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Yeo HL, Kaushal R, Kern LM. The Adoption of Surgical Innovations at Academic Versus Nonacademic Health Centers. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:750-755. [PMID: 28953563 DOI: 10.1097/acm.0000000000001932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE The value of the health care services provided by academic health centers (AHCs) in the United States increasingly is being questioned. AHCs play a prominent role in developing new surgical innovations, including new minimally invasive techniques, which are costly up front but can lead to significant benefits like decreased morbidity and lengths of stays. This study explored the role of AHCs in the adoption of these surgical innovations as a novel measure of their value. METHOD The authors combined data from the American Hospital Association and the State Inpatient Databases from California, Florida, Washington State, and New York. They compared the number and percentage of patients who received four new, innovative surgical procedures (vs. those who received the traditional procedures) at Council of Teaching Hospitals (COTH) hospitals to those at non-COTH hospitals from 2009 to 2011. RESULTS Overall, 61.1% (27,175) of the procedures performed at COTH hospitals used new techniques, compared with 47.2% (41,680) at non-COTH hospitals, across all years (P < .0001). The number and percentage of procedures using the new techniques increased in all years and for all procedures. CONCLUSIONS Not only do AHCs play a role in developing surgical innovations but they also adopt these new techniques more quickly than other hospitals, and thereby they provide additional benefits to patients. These findings provide an important and understudied perspective on the value of AHCs.
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Affiliation(s)
- Heather L Yeo
- H.L. Yeo is assistant professor of surgery, Departments of Surgery and Healthcare Policy and Research, Weill Cornell Medical College, and assistant attending surgeon, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York. R. Kaushal is chair, Department of Healthcare Policy and Research, executive director, Center for Healthcare Informatics and Policy, and Nanette Laitman Distinguished Professor of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York. She is also chief, Healthcare Policy and Research, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York. L.M. Kern is associate professor of medicine, Joan and Sanford I. Weill Department of Medicine, and associate professor of healthcare policy and research, Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
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Weingarten TN, Thompson LT, Licatino LK, Bailey CH, Schroeder DR, Sprung J. Ruptured Abdominal Aortic Aneurysm: Prediction of Mortality From Clinical Presentation and Glasgow Aneurysm Score. J Cardiothorac Vasc Anesth 2015; 30:323-9. [PMID: 26811271 DOI: 10.1053/j.jvca.2015.10.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine association of presenting clinical acuity and Glasgow Aneurysm Score (GAS) with perioperative and 1-year mortality. DESIGN Retrospective chart review. SETTING Major tertiary care facility. PARTICIPANTS Patients with ruptured abdominal aortic aneurysm (rAAA) from 2003 through 2013. INTERVENTIONS Emergency repair of rAAA. MEASUREMENTS AND MAIN RESULTS The authors reviewed outcomes after stable versus unstable presentation and by GAS. Unstable presentation included hypotension, cardiac arrest, loss of consciousness, and preoperative tracheal intubation. In total, 125 patients (40 stable) underwent repair. Perioperative mortality rates were 41% and 12% in unstable and stable patients, respectively (p<0.001). Unstable status had 88% sensitivity and 41% specificity for predicting perioperative mortality. Using logistic regression, higher GAS was associated with perioperative mortality (p<0.001). Using receiver operating characteristic analysis, the area under the curve was 0.72 (95% CI, 0.62-0.82) and cutoff GAS≥96 had 63% and 72% sensitivity and specificity, respectively. Perioperative mortality for GAS≥96 was 51% (25/49), whereas it was 20% (15/76) for GAS≤95. The estimated 1-year survival (95% CI) was 75% (62%-91%) for stable patients and 48% (38%-60%) for unstable patients. Estimated 1-year survival (95% CI) was 23% (13%-40%) for GAS≥96 and 77% (67%-87%) for GAS≤95. CONCLUSIONS Clinical presentation and GAS identified patients with rAAA who were likely to have a poor surgical outcome. GAS≥96 was associated with poor long-term survival, but>20% of these patients survived 1 year. Thus, neither clinical presentation nor GAS provided reliable guidance for decisions regarding futility of surgery.
