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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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Ramirez JL, Sung E, Jaramillo E, Gasper WJ, Conte MS, Boitano L, Iannuzzi JC. Development and Validation of a Novel Preoperative Risk Score to Identify Patients at Risk for Nonhome Discharge after Elective Endovascular Aortic Aneurysm Repair (EVAR). Ann Vasc Surg 2024; 99:341-348. [PMID: 37852368 DOI: 10.1016/j.avsg.2023.08.040] [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: 06/27/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after elective endovascular aortic repair (EVAR) is uncommon. However, NHD after surgery has an important impact on patient quality of life and postdischarge outcomes. Understanding factors that put patients undergoing EVAR at high risk for NHD is essential to providing adequate preoperative counseling and shared decision making. This study aimed to identify independent predictors of NHD following elective EVAR and to create a clinically useful preoperative risk score. METHODS Elective EVAR cases were queried from the Society for Vascular Surgery Vascular Quality Initiative 2014-2018. A risk score was created by splitting the data set into two-thirds for development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. The score was then validated, and model performance assessed. RESULTS Overall, 24,426 patients were included and 932 (3.8%) required NHD. Multivariable analysis in the development group identified independent predictors of NHD, which were used to create a 20-point risk score. Patients were stratified into 3 groups based upon their risk score: low risk (0-7 points; n = 16,699) with an NHD rate of 1.8%, moderate risk (8-13 points; n = 7,315) with an NHD rate of 7.3%, and high risk (≥14 points; n = 412) with an NHD rate of 21.8%. The risk score had good predictive ability with c-statistic = 0.75 for model development and c-statistic = 0.73 in the validation dataset. CONCLUSIONS This novel risk score can predict NHD following EVAR using characteristics that can be identified preoperatively. Utilization of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA; Chan Zuckerberg Biohub, San Francisco, CA
| | - Eric Sung
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Emanual Jaramillo
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Influence of Operative Time in the Results of Elective Endovascular Repair of Abdominal Aortic Aneurysms. Ann Vasc Surg 2022; 92:195-200. [PMID: 36566912 DOI: 10.1016/j.avsg.2022.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 11/21/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND A prolonged operative time (OT) is a well-recognized risk factor of postoperative complications after many open surgical procedures, although little is known about its impact in less-invasive endovascular procedures. We aimed to define the characteristics related to a prolonged OT in the endovascular treatment of aorto-iliac aneurysms (EVAR) and to evaluate the influence of OT on postoperative outcomes. METHODS Retrospective analysis of 284 consecutive patients (mean age 75 years, 95% male) who underwent an elective EVAR between 2000 and 2019. Operative characteristics related to OT and the impact of OT in postoperative results was studied using multiple lineal and logistic regression analyses, respectively. RESULTS The mean surgical time was 200 min. OT was associated (regression model) with the implantation of straight endografts (-38 min, P = 0.007), femoral artery surgery (+80 min, P < 0.001), hypogastric preservation procedures (+70 min, P < 0.001), associated peripheral arterial disease (+22 min, P = 0.013), general anesthesia (+34 min, P < 0.001), and aneurysm diameter (+9 min/cm, P = 0.002). During the postoperative period (<30 days or at discharge), 21% presented a complication and 2.8% died. OT was independently associated with a higher incidence of postoperative complications (odds ratio [OR] for each additional 30' of surgery = 1.34, P < 0.001), such as immediate (OR = 1.48, P = 0.003) and 6-month mortality (OR = 1.28, P = 0.025). CONCLUSIONS A prolonged OT is an independent risk factor for complications and mortality after EVAR. Surgeons must take this factor into consideration when defining the best therapeutic strategy for abdominal aortic aneurysms.
