1
|
Walker RL, Ghali WA, Chen G, Khalsa TK, Mangat BK, Campbell NRC, Dixon E, Rabi D, Jette N, Dhanoa R, Quan H. ACSC Indicator: testing reliability for hypertension. BMC Med Inform Decis Mak 2017. [PMID: 28651587 PMCID: PMC5485699 DOI: 10.1186/s12911-017-0487-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With high-quality community-based primary care, hospitalizations for ambulatory care sensitive conditions (ACSC) are considered avoidable. The purpose of this study was to test the inter-physician reliability of judgments of avoidable hospitalizations for one ACSC, uncomplicated hypertension, derived from medical chart review. METHODS We applied the Canadian Institute for Health Information's case definition to obtain a random sample of patients who had an ACSC hospitalization for uncomplicated hypertension in Calgary, Alberta. Medical chart review was conducted by three experienced internal medicine specialists. Implicit methods were used to judge avoidability of hospitalization using a validated 5-point scale. RESULTS There was poor agreement among three physicians raters when judging the avoidability of 82 ACSC hospitalizations for uncomplicated hypertension (κ = 0.092). The κ also remained low when assessing agreement between raters 1 and 3 (κ = 0.092), but the κ was lower (less than chance agreement) for raters 1 and 2 (κ = -0.119) and raters 2 and 3 (κ = -0.008). When the 5-point scale was dichotomized, there was fair agreement among three raters (κ = 0.217). The proportion of ACSC hospitalizations for uncomplicated hypertension that were rated as avoidable was 32.9%, 6.1% and 26.8% for raters 1, 2, and 3, respectively. CONCLUSIONS This study found a low proportion of ACSC hospitalization were rated as avoidable, with poor to fair agreement of judgment between physician raters. This suggests that the validity and utility of this health indicator is questionable. It points to a need to abandon the use of ACSC entirely; or alternatively to work on the development of explicit criteria for judging avoidability of hospitalization for ACSC such as hypertension.
Collapse
Affiliation(s)
- Robin L Walker
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada
| | - William A Ghali
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.,Department of Medicine, University of Calgary, Calgary, Canada
| | - Guanmin Chen
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Tej K Khalsa
- Department of Medicine, University of Calgary, Calgary, Canada
| | | | - Norm R C Campbell
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada.,Department of Medicine, University of Calgary, Calgary, Canada.,Department of Physiology and Pharmacology, University of Calgary, Calgary, Canada
| | - Elijah Dixon
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada.,Department of Surgery, University of Calgary, Calgary, Canada
| | - Doreen Rabi
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.,Department of Medicine, University of Calgary, Calgary, Canada
| | - Nathalie Jette
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Robyn Dhanoa
- Faculty of Nursing, University of Calgary, Calgary, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada. .,O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.
| |
Collapse
|
2
|
Schoof J, Lubahn W, Baeumer M, Kross R, Wallesch CW, Kozian A, Huth C, Goertler M. Impaired cerebral autoregulation distal to carotid stenosis/occlusion is associated with increased risk of stroke at cardiac surgery with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2007; 134:690-6. [PMID: 17723819 DOI: 10.1016/j.jtcvs.2007.03.018] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Revised: 03/20/2007] [Accepted: 03/29/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Severe carotid stenosis and occlusion are associated with an increased risk of stroke during and after cardiac surgery with cardiopulmonary bypass. Relevance of an impaired cerebral autoregulation caused by stenosis/occlusion is unknown. METHODS We prospectively assessed the incidence of stroke in relation to severity of carotid disease and corresponding autoregulatory reserve in 2797 patients who had coronary artery bypass graft and/or valve surgery with cardiopulmonary bypass. Patients underwent preoperative carotid sonography and, in case of severe extracranial disease, transcranial Doppler sonography with carbon dioxide stimulation to assess cerebrovascular reserve capacity. RESULTS Sixty-seven (2.4%) patients had an ischemic stroke, which was fatal in 5. Anterior hemispheric stroke occurred in 42 (1.9%) patients with no/low-grade stenosis, 6 (1.8%) with medium-grade stenosis, 1 (0.6%) with high-grade stenosis/occlusion and normal autoregulation, and 3 (27.3%) with high-grade stenosis/occlusion and exhausted autoregulatory reserve. Increased risk was observed in patients with high-grade stenosis/occlusion and exhausted autoregulatory reserve also after adjustment for potential confounders (adjusted odds ratio [OR] 28.3, 95% confidence interval [CI] 5.8-139.1). Stroke risk was not increased in patients with stenosis/occlusion and normal autoregulation (1.5%, adjusted OR 0.6, 95% CI 0.2-1.6). CONCLUSIONS Cerebrovascular reserve capacity evaluated by preoperative transcranial Doppler carbon dioxide testing is a major determinant of stroke risk in patients with carotid artery stenosis/occlusion undergoing cardiac surgery with cardiopulmonary bypass. Its assessment facilitates identification of patients with an excess perioperative stroke risk.