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Affiliation(s)
| | | | | | | | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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De Rango P, Lenti M, Cieri E, Simonte G, Cao P, Richards T, Manzone A. Association between sex and perioperative mortality following endovascular repair for ruptured abdominal aortic aneurysms. J Vasc Surg 2013; 57:1684-92. [DOI: 10.1016/j.jvs.2013.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 03/18/2013] [Accepted: 03/20/2013] [Indexed: 02/07/2023]
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Favorable discharge disposition and survival after successful endovascular repair of ruptured abdominal aortic aneurysm. J Vasc Surg 2013; 57:1495-502. [DOI: 10.1016/j.jvs.2012.11.089] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 11/21/2012] [Accepted: 11/21/2012] [Indexed: 11/20/2022]
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Kim HB, Choi YH, So YH, Min SK, Kim HC, Kim YI, Park JH, Chung JW. Tissue responses to endovascular stent grafts for saccular abdominal aortic aneurysms in a canine model. J Korean Med Sci 2012; 27:1170-6. [PMID: 23091313 PMCID: PMC3468752 DOI: 10.3346/jkms.2012.27.10.1170] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 08/14/2012] [Indexed: 11/20/2022] Open
Abstract
We investigated tissue responses to endoskeleton stent grafts for saccular abdominal aortic aneurysms (AAAs) in canines. Saccular AAAs were made with Dacron patch in 8 dogs, and were excluded by endoskeleton stent grafts composed of nitinol stent and expanded polytetrafluoroethylene graft. Animals were sacrificed at 2 months (Group 1; n = 3) or 6 months (Group 2; n = 5) after the placement, respectively. The aortas embedding stent grafts were excised en bloc for gross inspection and sliced at 5 to 8 mm intervals for histopathologic evaluation. Stent grafts were patent in all except a dog showing a thrombotic occlusion in Group 2. In the 7 dogs with patent lumen, the graft overhanging the saccular aneurysm was covered by thick or thin thrombi with no endothelial layer, and the graft over the aortic wall was completely covered by neointima with an endothelial layer. Transgraft cell migration was less active at an aneurysm than at adjacent normal aorta. In conclusion, endoskeleton stent grafts over saccular aneurysms show no endothelial coverage and poor transgraft cell migration in a canine model.
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Affiliation(s)
- Hyun Beom Kim
- Department of Radiology, National Cancer Center, Goyang, Korea
| | - Young Ho Choi
- Department of Radiology, Seoul National University Boramae Hospital, Seoul, Korea
| | - Young Ho So
- Department of Radiology, Seoul National University Boramae Hospital, Seoul, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Cheol Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Clinical Research Institute, Seoul, Korea
| | - Young Il Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Clinical Research Institute, Seoul, Korea
| | - Jae Hyung Park
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Clinical Research Institute, Seoul, Korea
| | - Jin Wook Chung
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Clinical Research Institute, Seoul, Korea
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Saqib N, Park SC, Park T, Rhee RY, Chaer RA, Makaroun MS, Cho JS. Endovascular repair of ruptured abdominal aortic aneurysm does not confer survival benefits over open repair. J Vasc Surg 2012; 56:614-9. [PMID: 22572008 DOI: 10.1016/j.jvs.2012.01.081] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 12/29/2011] [Accepted: 01/03/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) is being increasingly performed despite lack of good evidence for its superiority. Other reported studies suffer from patient selection and publication bias with limited follow-up. This study is a single-center propensity score comparing early and midterm outcomes between open surgical repair (OSR) and endovascular repair of rAAA (REVAR). METHODS A retrospective review from January 2001 to November 2010 identified 312 patients who underwent rAAA repairs. Thirty-one patients with antecedent AAA repair and three with incomplete records were excluded, leaving 37 REVARs and 241 OSRs. Propensity score-based matching for sex, age, preoperative hemodynamic status, surgeon's annual AAA volume, and preoperative cardiopulmonary resuscitation was performed in a 1:3 ratio to compare outcomes. Thirty-seven REVARs were matched with 111 OSRs. Late survival was estimated by Kaplan-Meier methods. RESULTS Operative time and blood replacement were higher with OSR. Overall complication rates were similar (54% REVAR vs 66% OSR; P = .23), except for higher incidences of tracheostomies (21% vs 3%; P = .015), myocardial infarction (38% vs 18%; P = .036), and acute tubular necrosis (47% vs 21%; P = .009) with OSR. Operative mortality rates were similar (22% REVAR vs 32% OSR), with an odds ratio of 0.63 for REVAR (95% confidence interval = [0.24, 1.48]; P = .40). No differences in the incidences for secondary interventions for aneurysm- or graft-related complications were noted (22% REVAR vs 22% OSR; P = .99). Kaplan-Meier estimates of 1-, 2-, and 3-year survival rates were also similar (50%, 50%, 42% REVAR vs 54%, 52%, 47% OSR; P = .66). CONCLUSIONS REVAR for rAAA does not seem to conclusively confer either acute or late survival advantages. Routine use of REVAR should be deferred until prospective, randomized trial data become available.
