions focus on improving processes of care that minimize morbidity and mortality from rescuable complications after cardiac surgery.
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Affiliation(s)
- Caroline R Gross
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Parth Patel
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robin Varghese
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Alabbadi S, Rowe G, Gill G, Vouyouka A, Chikwe J, Egorova N. Sex Disparities in Failure to Rescue After Cardiac Surgery in California and New York. Circ Cardiovasc Qual Outcomes 2022; 15:e009050. [PMID: 36458533 DOI: 10.1161/circoutcomes.122.009050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Women have a higher risk of mortality than men after cardiac surgery independent of other risk factors. The reason for this may not be limited to patient-specific variables. Failure to rescue (FTR) patients from death after a postoperative complication is a nationally endorsed quality care metric. We aimed to identify whether sex disparities exist in the quality of care after cardiac surgery using FTR rates. METHODS A retrospective analysis of 30 973 men (70.4%) and 13 033 women (29.6%) aged over 18 years undergoing coronary artery bypass graft or valve surgery in New York (2016-2019) and California (2016-2018) who experienced at least one serious postoperative complication. The primary outcome was the FTR. Multivariable logistic regression was used to identify predictors of death after complication. Propensity matching was used to adjust for baseline differences between sexes and yielded 12 657 pairs. RESULTS Female patients that experienced complications were older (mean age 67.8 versus 66.7, P<0.001), more frail (median frailty score 0.1 versus 0.07, P<0.001), and had more comorbidities (median Charlson score 2.5 versus 2.3, P<0.001) than male patients. The overall FTR rate was 5.7% (2524), men were less likely to die after a complication than women (4.8% versus 8%, P<0.001). Independent predictors of FTR included female sex (relative risk [RR]: 1.46 [CI, 1.30-1.62]), area-level poverty rate >20% (RR, 1.21 [CI, 1.01-1.59]), higher frailty (RR, 2.83 [CI, 1.35-5.93]), undergoing concomitant coronary artery bypass graft and valve surgeries (RR, 1.69 [CI, 1.49-1.9]), and higher number of postoperative complications (RR, 16.28 [CI, 14-18.89]). In the propensity-matched cohorts, the FTR rate remained significantly lower among men than women (6.0% versus 8.0%, P<0.001). CONCLUSIONS Women are less likely to be rescued from death following postoperative complications, independent of socioeconomic and clinical characteristics. Further research is warranted to investigate the clinical practices contributing to this disparity in quality of care following cardiac surgery.
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Affiliation(s)
- Sundos Alabbadi
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (S.A., A.V., N.E.)
| | - Georgina Rowe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., G.G., J.C.)
| | - George Gill
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., G.G., J.C.)
| | - Ageliki Vouyouka
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (S.A., A.V., N.E.)
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., G.G., J.C.)
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (S.A., A.V., N.E.)
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Chikwe J. Editor's Choice: Papers That May Change Your Practice. Ann Thorac Surg 2022; 114:359-363. [PMID: 35878951 DOI: 10.1016/j.athoracsur.2022.06.013] [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: 06/27/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Shahian DM, O'Brien SM. Composite Performance Measures: The Foundation of the STS Quality Measurement Program. Ann Thorac Surg 2022; 114:368-372. [PMID: 35690137 DOI: 10.1016/j.athoracsur.2022.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022]
Affiliation(s)
- David M Shahian
- Division of Cardiac Surgery, Department of Surgery, and Center for Quality and Safety, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
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Chikwe J. Editor’s Choice: Strengths, Challenges, and Opportunities. Ann Thorac Surg 2022; 113:1761-1766. [DOI: 10.1016/j.athoracsur.2022.04.028] [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: 04/25/2022] [Indexed: 11/01/2022]
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Affiliation(s)
- Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, 55 Fruit St, Cox 652, Boston, MA 02114.
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Bodmer NJ, Fielding-Singh V, Vanneman MW. Transcatheter Aortic Valve Dissemination: The More the Merrier or Too Much of a Good Thing? J Cardiothorac Vasc Anesth 2021; 36:925-928. [PMID: 34974961 DOI: 10.1053/j.jvca.2021.11.023] [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: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Natalie J Bodmer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Vikram Fielding-Singh
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
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Kilcoyne MF, Blanding WM, Kilic A. Commentary: Left ventricular assist device implantation and failure to rescue: New insights and familiar challenges. J Thorac Cardiovasc Surg 2021; 165:2124-2125. [PMID: 34862053 DOI: 10.1016/j.jtcvs.2021.11.011] [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: 11/08/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Maxwell F Kilcoyne
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Walker M Blanding
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC.
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