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Manstein SM, Laikhter E, Kazei DD, Comer CD, Shiah E, Lin SJ. The Upcoming Pass/Fail USMLE Step 1 Score Reporting: An Impact Assessment From Medical School Deans. Plast Surg (Oakv) 2023; 31:169-176. [PMID: 37188137 PMCID: PMC10170630 DOI: 10.1177/22925503211034838] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/22/2021] [Indexed: 11/15/2022] Open
Abstract
Background: The US Medical Licensing Examination (USMLE) Step 1 change to pass/fail has been met with mixed reviews, and the impact on medical student education and residency match is unknown. We surveyed medical school student affairs deans regarding their thoughts on the upcoming transition of Step 1 to pass/fail. Methods: A questionnaire was emailed to medical school deans. Deans were asked to rank the importance of the following after the Step 1 reporting change: Step 2 Clinical Knowledge (Step 2 CK), clerkship grades, letters of recommendation, personal statement, medical school reputation, class rank, Medical Student Performance Evaluation, and research. They were asked how the score change will affect curriculum, learning, diversity, and student mental health. Deans were asked to select 5 specialties they thought would be most affected. Results: Regarding perceived importance of residency applications following the scoring change, the most frequent number 1 choice was Step 2 CK. The majority of deans (93.5%, n = 43) felt that the change to pass/fail would benefit medical student education/learning environment; however, most (68.2%, n = 30) did not believe their school curriculum would change. Students applying to dermatology, neurosurgery, orthopedic surgery, ENT, and plastic surgery were felt to be most affected by the scoring change; 58.7% (n = 27) felt it would not adequately address future diversity. Conclusion: The majority of deans feel the USMLE Step 1 change to pass/fail would benefit medical student education. Deans feel that students applying to traditionally more competitive specialties (ie, programs with fewer overall residency positions available) will be most affected.
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Affiliation(s)
- Samuel M. Manstein
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Laikhter
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Carly D. Comer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eric Shiah
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel J. Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Elmer NA, Laikhter E, Hassell N, Veeramani A, Bustos VP, Manstein SM, Comer CD, Kinney J, Dowlatshahi AS, Lin SJ. Comparison of Complication Risks Following Lower Extremity Free Flap Reconstruction Based on Seven Pre-Operative Indications: Analysis of the ACS-NSQIP Database. Plast Surg (Oakv) 2023. [DOI: 10.1177/22925503231157093] [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: 03/03/2023] Open
Abstract
Background: Free tissue transfer is a valuable surgical option for the reconstruction of a myriad of complex lower extremity defects. Currently, there is a paucity of data that examines the risks of complications for each of these unique indications. Methods: Patients undergoing lower extremity free flap reconstruction from the ACS-NSQIP 2011–2019 database were stratified into groups based on the etiology and indication for reconstruction. Rates of major, surgical wound, and medical complications were compared over the first post-operative month. Multivariable logistic regression was used to identify complication predictors. Results: 425 lower extremity free flaps were analyzed. The most common indications for lower extremity free flap reconstruction were wound-related (29%), malignancy (21%), and trauma (17%). Seventeen percent of free flaps had a major post-operative complication, 9% had a surgical wound complication, and 16% had a medical complication. There were no significant differences in major complications between the indications. However, the independent risk factors for major complications varied widely. Those with an indication of malignancy and those who received a musculocutaneous free flap were significantly more likely to have a surgical wound complication compared to the remaining cohort ( p < 0.05). Those requiring free flap reconstruction for orthopedic hardware related concerns as well as those with wound related indications were significantly more likely to have a post-operative medical complication ( p < 0.05). Conclusion: Understanding the unique risk profiles between the various indications and populations of patients undergoing lower extremity free flap reconstruction is critical for providing accurate risk estimations and optimizing post-operative outcomes and monitoring.
