1
|
Bridgewater B, Sarathy PP, Bagguley S. 1318 IMPROVING PERFORMANCE OF MEDICATION REVIEW AND ASSESSMENT OF BONE HEALTH IN GERIATRIC ADMISSIONS: A QUALITY IMPROVEMENT PROJECT. Age Ageing 2023. [DOI: 10.1093/ageing/afac322.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Abstract
Introduction
Important parts of the comprehensive geriatric assessment (CGA) include medication review and assessment of bone health. Such aspects of CGA can be missed in clinical practice in the busy acute hospital setting. We aimed to improve performance of medication review, and assessment of bone health in patients with falls in the form of vitamin D levels and Fracture Risk Assessment Tool (FRAX) scoring, in admissions to the acute Care of the Elderly (COTE) team in a district general hospital in South Wales.
Method
Data were collected from documentation of the initial review of admissions under the acute COTE team, over a two-week period pre- and post- intervention. A new patient assessment document was produced for the initial COTE review with prompts for medication review, vitamin D levels and FRAX scoring.
Results
The sample included 38 admissions pre- and 32 admissions post- intervention. Implementation of the new patient assessment document resulted in an increase in medication review from 37% to 84% overall, and 91% in instances where the document was used. In patients with falls, we observed an increase in vitamin D level testing from 50% to 65% overall, and 83% where the document was used, and an increase in FRAX scoring from 22% to 47% overall, and 67% in cases where the document was used.
Conclusion
A standardised patient assessment document is a simple intervention that can be introduced easily on a departmental basis to act as an aide memoire for important aspects of the CGA. In this project the new patient assessment document produced an increase in performance of medication review and assessment of bone health. Future work will aim to improve utilisation of the assessment document and evaluate changes in prescribing practice as a result of its implementation.
Collapse
Affiliation(s)
- B Bridgewater
- Royal Glamorgan Hospital Care of the Elderly Department, , Llantrisant
| | - P Partha Sarathy
- Royal Glamorgan Hospital Care of the Elderly Department, , Llantrisant
| | - S Bagguley
- Royal Glamorgan Hospital Care of the Elderly Department, , Llantrisant
| |
Collapse
|
2
|
Hickey GL, Bridgewater B, Grant SW, Deanfield J, Parkinson J, Bryan AJ, Dalrymple-Hay M, Moat N, Buchan I, Dunning J. National Registry Data and Record Linkage to Inform Postmarket Surveillance of Prosthetic Aortic Valve Models Over 15 Years. JAMA Intern Med 2017; 177:79-86. [PMID: 27820610 DOI: 10.1001/jamainternmed.2016.6936] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Postmarket evidence generation for medical devices is important yet limited for prosthetic aortic valve devices in the United Kingdom. Objective To identify prosthetic aortic valve models that display unexpected patterns of mortality or reintervention using routinely collected national registry data and record linkage. Design, Setting, and Participants This observational study used data from all National Health Service and private hospitals in England and Wales that submit data to the National Adult Cardiac Surgery Audit (NACSA). All patients undergoing first-time elective and urgent aortic valve replacement surgery (with or without coronary artery bypass grafting) with a biological (n = 15 series) or mechanical (n = 10 series) prosthetic valve from 5 primary suppliers, and satisfying prespecified data quality criteria (n = 43 782 biological; n = 11 084 mechanical) between 1998 and 2013 were included. Valves were classified into series of related models. Outcome tracking was performed using multifaceted record linkage. The median follow-up was 4.1 years (maximum, 15.3 years). Cox proportional hazards regression with random effects (frailty models) were used to model valve effects on the outcomes, with and without adjustment for preoperative and intraoperative covariates. Main Outcomes and Measures Time to all-cause mortality or aortic valve reintervention (surgical or transcatheter). There were 13 104 deaths and 723 reinterventions during follow-up. Results Of 79 345 isolated aortic valve replacement procedures with or without coronary artery bypass grafting, 54 866 were analyzed. Biological valve implantation rates increased from 59% in 1998 and 1999 to 86% in 2012 and 2013. Two series of valves associated with significantly increased hazard of death or reintervention were identified (first series: frailty, 1.18; 95% prediction interval [PI], 1.06-1.32 and second series: frailty, 1.19; 95% PI, 1.09-1.31). These results were robust to covariate adjustment and sensitivity analyses. There were 3 prosthetic valves with a significant reduction in hazard (valve 1: frailty, 0.88; 95% PI, 0.80-0.96; valve 2: frailty, 0.88; 95% PI, 0.80-0.96; and valve 3: frailty, 0.88; 95% PI, 0.78-0.98). Conclusions and Relevance Meaningful evidence from the analysis of routinely collected registry data can inform postmarket surveillance of medical devices. Although the findings are associated with a number of caveats, 2 specific biological aortic valve series identified in this study may warrant further investigation.
Collapse
Affiliation(s)
- Graeme L Hickey
- University of Liverpool, Department of Biostatistics, Liverpool, L69 3GL, England2University College London, National Institute for Cardiovascular Outcomes Research (NICOR), London, EC1A 4NP, England
| | - Ben Bridgewater
- University College London, National Institute for Cardiovascular Outcomes Research (NICOR), London, EC1A 4NP, England3Computer Science Corporation, Kings Cross, London, N1C 4AG, England
| | - Stuart W Grant
- University College London, National Institute for Cardiovascular Outcomes Research (NICOR), London, EC1A 4NP, England4Academic Surgery Unit, University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Manchester, M23 9LT, UK
| | - John Deanfield
- University College London, National Institute for Cardiovascular Outcomes Research (NICOR), London, EC1A 4NP, England
| | - John Parkinson
- University College London, National Institute for Cardiovascular Outcomes Research (NICOR), London, EC1A 4NP, England
| | - Alan J Bryan
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, BS2 8HW, England
| | - Malcolm Dalrymple-Hay
- South West Cardiothoracic Centre, Derriford Hospital, Derriford, Plymouth, PL68DH, England
| | - Neil Moat
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, SW3 6NP, England
| | - Iain Buchan
- University of Manchester, Manchester Academic Health Science Centre, Centre for Health Informatics, Vaughan House, Manchester, M13 9GB, England
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, TS4 3BW, England
| |
Collapse
|
3
|
Saravanan P, West AL, Bridgewater B, Davidson NC, Calder PC, Dobrzynsky H, Trafford A, O'Neill SC. Omega-3 fatty acids do not alter P-wave parameters in electrocardiogram or expression of atrial connexins in patients undergoing coronary artery bypass surgery. Europace 2016; 18:1521-1527. [PMID: 26850746 DOI: 10.1093/europace/euv398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 10/05/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS We previously reported omega-3 polyunsaturated fatty acids (n-3PUFAs) supplementation does not reduce atrial fibrillation (AF) following coronary artery bypass graft (CABG) surgery. The aim of the present study is to evaluate the impact of n-3 PUFAs on electrocardiogram (ECG) atrial arrhythmic markers and compare with expression of gap-junction proteins, Connexins. METHODS AND RESULTS Subset of clinical trial subjects with right atrial sampling during CABG surgery included. Twelve-lead ECG performed at recruitment and at surgery [after supplementation with n-3 PUFA (∼1.8 g/day) or matched placebo] for ∼14 days. Electrocardiograms analysed for maximum P-wave duration (P-max) and difference between P-max and minimum P-wave duration, P-wave dispersion (PWD). Right atrial specimens analysed for expression of Connexins 40 and 43 using real-time quantitative polymerase chain reaction (qPCR) and western blot. Serum levels of n-3 PUFA at baseline, at surgery, and atrial tissue levels at surgery collated from file. Postoperative AF was quantified by analysing data from stored continuous electrograms. A total of 61 patients (n-3 PUFA 34, Placebo 27) had ECG analysis and AF burden, of which 52 patients (26 in each group) had qPCR and 16 (8 in each group) had western blot analyses for Connexins 40 and 43. No difference between the two groups in ECG parameters or expression of Connexin 40 or 43. P-wave dispersion in the preoperative ECG independently predicted occurrence of AF following CABG surgery. CONCLUSIONS Omega-3 polyunsaturated fatty acids supplementation does not alter pro-arrhythmic P-wave parameters in ECG or connexin expression in human atrium with no effect on the incidence of AF following CABG surgery.