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Affiliation(s)
- Naveed Saqib
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa 15213, USA
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Bonardelli S, Cervi E, Maffeis R, Nodari F, De Lucia M, Guadrini C, Viotti F, Portolani N, Giulini SM. Open surgery in endovascular aneurysm repair era: simplified classification in two risk groups owing to factors affecting mortality in 137 ruptured abdominal aortic aneurysms (RAAAs). Updates Surg 2011; 63:39-44. [PMID: 21336876 PMCID: PMC3047051 DOI: 10.1007/s13304-011-0053-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 01/31/2011] [Indexed: 12/03/2022]
Abstract
Our objective is to identify in 137 true RAAAs operated consecutively in open surgery: (1) diagnostic therapeutic aspects capable of influencing results, (2) risk classes with different prognosis, (3) any situations where the prognosis is so negative that surgery is not recommended. The relationship of 16 anamnestic, clinical and technical parameters prospectively collected with 30-day mortality was retrospectively evaluated by uni- and multivariate analyses. Thirty-day mortality was 37%. The univariate analysis identified as mortality predictors Hb ≤ 8 g/dl and circulatory shock at hospitalisation, but following the multivariate analysis only circulatory shock was a certainly significant risk-factor. The cumulative effect on mortality of the two parameters identified at univariate analysis translates into a statistically significant difference in mortality between two groups of patients: A (no or just one risk-factor) and B (two risk-factors). To reinstate euvolemia, rather than adequate haemoglobin values, improves the chances of success. A simple prognostic index into two risk classes is feasible, but abstention from surgery is not justified in any type of patient.
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Affiliation(s)
- Stefano Bonardelli
- Department of Medical and Surgical Sciences, Unit and Chair of Vascular Surgery, Universitá degli Studi, A.O. Spedali Civili Brescia, Italy
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Powell J, Hinchliffe R. Part One: For the Motion. Eur J Vasc Endovasc Surg 2010; 40:421-4. [DOI: 10.1016/j.ejvs.2010.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 06/07/2010] [Indexed: 11/28/2022]
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Veith FJ, Powell JT, Hinchliffe RJ. Is a randomized trial necessary to determine whether endovascular repair is the preferred management strategy in patients with ruptured abdominal aortic aneurysms? J Vasc Surg 2010; 52:1087-93. [DOI: 10.1016/j.jvs.2010.05.142] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 05/26/2010] [Accepted: 05/26/2010] [Indexed: 01/26/2023]
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Successful Occlusion of a Ruptured Aortic Aneurysm Using the Amplatzer Vascular Plug: A Technical Note. Cardiovasc Intervent Radiol 2010; 34 Suppl 2:S136-41. [DOI: 10.1007/s00270-010-9872-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Accepted: 04/08/2010] [Indexed: 11/26/2022]
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Ricotta JJ, Malgor RD, Oderich GS. Ruptured Endovascular Abdominal Aortic Aneurysm Repair: Part II. Ann Vasc Surg 2010; 24:269-77. [DOI: 10.1016/j.avsg.2009.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Accepted: 08/21/2009] [Indexed: 12/11/2022]
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Abstract
Abdominal aortic aneurysms cause about 6000 deaths per year in England and Wales, predominantly from rupture. Significant progress has been made in recent years in developing minimally invasive, endovascular methods of treatment. This review evaluates the current management options for abdominal aortic aneurysm.
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Affiliation(s)
- N R A Symons
- Department of Vascular Surgery, St Mary's Hospital, Imperial College Academic Health Sciences NHS Trust, London W2 1 NY
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Antonello M, Frigatti P, Maturi C, Lepidi S, Noventa F, Pittoni G, Deriu GP, Grego F. Open repair for ruptured abdominal aortic aneurysm: is it possible to predict survival? Ann Vasc Surg 2008; 23:159-66. [PMID: 18834704 DOI: 10.1016/j.avsg.2008.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Revised: 04/04/2008] [Accepted: 05/08/2008] [Indexed: 11/26/2022]
Abstract
The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.
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Affiliation(s)
- M Antonello
- Department of Cardiac, Thoracic, and Vascular Sciences, Vascular and Endovascular Surgery Section, University of Padua, Padua, Italy.
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Cho JS, Kim JY, Rhee RY, Gupta N, Marone LK, Dillavou ED, Makaroun MS. Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: Effect of surgeon volume on mortality. J Vasc Surg 2008; 48:10-7; discussion 17-8. [DOI: 10.1016/j.jvs.2008.02.067] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 02/25/2008] [Accepted: 02/26/2008] [Indexed: 11/29/2022]
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Reply. World J Surg 2008. [DOI: 10.1007/s00268-007-9464-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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