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Affiliation(s)
- Nicholas A. Elmer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Laikhter
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Natalie Hassell
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Anamika Veeramani
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Valeria P. Bustos
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel M. Manstein
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Carly D. Comer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jacquelyn Kinney
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Samuel J. Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Manstein SM, Laikhter E, Boustany AN, Shiah E, Comer CD, Bustos VP, Singhal D, Fukudome EY, Cauley RP, Morris DJ, Lee BT, Lin SJ. Outpatient Prosthetic Based Reconstruction During COVID-19 Pandemic Possible in Selected Patients Without Increased Complications. Plast Reconstr Surg 2023; 151:907e-914e. [PMID: 36584304 DOI: 10.1097/prs.0000000000010127] [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: 12/31/2022]
Abstract
BACKGROUND Following the reopening of elective surgery, our division transitioned from inpatient admission to same-day discharge for immediate prosthetic breast reconstruction in an effort to decrease the hospital's clinical burden and minimize potential COVID-19 exposure. This study aims to compare complication rates following this acute transition for patients who had inpatient and outpatient mastectomy with immediate alloplastic reconstruction. METHODS A retrospective chart review was performed on patients who underwent mastectomy with immediate prosthetic reconstruction. The outcome of interest was 30-day morbidity. Descriptive statistics were compared for patients with outpatient and inpatient surgeries. Odds ratios were calculated to determine whether any pre-operative factors increased odds of 30-day complications. RESULTS A total of 115 patients were included in this study. Twenty-six patients had outpatient surgery and 89 stayed inpatient postoperatively. Same-day discharge did not significantly impact the odds of having one or more 30-day complications (OR: 0.275, 95% CI: 0.047-1.618, p = 0.153). Patients with complications had significantly longer median operating times (5.0, IQR 4.0 - 6.0 vs. 4.0, IQR 3.0 - 5.0, p = 0.05), and there was a statistically significant association between length of surgery and odds of complication (OR: 1.596, 95% CI: 1.039-2.451, p = 0.033). Age was independently associated with increased risk of 30-day complication (OR: 1.062, 95% CI: 1.010-1.117, p = 0.020). CONCLUSIONS Our findings support a continuation of same-day discharge strategy which could decrease costs for patients and hospitals without increasing complications.
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Affiliation(s)
- Samuel M Manstein
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Shiah E, Laikhter E, Comer CD, Manstein SM, Bustos VP, Bain PA, Lee BT, Lin SJ. Neurotization in Innervated Breast Reconstruction: A Systematic Review of Techniques and Outcomes. J Plast Reconstr Aesthet Surg 2022; 75:2890-2913. [DOI: 10.1016/j.bjps.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 03/22/2022] [Accepted: 06/05/2022] [Indexed: 11/25/2022]
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Laikhter E, Comer CD, Shiah E, Manstein SM, Bain PA, Lin SJ. A Systematic Review and Meta-Analysis Evaluating the Impact of Tranexamic Acid Administration in Aesthetic Plastic Surgery. Aesthet Surg J 2022; 42:548-558. [PMID: 34486647 DOI: 10.1093/asj/sjab333] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Recent evidence suggests tranexamic acid (TXA) may improve outcomes in aesthetic surgery patients. OBJECTIVES This systematic review aimed to investigate the impact of TXA use in aesthetic plastic surgery on bleeding and aesthetic outcomes. METHODS A systematic literature search was conducted to identify studies evaluating TXA use in aesthetic plastic surgery. The primary outcome of interest was perioperative bleeding, reported as total blood loss (TBL), ecchymosis, and hematoma formation. Meta-analyses analyzing TBL and postoperative hematoma were performed. RESULTS Of 287 identified articles, 14 studies evaluating TXA use in rhinoplasty (6), rhytidectomy (3), liposuction (3), reduction mammaplasty (1), and blepharoplasty (1) were included for analysis. Of 820 total patients, 446 (54.4%) received TXA. Meta-analysis demonstrated TXA is associated with 26.3 mL average blood loss reduction (95% CI, -40.0 to -12.7 mL; P < 0.001) and suggested a trend toward decreased odds of postoperative hematoma with TXA use (odds ratio, 0.280; 95% CI, 0.076-1.029; P = 0.055). Heterogeneity among reporting of other outcomes precluded meta-analysis; however, 5 of 7 studies found significantly decreased postoperative ecchymosis levels within 7 days of surgery, 3 studies found statistically significant reductions in postoperative drain output, and 1 study reported significantly improved surgical site quality for patients who received TXA (P = 0.001). CONCLUSIONS TXA is associated with decreased blood loss and a trend toward decreased hematoma formation in aesthetic plastic surgery. Its use has the potential to increase patient satisfaction with postoperative recovery and decrease costs associated with complications, including hematoma evacuation. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Elizabeth Laikhter