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Walczak S, Velanovich V. Predicting Elective Surgical Patient Outcome Destination Based on the Preoperative Modified Frailty Index and Laboratory Values. J Surg Res 2022; 275:341-351. [PMID: 35339003 DOI: 10.1016/j.jss.2022.02.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 01/29/2022] [Accepted: 02/14/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION To determine the accuracy of preoperative modified frailty index (mFI) with or without laboratory values (mFI-labs or labs-continuous) in predicting postoperative discharge destination. Discharge destination is important to providers and patients. The ability to accurately predict discharge destination preoperatively can improve hospital resource utilization and help set patient and family expectations. METHODS Cohort analysis of the 2018 American College of Surgeon National Surgical Quality Improvement Project (ACS-NSQIP) Participant Use File of patients undergoing operations with complete data point sets: age, sex, operation work relative-value units; mFI-clinical based on 12 clinical findings, mFI-labs based on seven laboratory values. The nine hierarchical destinations: home, home with assistance, multi-level community, unskilled-care facility, rehabilitation facility, skilled-nursing facility, acute care hospital, hospice, or death, from best to worst outcome. Data were analyzed using univariate analysis, multiple logistic regression and supervised learning artificial neural networks. RESULTS Univariate and multivariate in general showed that patients with higher mFI-clinical and mFI-lab scores, as well as older age and more complex operations were more likely to be discharged to facilities other than home. However, these statistical techniques could not predict the exact destination. An artificial neural network analysis demonstrated perfect location prediction in 64.9% of cases and within one level of prefect prediction is 87.4%. CONCLUSIONS Using a limited number of preoperative factors, combining the mFI-clinical with laboratory values significantly improves the destination prediction performance significantly better than using the values separately. Preoperative knowledge of the likely discharge destination can benefit postoperative care planning and delivery.
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Affiliation(s)
- Steven Walczak
- School of Information and Florida Center for Cybersecurity, University of South Florida, Tampa, Florida
| | - Vic Velanovich
- Department of Surgery, Morsani College of Medicine, University of South Florida, Tampa, Florida.
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Zil-E-Ali A, Aziz F, Medina D, Nejim B, Radtka JF. Fenestrated Endovascular Abdominal Aortic Aneurysm Repair (FEVAR) in Octogenarians is Associated with Higher Mortality and Increased Incidence of Non-Home Discharge. J Vasc Surg 2022; 75:1846-1854.e7. [DOI: 10.1016/j.jvs.2022.01.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 01/08/2022] [Indexed: 12/31/2022]
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Ramirez JL, Lopez J, Sanders K, Schneider PA, Gasper WJ, Conte MS, Sosa JA, Iannuzzi JC. Understanding value and patient complexity among common inpatient vascular surgery procedures. J Vasc Surg 2021; 74:1343-1353.e2. [PMID: 33887430 DOI: 10.1016/j.jvs.2021.03.036] [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: 10/09/2020] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Vascular surgery patients are highly complex, second only to patients undergoing cardiac procedures. However, unlike cardiac surgery, work relative value units (wRVU) for vascular surgery were undervalued based on an overall patient complexity score. This study assesses the correlation of patient complexity with wRVUs for the most commonly performed inpatient vascular surgery procedures. METHODS The 2014 to 2017 National Surgical Quality Improvement Program Participant Use Data Files were queried for inpatient cases performed by vascular surgeons. A previously developed patient complexity score using perioperative domains was calculated based on patient age, American Society of Anesthesiologists class of ≥4, major comorbidities, emergent status, concurrent procedures, additional procedures, hospital length of stay, nonhome discharge, and 30-day major complications, readmissions, and mortality. Procedures were assigned points based on their relative rank and then an