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AMA Town Hall: Doctors call for meaningful use delay
Stage 3 of meaningful use should be delayed until Medicare value-based care programs are developed.
To move the Centers for Medicare & Medicaid Services toward that goal, the American Medical Association has created a new website – Break the Red Tape – where physicians can share their good and bad experiences with electronic health records (EHRs) in an effort to help policymakers understand the landscape.
“We want to hear … both what is working so that we can help try to make that happen, but we also need to hear what is not working so that we can send a clear message through our stories, through our real-world experience, to those in policymaking so that they can help us to craft better policies and a better program that will make electronic health records and the policies that the federal government that seek to advance and support the adoption of those tools more effective,” Dr. Stephen Stack, AMA president said July 20 during a town hall event in Atlanta.
At the event, physicians shared how EHRs have affected their practices; many of the comments were negative, though a few bright spots, including electronic prescribing, were highlighted.
Dr. Stack summed up the majority of comments under two key points – usability and interoperability.
“We’ve got to fix the usability, and you all have clearly shown through your stories that information is not being exchanged and that’s not our fault because we didn’t write the code and we didn’t build the wires that connect it,” he said.
Usability issues have translated to decreased productivity, even for those who are experienced in with EHRs. Dr. Melissa Rhodes, a pulmonary, critical care, and sleep physician at Respiratory Consultants of Georgia, said that even though she has been using EHRs since 2006, she still faces a loss of patient care time.
“Every time they have more regulations, more things that I have to answer, takes time away from the patient,” Dr. Rhodes said. She said that she currently sees two-thirds of the patients she could see, and added that she is now asking prospective employees if they know how to type, acknowledging that without that skill, her work flow would be even less productive.
Another comment on usability came from Dr. Albert Johary, a solo-practice internist in Dunwoody, Ga., who has participated in meaningful use for 4 years. He highlighted smoking cessation to illustrate how EHRs are making things more challenging. Prior to EHRs, he would chart that a patient was wanting help to quit smoking and note a prescription for varenicline.
With the EHR he is using now, which he did not identify, he said that he must account for a number of different steps.
“What I’ve started doing is I am doing this in front of the patients,” Dr. Johary said. “I am trying to work with it. I think meaningful use is not necessarily a bad thing,” but even giving notes to a patient is “a four- or five-step process.”
Interoperability “is a major issue” as well, he said, noting that he is part of the Emory Integrated Health Network and now is having to switch EHRs because of the lack of interoperability with the network.
Dr. Stack noted that the AMA supports the alignment of meaningful use with the coming value-based payment reforms. “We do believe that we should pause Stage 3 meaningful use so that it can align with these other new payment delivery models as we go forward,” he said. “We are now going to have the MIPS [Merit-based Incentive Payment System] program, which is going to have meaningful use as a substantial portion of it,” Dr. Stack continued. “We think that the rule making for these two should happen concurrently so that it makes sense when it comes out, not that we do them wrong the first time and have to redo them again to make it all make sense.”
Stage 3 of meaningful use should be delayed until Medicare value-based care programs are developed.
To move the Centers for Medicare & Medicaid Services toward that goal, the American Medical Association has created a new website – Break the Red Tape – where physicians can share their good and bad experiences with electronic health records (EHRs) in an effort to help policymakers understand the landscape.
“We want to hear … both what is working so that we can help try to make that happen, but we also need to hear what is not working so that we can send a clear message through our stories, through our real-world experience, to those in policymaking so that they can help us to craft better policies and a better program that will make electronic health records and the policies that the federal government that seek to advance and support the adoption of those tools more effective,” Dr. Stephen Stack, AMA president said July 20 during a town hall event in Atlanta.
At the event, physicians shared how EHRs have affected their practices; many of the comments were negative, though a few bright spots, including electronic prescribing, were highlighted.
Dr. Stack summed up the majority of comments under two key points – usability and interoperability.
“We’ve got to fix the usability, and you all have clearly shown through your stories that information is not being exchanged and that’s not our fault because we didn’t write the code and we didn’t build the wires that connect it,” he said.
Usability issues have translated to decreased productivity, even for those who are experienced in with EHRs. Dr. Melissa Rhodes, a pulmonary, critical care, and sleep physician at Respiratory Consultants of Georgia, said that even though she has been using EHRs since 2006, she still faces a loss of patient care time.
“Every time they have more regulations, more things that I have to answer, takes time away from the patient,” Dr. Rhodes said. She said that she currently sees two-thirds of the patients she could see, and added that she is now asking prospective employees if they know how to type, acknowledging that without that skill, her work flow would be even less productive.
Another comment on usability came from Dr. Albert Johary, a solo-practice internist in Dunwoody, Ga., who has participated in meaningful use for 4 years. He highlighted smoking cessation to illustrate how EHRs are making things more challenging. Prior to EHRs, he would chart that a patient was wanting help to quit smoking and note a prescription for varenicline.
With the EHR he is using now, which he did not identify, he said that he must account for a number of different steps.
“What I’ve started doing is I am doing this in front of the patients,” Dr. Johary said. “I am trying to work with it. I think meaningful use is not necessarily a bad thing,” but even giving notes to a patient is “a four- or five-step process.”