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - Carly D Comer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - Eric Shiah
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - Samuel M Manstein
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - Paul A Bain
- Countway Library, Harvard Medical School , Boston, MA , USA
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
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Perez-Iglesias CT, Laikhter E, Kang CO, Nassar AH, Maselli AM, Cauley R, Lee BT. Current Applications of Ultrasound Imaging in the Preoperative Planning of DIEP Flaps. J Reconstr Microsurg 2022; 38:221-227. [DOI: 10.1055/s-0041-1740955] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Abstract
Background The deep inferior epigastric artery perforator (DIEP) flap has become the gold standard for autologous breast reconstruction at many institutions. Although the deep inferior epigastric artery displays significant anatomic variability in its intramuscular course, branching pattern and location of perforating vessels, the ability to preoperatively visualize and map relevant vascular anatomy has increased the efficiency, safety and reliability of the DIEP flap. While computed tomography angiography (CTA) is often cited as the preoperative imaging modality of choice for perforator flaps, more recent advances in ultrasound technology have made it an increasingly attractive alternative.
Methods An extensive literature review was performed to identify the most common applications of ultrasound technology in the preoperative planning of DIEP flaps.
Results This review demonstrated that multiple potential uses for ultrasound technology in DIEP flap reconstruction including preoperative perforator mapping, evaluation of the superficial inferior epigastric system and as a potential adjunct in flap delay procedures. Available studies suggest that ultrasound compares favorably to other widely-used imaging modalities for these indications.
Conclusion This article presents an in-depth review of the current applications of ultrasound in the preoperative planning of DIEP flaps and explores some potential areas for future investigation.
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Affiliation(s)
- Carolina Torres Perez-Iglesias
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Laikhter
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christine O. Kang
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amer H. Nassar
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy M. Maselli
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ryan Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T. Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Laikhter E, Shiah E, Manstein SM, Comer CD, Bustos VP, Lin SJ. Trends and characteristics of neurotization during breast reconstruction: perioperative outcomes using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). J Plast Surg Hand Surg 2021; 56:291-297. [PMID: 34524064 DOI: 10.1080/2000656x.2021.1973484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/20/2022]
Abstract
This study aimed to investigate the impact of performing neurotization during breast reconstruction on total operating time and post-operative morbidity. The 2015 through 2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases were utilized to identify patients who underwent breast reconstruction with and without neurotization. Baseline demographics, comorbidities, operative characteristics and outcomes were examined for each group. Thirty-day complication and readmission rates were compared using univariable and multivariable logistic regressions. Of 73,507 patients identified who underwent breast reconstruction, 240 had reconstruction with neurotization. Autologous reconstruction was more prevalent for patients with neurotization (90.8% vs. 18.5%, p<.001). Average operating time was longer when neurotization was performed during both autologous (527.1 ± 152.4 vs. 414.8 ± 186.3, p<.001) and alloplastic-only reconstruction (310.9 ± 115.9 vs. 173.0 ± 94.3, p<.001). The likelihood total operating time exceeded 521 min (two standard deviations above average) increased when neurotization was performed (OR 2.464, CI 1.864-3.255, p<.001). Thirty-day complications occurred in 13.8% of patients with neurotization and 6.8% without (p<.001). Similarly, 30-day readmission rates were higher for patients with neurotization (7.5% vs. 4.2%, p<.001). However, when adjusted for comorbidities and operative characteristics, neurotization did not significantly impact 30-day complication rates (OR 0.802, CI 0.548-1.174, p=.256) or 30-day readmission rates (OR 1.352, CI 0.822-2.223, p=.077). Although neurotization during breast reconstruction increases operating time, comorbidities and procedural characteristics play a greater role in post-operative outcomes than neurotization alone.
