Guías de práctica clínica de la Sociedad Española de Cardiología en valvulopatías

Sentinel Amenable Mortality: A New Way to Assess the Quality of Healthcare by Examining Causes of Premature Death for Which Highly Efficacious Medical Interventions Are Available

BACKGROUND

Amenable mortality, or premature deaths that could be prevented with medical care, is a proven indicator for assessing healthcare quality when adapted to a country or region's specific healthcare context. This concept is currently used to evaluate the performance of national and international healthcare systems. However, the levels of efficacy and effectiveness determined using this indicator can vary greatly depending on the causes of death that are included. We introduce a new approach by identifying a subgroup of causes for which there are available treatments with a high level of efficacy. These causes should be considered sentinel events to help identify limitations in the effectiveness and quality of health provision.

METHODS

We conducted an extensive literature review using a list of amenable causes of death compiled by Spanish researchers. We complemented this approach by assessing the time trends of amenable mortality in two high-income countries that have a similar quality of healthcare but very different systems of provision, namely, Spain and the United States. This enabled us to identify different levels of efficacy of medical interventions (high, medium, and low). We consulted a group of medical experts and combined this information to help make the final classification of sentinel amenable causes of death.

RESULTS

Sentinel amenable mortality includes causes such as surgical conditions, thyroid diseases, and asthma. The remaining amenable causes of death either have a higher complexity in terms of the disease or need more effective medical interventions or preventative measures to guarantee early detection and adherence to treatment. These included cardiovascular diseases, diabetes, hypertension, all amenable cancers, and some infectious diseases such as pneumonia, influenza, and tuberculosis.

CONCLUSIONS

Sentinel amenable mortality could act as a good sentinel indicator to identify major deficiencies in healthcare quality and provision and detect inequalities across populations.

[Does the EuroSCORE identify patients at minimum risk of mortality from heart surgery?]

INTRODUCTION AND OBJECTIVES

Risk of hospital death is one of the key factors considered by the clinical cardiologist when weighting indications for surgery. Risk estimation scales establish distinct levels of risk in quantitative terms. The aim of the present study was to investigate whether a low EuroSCORE value corresponds to low mortality in our setting.

PATIENTS AND METHODS

During 1999-2000 we prospectively calculated the EuroSCORE for all patients who underwent isolated coronary (CS) or valvular (VS) surgery. We then analyzed intrahospital mortality of patients with a low EuroSCORE. The validation group consisted of patients who underwent surgery in 2001 and obtained a low EuroSCORE.

RESULTS

During 1999-2000 we identified 116 patients (16.2% of all patients treated with isolated CS or CV) with a low EuroSCORE (50 8.6 years; 65% male). Fifty-seven of these patients underwent isolated CS, and 59 of them isolated VS. Intrahospital mortality was zero. In 2001 we identified 59 (16.1%) such patients (49 8.7 years; 68% male), of whom 35 underwent isolated CS and 24 underwent isolated VS. Intrahospital mortality during this period was again zero.

CONCLUSIONS

A low EuroSCORE identifies a population of patients with minimum risk of mortality after isolated coronary or valve surgery. The score may be useful as a sentinel indicator in analyses of the complex issue of quality of cardiac surgery.

[Predictive factors of abnormal dynamic intraventricular gradient after valve replacement in severe aortic stenosis]

INTRODUCTION

Dynamic intraventricular gradients (DIG) after valve replacement in severe aortic stenosis have been reported, although the incidence of DIG and clinical signs are still poorly understood.Aim. To evaluate the incidence of DIG)and determine risk factors and associated morbimortality.

PATIENTS AND METHOD

One hundred nine consecutive patients with severe aortic valve stenosis undergoing valve replacement were studied prospectively by echocardiography to detect the postoperative appearance of DIG, defined as a maximum flow velocity >/= 2.5 m/s.

RESULTS

Sixteen patients (14.9%) developed postoperative DIG. Significant differences between the patients with or without DIG were found for ventricular diameter (left end-diastolic ventricular diameter (LEDVD) 43.2 vs. 47.7 mm, respectively, p < 0.001; left end-systolic ventricular diameter (LESVD) 21 vs. 29 mm, p < 0.001); left ventricular mass index (165 vs. 193 g/m(2), p < 0.05); mean aortic valve gradient (68 vs. 59 mmHg, p < 0.01),; ejection fraction (73 vs. 61%, p < 0.001). No significant differences were found with respect to ventricular wall thicknesses (septal 16.3 vs. 15.7; posterior 14.37 vs. 14.62), the presence of aortic insufficiency, or other postoperative factors (anemia, inotropic agents, etc.).

CONCLUSIONS

DIG after aortic valve replacement to treat severe stenosis is not unusual (15%). DIG is usually found at a midventricular location, close to the septum. In patients with postoperative DIG the most common associated factors were small LEDVD, high ejection fractions and ratios of intraventricular septal to posterior wall ratios, high valve gradients and small left ventricular masses. Preoperative echocardiography can identify patients with a higher risk of developing DIG after aortic valve replacement.

[The role of mitral valve balloon valvuloplasty in the treatment of rheumatic mitral valve stenosis during pregnancy]

OBJECTIVE

To analyze the immediate results and the clinical evolution of a group of fertile age women with rheumatic mitral stenosis, in whom percutaneous balloon mitral valvuloplasty was performed before or during pregnancy.

PATIENTS AND METHOD

Eighty-one women with mitral stenosis, submitted to balloon mitral vavuloplasty, were studied. They were divided into three groups, according to their desire of no further pregnancies (group A; n = 19), pregnancy during the follow-up (group B; n = 23) or valvuloplasty was performed during pregnancy (group C; n = 39). Patients from group B and C were controlled during pregnancy, childbirth and puerperium, and the newborns of women in group C were followed from birth to the age of 5 years.

RESULTS

Mortality in the three groups was null and the incidence of miscarriage was 2 (8.6%) in group B and 3 (9.1%) in group C. Normal delivery was predominant in group B and delivery by caesarean was predominant in group B. Success was immediate in all the cases. The procedure was repeated in 3 women due to restenosis. The media valvar area rase from 0.93 to 2.05 cm2 in group A, from 1.28 to 2.04 cm2 in group B and from 0.84 to 2.14 cm2 in group C (intergroup p = NS). The functional class improved in the three groups of patients.

CONCLUSION

Percutaneous balloon mitral valvuloplasty is an effective, efficient method for the treatment of rheumatic mitral stenosis during pregnancy, after organogenesis, or at any time in a woman's life, as long as it is indicated according to clinical and echocardiographic evaluation criteria.