Interoperability “is a major issue” as well, he said, noting that he is part of the Emory Integrated Health Network and now is having to switch EHRs because of the lack of interoperability with the network.
Dr. Stack noted that the AMA supports the alignment of meaningful use with the coming value-based payment reforms. “We do believe that we should pause Stage 3 meaningful use so that it can align with these other new payment delivery models as we go forward,” he said. “We are now going to have the MIPS [Merit-based Incentive Payment System] program, which is going to have meaningful use as a substantial portion of it,” Dr. Stack continued. “We think that the rule making for these two should happen concurrently so that it makes sense when it comes out, not that we do them wrong the first time and have to redo them again to make it all make sense.”
Stage 3 of meaningful use should be delayed until Medicare value-based care programs are developed.
To move the Centers for Medicare & Medicaid Services toward that goal, the American Medical Association has created a new website – Break the Red Tape – where physicians can share their good and bad experiences with electronic health records (EHRs) in an effort to help policymakers understand the landscape.
“We want to hear … both what is working so that we can help try to make that happen, but we also need to hear what is not working so that we can send a clear message through our stories, through our real-world experience, to those in policymaking so that they can help us to craft better policies and a better program that will make electronic health records and the policies that the federal government that seek to advance and support the adoption of those tools more effective,” Dr. Stephen Stack, AMA president said July 20 during a town hall event in Atlanta.
At the event, physicians shared how EHRs have affected their practices; many of the comments were negative, though a few bright spots, including electronic prescribing, were highlighted.
Dr. Stack summed up the majority of comments under two key points – usability and interoperability.
“We’ve got to fix the usability, and you all have clearly shown through your stories that information is not being exchanged and that’s not our fault because we didn’t write the code and we didn’t build the wires that connect it,” he said.
Usability issues have translated to decreased productivity, even for those who are experienced in with EHRs. Dr. Melissa Rhodes, a pulmonary, critical care, and sleep physician at Respiratory Consultants of Georgia, said that even though she has been using EHRs since 2006, she still faces a loss of patient care time.
“Every time they have more regulations, more things that I have to answer, takes time away from the patient,” Dr. Rhodes said. She said that she currently sees two-thirds of the patients she could see, and added that she is now asking prospective employees if they know how to type, acknowledging that without that skill, her work flow would be even less productive.
Another comment on usability came from Dr. Albert Johary, a solo-practice internist in Dunwoody, Ga., who has participated in meaningful use for 4 years. He highlighted smoking cessation to illustrate how EHRs are making things more challenging. Prior to EHRs, he would chart that a patient was wanting help to quit smoking and note a prescription for varenicline.
With the EHR he is using now, which he did not identify, he said that he must account for a number of different steps.
“What I’ve started doing is I am doing this in front of the patients,” Dr. Johary said. “I am trying to work with it. I think meaningful use is not necessarily a bad thing,” but even giving notes to a patient is “a four- or five-step process.”
Interoperability “is a major issue” as well, he said, noting that he is part of the Emory Integrated Health Network and now is having to switch EHRs because of the lack of interoperability with the network.
Dr. Stack noted that the AMA supports the alignment of meaningful use with the coming value-based payment reforms. “We do believe that we should pause Stage 3 meaningful use so that it can align with these other new payment delivery models as we go forward,” he said. “We are now going to have the MIPS [Merit-based Incentive Payment System] program, which is going to have meaningful use as a substantial portion of it,” Dr. Stack continued. “We think that the rule making for these two should happen concurrently so that it makes sense when it comes out, not that we do them wrong the first time and have to redo them again to make it all make sense.”
Talent: Too much or too little depends on the kind of team
Talent facilitates team performance, but only up to a point, depending on the type of team. For highly interdependent teams, there is a threshold where the benefits of more talent decrease and eventually become detrimental rather than beneficial, according to an analysis of five studies performed by Roderick I. Swaab and his colleagues.
Surveys across industries and countries show that organizations consider talent attraction is their top priority, presumably based on the belief that more talent is better and the relationship between talent and team performance is linear and monotonic, they stated in Psychological Science (2014;25:1581-91)
The researchers analyzed the results of five studies they performed to investigate this relationship, comparing the impact of talent on team performance in the highly interdependent sports soccer (World Cup performance) and basketball (NBA), compared with the less interdependent sport of baseball (MLB).
In the case of soccer, team performance data were based on the average Fédération Internationale de Football Association (FIFA) rankings of national teams during the 2010 and 2014 World Cup qualification periods. Top talent was assessed by dividing the team’s numbers of players in each national team active in one of the world’s elite clubs divided by the total number of players on the national team.
In the case of the NBA, top talent was determined using the individual players’ estimated wins added (EWA) as determined over a 10-year period (2002-2012), with an index determining whether a player was in the top one-third (1) or not (0). Team performance was measured using each team’s end-of-year win percentage.
For baseball, top talent was determined using a player’s wins above replacement statistic (WAR), which is the number of wins a player contributes relative to a freely available minor-league player. Team performance was measured using each team’s win percentage.