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Affiliation(s)
- Elizabeth Laikhter
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eric Shiah
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel M Manstein
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Carly D Comer
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Young MN, Kolte D, Cadigan ME, Laikhter E, Sinclair K, Pomerantsev E, Fifer MA, Sundt TM, Yeh RW, Jaffer FA. Multidisciplinary Heart Team Approach for Complex Coronary Artery Disease: Single Center Clinical Presentation. J Am Heart Assoc 2020; 9:e014738. [PMID: 32308096 PMCID: PMC7428540 DOI: 10.1161/jaha.119.014738] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background The Heart Team approach is ascribed a Class I recommendation in contemporary guidelines for revascularization of complex coronary artery disease. However, limited data are available regarding the decision-making and outcomes of patients based on this strategy. Methods and Results One hundred sixty-six high-risk coronary artery disease patients underwent Heart Team evaluation at a single institution between January 2015 and November 2018. We prospectively collected data on demographics, symptoms, Society of Thoracic Surgeons Predicted Risk of Mortality/Synergy Between PCI with Taxus and Cardiac Surgery (STS-PROM/SYNTAX) scores, mode of revascularization, and outcomes. Mean age was 70.0 years; 122 (73.5%) patients were male. Prevalent comorbidities included diabetes mellitus (51.8%), peripheral artery disease (38.6%), atrial fibrillation (27.1%), end-stage renal disease on dialysis (13.3%), and chronic obstructive pulmonary disease (21.7%). Eighty-seven (52.4%) patients had New York Heart Association III-IV and 112 (67.5%) had Canadian Cardiovascular Society III-IV symptomatology. Sixty-seven (40.4%) patients had left main and 118 (71.1%) had 3-vessel coronary artery disease. The median STS-PROM was 3.6% (interquartile range 1.9, 8.0) and SYNTAX score was 26 (interquartile range 20, 34). The median number of physicians per Heart Team meeting was 6 (interquartile range 5, 8). Seventy-nine (47.6%) and 49 (29.5%) patients underwent percutaneous coronary intervention and coronary artery bypass grafting, respectively. With increasing STS-PROM (low, intermediate, high operative risk), coronary artery bypass graft was performed less often (47.9%, 18.5%, 15.2%) and optimal medical therapy was recommended more often (11.3%, 18.5%, 30.3%). There were no trends in recommendation for coronary artery bypass graft, percutaneous coronary intervention, or optimal medical therapy by SYNTAX score tertiles. In-hospital and 30-day mortality was 3.9% and 4.8%, respectively. Conclusions Integrating a multidisciplinary Heart Team into institutional practice is feasible and provides a formalized approach to evaluating complex coronary artery disease patients. The comprehensive assessment of surgical, anatomical, and other risk scores using a decision aid may guide appropriate, evidence-based management within this team-based construct.