overall score was created by summing the total points. An observed to expected ratio (O/E) was calculated using open ruptured abdominal aortic aneurysm repair (rOAAA) as the referent and then applied to an adjusted median wRVU per operative minute. RESULTS Among 164,370 cases, patient complexity was greatest for rOAAA (complexity score = 128) and the least for carotid endarterectomy (CEA) (complexity score = 29). Patients undergoing rOAAA repair had the greatest proportion of American Society of Anesthesiologists class of ≥IV (84.8%; 95% confidence interval [CI], 82.6%-86.8%), highest mortality (35.5%; 95% CI, 32.8%-38.3%), and major complication rate (87.1%; 95% CI, 85.1%-89.0%). Patients undergoing CEA had the lowest mortality (0.7%; 95% CI, 0.7%-0.8%), major complication rate (8.2%; 95% 95% CI, 8.0%-8.5%), and shortest length of stay (2.7 days; 95% CI, 2.7-2.7). The median wRVU ranged from 10.0 to 42.1 and only weakly correlated with overall complexity (Spearman's ρ = 0.11; P < .01). The median wRVU per operative minute was greatest for thoracic endovascular aortic repair (0.25) and lowest for both axillary-femoral artery bypass (0.12) and open femoral endarterectomy, thromboembolectomy, or reconstruction (0.12). After adjusting for patient complexity, CEA (O/E = 3.8) and transcarotid artery revascularization (O/E = 2.8) had greater than expected O/E. In contrast, lower extremity bypass (O/E = 0.77), lower extremity embolectomy (O/E = 0.79), and open abdominal aortic repair (O/E = 0.80) had a lower than expected O/E. CONCLUSIONS Patient complexity varies substantially across vascular procedures and is not captured effectively by wRVUs. Increased operative time for open procedures is not adequately accounted for by wRVUs, which may unfairly penalize surgeons who perform complex open operations.
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Affiliation(s)
- Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Jose Lopez
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Katherine Sanders
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Peter A Schneider
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, Calif.
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Hung YC, Wolf JH, D'Adamo CR, Demos J, Katlic MR, Svoboda S. Preoperative functional status is associated with discharge to nonhome in geriatric individuals. J Am Geriatr Soc 2021; 69:1856-1864. [PMID: 33780000 DOI: 10.1111/jgs.17128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/23/2021] [Accepted: 02/28/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Discharging older individuals to rehabilitation facilities is associated with adverse outcomes, including readmission or increased mortality rate. As preoperative functional status is an important factor impacting patient outcome, we hypothesized that this would be associated with patient disposition to nonhome locations. MATERIALS AND METHODS A retrospective analysis was performed using data from the 2013-2018 American College of Surgeons National Surgical Quality Improvement Program, including targeted variables from the Geriatric Pilot Project. Patients aged 65 and older in 33 institutions across the nation were included (n = 44,219). Preoperative functional status was categorized as independent, partially dependent, and dependent. The primary outcome was home versus nonhome disposition. Nonhome was defined as rehabilitation facility and nursing home. Descriptive analyses were performed. Variables associated with postoperative discharge to nonhome were identified using logistic regression. RESULTS The largest percentage of operations was orthopedics (40.8%), followed by general surgery (29.2%) and vascular operations (10.0%). The majority of the patients were independent before operations (93.1% independent, 6% partially dependent, and 0.9% totally dependent). In regression analyses, patients who were partially dependent preoperatively had five times higher odds of discharging to nonhome, compared to patients who were independent (odds ratio [OR] 5.04, p < 0.01). Similarly, patients who were totally dependent had 3.2 higher odds of discharging to nonhome than patients who were independent (OR 3.22, p < 0.01). CONCLUSION Better preoperative functional status is associated with patient discharge to home in older adults. Preoperative interventions aimed at improving functional status, such as prehabilitation, may be beneficial in improving patient outcomes.