Collapse
Affiliation(s)
- Julia Schoof
- Department of Neurology, University of Magdeburg, Magdeburg, Germany
| | | | | | | | | | | | | | | |
Collapse
|
3
|
Ma Quintana J, Escobar A, Aróstegui I. Development of appropriateness explicit criteria for cataract extraction by phacoemulsification. BMC Health Serv Res 2006; 6:23. [PMID: 16512906 PMCID: PMC1409777 DOI: 10.1186/1472-6963-6-23] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Accepted: 03/02/2006] [Indexed: 11/24/2022] Open
Abstract
Background Consensus development techniques were used in the late 1980s to create explicit criteria for the appropriateness of cataract extraction. We developed a new appropriateness of indications tool for cataract following the RAND method. We tested the validity of our panel results. Methods Criteria were developed using a modified Delphi panel judgment process. A panel of 12 ophthalmologists was assembled. Ratings were analyzed regarding the level of agreement among panelists. We studied the influence of all variables on the final panel score using linear and logistic regression models. The explicit criteria developed were summarized by classification and regression tree analysis. Results Of the 765 indications evaluated by the main panel in the second round, 32.9% were found appropriate, 30.1% uncertain, and 37% inappropriate. Agreement was found in 53% of the indications and disagreement in 0.9%. Seven variables were considered to create the indications and divided into three groups: simple cataract, with diabetic retinopathy, or with other ocular pathologies. The preoperative visual acuity in the cataractous eye and visual function were the variables that best explained the panel scoring. The panel results were synthesized and presented in three decision trees. Misclassification error in the decision trees, as compared with the panel original criteria, was 5.3%. Conclusion The parameters tested showed acceptable validity for an evaluation tool. These results support the use of this indication algorithm as a screening tool for assessing the appropriateness of cataract extraction in field studies and for the development of practice guidelines.
Collapse
Affiliation(s)
- José Ma Quintana
- Unidad de Investigación, Hospital de Galdakao, Galdakao, Vizcaya, Spain
| | - Antonio Escobar
- Unidad de Investigación, Hospital de Basurto, Bilbao, Vizcaya, Spain
| | - Inmaculada Aróstegui
- Departamento de Matemática Aplicada, Estadística e Investigación Operativa, Universidad del País Vasco, Lejona, Vizcaya, Spain
| |
Collapse
|
4
|
Kennedy J, Quan H, Buchan AM, Ghali WA, Feasby TE. Statins Are Associated With Better Outcomes After Carotid Endarterectomy in Symptomatic Patients. Stroke 2005; 36:2072-6. [PMID: 16179564 DOI: 10.1161/01.str.0000183623.28144.32] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Statins have been associated with a reduction in mortality from noncardiac surgery. This study aimed to determine whether statin use on admission to hospital for carotid endarterectomy was associated with a reduction of in-hospital adverse outcomes. METHODS Data describing patient characteristics, surgical indication, statin treatment, and in-hospital outcomes of death, ischemic stroke or death and cardiac outcomes were collected from a chart review of all patients (3360) undergoing carotid endarterectomy in Western Canada from January 2000 to December 2001. Outcomes of patients on statins versus those not on statins were compared using logistic regression to account for differences in patient characteristics, and propensity score methods to account for factors influencing patient allocation to statins. RESULTS Eight hundred and fifteen of 2031 symptomatic patients and 665 of 1252 asymptomatic patients were on a statin at the time of hospital admission. Statin use by symptomatic patients was associated with reduced in-hospital mortality and in-hospital ischemic stroke or death, but not in-hospital cardiac outcomes (adjusted odds ratio 0.25 [CI, 0.07 to 0.90], 0.55 [CI, 0.32 to 0.95], 0.87 [CI, 0.49 to 1.54], respectively). The improvement in outcomes was robust when tested using propensity score matching. This association was not seen in asymptomatic patients on statins (adjusted odds ratio, in-hospital mortality 0.54 [CI, 0.13 to 2.24]; in-hospital ischemic stroke or death 1.34 [CI, 0.61 to 2.93]; in-hospital cardiac outcomes 1.37 [CI, 0.73 to 2.58]). CONCLUSIONS These findings are suggestive of a protective effect of statin therapy in symptomatic patients pre-treated at the time of carotid endarterectomy, though this needs confirmation in a randomized controlled trial.
Collapse
Affiliation(s)
- James Kennedy
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | | | | | | | | |
Collapse
|