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Zhan YF, Li F, Wu LC, Li JM, Zhu CY, Han MS, Sheng Y. Role of Charlson comorbidity index in predicting the ICU admission in patients with thoracic aortic aneurysm undergoing surgery. J Orthop Surg Res 2023; 18:870. [PMID: 37968686 PMCID: PMC10652551 DOI: 10.1186/s13018-023-04364-6] [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: 09/28/2023] [Accepted: 11/10/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVES This study aimed to explore the value of the Charlson comorbidity index (CCI) in predicting ICU admission in patients with aortic aneurysm (AA). METHODS The clinical data of patients were obtained from the Medical Information Mart for Intensive Care-IV database. The association between CCI and ICU admission was explored by restricted cubic spline (RCS), threshold effect analysis, generalized linear model, logistic regression, interaction, and mediation analyses. Its clinical value was evaluated by decision curve analysis (DCA), receiver operating characteristic curve (ROC), DeLong's test, and net reclassification index (NRI) analyses. RESULTS The ICU admission was significantly associated with the thoracic AA (TAA), unruptured status, and surgery status. Therefore, 288 candidate patients with unruptured TAA who received surgery were enrolled in the further analysis. We found that CCI was independently associated with the ICU admission of candidates (P = 0.005). Further, their nonlinear relationship was observed (adjusted P = 0.008), and a significant turning point of 6 was identified. The CCI had a favorable performance in predicting ICU admission (area under curve = 0.728) and achieved a better clinical net benefit. New models based on CCI significantly improved the accuracy of prediction. Besides the importance of CCI in ICU admission, CCI also exerted important interaction effect (rather than mediating effects) on the association of other variables (such as age and blood variables) with ICU admission requirements (all P < 0.05). CONCLUSIONS The CCI is an important predictor of ICU admission after surgery in patients with unruptured TAA.
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Affiliation(s)
- Yu-Fei Zhan
- Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, No.369 Yingbin Road, Nanyuan Street, Linping District, Hangzhou, 311100, Zhejiang, China
| | - Feng Li
- Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, No.369 Yingbin Road, Nanyuan Street, Linping District, Hangzhou, 311100, Zhejiang, China
| | - Long-Chuan Wu
- Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, No.369 Yingbin Road, Nanyuan Street, Linping District, Hangzhou, 311100, Zhejiang, China
| | - Jun-Ming Li
- Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, No.369 Yingbin Road, Nanyuan Street, Linping District, Hangzhou, 311100, Zhejiang, China
| | - Can-Yan Zhu
- Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, No.369 Yingbin Road, Nanyuan Street, Linping District, Hangzhou, 311100, Zhejiang, China
| | - Ming-Shuai Han
- Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, No.369 Yingbin Road, Nanyuan Street, Linping District, Hangzhou, 311100, Zhejiang, China
| | - Yi Sheng
- Emergency Medicine, Linping Campus, The Second Affiliated Hospital of Zhejiang University School of Medicine, No.369 Yingbin Road, Nanyuan Street, Linping District, Hangzhou, 311100, Zhejiang, China.
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Cheng TW, Farber A, Levin SR, Malas MB, Garg K, Patel VI, Kayssi A, Rybin D, Hasley RB, Siracuse JJ. Perioperative Outcomes for Centers Routinely Admitting Postoperative Endovascular Aortic Aneurysm Repair to the ICU. J Am Coll Surg 2021; 232:856-863. [PMID: 33887484 DOI: 10.1016/j.jamcollsurg.2021.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Intensive care unit (ICU) admission after endovascular aortic aneurysm repair (EVAR) varies across medical centers. We evaluated the association of postoperative ICU use with perioperative and long-term outcomes after EVAR. STUDY DESIGN The Vascular Quality Initiative (2003-2019) was queried for index elective EVARs. Included centers were categorized by percentage of patients with EVARs postoperatively admitted to the ICU; routine ICU (rICU) centers as ≥80% ICU admissions and nonroutine ICU (nrICU) centers as ≤20% ICU admissions. Patients admitted preoperatively or with same day discharge were excluded. Perioperative outcomes and survival were compared between rICU and nrICU centers. RESULTS Of 45,310 EVARs in the database, 35,617 were performed at rICU or nrICU centers - 5,443 (15.3%) at 71 rICU centers and 30,174 (84.7%) at 200 nrICU centers. Overall, mean age was 73.4 years and 81.6% were male. Postoperative myocardial infarction, pulmonary complications, stroke, leg ischemia, and in-hospital mortality were similar between rICU and nrICU centers (all p > 0.05). Postoperative length of stay (LOS) was prolonged at rICU centers (mean) (2.2 ± 3.6 vs 2 ± 4.2 days, p < 0.001). One-year survival was similar between rICU and nrICU centers, respectively, (94.9% vs 95.4%, p = 0.085). When compared with nrICU centers, rICU centers had similar 1-year mortality risk (hazard ratio [HR] 1.15, 95% CI 0.99-1.34, p = 0.076), but were associated with longer postoperative LOS (means ratio 1.1, 95% CI 1.08-1.13, p < 0.001). CONCLUSIONS Routine ICU use after EVAR was associated with prolonged postoperative LOS, without improved perioperative/long-term morbidity or mortality. Updated care pathways to include postoperative admission to lower acuity care units may reduce costs without compromising care.