In their results, basketball and soccer, the two most interdependent of the three sports, both showed a significant quadratic effect in which top talent benefited performance only up to a point, after which the marginal benefit of talent decreased and turned negative.
These results were in contrast to those seen with baseball. “As we predicted, the effect of top talent never turned negative in baseball, a sport in which task interdependence is relatively low. Thus there was no too-much-talent effect in baseball unlike in football [soccer] and basketball” according to the researchers.
“We predict that the too-much-talent effect will be found in other organizational contexts as well,” they added.
“Just as a colony of high-performing chickens competing for dominance suffers decrements in overall egg production and increases in bird mortality, teams with too much talent appear to divert attention away from coordination as team members peck at each other in their attempts to establish intergroup standing. In many cases, too much talent can be the seed of failure,” Mr. Swaab and his colleagues concluded.
The authors all declared that they had no conflicts of interest relative to the paper.
Mr. Swaab and his colleagues hypothesized the “too-much-talent effect” and found that talent often facilitates team performance, but only up to a point. They report that the relationship between talent and performance is not linear and monotonic. In contrast, they found that the relationship in football and basketball eventually turns negative (Psychol. Science 2014;25;1581-91). We have all heard the phrase, “There is no ‘I’ in team,” and it is clear that in certain sports, a team is necessary. No single cyclist can win the Tour de France without a strong team of support, and a soccer striker who is arrogant and feels he or she can score alone will fail to pass to the open teammate time and time again. We have all seen this strategy fail to result in a win. In contrast, one role of the midfielder in soccer is to provide selfless service to the striker – for the benefit of the team.
The cardiothoracic surgery world that we all work in can benefit from the findings reported by Swaab and colleagues. The individual with the “talent” in the cardiothoracic surgery realm – the skilled surgeon – may not be the best at building teams that work well together, and putting together several talented surgeons does not make an outstanding surgical team. Surgeons are not trained to be leaders, team builders, or to model collaborative behavior. A good leader requires emotional intelligence to be aware of others around her and of the successes and failures of the team. Lynda Gratton and Tamara J. Erickson found that the most productive, innovative teams were led by people who were both task- and relationship-oriented and that these leaders changed their style during the project (Eight Ways to Build Collaborative Teams, Harvard Bushiness Review, November 2007). Their findings were similar to those reported by Mr. Swaab and his colleagues in that they also found that the greater the proportion of highly educated specialists on a team, the more likely the team is to disintegrate into unproductive conflicts.
If we wish to establish world-renowned service lines or surgical programs, we would be well served by understanding that a great team requires collaboration, cohesion, and diversity. Diversity not only in talent but also in background and experiences. In addition, surgeon leaders cannot score all of the goals alone; they need an integrated, cohesive, diverse, and collaborative team to provide excellent patient care.
Dr. Jennifer S. Lawton is a professor of surgery at the division of cardiothoracic surgery, Washington University, St. Louis. She is also an associate medical editor for Vascular Specialist.
Mr. Swaab and his colleagues hypothesized the “too-much-talent effect” and found that talent often facilitates team performance, but only up to a point. They report that the relationship between talent and performance is not linear and monotonic. In contrast, they found that the relationship in football and basketball eventually turns negative (Psychol. Science 2014;25;1581-91). We have all heard the phrase, “There is no ‘I’ in team,” and it is clear that in certain sports, a team is necessary. No single cyclist can win the Tour de France without a strong team of support, and a soccer striker who is arrogant and feels he or she can score alone will fail to pass to the open teammate time and time again. We have all seen this strategy fail to result in a win. In contrast, one role of the midfielder in soccer is to provide selfless service to the striker – for the benefit of the team.
The cardiothoracic surgery world that we all work in can benefit from the findings reported by Swaab and colleagues. The individual with the “talent” in the cardiothoracic surgery realm – the skilled surgeon – may not be the best at building teams that work well together, and putting together several talented surgeons does not make an outstanding surgical team. Surgeons are not trained to be leaders, team builders, or to model collaborative behavior. A good leader requires emotional intelligence to be aware of others around her and of the successes and failures of the team. Lynda Gratton and Tamara J. Erickson found that the most productive, innovative teams were led by people who were both task- and relationship-oriented and that these leaders changed their style during the project (Eight Ways to Build Collaborative Teams, Harvard Bushiness Review, November 2007). Their findings were similar to those reported by Mr. Swaab and his colleagues in that they also found that the greater the proportion of highly educated specialists on a team, the more likely the team is to disintegrate into unproductive conflicts.
If we wish to establish world-renowned service lines or surgical programs, we would be well served by understanding that a great team requires collaboration, cohesion, and diversity. Diversity not only in talent but also in background and experiences. In addition, surgeon leaders cannot score all of the goals alone; they need an integrated, cohesive, diverse, and collaborative team to provide excellent patient care.
Dr. Jennifer S. Lawton is a professor of surgery at the division of cardiothoracic surgery, Washington University, St. Louis. She is also an associate medical editor for Vascular Specialist.