Collapse
Affiliation(s)
| | - Annette L West
- Faculty of Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - Ben Bridgewater
- Department of Cardiology, University Hospital of South Manchester, Manchester, UK
| | - Neil C Davidson
- Department of Cardiology, University Hospital of South Manchester, Manchester, UK
| | - Philip C Calder
- Faculty of Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - Halina Dobrzynsky
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Andrew Trafford
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Stephen C O'Neill
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
4
|
Bashir M, Shaw MA, Grayson AD, Fok M, Hickey GL, Grant SW, Bridgewater B, Oo AY. Development and Validation of Elective and Nonelective Risk Prediction Models for In-Hospital Mortality in Proximal Aortic Surgery Using the National Institute for Cardiovascular Outcomes Research (NICOR) Database. Ann Thorac Surg 2016; 101:1670-6. [DOI: 10.1016/j.athoracsur.2015.10.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 08/30/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
|
5
|
Attia RQ, Hickey GL, Grant SW, Bridgewater B, Roxburgh JC, Kumar P, Ridley P, Bhabra M, Millner RWJ, Athanasiou T, Casula R, Chukwuemka A, Pillay T, Young CP. Minimally Invasive versus Conventional Aortic Valve Replacement: A Propensity-Matched Study from the UK National Data. Innovations 2016. [DOI: 10.1177/155698451601100104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Rizwan Q. Attia
- Department of Cardiothoracic Surgery, Guy's and St Thomas’ Hospital, London, UK
| | - Graeme L. Hickey
- Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- National Institute for Cardiovascular Outcomes Research, Institute of Cardiovascular Science, University College London, London, UK
| | - Stuart W. Grant
- Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Cardiothoracic Surgery, Manchester Academic Health Science Centre, University Hospital of South Manchester, Wythenshawe, UK
| | - Ben Bridgewater
- Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- National Institute for Cardiovascular Outcomes Research, Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiothoracic Surgery, Manchester Academic Health Science Centre, University Hospital of South Manchester, Wythenshawe, UK
| | - James C. Roxburgh
- Department of Cardiothoracic Surgery, Guy's and St Thomas’ Hospital, London, UK
| | - Pankaj Kumar
- Department of Cardiothoracic Surgery, Morriston Hospital, Morriston, Swansea, UK
| | - Paul Ridley
- Department of Cardiothoracic Surgery North Staffordshire Royal Infirmary, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, UK
| | - Moninder Bhabra
- Department of Cardiothoracic Surgery, Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK
| | - Russell W. J. Millner
- Department of Cardiothoracic Surgery, Lancashire Cardiac Centre, Victoria Hospital NHS Trust, Blackpool, UK
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Roberto Casula
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Andrew Chukwuemka
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Thasee Pillay
- Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | | |
Collapse
|
6
|
Hickey GL, Pullan M, Oo A, Mediratta N, Chalmers J, Bridgewater B, Poullis M. A comparison of survival between on-pump and off-pump left internal mammary artery bypass graft surgery for isolated left anterior descending coronary artery disease: an analysis of the UK National Adult Cardiac Surgery Audit Registry. Eur J Cardiothorac Surg 2015; 49:1441-9. [DOI: 10.1093/ejcts/ezv396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/08/2015] [Indexed: 11/13/2022] Open
|
7
|
Moat N, Duncan A, Stephens SV, Hickey GL, Cunningham D, de Belder M, Blackman DJ, Hildick-Smith D, Bridgewater B, Ludman P. TCT-667 Aortic Valve Intervention In Octogenarians In The “TAVI-Era”: Analysis Of The UK National Adult Cardiac Surgery Audit Registry And The UK Transcatheter Aortic Valve Implantation (TAVI) Registry between 2006 and 2012. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.08.686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
8
|
Grant SW, Hickey GL, Ludman P, Moat N, Cunningham D, de Belder M, Blackman DJ, Hildick-Smith D, Uppal R, Kendall S, Bridgewater B. Activity and outcomes for aortic valve implantations performed in England and Wales since the introduction of transcatheter aortic valve implantation. Eur J Cardiothorac Surg 2015; 49:1164-73. [PMID: 26276837 DOI: 10.1093/ejcts/ezv270] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 06/30/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The first transcatheter aortic valve implantation (TAVI) in England and Wales was performed in 2007. This study presents the subsequent national activity and outcomes for both TAVI and aortic valve replacement (AVR). METHODS Data for all AVR and TAVI procedures between January 2006 and December 2012 in England and Wales were included. The number of procedures, patient characteristics, in-hospital and 30-day mortality, postoperative length of stay (PLOS) and survival were analysed separately for: isolated AVR; AVR + coronary artery bypass graft (CABG) surgery; AVR + other surgery and TAVI. RESULTS The number of TAVIs increased from 66 in 2007 (0.8% of all implants) to 1186 in 2012 (10.9% of all implants). AVR activity also increased over the study period. TAVI patients were older and had a higher mean logistic EuroSCORE than all AVR groups. The 30-day mortality rates were 2.1% for isolated AVR, 3.9% for AVR + CABG, 7.7% for AVR + other surgery and 6.2% for TAVI. In-hospital mortality has significantly improved for all groups. The 5-year survival rates were 82.6% for isolated AVR, 81.7% for AVR + CABG, 74.5% for AVR + other surgery and 46.1% for TAVI. The median PLOS after TAVI was similar to that of isolated AVR but shorter than that of the other AVR groups. CONCLUSIONS Since the introduction of TAVI, there has been an increase in both TAVI and AVR activity. TAVIs now represent over 10% of all aortic valve implants. There are distinct differences between procedural groups with respect to patient risk factors. Outcomes for all procedural groups have improved, but long-term TAVI results are required before its role in the treatment of aortic stenosis can be fully defined.