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Affiliation(s)
- Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Karan Garg
- NYU Langone Medical Center, Division of Vascular Surgery, New York, NY
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, New York-Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Ahmed Kayssi
- Division of Vascular Surgery, University of Toronto, Toronto, ON
| | - Denis Rybin
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Rebecca B Hasley
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
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Siracuse JJ, Woodson J, Ellis RP, Farber A, Roddy SP, Kalesan B, Levin SR, Osborne NH, Srinivasan J. Intermittent claudication treatment patterns in the commercially insured non-Medicare population. J Vasc Surg 2021; 74:499-504. [PMID: 33548437 DOI: 10.1016/j.jvs.2020.10.090] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/25/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Despite published guidelines and data for Medicare patients, it is uncertain how younger patients with intermittent claudication (IC) are treated. Additionally, the degree to which treatment patterns have changed over time with the expansion of endovascular interventions and outpatient centers is unclear. Our goal was to characterize IC treatment patterns in the commercially insured non-Medicare population. METHODS The IBM MarketScan Commercial Database, which includes more than 8 billion US commercial insurance claims, was queried for patients newly diagnosed with IC from 2007 to 2016. Patient demographics, medication profiles, and open/endovascular interventions were evaluated. Time trends were modeled using simple linear regression and goodness-of-fit was assessed with coefficients of determination (R2). A patient-centered cohort sample and a procedure-focused dataset were analyzed. RESULTS Among 152,935,013 unique patients in the database, there were 300,590 patients newly diagnosed with IC. The mean insurance coverage was 4.4 years. The median patients age was 58 years and 56% of patients were male. The prevalence of statin use was 48% among patients at the time of IC diagnosis and increased to 52% among patients after one year from diagnosis. Interventions were performed in 14.3%, of whom 20% and 6% underwent two or more and three or more interventions, respectively. The median time from diagnosis to intervention decreased from 230 days in 2008 days to 49 days in 2016 (R2 = 0.98). There were 16,406 inpatient and 102,925 ambulatory interventions for IC over the study period. Among ambulatory interventions, 7.9% were performed in office-based/surgical centers. The proportion of atherectomies performed in the ambulatory setting increased from 9.7% in 2007 to 29% in 2016 (R2 = 0.94). In office-based/surgical centers, 57.6% of interventions for IC used atherectomy in 2016. Atherectomy was used in ambulatory interventions by cardiologists in 22.6%, surgeons in 15.2%, and radiologists in 13.6% of interventions. Inpatient atherectomy rates remained stable over the study period. Open and endovascular tibial interventions were performed in 7.9% and 7.8% of ambulatory and inpatient IC interventions, respectively. Tibial bypasses were performed in 8.2% of all open IC interventions. CONCLUSIONS There has been shorter time to intervention in the treatment of younger, commercially insured patients with IC, with many receiving multiple interventions. Statin use was low. Ambulatory procedures, especially in office-based/surgical centers, increasingly used atherectomy, which was not observed in inpatient settings.
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Affiliation(s)
- Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass.
| | - Jonathan Woodson
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass; Institute for Health System Innovation and Policy, Boston University, Boston, Mass; Questrom School of Business, Boston University, Boston, Mass
| | | | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass
| | - Sean P Roddy
- Division of Vascular Surgery, Albany Medical College, Albany, NY
| | - Bindu Kalesan
- Department of Medicine, Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Preventive Medicine and Epidemiology, Boston University School of Medicine, Boston, Mass
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Mass
| | - Nicholas H Osborne
- Division of Vascular and Endovascular Surgery, University of Michigan Medical Center, Ann Arbor, Mich
| | - Jayakanth Srinivasan
- Institute for Health System Innovation and Policy, Boston University, Boston, Mass; Questrom School of Business, Boston University, Boston, Mass
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Quantifying the risk-adjusted hospital costs of postoperative complications after lower extremity bypass in patients with claudication. J Vasc Surg 2020; 73:1361-1367.e1. [PMID: 32931872 DOI: 10.1016/j.jvs.2020.08.130] [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: 04/15/2020] [Accepted: 08/14/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Increasing evidence has shown that the risks associated with surgical revascularization for intermittent claudication outweigh the benefits. The aim of our study was to quantify the cost of care associated with perioperative complications after elective lower extremity bypass (LEB) in patients presenting with intermittent claudication. METHODS All patients undergoing first-time LEB for claudication in the Healthcare Database (2009-2015) were included. The primary outcome was in-hospital postoperative complications, including major adverse limb events (MALE), major adverse cardiac events (MACE), acute kidney injury, and wound complications. The overall crude hospital costs are reported, and a generalized linear model with log link and inverse Gaussian distribution was used to calculate the predicted hospital costs for specific complications. RESULTS Overall, 7154 patients had undergone elective LEB for claudication during the study period. The median age was 66 years (interquartile range, 59-73 years), 67.5% were male, and 75.3% were white. Two thirds of patients (61.2%) had Medicare insurance, followed by private insurance (26.9%), Medicaid (7.7%), and other insurance (4.2%). In-hospital complications occurred in 8.5% of patients, including acute kidney injury in 3.0%, MALE in 2.8%, wound complications in 2.3%, and MACE in 1.0%. The overall median crude hospital cost was $11,783 (interquartile range, $8911-$15,767) per patient. The incremental increase in cost associated with a postoperative complication was significant, ranging from $6183 (95% confidence interval, $4604-$7762) for MALE to $10,485 (95% confidence interval, $6529-$14,441) for MACE after risk adjustment. CONCLUSIONS Postoperative complications after elective LEB for claudication are not uncommon and increase the in-hospital costs by 46% to 78% depending on the complication. Surgical revascularization for claudication should be used sparingly in carefully selected patients.
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