Mr. Swaab and his colleagues hypothesized the “too-much-talent effect” and found that talent often facilitates team performance, but only up to a point. They report that the relationship between talent and performance is not linear and monotonic. In contrast, they found that the relationship in football and basketball eventually turns negative (Psychol. Science 2014;25;1581-91). We have all heard the phrase, “There is no ‘I’ in team,” and it is clear that in certain sports, a team is necessary. No single cyclist can win the Tour de France without a strong team of support, and a soccer striker who is arrogant and feels he or she can score alone will fail to pass to the open teammate time and time again. We have all seen this strategy fail to result in a win. In contrast, one role of the midfielder in soccer is to provide selfless service to the striker – for the benefit of the team.
The cardiothoracic surgery world that we all work in can benefit from the findings reported by Swaab and colleagues. The individual with the “talent” in the cardiothoracic surgery realm – the skilled surgeon – may not be the best at building teams that work well together, and putting together several talented surgeons does not make an outstanding surgical team. Surgeons are not trained to be leaders, team builders, or to model collaborative behavior. A good leader requires emotional intelligence to be aware of others around her and of the successes and failures of the team. Lynda Gratton and Tamara J. Erickson found that the most productive, innovative teams were led by people who were both task- and relationship-oriented and that these leaders changed their style during the project (Eight Ways to Build Collaborative Teams, Harvard Bushiness Review, November 2007). Their findings were similar to those reported by Mr. Swaab and his colleagues in that they also found that the greater the proportion of highly educated specialists on a team, the more likely the team is to disintegrate into unproductive conflicts.
If we wish to establish world-renowned service lines or surgical programs, we would be well served by understanding that a great team requires collaboration, cohesion, and diversity. Diversity not only in talent but also in background and experiences. In addition, surgeon leaders cannot score all of the goals alone; they need an integrated, cohesive, diverse, and collaborative team to provide excellent patient care.
Dr. Jennifer S. Lawton is a professor of surgery at the division of cardiothoracic surgery, Washington University, St. Louis. She is also an associate medical editor for Vascular Specialist.
Talent facilitates team performance, but only up to a point, depending on the type of team. For highly interdependent teams, there is a threshold where the benefits of more talent decrease and eventually become detrimental rather than beneficial, according to an analysis of five studies performed by Roderick I. Swaab and his colleagues.
Surveys across industries and countries show that organizations consider talent attraction is their top priority, presumably based on the belief that more talent is better and the relationship between talent and team performance is linear and monotonic, they stated in Psychological Science (2014;25:1581-91)
The researchers analyzed the results of five studies they performed to investigate this relationship, comparing the impact of talent on team performance in the highly interdependent sports soccer (World Cup performance) and basketball (NBA), compared with the less interdependent sport of baseball (MLB).
In the case of soccer, team performance data were based on the average Fédération Internationale de Football Association (FIFA) rankings of national teams during the 2010 and 2014 World Cup qualification periods. Top talent was assessed by dividing the team’s numbers of players in each national team active in one of the world’s elite clubs divided by the total number of players on the national team.
In the case of the NBA, top talent was determined using the individual players’ estimated wins added (EWA) as determined over a 10-year period (2002-2012), with an index determining whether a player was in the top one-third (1) or not (0). Team performance was measured using each team’s end-of-year win percentage.
For baseball, top talent was determined using a player’s wins above replacement statistic (WAR), which is the number of wins a player contributes relative to a freely available minor-league player. Team performance was measured using each team’s win percentage.
In their results, basketball and soccer, the two most interdependent of the three sports, both showed a significant quadratic effect in which top talent benefited performance only up to a point, after which the marginal benefit of talent decreased and turned negative.
These results were in contrast to those seen with baseball. “As we predicted, the effect of top talent never turned negative in baseball, a sport in which task interdependence is relatively low. Thus there was no too-much-talent effect in baseball unlike in football [soccer] and basketball” according to the researchers.
“We predict that the too-much-talent effect will be found in other organizational contexts as well,” they added.
“Just as a colony of high-performing chickens competing for dominance suffers decrements in overall egg production and increases in bird mortality, teams with too much talent appear to divert attention away from coordination as team members peck at each other in their attempts to establish intergroup standing. In many cases, too much talent can be the seed of failure,” Mr. Swaab and his colleagues concluded.
The authors all declared that they had no conflicts of interest relative to the paper.
Talent facilitates team performance, but only up to a point, depending on the type of team. For highly interdependent teams, there is a threshold where the benefits of more talent decrease and eventually become detrimental rather than beneficial, according to an analysis of five studies performed by Roderick I. Swaab and his colleagues.
Surveys across industries and countries show that organizations consider talent attraction is their top priority, presumably based on the belief that more talent is better and the relationship between talent and team performance is linear and monotonic, they stated in Psychological Science (2014;25:1581-91)
The researchers analyzed the results of five studies they performed to investigate this relationship, comparing the impact of talent on team performance in the highly interdependent sports soccer (World Cup performance) and basketball (NBA), compared with the less interdependent sport of baseball (MLB).
In the case of soccer, team performance data were based on the average Fédération Internationale de Football Association (FIFA) rankings of national teams during the 2010 and 2014 World Cup qualification periods. Top talent was assessed by dividing the team’s numbers of players in each national team active in one of the world’s elite clubs divided by the total number of players on the national team.