Collapse
Affiliation(s)
- Stuart W Grant
- Department of Cardiothoracic Surgery, Manchester Academic Health Science Centre, University of Manchester, University Hospital of South Manchester, Manchester, UK National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London, UK
| | - Graeme L Hickey
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London, UK Department of Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, The Farr Institute @ HeRC, Liverpool, UK
| | - Peter Ludman
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London, UK Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
| | - Neil Moat
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London, UK Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - David Cunningham
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London, UK
| | - Mark de Belder
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London, UK Department of Cardiothoracic Services, The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Rakesh Uppal
- Department of Cardiothoracic Surgery, Barts Health, St Bartholomew's Hospital, London, UK William Harvey Research Institute and NIHR Cardiovascular Biomedical Research Unit, Barts and the London School of Medicine, London, UK
| | - Simon Kendall
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London, UK Department of Cardiothoracic Services, The James Cook University Hospital, Middlesbrough, UK
| | - Ben Bridgewater
- Department of Cardiothoracic Surgery, Manchester Academic Health Science Centre, University of Manchester, University Hospital of South Manchester, Manchester, UK National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London, UK
| |
Collapse
|
9
|
Barnard J, Grant SW, Hickey GL, Bridgewater B. Is social deprivation an independent predictor of outcomes following cardiac surgery? An analysis of 240,221 patients from a national registry. BMJ Open 2015; 5:e008287. [PMID: 26124512 PMCID: PMC4486967 DOI: 10.1136/bmjopen-2015-008287] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Social deprivation impacts on healthcare outcomes but is not included in the majority of cardiac surgery risk prediction models. The objective was to investigate geographical variations in social deprivation of patients undergoing cardiac surgery and identify whether social deprivation is an independent predictor of outcomes. METHODS National Adult Cardiac Surgery Audit data for coronary artery bypass graft (CABG), or valve surgery performed in England between April 2003 and March 2013, were analysed. Base hospitals in England were divided into geographical regions. Social deprivation was measured by quintile groups of the index of multiple deprivation (IMD) score with the first quintile group (Q1) being the least, and the last quintile group (Q5) the most deprived group. In-hospital mortality and midterm survival were analysed using mixed effects logistic, and stratified Cox proportional hazards regression models respectively. RESULTS 240,221 operations were analysed. There was substantial regional variation in social deprivation with the proportion of patients in IMD Q5 ranging from 34.5% in the North East to 6.5% in the East of England. Following adjustment for preoperative risk factors, patients undergoing all cardiac surgery in IMD Q5 were found to have an increased risk of in-hospital mortality relative to IMD Q1 (OR=1.13; 95%CI 1.03 to 1.24), as were patients undergoing isolated CABG (OR=1.19; 95%CI 1.03 to 1.37). For midterm survival, patients in IMD Q5 had an increased hazard in all groups (HRs ranged between 1.10 (valve+CABG) and 1.26 (isolated CABG)). For isolated CABG, the median postoperative length of stay was 6 and 7 days, respectively, for IMD Q1-Q4 and Q5. CONCLUSIONS Significant regional variation exists in the social deprivation of patients undergoing cardiac surgery in England. Social deprivation is associated with an increased risk of in-hospital mortality and reduced midterm survival. These findings have implications for health service provision, risk prediction models and analyses of surgical outcomes.
Collapse
Affiliation(s)
- James Barnard
- Department of Cardiothoracic Surgery, University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Manchester, UK
| | - Stuart W Grant
- Department of Cardiothoracic Surgery, University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Manchester, UK
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, Institute of Cardiovascular Science, London, UK
- Academic Surgery Unit, University of Manchester, Manchester Academic Health Science Centre, Education and Research Centre, Manchester, UK
| | - Graeme L Hickey
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, Institute of Cardiovascular Science, London, UK
- Academic Surgery Unit, University of Manchester, Manchester Academic Health Science Centre, Education and Research Centre, Manchester, UK
- Department of Epidemiology and Population Health, University of Liverpool, Institute of Infection and Global Health, The Farr Institute@HeRC, Liverpool, UK
| | - Ben Bridgewater
- Department of Cardiothoracic Surgery, University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Manchester, UK
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, Institute of Cardiovascular Science, London, UK
| |
Collapse
|
10
|
Affiliation(s)
- Ben Bridgewater
- University Hospital of South Manchester NHS Foundation Trust
| |
Collapse
|
11
|
Hickey GL, Grant SW, Freemantle N, Cunningham D, Munsch CM, Livesey SA, Roxburgh J, Buchan I, Bridgewater B. Surgeon length of service and risk-adjusted outcomes: linked observational analysis of the UK National Adult Cardiac Surgery Audit Registry and General Medical Council Register. J R Soc Med 2014; 107:355-64. [PMID: 25193057 DOI: 10.1177/0141076814538788] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To explore the relationship between in-hospital mortality following adult cardiac surgery and the time since primary clinical qualification for the responsible consultant cardiac surgeon (a proxy for experience). DESIGN Retrospective analysis of prospectively collected national registry data over a 10-year period using mixed-effects multiple logistic regression modelling. Surgeon experience was defined as the time between the date of surgery and award of primary clinical qualification. SETTING UK National Health Service hospitals performing cardiac surgery between January 2003 and December 2012. PARTICIPANTS All patients undergoing coronary artery bypass grafts and/or valve surgery under the care of a consultant cardiac surgeon. MAIN OUTCOME MEASURES All-cause in-hospital mortality. RESULTS A total of 292,973 operations performed by 273 consultant surgeons (with lengths of service from 11.2 to 42.0 years) were included. Crude mortality increased approximately linearly until 33 years service, before decreasing. After adjusting for case-mix and year of surgery, there remained a statistically significant (p=0.002) association between length of service and in-hospital mortality (odds ratio 1.013; 95% CI 1.005-1.021 for each year of 'experience'). CONCLUSIONS Consultant cardiac surgeons take on increasingly complex surgery as they gain experience. With this progression, the incidence of adverse outcomes is expected to increase, as is demonstrated in this study. After adjusting for case-mix using the EuroSCORE, we observed an increased risk of mortality in patients operated on by longer serving surgeons. This finding may reflect under-adjustment for risk, unmeasured confounding or a real association. Further research into outcomes over the time course of surgeon's careers is required.