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Affiliation(s)
- Michael N Young
- Division of Cardiology Dartmouth-Hitchcock Medical Center Geisel School of Medicine at Dartmouth Lebanon NH
| | - Dhaval Kolte
- Division of Cardiology Massachusetts General Hospital Boston MA
| | - Mary E Cadigan
- Division of Cardiology Massachusetts General Hospital Boston MA
| | | | - Kevin Sinclair
- Division of Cardiology Massachusetts General Hospital Boston MA
| | | | - Michael A Fifer
- Division of Cardiology Massachusetts General Hospital Boston MA
| | - Thoralf M Sundt
- Division of Cardiology Massachusetts General Hospital Boston MA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA
| | - Farouc A Jaffer
- Division of Cardiology Massachusetts General Hospital Boston MA
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Fiedler AG, Bhambhani V, Laikhter E, Picard MH, Wasfy MM, Tolis G, Melnitchouk S, Sundt TM, Wasfy JH. Aortic valve replacement associated with survival in severe regurgitation and low ejection fraction. Heart 2018; 104:835-840. [PMID: 29092919 DOI: 10.1136/heartjnl-2017-312024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/30/2017] [Accepted: 10/04/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Although guidelines support aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR) and left ventricular ejection fraction (LVEF) <50%, severe left ventricular dysfunction (LVEF <35%) is thought to confer high surgical risk. We sought to determine if a survival benefit exists with AVR compared with medical management in this high-risk, relatively rare population. METHODS A large institutional echocardiography database was queried to identify patients with severe AR and LVEF <35%. Manual chart review was performed. Due to small sample size and population heterogeneity, corrected group prognosis method was applied, which calculates the adjusted survival curve for each individual using fitted Cox proportional hazard model. Average survival adjusted for comorbidities and age was then calculated using the weighted average of the individual survival curves. RESULTS Initially, 2 54 614 echocardiograms were considered, representing 1 45 785 unique patients, of which 40 patients met inclusion criteria. Of those, 18 (45.0%) underwent AVR and 22 (55.0%) were managed medically. Absolute mortality was 27.8% in the AVR group and 91.2% in the medical management group. After multivariate adjustment, end-stage renal disease (HR=17.633, p=0.0335) and peripheral arterial disease (HR=6.050, p=0.0180) were associated with higher mortality. AVR was associated with lower mortality (HR=0.143, p=0.0490). Mean follow-up time of the study cohort was 6.58 years, and mean survival for patients undergoing AVR was 6.31 years. CONCLUSIONS Even after adjustment for clinical characteristics and patient age, AVR is associated with higher survival for patients with low LVEF and severe AR. Although treatment selection bias cannot be completely eliminated by this analysis, these results provide some evidence that surgery may be associated with prolonged survival in this high-risk patient group.
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Affiliation(s)
- Amy G Fiedler
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vijeta Bhambhani
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Laikhter
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Meagan M Wasfy
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Martin LM, Thompson RW, Ferris TG, Singh JP, Laikhter E, Bhambhani V, Wasfy JH. Abstract 014: Evaluation of Readmission after Acute Myocardial Infarction for Patients Included in Medicare’s Hospital Readmissions Reduction Program. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.014] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Medicare’s Hospital Readmissions Reduction Program assesses financial penalties for hospitals based on risk-standardized readmission rates after specific episodes of care, including acute myocardial infarction (AMI). Whether the algorithm accurately identifies patients with AMI who have preventable readmission is unknown.
Methods:
Using administrative data from Medicare, we conducted physician-adjudicated chart reviews of all patients considered 30 day readmissions after AMI attributed to one hospital from July 2012-June 2015. We extracted information about revascularization during index hospitalization. For patients readmitted to the index hospital or an affiliate, we also extracted reason for readmission.
Results:
Of 199 admissions, 66 (33.2%) received PCI and 19 (9.6%) underwent CABG on index hospitalization. The remainder of patients did not receive any intervention, i.e. 39 patients (19.6%) were declined due to procedural risk, 15 (7.5%) because of goals of care and 14 (7.0%) refused revascularization. Forty-six patients (23.1%) had troponin elevation in the absence of an MI and did not have an indication for revascularization. The most common diagnoses of the 161 (80.9%) patients readmitted to the index hospital or an affiliate were infections and cardiac and non-cardiac chest discomfort (Table 1).