In the case of the NBA, top talent was determined using the individual players’ estimated wins added (EWA) as determined over a 10-year period (2002-2012), with an index determining whether a player was in the top one-third (1) or not (0). Team performance was measured using each team’s end-of-year win percentage.
For baseball, top talent was determined using a player’s wins above replacement statistic (WAR), which is the number of wins a player contributes relative to a freely available minor-league player. Team performance was measured using each team’s win percentage.
In their results, basketball and soccer, the two most interdependent of the three sports, both showed a significant quadratic effect in which top talent benefited performance only up to a point, after which the marginal benefit of talent decreased and turned negative.
These results were in contrast to those seen with baseball. “As we predicted, the effect of top talent never turned negative in baseball, a sport in which task interdependence is relatively low. Thus there was no too-much-talent effect in baseball unlike in football [soccer] and basketball” according to the researchers.
“We predict that the too-much-talent effect will be found in other organizational contexts as well,” they added.
“Just as a colony of high-performing chickens competing for dominance suffers decrements in overall egg production and increases in bird mortality, teams with too much talent appear to divert attention away from coordination as team members peck at each other in their attempts to establish intergroup standing. In many cases, too much talent can be the seed of failure,” Mr. Swaab and his colleagues concluded.
The authors all declared that they had no conflicts of interest relative to the paper.
FROM PSYCHOLOGICAL SCIENCE
Key clinical point: Talent facilitates team performance, but it’s only up to a point, depending on the type of team.
Major finding: For highly interdependent teams, there is a threshold where the benefits of more talent decrease and eventually become detrimental rather than beneficial.
Data source: Five studies compared the impact of talent on team performance in the highly interdependent sports soccer (World Cup performance) and basketball (NBA), compared with the less interdependent sport of baseball (MLB)
Disclosures: The authors of the study reported no relevant disclosures.
CABG costs more in patients with diabetes
The rate of diabetic coronary artery bypass graft patients has increased more than fivefold in recent decades, and these patients are more likely to have worse outcomes and higher treatment costs, a study showed.
The percentage of patients who had diabetes among all those undergoing coronary artery bypass grafting (CABG) increased from 7% in the 1970s to 37% in the 2000s, according to a database study of 55,501 patients operated on at the Cleveland Clinic.
Patients were identified and preoperative, operative, and postoperative variables were identified, resulting in 45,139 nondiabetic patients assessed and 10,362 diabetic patients (defined as those diabetic patients pharmacologically treated with either insulin or an oral agent) evaluated. The endpoints assessed were in-hospital adverse outcomes as determined by the Society of Thoracic Surgeons National Database, in-hospital direct technical costs, and time-related mortality, according to Dr. Sajjad Raza and his colleagues at the Cleveland Clinic in the August issue of the Journal of Thoracic and Cardiovascular Surgery (150:294-301).
Compared with nondiabetics, diabetic patients undergoing CABG were older and were more likely to be overweight, to be women, and to have a history of heart failure, peripheral arterial disease, carotid disease, hypertension, renal failure, stroke, and advanced coronary artery disease. Over time, the cardiovascular risk profile of the entire population changed, becoming even more pronounced for all patients, but more so for diabetics.
Overall long-term survival at 6 months and at 1, 5 10, 15, and 20 years for diabetic patients was 95%, 94%, 80%, 54%, 31%, and 18%, respectively, compared with 97%, 97%, 90%, 76%, 59%, and 42% for nondiabetic patients, a significant difference at P <.0001.
Propensity matching of similar diabetic and nondiabetic patients showed that deep sternal wound infection and stroke occurred significantly more often in diabetics, although there were no significant differences in cost remaining after matching, even though the length of stay greater than 14 days remained higher for diabetic patients.
Among diabetics, overall survival at 6 months and at 1, 5, 10, 15, and 20 years after CABG was 95%, 94%, 80%, 54%, 31%, and 18%, respectively, compared with overall survival in nondiabetics at 97%, 97%, 90%, 76%, 59%, and 42%, respectively, a significant difference (P <.0001).
“Although long-term survival after CABG is worse in diabetics and high-risk nondiabetics, it is important to note that, in general, high-risk patients reap the greatest survival benefit from CABG. Moreover, using surgical techniques that are associated with better long-term survival after CABG in diabetics could further enhance this survival benefit,” Dr. Raza and his colleagues wrote.
“Diabetes is both a marker for high-risk, resource-intensive, and expensive care after CABG and an independent risk factor for reduced long-term survival,” they added. “Diabetic patients and those with a similar high-risk profile set to undergo CABG should be made aware that their risks of postoperative complications are higher than average, and measures should be taken to reduce their postoperative complications,” Dr. Raza and his colleagues concluded.
The authors reported that they had no relevant conflicts of interest.
Patients with diabetes, with or without metabolic syndrome, represent an increasing challenge for cardiac surgery. CABG has been shown to convey a mortality benefit in such patients who also have multivessel disease. This study confirms what most clinicians already know – that the outcomes of patients with diabetes are worse than those in nondiabetic patients, according to Dr. Mani Arsalan and Dr. Michael Mack. “What is particularly important about this study, however, is that it is a single institutional experience with known surgical excellence and a very meticulous and complete outcomes database,” they wrote (J. Thorac. Cardiovasc. Surg. 2015;150:284-5).