Collapse
Affiliation(s)
- Graeme L Hickey
- Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London W1T 7HA, UK
| | - Stuart W Grant
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London W1T 7HA, UK Department of Cardiothoracic Surgery, Manchester Academic Health Science Centre, University of Manchester, University Hospital of South Manchester, Manchester M23 9LT, UK
| | - Nick Freemantle
- Department of Primary Care and Population Health, University College London, London NW3 2PF, UK
| | - David Cunningham
- National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London W1T 7HA, UK
| | - Christopher M Munsch
- Department of Cardiothoracic Surgery, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - Steven A Livesey
- Department of Cardiac Surgery, University Hospital Southampton, Southampton SO16 6YD, UK
| | - James Roxburgh
- Department of Cardiothoracic Surgery, St Thomas' Hospital, London SE1 7EH, UK
| | - Iain Buchan
- Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Ben Bridgewater
- Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK National Institute for Cardiovascular Outcomes Research (NICOR), University College London, London W1T 7HA, UK Department of Primary Care and Population Health, University College London, London NW3 2PF, UK
| |
Collapse
|
12
|
Dimarakis I, Grant S, Corless R, Velissaris T, Prince M, Bridgewater B, Asimakopoulos G. Impact of hepatic cirrhosis on outcome in adult cardiac surgery. Thorac Cardiovasc Surg 2014; 63:58-66. [PMID: 25291160 DOI: 10.1055/s-0034-1389084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Increasing prevalence of hepatic disease is likely to translate in a growing number of patients with significant hepatic disease requiring cardiac surgery. Available cardiac risk stratification models do not address the risk associated with hepatic disease. However, weighted mean mortality rates based on previous studies of cardiac surgery in patients with hepatic disease demonstrate operative mortality rates that range from 9.88% (standard deviation [SD] 9.69) for patients in Child-Turcotte-Pugh (CTP) class A cirrhosis to 69.23% (SD 28.55) for patients with CTP class C cirrhosis. This review comprehensively appraises the pathophysiology of hepatic disease, reported clinical outcomes and considerations for risk stratification.
Collapse
Affiliation(s)
- Ioannis Dimarakis
- Department of Cardiothoracic Surgery, University Hospital South Manchester, Manchester, United Kingdom
| | - Stuart Grant
- Department of Cardiothoracic Surgery, University Hospital South Manchester, Manchester, United Kingdom
| | - Rebecca Corless
- Department of Clinical Oncology Research, University Hospital South Manchester, Manchester, United Kingdom
| | - Theodore Velissaris
- Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Martin Prince
- Department of Gastroenterology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ben Bridgewater
- Department of Cardiothoracic Surgery, University Hospital South Manchester, Manchester, United Kingdom
| | - George Asimakopoulos
- Department of Cardiac Surgery, Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom
| |
Collapse
|
13
|
Hickey GL, Grant SW, Bridgewater B, Kendall S, Bryan AJ, Kuo J, Dunning J. A comparison of outcomes between bovine pericardial and porcine valves in 38 040 patients in England and Wales over 10 years. Eur J Cardiothorac Surg 2014; 47:1067-74. [DOI: 10.1093/ejcts/ezu307] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 07/04/2014] [Indexed: 11/15/2022] Open
|
14
|
Calvert PA, Cockburn J, Wynne D, Ludman P, Rana BS, Northridge D, Mullen MJ, Malik I, Turner M, Khogali S, Veldtman GR, Been M, Butler R, Thomson J, Byrne J, MacCarthy P, Morrison L, Shapiro LM, Bridgewater B, de Giovanni J, Hildick-Smith D. Percutaneous Closure of Postinfarction Ventricular Septal Defect. Circulation 2014; 129:2395-402. [DOI: 10.1161/circulationaha.113.005839] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background—
Postinfarction ventricular septal defect carries a grim prognosis. Surgical repair offers reasonable outcomes in patients who survive a healing phase. Percutaneous device implantation represents a potentially attractive early alternative.
Methods and Results—
Postinfarction ventricular septal defect closure was attempted in 53 patients from 11 centers (1997–2012; aged 72±11 years; 42% female). Nineteen percent had previous surgical closure. Myocardial infarction was anterior (66%) or inferior (34%). Time from myocardial infarction to closure procedure was 13 (first and third quartiles, 5–54) days. Devices were successfully implanted in 89% of patients. Major immediate complications included procedural death (3.8%) and emergency cardiac surgery (7.5%). Immediate shunt reduction was graded as complete (23%), partial (62%), or none (15%). Median length of stay after the procedure was 5.0 (2.0–9.0) days. Fifty-eight percent survived to discharge and were followed up for 395 (63–1522) days, during which time 4 additional patients died (7.5%). Factors associated with death after postinfarction ventricular septal defect closure included the following: age (hazard ratio [HR]=1.04;
P
=0.039), female sex (HR=2.33;
P
=0.043), New York Heart Association class IV (HR=4.42;
P
=0.002), cardiogenic shock (HR=3.75;
P
=0.003), creatinine (HR=1.007;
P
=0.003), defect size (HR=1.09;
P
=0.026), inotropes (HR=4.18;
P
=0.005), and absence of revascularization therapy for presenting myocardial infarction (HR=3.28;
P
=0.009). Prior surgical closure (HR=0.12;
P
=0.040) and immediate shunt reduction (HR=0.49;
P
=0.037) were associated with survival.
Conclusions—
Percutaneous closure of postinfarction ventricular septal defect is a reasonably effective treatment for these extremely high-risk patients. Mortality remains high, but patients who survive to discharge do well in the longer term.