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Affiliation(s)
- Ya-Ching Hung
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Joshua H Wolf
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Christopher R D'Adamo
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jasmine Demos
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Mark R Katlic
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Shane Svoboda
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
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Ramirez JL, Zarkowsky DS, Ramirez FD, Gasper WJ, Cohen BE, Conte MS, Grenon SM, Iannuzzi JC. Depression Predicts Non-Home Discharge After Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2021; 74:131-140. [PMID: 33503503 DOI: 10.1016/j.avsg.2020.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mental health's impact on vascular surgical patients has long been overlooked. While outside the expertise of most surgeons, understanding the role that depression plays in the postoperative course could provide additional insight into opportunities to improve surgical outcomes and healthcare value. Additionally, non-home discharge (NHD) to a rehabilitation or skilled nursing facility after surgery is associated with impaired quality of life and higher postdischarge complications, readmissions, and mortality. We hypothesized that depression would be associated with an increased risk for NHD following abdominal aortic aneurysm (AAA) repair. METHODS Nonruptured AAA repair cases were identified from the National Inpatient Sample (NIS) using ICD-9 codes between 2005 and 2014. Depression, comorbidities, postoperative complications, and discharge destination were evaluated using statistical tests as appropriate to the data. A hierarchical multivariable logistic regression controlling for hospital level variation was used to examine the independent association between depression, and the primary outcome of NHD controlling for median income and confounders meeting P < 0.05 on univariate analysis. RESULTS There were 99,934 total cases analyzed, of which 4,755 (4.8%) were diagnosed with depression and 10,618 (11.9%) required NHD. Patients with depression were younger, more likely to be women, white, have diabetes, chronic obstructive pulmonary disease, hypertension, tobacco use, and more likely to experience a postoperative complication. On adjusted multivariable analysis, patients with depression were more likely to require NHD (odds ratio [OR] 1.87, 95% confidence interval [CI]: 1.68-2.08, c-statistic = 0.82). On stratified analysis by operative approach, depression had a larger effect estimate in endovascular repair (OR 2.19; 95% CI: 1.90-2.52) versus open repair (OR 1.60; 95% CI: 1.38-1.87). CONCLUSIONS In a nationally representative sample, patients with depression were more likely to require NHD after AAA repair. This study highlights the importance that depression plays in postoperative outcomes after AAA repair. Furthermore, addressing mental health preoperatively has the potential to improve outcomes in patients undergoing AAA repair.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO
| | - Faustine D Ramirez
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - S Marlene Grenon
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Callaway NF, Vail D, Al-Moujahed A, Ludwig C, Ji MH, Mahajan VB, Pershing S, Moshfeghi DM. Sex Differences in the Repair of Retinal Detachments in the United States. Am J Ophthalmol 2020; 219:284-294. [PMID: 32640255 PMCID: PMC10832663 DOI: 10.1016/j.ajo.2020.06.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/26/2020] [Accepted: 06/27/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE To investigate differences between women and men in the repair of rhegmatogenous retinal detachments (RRDs) in the United States. DESIGN Retrospective cohort study. METHODS Setting: A large insurance claims database. PARTICIPANTS Subjects with an incident RRD between 2007 and 2015. DATA Demographic data, comorbid ocular conditions associated with RRD, systemic comorbidities, and surgical intervention (pneumatic retinopexy [PR], pars plana vitrectomy [PPV], laser barricade, or scleral buckle [SB]) were collected. MAIN OUTCOME MEASURES Odds of receipt of surgical intervention for incident RRD, time to repair, type of intervention, and the rate of reoperation by sex. RESULTS The study period included 133 million eligible records with 61,071 cases of incident RRD among which 43% (n = 26,289) were women. The primary outcome model had 23,933 confirmed RRD cases with a 93% retinal detachment repair rate. Women had 34% reduced odds of receipt of surgical repair of an RRD (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.59, 0.73; P < .001) after adjusting for confounders. This effect persisted in all sensitivity models. Among patients who received repair, women were more often delayed (0.17 days, P = .04). Women were more likely to undergo primary laser barricade (relative risk ratio [RRR] 1.68, P < .001), primary SB (RRR 1.15, P < .001), and PR (RRR 1.07, P < .04) than men. The odds of reoperation were lower in women (OR 0.91, 95% CI 0.85, 0.96; P = .002) after adjustment. CONCLUSIONS Insured women are less likely than insured men to receive surgical intervention for an RRD. Based on the results of this study, if the odds of repair were equal between women and men in the United States, then 781 more women would receive surgery each year, or 7,029 more during the study period. Women are more likely to have the repair performed with scleral buckle, laser barricade, and pneumatic retinopexy. The reason for these sex differences in RRD repair remains unknown and requires further investigation.