Given their findings and the fact that CABG can be expected to remain the mainstay of treatment of multivessel disease in diabetics because of the results of the FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease) trial, surgeons should pay increased attention to the details of the procedure for these patients. There should be an increased use of bilateral internal mammary arteries, which has been distressingly low, and yet can provide a 23% mortality benefit. “Two arteries are better than one.” Despite the increased risk of deep sternal infection, “the use of skeletonized bilateral internal mammary arteries in young, nonobese diabetic patients with a greater than 10-year life expectancy seems a reasonable risk to take,” Dr. Arsalan and Dr. Mack wrote. In addition, where possible, reaching satisfactory glycemic control before surgery can help decrease early complications. “The weight may be increasingly on our patients, but the real weight is on us as surgeons to help improve their early and long-term survival,” they concluded.
Dr. Arsalan and Dr. Mack are cardiovascular surgeons at Baylor Scott & White Health, Dallas. Their remarks were part of an invited commentary published with the paper.
Patients with diabetes, with or without metabolic syndrome, represent an increasing challenge for cardiac surgery. CABG has been shown to convey a mortality benefit in such patients who also have multivessel disease. This study confirms what most clinicians already know – that the outcomes of patients with diabetes are worse than those in nondiabetic patients, according to Dr. Mani Arsalan and Dr. Michael Mack. “What is particularly important about this study, however, is that it is a single institutional experience with known surgical excellence and a very meticulous and complete outcomes database,” they wrote (J. Thorac. Cardiovasc. Surg. 2015;150:284-5).
Given their findings and the fact that CABG can be expected to remain the mainstay of treatment of multivessel disease in diabetics because of the results of the FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease) trial, surgeons should pay increased attention to the details of the procedure for these patients. There should be an increased use of bilateral internal mammary arteries, which has been distressingly low, and yet can provide a 23% mortality benefit. “Two arteries are better than one.” Despite the increased risk of deep sternal infection, “the use of skeletonized bilateral internal mammary arteries in young, nonobese diabetic patients with a greater than 10-year life expectancy seems a reasonable risk to take,” Dr. Arsalan and Dr. Mack wrote. In addition, where possible, reaching satisfactory glycemic control before surgery can help decrease early complications. “The weight may be increasingly on our patients, but the real weight is on us as surgeons to help improve their early and long-term survival,” they concluded.
Dr. Arsalan and Dr. Mack are cardiovascular surgeons at Baylor Scott & White Health, Dallas. Their remarks were part of an invited commentary published with the paper.
Patients with diabetes, with or without metabolic syndrome, represent an increasing challenge for cardiac surgery. CABG has been shown to convey a mortality benefit in such patients who also have multivessel disease. This study confirms what most clinicians already know – that the outcomes of patients with diabetes are worse than those in nondiabetic patients, according to Dr. Mani Arsalan and Dr. Michael Mack. “What is particularly important about this study, however, is that it is a single institutional experience with known surgical excellence and a very meticulous and complete outcomes database,” they wrote (J. Thorac. Cardiovasc. Surg. 2015;150:284-5).
Given their findings and the fact that CABG can be expected to remain the mainstay of treatment of multivessel disease in diabetics because of the results of the FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease) trial, surgeons should pay increased attention to the details of the procedure for these patients. There should be an increased use of bilateral internal mammary arteries, which has been distressingly low, and yet can provide a 23% mortality benefit. “Two arteries are better than one.” Despite the increased risk of deep sternal infection, “the use of skeletonized bilateral internal mammary arteries in young, nonobese diabetic patients with a greater than 10-year life expectancy seems a reasonable risk to take,” Dr. Arsalan and Dr. Mack wrote. In addition, where possible, reaching satisfactory glycemic control before surgery can help decrease early complications. “The weight may be increasingly on our patients, but the real weight is on us as surgeons to help improve their early and long-term survival,” they concluded.
Dr. Arsalan and Dr. Mack are cardiovascular surgeons at Baylor Scott & White Health, Dallas. Their remarks were part of an invited commentary published with the paper.
The rate of diabetic coronary artery bypass graft patients has increased more than fivefold in recent decades, and these patients are more likely to have worse outcomes and higher treatment costs, a study showed.
The percentage of patients who had diabetes among all those undergoing coronary artery bypass grafting (CABG) increased from 7% in the 1970s to 37% in the 2000s, according to a database study of 55,501 patients operated on at the Cleveland Clinic.
Patients were identified and preoperative, operative, and postoperative variables were identified, resulting in 45,139 nondiabetic patients assessed and 10,362 diabetic patients (defined as those diabetic patients pharmacologically treated with either insulin or an oral agent) evaluated. The endpoints assessed were in-hospital adverse outcomes as determined by the Society of Thoracic Surgeons National Database, in-hospital direct technical costs, and time-related mortality, according to Dr. Sajjad Raza and his colleagues at the Cleveland Clinic in the August issue of the Journal of Thoracic and Cardiovascular Surgery (150:294-301).