Collapse
Affiliation(s)
- Patrick A. Calvert
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - James Cockburn
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Dylan Wynne
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Peter Ludman
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Bushra S. Rana
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - David Northridge
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Michael J. Mullen
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Iqbal Malik
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Mark Turner
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Saib Khogali
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Gruschen R. Veldtman
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Martin Been
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Rob Butler
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - John Thomson
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Jonathan Byrne
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Philip MacCarthy
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Lindsay Morrison
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Len M. Shapiro
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Ben Bridgewater
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - Jo de Giovanni
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| | - David Hildick-Smith
- From the University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK (P.A.C., P.L., J.d.G.); University of Cambridge, Cambridge, UK (P.A.C.); Papworth Hospital National Health Service Foundation Trust, Cambridge, UK (P.A.C., B.S.R., L.M.S.); Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK (J.C., D.W., D.H.-S.); Edinburgh Royal Infirmary, Edinburgh, UK (D.N.); The Heart Hospital, University College London, London, UK (M.J.M.); Imperial
| |
Collapse
|
15
|
Dimarakis I, Grant SW, Hickey GL, Patel R, Livesey S, Moat N, Wells F, Bridgewater B. Mitral valve prosthesis choice for patients aged 65 years and over in the UK. Are the guidelines being followed and does it matter? Heart 2013; 100:500-7. [PMID: 24345391 DOI: 10.1136/heartjnl-2013-304783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Current guidelines recommend that most patients aged ≥65 years should undergo mitral valve replacement (MVR) using a biological prosthesis. The objectives of this study were to assess whether these guidelines are being followed in UK practice, and to investigate whether the guidelines are appropriate based on in-hospital mortality and mid-term survival. METHODS Data from the National Institute for Cardiovascular Outcomes Research Adult Cardiac Surgery Audit database from all National Health Service (NHS) hospitals and some private hospitals performing adult cardiac surgery in the UK between April 2001 and March 2011 were analysed. The overall cohort included 3862 patients aged ≥65 years who underwent first-time MVR. Propensity score matching and regression adjustment were used to compare outcomes between prosthesis groups. RESULTS The mean age was 73.0 years (SD 4.9) with 50% of patients having surgery with a mechanical prosthesis. This proportion decreased over the study period and with increasing patient age with marked variation between hospitals. In the propensity-matched cohort, in-hospital mortality in the biological group was 6.9%, and in the mechanical group it was 5.9% giving an unadjusted OR of 1.17 (95% CI 0.84 to 1.63). There was no significant difference in mid-term survival between the matched groups with an unadjusted HR for biological prosthesis of 1.08 (95% CI 0.93 to 1.24). Similar results were found when using regression adjustment on unmatched data. CONCLUSIONS Current guidelines concerning age and mitral valve prosthesis choice are not being followed for patients aged ≥65 years. With regards to in-hospital and mid-term mortality, this study demonstrates that there is no difference between prosthesis types.
Collapse
Affiliation(s)
- Ioannis Dimarakis
- Department of Cardiothoracic Surgery, Manchester Academic Health Science Centre, University of Manchester, University Hospital of South Manchester, , Manchester, UK
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Abstract
BACKGROUND The calibration of several cardiac clinical prediction models has deteriorated over time. We compare different model fitting approaches for in-hospital mortality after cardiac surgery that adjust for cross-sectional case mix in a heterogeneous patient population. METHODS AND RESULTS Data from >300 000 consecutive cardiac surgery procedures performed at all National Health Service and some private hospitals in England and Wales between April 2001 and March 2011 were extracted from the National Institute for Cardiovascular Outcomes Research clinical registry. The study outcome was in-hospital mortality. Model approaches included not updating, periodic refitting, rolling window, and dynamic logistic regression. Covariate adjustment was made in each model using variables included in the logistic European System for Cardiac Operative Risk Evaluation model. The association between in-hospital mortality and some variables changed with time. Notably, the intercept coefficient has been steadily decreasing during the study period, consistent with decreasing observed mortality. Some risk factors, such as operative urgency and postinfarct ventricular septal defect, have been relatively stable over time, whereas other risk factors, such as left ventricular function and surgery on the thoracic aorta, have been associated with lower risk relative to the static model. CONCLUSIONS Dynamic models or periodic model refitting is necessary to counteract calibration drift. A dynamic modeling framework that uses contemporary and available historic data can provide a continuously smooth update mechanism that also allows for inferences to be made on individual risk factors. Better models that withstand the effects of time give advantages for governance, quality improvement, and patient-level decision making.
Collapse
Affiliation(s)
- Graeme L Hickey
- University of Manchester, Centre for Health Informatics, Manchester, United Kingdom
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Hickey GL, Cosgriff R, Grant SW, Cooper G, Deanfield J, Roxburgh J, Bridgewater B. A technical review of the United Kingdom National Adult Cardiac Surgery Governance Analysis 2008–11. Eur J Cardiothorac Surg 2013; 45:225-33. [DOI: 10.1093/ejcts/ezt476] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
|
18
|
|
19
|
Head SJ, Howell NJ, Osnabrugge RLJ, Bridgewater B, Keogh BE, Kinsman R, Walton P, Gummert JF, Pagano D, Kappetein AP. The European Association for Cardio-Thoracic Surgery (EACTS) database: an introduction. Eur J Cardiothorac Surg 2013; 44:e175-80. [PMID: 23786918 DOI: 10.1093/ejcts/ezt303] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Continuous monitoring of surgical outcomes through benchmarking and the identification of best practices has become increasingly important. A structured approach to data collection, coupled with validation, analysis and reporting, is a powerful tool in these endeavours. However, inconsistencies in standards and practices have made comparisons within and between European countries cumbersome. The European Association for Cardio-Thoracic Surgery (EACTS) has established a large international database with the goals of (i) working with other organizations towards universal data collection and creating a European-wide repository of information on the practice of cardio-thoracic surgery, and (ii) disseminating that information in scientific, peer-reviewed articles. We report on the process of data collection, as well as on an overview of the data in the database. METHODS The EACTS Database Committee met for the first time in Monaco, September 2002, to establish the ground rules for the process of setting up the database. Subsequently, data have been collected and merged by Dendrite Clinical Systems Ltd. RESULTS As of December 2008, the database included 1,074,168 patient records from 366 hospitals located in 29 countries. The latest submission from the years 2006-08 included 404,721 records. The largest contributors were the UK (32.0%), Germany (20.9%) and Belgium (7.3%). Isolated coronary bypass surgery was the most frequently performed operation; the proportion of surgical workload that comprised isolated coronary artery bypass grafting varied from country to country: 30% in Spain and almost 70% in Denmark. Isolated valve procedures constituted 12% of all procedures in Norway and 32% in Spain. Baseline demographics showed an increase in the mean age and the percentage of patients that were female over time. Remarkably, the mortality rates for all procedures declined over the period analysed, to 2.2% (95% confidence interval [CI] 2.2-2.3%) for isolated coronary bypass, 3.4% (95% CI 3.3-3.5%) for isolated valve and 6.2% (95% CI 6.0-6.5%) for bypass + valve procedures. CONCLUSION The EACTS database has proven to be an important step forward in providing opportunities for monitoring cardiac surgical care across Europe. As the database continues to expand, it will facilitate research projects, establish benchmarking standards and identify potential areas for quality improvements.
Collapse
Affiliation(s)
- Stuart J Head
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
|
21
|
Bridgewater B. Almanac 2012 adult cardiac surgery: journals present selected research that has driven recent advances in clinical cardiology. Anadolu Kardiyol Derg 2013; 13:414-421. [PMID: 23591588 DOI: 10.5152/akd.2013.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.