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Affiliation(s)
- Natalia F Callaway
- Byers Eye Institute at the Stanford University School of Medicine, Palo Alto, California, USA.
| | - Daniel Vail
- Byers Eye Institute at the Stanford University School of Medicine, Palo Alto, California, USA
| | - Ahmad Al-Moujahed
- Byers Eye Institute at the Stanford University School of Medicine, Palo Alto, California, USA
| | - Cassie Ludwig
- Byers Eye Institute at the Stanford University School of Medicine, Palo Alto, California, USA
| | - Marco H Ji
- Byers Eye Institute at the Stanford University School of Medicine, Palo Alto, California, USA
| | - Vinit B Mahajan
- Byers Eye Institute at the Stanford University School of Medicine, Palo Alto, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Suzann Pershing
- Byers Eye Institute at the Stanford University School of Medicine, Palo Alto, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Darius M Moshfeghi
- Byers Eye Institute at the Stanford University School of Medicine, Palo Alto, California, USA
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Ramirez JL, Zarkowsky DS, Boitano LT, Conrad MF, Arya S, Gasper WJ, Conte MS, Iannuzzi JC. A novel preoperative risk score for nonhome discharge after elective thoracic endovascular aortic repair. J Vasc Surg 2020; 73:1549-1556. [PMID: 33065243 DOI: 10.1016/j.jvs.2020.10.005] [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: 07/11/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its large impact on patients. Understanding postsurgical NHD risk is essential to providing adequate preoperative counseling and shared decision making, particularly for elective surgeries. We aimed to identify independent predictors of NHD after elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAA) and to create a clinically useful preoperative risk score. METHODS Elective TEVAR cases for descending TAA were queried from the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2018. A risk score was created by splitting the dataset into two-thirds for model development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. This score was then cross-validated and model performance assessed. RESULTS Overall, 1469 patients were included and 213 (14.5%) required NHD. At baseline, patients who required NHD were more likely to be ≥80 years old (35.2% vs 19.4%), female (58.7% vs 40.6%), functionally dependent (42.3% vs 24.0%), and anemic (46.5% vs 27.8%), and to have chronic obstructive pulmonary disease (41.3% vs 33.4%), congestive heart failure (18.8% vs 11.1%), and American Society of Anesthesiologists class ≥4 (51.6% vs 39.8%; all P < .05). Multivariable analysis in the development group identified independent predictors of NHD that were used to create an 18-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-7 points; n = 563) with an NHD rate of 4.3%, moderate risk (8-11 points; n = 701) with an NHD rate of 17.0%, and high risk (≥12 points; n = 205) with an NHD rate of 34.2%. The risk score had good predictive ability with a c-statistic of 0.75 for model development and a c-statistic of 0.72 in the validation dataset. CONCLUSIONS This novel risk score can predict NHD after TEVAR for TAA using characteristics that can be identified preoperatively. The use of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, Colo
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University, Palo Alto, Calif
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
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Almorza C, Marcos L, Diaz C, Galarza A, Casajuana E, Mateos E, Clara A. Influence of Operative Time in the Results of Infrainguinal Bypass for Chronic Limb Threatening Ischemia. World J Surg 2020; 44:4261-4266. [PMID: 32783123 DOI: 10.1007/s00268-020-05726-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND An increased operative time (OT) has been associated with a higher rate of adverse outcomes after several surgical procedures although scarce evidence exists for infrainguinal bypass surgery (IBS) and its impact beyond the postoperative period. The aim of this study was to define surgical characteristics related to a prolonged OT in IBS for chronic limb threatening ischemia and its influence on postoperative and 1-year outcomes. MATERIALS AND METHODS Retrospective study of 249 consecutive patients (mean age 72.4 years, 73.1% male) undergoing IBS for CLI between 2008 and 2018. The characteristics related to the duration of surgery and its impact on outcome were assessed with a multiple linear regression