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Herrlett K, Epple J, Lingwal N, Schmitz-Rixen T, Böckler D, Grundmann RT. [Inpatient rehabilitation for patients 65 years and older with abdominal aortic aneurysm repair: Indications and long-term outcome]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2024; 184:71-79. [PMID: 38142201 DOI: 10.1016/j.zefq.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/15/2023] [Accepted: 10/25/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND In Germany, there is no data available on the frequency of inpatient rehabilitation (IR) after elective endovascular (EVAR) and open (OAR) abdominal aortic aneurysm (AAA) repair. OBJECTIVE To report for the first time on the outcome of patients 65 years and older and thus of retirement age with and without IR after AAA repair in a retrospective analysis of routine data from all eleven regional companies of the AOK health insurance fund (AOK-Gesundheit). METHODS Anonymized data of 16,358 patients 65 years and older with intact abdominal aortic aneurysm treated with EVAR (n = 12,960) or OAR (n = 3,398) between 01/01/2010 and 12/31/2016 were analyzed. Patients with postoperative IR (n = 1,531) were compared to those without postoperative IR (n = 14,827) with respect to general patient characteristics, comorbidities, perioperative and postoperative outcomes, and survival. The average follow-up of patients with postoperative and without postoperative IR was 49.9 months and 51.8 months, respectively. RESULTS 5.4% of EVAR patients, but 24.6% of OAR patients were referred to IR (p < 0.001). Patients with IR were sicker than those without IR. Parameters significantly influencing the use of IR included OAR vs EVAR (Odds Ratio [OR] 6.03), condition after cerebral infarction (OR 1.53), and women vs men (OR 1.49). Perioperative influencing parameters were cerebral infarction (OR 2.40), blood transfusions (OR 2.21) and complex critical care (OR 2.15). After nine years, the Kaplan-Meier estimated survival was 41.9% for patients with vs 43.4% for those without IR in the EVAR group (p = 0.178). For OAR, it was 50.2% for patients with IR vs 49.8% for patients without IR (p = 0.006). In multivariate regression analysis, postoperative IR had a significant effect on long-term survival in OAR but not in EVAR patients. CONCLUSION There are no generally binding guidelines for the indication of IR after AAA repair. It should therefore be a requirement for the future that the fitness of each patient with elective AAA repair be determined with a score before and after the procedure in order to make indications for AHB more comparable. The score should be documented in the hospital discharge letter.
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Affiliation(s)
- Katrin Herrlett
- Klinik für Gefäß- und Endovaskularchirurgie, Klinikum der Goethe-Universität, Frankfurt am Main, Deutschland
| | - Jasmin Epple
- Klinik für Gefäß- und Endovaskularchirurgie, Klinikum der Goethe-Universität, Frankfurt am Main, Deutschland
| | - Neelam Lingwal
- Institut für Biostatistik und mathematische Modellierung, Goethe-Universität, Frankfurt am Main, Deutschland
| | | | - Dittmar Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Reinhart T Grundmann
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.
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Elkbuli A, Dowd B, Narvel RI, Smith Z, McKenney M, Boneva D. A National Analysis of Traumatic Thoracic Aortic Repair: Does Insurance Status Matter? Am Surg 2020; 86:1543-1547. [PMID: 32716631 DOI: 10.1177/0003134820933559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Traumatic thoracic aortic injuries (TAIs) carry a substantial mortality. Our study aim was to evaluate the impact of insurance status on outcomes in severely injured trauma patients after either thoracic endovascular aortic repair (TEVAR) or open repair using the National Trauma Data Bank Research Data Set (NTDB-RDS). METHODS The NTDB-RDS was reviewed for outcomes in severely injured patients and TAI repair method (TEVAR vs open). Patients were divided into insured (Medicaid, Medicare, private insurance) and uninsured (self-pay) status groups. Patients were further divided by injury severity score (ISS) of 15-24 and ≥25 to adjust for injury burden. Demographic characteristics and outcome measures were compared. Chi-square, t-test, and analysis of variance were used with significance defined as P < .05. RESULTS Within the NTDB-RDS, a review of nearly 1 million patients led to 241 that underwent repair for TAI and had insurance status and repair type documented. 88.8% (214/241) of patients were insured, while 11.2% (27/241) of patients were uninsured. There were no significant differences in repair type based on insurance status. For open repair with an ISS ≥25, mortality was significantly higher in the uninsured group compared with insured (55.5% vs 21.9%, P = .001). CONCLUSION For open repair in patients with TAI and high injury burden, uninsured status was associated with a significant increase in mortality rate compared with insured patients. Future studies should investigate the effect of insurance type on TAI outcomes and causes of higher mortality in uninsured patients.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA
| | - Brianna Dowd
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA.,University of South Florida, Tampa, FL, USA
| | | | - Zachary Smith
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA.,University of South Florida, Tampa, FL, USA
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, FL, USA.,University of South Florida, Tampa, FL, USA