Collapse
Affiliation(s)
- Ben Bridgewater
- University Hospital of South Manchester, Manchester, United Kingdom.
| |
Collapse
|
22
|
Ludman PF, Cunningham AD, Moat NE, Bridgewater B, Hickey G, de Belder MA, Hildick-Smith D. 143 AN ALL-EMBRACING ANALYSIS COMBINING THE UK TAVI AND CARDIAC SURGICAL REGISTRIES (IN NICOR) TO DESCRIBE THE ACTIVITY, TREND AND OUTCOMES IN 36 026 PATIENTS WHO UNDERWENT AORTIC VALVE INTERVENTION IN THE 5 YEARS FROM 2006 TO 2010. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
23
|
Bridgewater B. Almanac 2012: Adult cardiac surgery. Arch Cardiol Mex 2013; 83:64-71. [PMID: 23453923 DOI: 10.1016/j.acmx.2013.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/15/2013] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ben Bridgewater
- University Hospital of South Manchester, Manchester, United Kingdom.
| |
Collapse
|
24
|
Abstract
BACKGROUND Accurate risk-adjustment models are useful for clinical decision making and are important for minimizing any tendency toward risk-averse clinical practice. In cardiac surgery, emergency patients are potentially at greatest risk of inappropriate risk-averse clinical decisions. UK cardiac surgery outcomes are currently risk-adjusted with EuroSCORE models. The objective of this study was to assess the performance of the EuroSCORE models in emergency cardiac surgery. METHODS AND RESULTS The National Institute for Cardiovascular Outcomes Research database was used to identify adult cardiac surgery procedures performed in the United Kingdom between April 2008 and March 2011. A subset of procedures (July 2010-March 2011) was used for EuroSCORE II validation. The outcome measure was in-hospital mortality. Model calibration (Hosmer-Lemeshow test, calibration plots, calculation of calibration intercept and slope) and discrimination (area under receiver-operating characteristic curve [area under the curve]) were assessed. In total, 109 988 cardiac procedures at 41 hospitals were included, of which 3342 were defined as emergency procedures. Compared with performance in all cardiac surgery and nonemergency cardiac surgery, the logistic EuroSCORE and EuroSCORE II models had poorer discrimination (area under the curve, 0.703 and 0.690, respectively) and poorer calibration for emergency surgery. The EuroSCORE risk factors of female sex, chronic pulmonary disease, neurological disease, active endocarditis, unstable angina, recent myocardial infarction, and pulmonary hypertension were not identified as important risk factors for emergency cardiac surgery. CONCLUSIONS Both EuroSCORE models demonstrated poor calibration and comparatively poor discrimination for emergency cardiac surgery. This has important implications when these models are used for clinical decision making or to adjust governance analyses.
Collapse
Affiliation(s)
- Stuart W Grant
- Manchester Academic Health Science Centre, Department of Cardiothoracic Surgery, University Hospital of South Manchester, Southmoor Rd, Manchester, UK.
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Bridgewater B. Almanac 2012 adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology. Egypt Heart J 2013. [DOI: 10.1016/j.ehj.2012.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
26
|
|
27
|
Affiliation(s)
- Ben Bridgewater
- Department of Cardiothoracic Surgery, University Hospital of South Manchester, Manchester M23 9LT, UK.
| | | | | | | | | |
Collapse
|
28
|
Head SJ, Osnabrugge RLJ, Howell NJ, Freemantle N, Bridgewater B, Pagano D, Kappetein AP. A systematic review of risk prediction in adult cardiac surgery: considerations for future model development. Eur J Cardiothorac Surg 2013; 43:e121-9. [PMID: 23423916 DOI: 10.1093/ejcts/ezt044] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Risk prediction in adult patients undergoing cardiac surgery remains inaccurate and should be further improved. Therefore, we aimed to identify risk factors that are predictive of mortality, stroke, renal failure and/or length of stay after adult cardiac surgery in contemporary practice. METHODS We searched the Medline database for English-language original contributions from January 2000 to December 2011 to identify preoperative independent risk factors of one of the following outcomes after adult cardiac surgery: death, stroke, renal failure and/or length of stay. Two investigators independently screened the studies. Inclusion criteria were (i) the study described an adult cardiac patient population; (ii) the study was an original contribution; (iii) multivariable analyses were performed to identify independent predictors; (iv) ≥ 1 of the predefined outcomes was analysed; (v) at least one variable was an independent predictor, or a variable was included in a risk model that was developed. RESULTS The search yielded 5768 studies. After the initial title screening, a second screening of the full texts of 1234 studies was performed. Ultimately, 844 studies were included in the systematic review. In these studies, we identified a large number of independent predictors of mortality, stroke, renal failure and length of stay, which could be categorized into variables related to: disease pathology, planned surgical procedure, patient demographics, patient history, patient comorbidities, patient status, blood values, urine values, medication use and gene mutations. Many of these variables are frequently not considered as predictive of outcomes. CONCLUSIONS Risk estimates of mortality, stroke, renal failure and length of stay may be improved by the inclusion of additional (non-traditional) innovative risk factors. Current and future databases should consider collecting these variables.
Collapse
Affiliation(s)
- Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | | | | | | | | | | |
Collapse
|
29
|
Bridgewater B. Almanac 2012: adult cardiac surgery: the national society journals present selected research that has driven recent advances in clinical cardiology. Rev Port Cardiol 2013; 32:173-80. [PMID: 23369506 DOI: 10.1016/j.repc.2012.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 11/15/2012] [Indexed: 11/17/2022] Open
Abstract
This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.
Collapse
|
30
|
Bridgewater B. Almanac 2012: Adult cardiac surgery: The national society journals present selected research that has driven recent advances in clinical cardiology. Revista Portuguesa de Cardiologia (English Edition) 2013. [DOI: 10.1016/j.repce.2013.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
31
|
Hickey GL, Grant SW, Cosgriff R, Dimarakis I, Pagano D, Kappetein AP, Bridgewater B. Clinical registries: governance, management, analysis and applications. Eur J Cardiothorac Surg 2013; 44:605-14. [DOI: 10.1093/ejcts/ezt018] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
32
|
|
33
|
Bridgewater B. Almanac 2012 adult cardiac surgery: the National Society Journals present selected research that has driven recent advances in clinical cardiology. Hellenic J Cardiol 2013; 54:5-14. [PMID: 23340123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches to conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.