and a multivariate logistic regression, respectively. RESULTS Interventions associated with a prolonged OT included the bypass to a below-the-knee artery (additional 36 min, p = 0.002), the need for an alternative vein or a hybrid PTFE-vein graft (additional 37 min, p = 0.02) and inflow associated procedures (additional 47 min, p < 0.001). OT was associated with a higher rate of postoperative complications (OR for each additional 30 min 1.123, 95% CI 1.021-1.234) and need for a sociosanitary facility at discharge (OR 1.143, 95% CI 1.033-1.265). At 1-year of follow-up, OT was related to a higher major amputation rate (OR 1.201, 95% CI 1.036-1.393) and non-significantly to mortality (OR 1.125, 95% CI 0.999-1.268). CONCLUSIONS A prolonged OT is a risk factor for adverse outcomes after IBS that extends beyond the immediate postoperative period. Further research is needed to evaluate how an expected high OT might influence decision-making.
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Affiliation(s)
- Cristina Almorza
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Lidia Marcos
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Carles Diaz
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Andrés Galarza
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Eduard Casajuana
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Eduard Mateos
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Albert Clara
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain. .,Universitat Autónoma de Barcelona, Barcelona, Spain. .,CIBER Cardiovascular, Barcelona, Spain.
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Ramirez JL, Gasper WJ, Seib CD, Finlayson E, Conte MS, Sosa JA, Iannuzzi JC. Patient complexity by surgical specialty does not correlate with work relative value units. Surgery 2020; 168:371-378. [PMID: 32336468 DOI: 10.1016/j.surg.2020.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/23/2020] [Accepted: 03/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Understanding the differences in how patient complexity varies across surgical specialties can inform policy decisions about appropriate resource allocation and reimbursement. This study evaluated variation in patient complexity across surgical specialties and the correlation between complexity and work relative value units. STUDY DESIGN The 2017 American College of Surgeons National Surgical Quality Improvement Program was queried for cases involving otolaryngology and general, neurologic, vascular, cardiac, thoracic, urologic, orthopedic, and plastic surgery. A total of 10 domains of patient complexity were measured: American Society of Anesthesiologists class ≥4, number of major comorbidities, emergency operation, major complications, concurrent procedures, additional procedures, length of stay, non-home discharge, readmission, and mortality. Specialties were ranked by their complexity domains and the domains summed to create an overall complexity score. Patient complexity then was evaluated for correlation with work relative value units. RESULTS Overall, 936,496 cases were identified. Cardiac surgery had the greatest total complexity score and was most complex across 4 domains: American Society of Anesthesiologists class ≥4 (78.5%), 30-day mortality (3.4%), major complications (56.9%), and mean length of stay (9.8 days). Vascular surgery had the second greatest complexity score and ranked the greatest on the domains of major comorbidities (2.7 comorbidities) and 30-day readmissions (10.1%). The work relative value units did not correlate with overall complexity score (Spearman's ρ = 0.07; P < .01). Although vascular surgery had the second most complex patients, it ranked fifth greatest in median work relative value units. Similarly, general surgery was the fifth most complex but had the second-least median work relative value units. CONCLUSION Substantial differences exist between patient complexity across specialties, which do not correlate with work relative value units. Physician effort is determined largely by patient complexity, which is not captured appropriately by the current work relative value units.
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Affiliation(s)
- Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Carolyn D Seib
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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13
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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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