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Delpirou Nouh C, Samkutty DG, Chandrashekhar S, Santucci JA, Ford L, Xu C, Hollabaugh KM, Bohnstedt BN, Ray B. Management of Aneurysmal Subarachnoid Hemorrhage: Variation in Clinical Practice and Unmet Need for Follow-up among Survivors-A Single-Center Perspective. World Neurosurg 2020; 139:e608-e617. [PMID: 32339727 DOI: 10.1016/j.wneu.2020.04.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of the present study is to investigate the existence and/or prevalence of clinical practice variation in management of aneurysmal subarachnoid hemorrhage (aSAH) and to determine the need for long-term follow-up. METHODS A single-center study was carried out of patients with aSAH over a 5-year period divided into 2 halves (2.5 years each) before and after addition of a dually trained cerebrovascular neurosurgeon. In-hospital clinical practice, clinical outcome (mortality and discharge destination) and long-term outcome (modified Rankin Scale score and Telephone Interview for Cognitive Status [TICS]) were compared using descriptive summaries and nonparametric tests. RESULTS Among 251 patients admitted with aSAH, 115 (45.8%) were before the index event, whereas 136 (54.2%) were during the later period. The aneurysm-securing procedure changed from coil embolization to clip ligation (12/115 [10.4%] vs. 84/136 [61.8%]; P < 0.0001) during the latter years. Interventional treatment for cerebral vasospasm has decreased (58/115 [50.4%] vs. 49/136 [36.0%]; P = 0.0002). Patients surviving hospitalization had more clinic follow-up after discharge during the latter period (42/85 [49.4%] vs. 76/105 [72.4%]; P = 0.0012) and ventriculoperitoneal shunt placement for delayed hydrocephalus (1/85 [1.2%] vs. 9/105 [8.6%]; P = 0.02). A subcohort of aSAH survivors (n = 46) had lower median TICS score during the earlier study period (31.5 [interquartile range, 22-36] vs. 33 [interquartile range, 27-38]; P = 0.038). Similarly, preictal smoking status and hyperlipidemia were associated with adverse TICS score in a multivariate model (P = 0.007). CONCLUSIONS Postdischarge clinical follow-up has improved facilitating recognition and treatment of delayed hydrocephalus. Existence of cognitive deficits among survivors calls for establishment of multidisciplinary clinics for long-term management of aSAH.
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Affiliation(s)
- Claire Delpirou Nouh
- Department of Neurology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Danny G Samkutty
- Department of Neurology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Swathy Chandrashekhar
- Department of Neurology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Joshua A Santucci
- Department of Neurology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Lance Ford
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Chao Xu
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kimberly M Hollabaugh
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Bradley N Bohnstedt
- Department of Neurosurgery, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Bappaditya Ray
- Department of Neurology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
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Iannuzzi JC, Boitano LT, Cooper MA, Watkins MT, Eagleton MJ, Clouse WD, Conte MS, Conrad MF. Risk score for nonhome discharge after lower extremity bypass. J Vasc Surg 2019; 71:889-895. [PMID: 31519514 DOI: 10.1016/j.jvs.2019.07.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/03/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Patients undergoing lower extremity bypass (LEB) for peripheral artery disease require intensive health care resource utilization including rehabilitation and skilled nursing facilities. However, few studies have evaluated factors that lead to nonhome discharge (NHD) in this population of patients. This study sought to predict NHD by preoperative risk factors in patients undergoing LEB for peripheral artery disease using a novel risk score. METHODS The Vascular Study Group of New England database was queried for elective LEB for peripheral artery disease including claudication and critical limb ischemia from 2003 to 2017. Patients were excluded if the procedure was not elective, if they were not admitted from home, if they were bedridden, or if they died during the index admission. Only preoperative factors were considered in the analysis. The primary end point was NHD including rehabilitation and skilled nursing facilities. Data were split two-thirds for model derivation and one-third for validation. In the derivation cohort, bivariate analysis assessed the association of preoperative factors with NHD. A parsimonious manual stepwise binary logistic regression for NHD aimed at maximizing the C statistic while maintaining model simplicity was performed. A risk score was developed using the β coefficients and applied to the validation data set. The risk score performance was assessed using a C statistic and Hosmer-Lemeshow test for model fit. RESULTS There were 10,145 cases included with an overall NHD rate of 26.4% (n = 2676). Mean age was 66 years (range, 41-90 years). NHD patients were older (72 years vs 64 years; P < .01) and more frequently male (57.2% vs 42.8%; P < .01) and nonwhite (16.1% vs 9.9%; P < .01); they more frequently had tissue loss (54.2% vs 23.0%; P < .01), anemia (16.0% vs 5.3%; P < .01), severe cardiac comorbidity (21.8% vs 10.5%; P < .01), and insulin-dependent diabetes (33.3% vs 18.2%; P < .01). On multivariable analysis, factors associated with NHD included age, sex, nonwhite race, tissue loss, cardiac comorbidity, partial ambulatory deficit, and insulin-dependent diabetes. The C statistic was 0.78 in the derivation group and 0.79 in the validation group, with Hosmer-Lemeshow P > .999. The risk score ranged from 0 to 18, with a mean score of 4 (standard deviation ±3.5). The risk score was divided into low risk (0-4 points; n = 5272 [52%]; NHD = 10.1%]), moderate risk (5-9 points; n = 3663 [36.7%]; NHD = 36.7%), and high risk (≥10 points; n = 1210 [11.9%]; NHD = 66.1%). CONCLUSIONS This novel risk score was highly predictive for NHD after LEB for peripheral artery disease using only preoperative comorbidities. High-risk patients account for 12% of LEB but nearly a third of all patients requiring NHD. This risk score can be used preoperatively to determine high-risk patients for NHD, which may help improve preoperative counseling and hospital efficiency by allocating resources appropriately.
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Affiliation(s)
- James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, Calif.
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Michol A Cooper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Michael T Watkins
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, Calif
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
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