Collapse
|
34
|
Hickey GL, Grant SW, Murphy GJ, Bhabra M, Pagano D, McAllister K, Buchan I, Bridgewater B. Dynamic trends in cardiac surgery: why the logistic EuroSCORE is no longer suitable for contemporary cardiac surgery and implications for future risk models. Eur J Cardiothorac Surg 2012; 43:1146-52. [PMID: 23152436 DOI: 10.1093/ejcts/ezs584] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Progressive loss of calibration of the original EuroSCORE models has necessitated the introduction of the EuroSCORE II model. Poor model calibration has important implications for clinical decision-making and risk adjustment of governance analyses. The objective of this study was to explore the reasons for the calibration drift of the logistic EuroSCORE. METHODS Data from the Society for Cardiothoracic Surgery in Great Britain and Ireland database were analysed for procedures performed at all National Health Service and some private hospitals in England and Wales between April 2001 and March 2011. The primary outcome was in-hospital mortality. EuroSCORE risk factors, overall model calibration and discrimination were assessed over time. RESULTS A total of 317 292 procedures were included. Over the study period, mean age at surgery increased from 64.6 to 67.2 years. The proportion of procedures that were isolated coronary artery bypass grafts decreased from 67.5 to 51.2%. In-hospital mortality fell from 4.1 to 2.8%, but the mean logistic EuroSCORE increased from 5.6 to 7.6%. The logistic EuroSCORE remained a good discriminant throughout the study period (area under the receiver-operating characteristic curve between 0.79 and 0.85), but calibration (observed-to-expected mortality ratio) fell from 0.76 to 0.37. Inadequate adjustment for decreasing baseline risk affected calibration considerably. DISCUSSIONS Patient risk factors and case-mix in adult cardiac surgery change dynamically over time. Models like the EuroSCORE that are developed using a 'snapshot' of data in time do not account for this and can subsequently lose calibration. It is therefore important to regularly revalidate clinical prediction models.
Collapse
Affiliation(s)
- Graeme L Hickey
- Northwest Institute for Bio-Health Informatics, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Bridgewater B. Almanac 2012--adult cardiac surgery: the national society journals present selected research that has driven recent advances in clinical cardiology. Heart 2012; 98:1412-7. [PMID: 22965796 DOI: 10.1136/heartjnl-2011-301539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.
Collapse
|
36
|
McAllister K, Hickey G, Grant S, Bridgewater B, Buchan I. OP71 Discriminating Clinical Outcome Models May Drift Unacceptably: Example of Cardiac Surgery Mortality. Br J Soc Med 2012. [DOI: 10.1136/jech-2012-201753.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
37
|
Richardson M, Howell N, Freemantle N, Bridgewater B, Pagano D. Prediction of in-hospital death following aortic valve replacement: a new accurate model. Eur J Cardiothorac Surg 2012; 43:704-8. [PMID: 22918183 DOI: 10.1093/ejcts/ezs457] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Aortic valve replacement (AVR) is accepted as the standard treatment for severe symptomatic aortic valve stenosis and regurgitation. As novel treatments are introduced for patients at high risk for conventional surgery, it is important to have models that accurately predict procedural risk. The aim of this study was to develop and validate a risk-stratification model to predict in-hospital risk of death for patients undergoing AVR and to compare the model with existing algorithms. METHODS We reviewed data from the Central Cardiac Adult Database, which holds prospectively collected clinical information on all adult patients undergoing cardiac surgery in National Health Service (NHS) hospitals and some private providers in the UK and Ireland. We included all the patients undergoing AVR with or without coronary artery bypass grafting. The study population consists of 55 157 patients undergoing surgery between 1 April 2001 and 31 March 2009. The model was built using data from April 2001 to March 2008 and validated using data from patients undergoing surgery from April 2008 to March 2009. The model was compared against the additive and logistic EuroSCORE models and a valve-specific risk-prediction model. RESULTS The final multivariable model includes items describing cardiovascular risk status and procedural factors. Applying the model to the independent validation dataset provided a c-statistic (index of rank correlation) of 0.791, which was substantially better than that achieved by previously developed risk models in Europe, and significantly improved risk prediction in higher-risk patients. CONCLUSIONS We have produced an accurate risk model to predict outcome following AVR surgery. It will be of use for patient selection and informed consent, and of particular interest in defining those patients at high risk who may benefit from novel approaches to AVR.
Collapse
Affiliation(s)
- Matthew Richardson
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | | | | | | | | | | |
Collapse
|
38
|
Grant SW, Hickey GL, Dimarakis I, Trivedi U, Bryan A, Treasure T, Cooper G, Pagano D, Buchan I, Bridgewater B. How does EuroSCORE II perform in UK cardiac surgery; an analysis of 23 740 patients from the Society for Cardiothoracic Surgery in Great Britain and Ireland National Database. Heart 2012; 98:1568-72. [DOI: 10.1136/heartjnl-2012-302483] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
39
|
Grant SW, Grayson AD, Zacharias J, Dalrymple-Hay MJR, Waterworth P, Bridgewater B. The Authors' reply. Heart 2012. [DOI: 10.1136/heartjnl-2012-302094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
40
|
Moat NE, Ludman P, de Belder MA, Bridgewater B, Cunningham AD, Young CP, Thomas M, Kovac J, Spyt T, MacCarthy PA, Wendler O, Hildick-Smith D, Davies SW, Trivedi U, Blackman DJ, Levy RD, Brecker SJD, Baumbach A, Daniel T, Gray H, Mullen MJ. Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis: the U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry. J Am Coll Cardiol 2011; 58:2130-8. [PMID: 22019110 DOI: 10.1016/j.jacc.2011.08.050] [Citation(s) in RCA: 682] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 07/26/2011] [Accepted: 08/09/2011] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The objective was to define the characteristics of a real-world patient population treated with transcatheter aortic valve implantation (TAVI), regardless of technology or access route, and to evaluate their clinical outcome over the mid to long term. BACKGROUND Although a substantial body of data exists in relation to early clinical outcomes after TAVI, there are few data on outcomes beyond 1 year in any notable number of patients. METHODS The U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry was established to report outcomes of all TAVI procedures performed within the United Kingdom. Data were collected prospectively on 870 patients undergoing 877 TAVI procedures up until December 31, 2009. Mortality tracking was achieved in 100% of patients with mortality status reported as of December 2010. RESULTS Survival at 30 days was 92.9%, and it was 78.6% and 73.7% at 1 year and 2 years, respectively. There was a marked attrition in survival between 30 days and 1 year. In a univariate model, survival was significantly adversely affected by renal dysfunction, the presence of coronary artery disease, and a nontransfemoral approach; whereas left ventricular function (ejection fraction <30%), the presence of moderate/severe aortic regurgitation, and chronic obstructive pulmonary disease remained the only independent predictors of mortality in the multivariate model. CONCLUSIONS Midterm to long-term survival after TAVI was encouraging in this high-risk patient population, although a substantial proportion of patients died within the first year.