Compared with nondiabetics, diabetic patients undergoing CABG were older and were more likely to be overweight, to be women, and to have a history of heart failure, peripheral arterial disease, carotid disease, hypertension, renal failure, stroke, and advanced coronary artery disease. Over time, the cardiovascular risk profile of the entire population changed, becoming even more pronounced for all patients, but more so for diabetics.
Overall long-term survival at 6 months and at 1, 5 10, 15, and 20 years for diabetic patients was 95%, 94%, 80%, 54%, 31%, and 18%, respectively, compared with 97%, 97%, 90%, 76%, 59%, and 42% for nondiabetic patients, a significant difference at P <.0001.
Propensity matching of similar diabetic and nondiabetic patients showed that deep sternal wound infection and stroke occurred significantly more often in diabetics, although there were no significant differences in cost remaining after matching, even though the length of stay greater than 14 days remained higher for diabetic patients.
Among diabetics, overall survival at 6 months and at 1, 5, 10, 15, and 20 years after CABG was 95%, 94%, 80%, 54%, 31%, and 18%, respectively, compared with overall survival in nondiabetics at 97%, 97%, 90%, 76%, 59%, and 42%, respectively, a significant difference (P <.0001).
“Although long-term survival after CABG is worse in diabetics and high-risk nondiabetics, it is important to note that, in general, high-risk patients reap the greatest survival benefit from CABG. Moreover, using surgical techniques that are associated with better long-term survival after CABG in diabetics could further enhance this survival benefit,” Dr. Raza and his colleagues wrote.
“Diabetes is both a marker for high-risk, resource-intensive, and expensive care after CABG and an independent risk factor for reduced long-term survival,” they added. “Diabetic patients and those with a similar high-risk profile set to undergo CABG should be made aware that their risks of postoperative complications are higher than average, and measures should be taken to reduce their postoperative complications,” Dr. Raza and his colleagues concluded.
The authors reported that they had no relevant conflicts of interest.
The rate of diabetic coronary artery bypass graft patients has increased more than fivefold in recent decades, and these patients are more likely to have worse outcomes and higher treatment costs, a study showed.
The percentage of patients who had diabetes among all those undergoing coronary artery bypass grafting (CABG) increased from 7% in the 1970s to 37% in the 2000s, according to a database study of 55,501 patients operated on at the Cleveland Clinic.
Patients were identified and preoperative, operative, and postoperative variables were identified, resulting in 45,139 nondiabetic patients assessed and 10,362 diabetic patients (defined as those diabetic patients pharmacologically treated with either insulin or an oral agent) evaluated. The endpoints assessed were in-hospital adverse outcomes as determined by the Society of Thoracic Surgeons National Database, in-hospital direct technical costs, and time-related mortality, according to Dr. Sajjad Raza and his colleagues at the Cleveland Clinic in the August issue of the Journal of Thoracic and Cardiovascular Surgery (150:294-301).
Compared with nondiabetics, diabetic patients undergoing CABG were older and were more likely to be overweight, to be women, and to have a history of heart failure, peripheral arterial disease, carotid disease, hypertension, renal failure, stroke, and advanced coronary artery disease. Over time, the cardiovascular risk profile of the entire population changed, becoming even more pronounced for all patients, but more so for diabetics.
Overall long-term survival at 6 months and at 1, 5 10, 15, and 20 years for diabetic patients was 95%, 94%, 80%, 54%, 31%, and 18%, respectively, compared with 97%, 97%, 90%, 76%, 59%, and 42% for nondiabetic patients, a significant difference at P <.0001.
Propensity matching of similar diabetic and nondiabetic patients showed that deep sternal wound infection and stroke occurred significantly more often in diabetics, although there were no significant differences in cost remaining after matching, even though the length of stay greater than 14 days remained higher for diabetic patients.
Among diabetics, overall survival at 6 months and at 1, 5, 10, 15, and 20 years after CABG was 95%, 94%, 80%, 54%, 31%, and 18%, respectively, compared with overall survival in nondiabetics at 97%, 97%, 90%, 76%, 59%, and 42%, respectively, a significant difference (P <.0001).
“Although long-term survival after CABG is worse in diabetics and high-risk nondiabetics, it is important to note that, in general, high-risk patients reap the greatest survival benefit from CABG. Moreover, using surgical techniques that are associated with better long-term survival after CABG in diabetics could further enhance this survival benefit,” Dr. Raza and his colleagues wrote.
“Diabetes is both a marker for high-risk, resource-intensive, and expensive care after CABG and an independent risk factor for reduced long-term survival,” they added. “Diabetic patients and those with a similar high-risk profile set to undergo CABG should be made aware that their risks of postoperative complications are higher than average, and measures should be taken to reduce their postoperative complications,” Dr. Raza and his colleagues concluded.
The authors reported that they had no relevant conflicts of interest.
FROM JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: The percentage of CABG patients with diabetes increased from 7% in the 1970s to 37% in the 2000s. The risk/benefit ratio warrants greater use of bilateral mammary arteries except in obese women with diabetes.
Major finding: Diabetic patients had significantly worse outcomes than nondiabetics with regard to hospital death, deep sternal wound infections, strokes, and renal failure as well as hospital stay and costs.