Conclusions:
Our results demonstrate that many AMI patients who count towards the Medicare penalty do not receive revascularization during the index hospitalization because of high procedural risk or patient preference. Focusing on these patients may improve readmission metric performance. Furthermore, adding administrative codes for prohibitive procedural risk may improve accuracy of the metric as a measure of quality.
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Affiliation(s)
- Lila M Martin
- Dept of Medicine, Massachusetts General Hosp, Harvard Med Sch,, Boston, MA
| | - Ryan W Thompson
- Dept of Medicine, Massachusetts General Hosp, Harvard Med Sch,, Boston, MA
| | - Timothy G Ferris
- Dept of Medicine, Massachusetts General Hosp, Harvard Med Sch,, Boston, MA
| | - Jagmeet P Singh
- Cardiology Div, Dept of Medicine, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Elizabeth Laikhter
- Cardiology Div, Dept of Medicine, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Vijeta Bhambhani
- Cardiology Div, Dept of Medicine, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Jason H Wasfy
- Cardiology Div, Dept of Medicine, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
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Fiedler A, Bhambhani V, Laikhter E, Picard M, Sundt T, Wasfy J. Abstract 163: Aortic Valve Replacement Confers a Survival Benefit in Patients With Severe Aortic Insufficiency With Depressed Left Ventricular Ejection Fraction. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.163] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Although guidelines support aortic valve replacement (AVR) in patients with severe aortic regurgitation (AI) and left ventricular ejection fraction (LVEF) < 50%, severe left ventricular dysfunction (LVEF < 35%) is thought to confer very high surgical risk. The survival benefit associated with surgical intervention, however, is unknown. We evaluated long term outcomes of this patient population with and without surgical intervention.
Methods:
To capture patients who did and did not undergo AVR, we queried a single institutions echocardiography database to identify all patients with severe AR and LVEF < 35%. Manual chart review was performed to identify key demographic, clinical, and operative details. This retrospective cohort was then merged with institutional patient data. Due to small sample size and population heterogeneity, corrected group prognosis method was applied, which calculates the adjusted survival curve for each individual using fitted Cox proportional hazard model. Average survival adjusted for co-morbidities and age was then calculated using the weighted average of the individual survival curves.
Results:
Of 43 echocardiograms representing 41 unique patients, 40 patients met inclusion criteria. Of those, 18 (45.0%) underwent AVR and 22 (55.0%) were managed medically. After multivariate adjustment, end stage renal disease (HR = 17.633, p =0.0335) and peripheral arterial disease (HR = 6.050, p =0.0180) were associated with increased long term mortality. AVR was associated with decreased mortality (HR = 0.143, p =0.0490, see Figure 1). The mean survival for patients undergoing AVR was 6.3 years. The mean follow-up time was 6.58 years.
Conclusions:
Even after adjustment for clinical characteristics and patient age, AVR is associated with increased survival for patients with severe systolic dysfunction and severe aortic insufficiency. Although treatment selection bias cannot be completely eliminated with this retrospective cohort design, these results support performing surgery on this high-risk patient group.
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Young M, Laikhter E, Sinclair K, Cadigan M, Pomerantsev E, Fifer M, Sundt T, Yeh R, Jaffer F. EMPLOYING THE MULTIDISCIPLINARY HEART TEAM APPROACH FOR COMPLEX CORONARY ARTERY DISEASE: A SINGLE CENTER EXPERIENCE. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)35933-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wasfy JH, Rao SK, Essien UR, Richardson CA, Jeune T, Goldstein SA, Laikhter E, Chittle MD, Weil M, Wein M, Ferris TG. Initial experience with endocrinology e-consults. Endocrine 2017; 55:640-642. [PMID: 27507674 DOI: 10.1007/s12020-016-1053-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sandhya K Rao
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Utibe R Essien
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Tamika Jeune
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan A Goldstein
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Laikhter
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Melissa D Chittle
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michelle Weil
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc Wein
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy G Ferris
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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