Collapse
Affiliation(s)
- Neil E Moat
- Royal Brompton and Harefield National Health Service (NHS) Foundation Trust, London, United Kingdom.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Affiliation(s)
- Ben Bridgewater
- South Manchester University Hospitals NHS Trust, Manchester M23 9LT, UK.
| |
Collapse
|
42
|
Grant SW, Devbhandari MP, Grayson AD, Dimarakis I, Kadir I, Saravanan DMT, Levy RD, Ray SG, Bridgewater B. What is the impact of providing a transcatheter aortic valve implantation service on conventional aortic valve surgical activity: patient risk factors and outcomes in the first 2 years. Heart 2011; 96:1633-7. [PMID: 20937751 DOI: 10.1136/hrt.2010.203661] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To assess the impact of introducing a transcatheter aortic valve implantation (TAVI) service on aortic valve surgical activity and outcomes. DESIGN A retrospective analysis of prospectively collected data. SETTING University hospital of south Manchester. PATIENTS 815 consecutive patients undergoing isolated aortic valve replacement (AVR) or coronary artery bypass grafting plus AVR from January 2006 to December 2009. Fifty consecutive patients who underwent TAVI from January 2008 to December 2009. MAIN OUTCOME MEASURES Aortic valve surgical activity in the 2years before the introduction of a TAVI service and in the 2years following. Outcomes following conventional aortic valve surgery and TAVI. RESULTS In the 2years following the introduction of TAVI at this centre, conventional AVR activity has increased by 37% compared with an 8% increase nationally (p<0.001). Compared with the 2years before TAVI there was no change in the mean logistic EuroSCORE (7.4 vs 7.9 p=0.16) or crude mortality rate (2.9% vs 2.1% p=0.48). Fifty high-risk patients underwent TAVI with a 30-day mortality rate of 0%. The mean logistic EuroSCORE of the TAVI patients was 25.3. CONCLUSIONS TAVI is an emerging alternative to AVR in high-risk patients. Since the introduction of a TAVI service at this centre, conventional AVR activity has increased. Despite a trend of increasing mean logistic EuroSCORE indicating that more complex cases are being undertaken, there has been a non-significant reduction in the crude mortality rate. Offering a TAVI service has a positive impact on the volume of conventional AVR surgical activity.
Collapse
Affiliation(s)
- S W Grant
- University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Bridgewater B, Kinsman R, Walton P, Gummert J, Kappetein AP. The 4th European Association for Cardio-Thoracic Surgery adult cardiac surgery database report. Interact Cardiovasc Thorac Surg 2011; 12:4-5. [PMID: 21177301 DOI: 10.1510/icvts.2010.251744] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
44
|
|
45
|
|
46
|
|
47
|
Abstract
UNLABELLED AIMS OF THE SCTS ADULT CARDIAC SURGERY DATABASE: To measure the quality of care of adult cardiac surgery in GB and Ireland and provide information for quality improvement and research. QUALITY OF CARE INTERVENTIONS Feedback of structured data to hospitals, publication of named hospital and surgeon mortality data, publication of benchmarked activity and risk adjusted clinical outcomes through intermittent comprehensive database reports, annual screening of all hospital and individual surgeon risk adjusted mortality rates by the professional society. SETTING All NHS hospitals in England, Scotland and Wales with input from some private providers and hospitals in Ireland. YEARS 1994-ongoing. POPULATION Consecutive patients, unconsented. Current number of records: 400000. STARTPOINTS Adult cardiac surgery operations excluding cardiac transplantation and ventricular assist devices. BASELINE DATA 129 fields covering demographic factors, pre-operative risk factors, operative details and post-operative in-hospital outcomes. DATA CAPTURE Entry onto local software systems by direct key board entry or subsequent transcription from paper records, with subsequent electronic upload to the central cardiac audit database. Non-financial incentives at hospital level. DATA QUALITY Local validation processes exist in the hospitals. There is currently no external data validation process. ENDPOINTS AND LINKAGES TO OTHER DATA All cause mortality is obtained through linkage with Office for National Statistics. No other linkages exist at present. ACCESS TO DATA Available for research and audit by application to the SCTS database committee at http://www.scts.org.
Collapse
|
48
|
Saravanan P, Bridgewater B, West AL, O'Neill SC, Calder PC, Davidson NC. Omega-3 fatty acid supplementation does not reduce risk of atrial fibrillation after coronary artery bypass surgery: a randomized, double-blind, placebo-controlled clinical trial. Circ Arrhythm Electrophysiol 2009; 3:46-53. [PMID: 20042769 DOI: 10.1161/circep.109.899633] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Omega-3 polyunsaturated fatty acids (n-3 PUFA) have been reported to reduce the risk of sudden cardiac death presumed to be due to fatal ventricular arrhythmias, but their effect on atrial arrhythmias is unclear. METHODS AND RESULTS Patients (n=108) undergoing coronary artery bypass graft surgery were randomly assigned to receive 2 g/d n-3 PUFA or placebo (olive oil) for at least 5 days before surgery (median, 16 days; range, 12 to 21 days). Phospholipid n-3 PUFA were measured in serum at study entry and at surgery and in right atrial appendage tissue at surgery. Echocardiography was used to assess left ventricular function and left atrial dimensions. Postoperative continuous ECG monitoring (Lifecard CF) for 5 days or until discharge, if earlier, was performed with a daily 12-lead ECG and clinical review if patients remained in the hospital beyond 5 days. Lifecard recordings were analyzed for episodes of atrial fibrillation (AF) > or =30 seconds (primary outcome). Clinical AF, AF burden (% time in AF), hospital stay, and intensive care/high dependency care stay were measured as secondary outcomes. One hundred three patients completed the study (51 in the placebo group and 52 in the n-3 PUFA group). There were no clinically relevant differences in baseline characteristics between groups. n-3 PUFA levels were higher in serum and right atrial tissue in the active treatment group. There was no significant difference between groups in the primary outcome of AF (95% confidence interval [CI], -6% to 30%, P=0.28) in any of the secondary outcomes or in AF-free survival. CONCLUSIONS Omega-3 PUFA do not reduce the risk of AF after coronary artery bypass graft surgery. Clinical Trial Registration- www.ukcrn.org.uk. Identifier: 4437.
Collapse
|
49
|
Abstract
Data are available for every Cardiac Surgery unit in Britain and in 70 % are identifiable by surgeon. The data are linked to registration of deaths so survival for a range of operations, and associated patient or procedure related factors, can be evaluated. The choice of statistical triggers (outside 99.99 % confidence intervals) and the time frames of reported data (averaged over three years) (See P.285/353 of the report http://www.scts.org/documents/PDF/5thBlueBook2003.pdf) reduces its value as an early warning system but the rigour of data collecting systems and the level of scrutiny required probably ensure that poor performance will be detected.
Collapse
Affiliation(s)
- T Treasure
- Clinical Operational Research Unit, UCL (Department of Mathematics), London.
| | | | | |
Collapse
|
50
|
Bridgewater B. On why funding clinical audit is essential. Quality must be seen to be done. Health Serv J 2009; 119:13. [PMID: 20726087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
|