Data source: A retrospective analysis of a prospective database of patients undergoing first-time CABG at the Cleveland Clinic from 1972 to 2011.
Disclosures: The authors reported that they had no relevant conflicts of interest.
Dicloxacillin may cut INR levels in warfarin users
The antibiotic dicloxacillin appears to markedly decrease INR levels in patients taking warfarin, reducing the mean INR to subtherapeutic ranges in the majority who take both drugs concomitantly, according to a research letter to the editor published online July 20 in JAMA.
Adverse interactions between warfarin and other drugs are often suspected, but solid data are lacking. Case reports have suggested that the commonly used antibiotic dicloxacillin reduces warfarin’s anticoagulant effects, but no studies have examined the issue, said Anton Pottegård, Ph.D., of the department of clinical pharmacology, University of Southern Denmark, Odense, and his associates (JAMA 2015;314:296-7).
To further investigate that possibility, the investigators analyzed information in an anticoagulant database covering 7,400 patients treated by three outpatient clinics and 50 general practitioners during a 15-year period. They focused on weekly INR levels recorded for 236 patients (median age, 68 years), most of whom took warfarin because of atrial fibrillation or heart valve replacement.
The mean INR level before dicloxacillin exposure was 2.59, compared with 1.97 after dicloxacillin exposure (P < .001). A total of 144 patients (61%) had subtherapeutic INR levels (< 2.0) during the 2-4 weeks following a course of dicloxacillin, Dr. Pottegård and his associates said.
A similar but less drastic decrease was observed among the 64 patients taking a different anticoagulant, phenprocoumon, who were given dicloxacillin. Mean INR levels dropped from 2.61 before exposure to 2.30 afterward (P = .003), and 41% of the group had subtherapeutic INR levels after taking the antibiotic.
No sponsor was reported for this study. Dr. Pottegård and his associates reported having no relevant financial disclosures.
The antibiotic dicloxacillin appears to markedly decrease INR levels in patients taking warfarin, reducing the mean INR to subtherapeutic ranges in the majority who take both drugs concomitantly, according to a research letter to the editor published online July 20 in JAMA.
Adverse interactions between warfarin and other drugs are often suspected, but solid data are lacking. Case reports have suggested that the commonly used antibiotic dicloxacillin reduces warfarin’s anticoagulant effects, but no studies have examined the issue, said Anton Pottegård, Ph.D., of the department of clinical pharmacology, University of Southern Denmark, Odense, and his associates (JAMA 2015;314:296-7).
To further investigate that possibility, the investigators analyzed information in an anticoagulant database covering 7,400 patients treated by three outpatient clinics and 50 general practitioners during a 15-year period. They focused on weekly INR levels recorded for 236 patients (median age, 68 years), most of whom took warfarin because of atrial fibrillation or heart valve replacement.
The mean INR level before dicloxacillin exposure was 2.59, compared with 1.97 after dicloxacillin exposure (P < .001). A total of 144 patients (61%) had subtherapeutic INR levels (< 2.0) during the 2-4 weeks following a course of dicloxacillin, Dr. Pottegård and his associates said.
A similar but less drastic decrease was observed among the 64 patients taking a different anticoagulant, phenprocoumon, who were given dicloxacillin. Mean INR levels dropped from 2.61 before exposure to 2.30 afterward (P = .003), and 41% of the group had subtherapeutic INR levels after taking the antibiotic.
No sponsor was reported for this study. Dr. Pottegård and his associates reported having no relevant financial disclosures.
The antibiotic dicloxacillin appears to markedly decrease INR levels in patients taking warfarin, reducing the mean INR to subtherapeutic ranges in the majority who take both drugs concomitantly, according to a research letter to the editor published online July 20 in JAMA.
Adverse interactions between warfarin and other drugs are often suspected, but solid data are lacking. Case reports have suggested that the commonly used antibiotic dicloxacillin reduces warfarin’s anticoagulant effects, but no studies have examined the issue, said Anton Pottegård, Ph.D., of the department of clinical pharmacology, University of Southern Denmark, Odense, and his associates (JAMA 2015;314:296-7).
To further investigate that possibility, the investigators analyzed information in an anticoagulant database covering 7,400 patients treated by three outpatient clinics and 50 general practitioners during a 15-year period. They focused on weekly INR levels recorded for 236 patients (median age, 68 years), most of whom took warfarin because of atrial fibrillation or heart valve replacement.
The mean INR level before dicloxacillin exposure was 2.59, compared with 1.97 after dicloxacillin exposure (P < .001). A total of 144 patients (61%) had subtherapeutic INR levels (< 2.0) during the 2-4 weeks following a course of dicloxacillin, Dr. Pottegård and his associates said.
A similar but less drastic decrease was observed among the 64 patients taking a different anticoagulant, phenprocoumon, who were given dicloxacillin. Mean INR levels dropped from 2.61 before exposure to 2.30 afterward (P = .003), and 41% of the group had subtherapeutic INR levels after taking the antibiotic.
No sponsor was reported for this study. Dr. Pottegård and his associates reported having no relevant financial disclosures.
FROM JAMA
Key clinical point: The antibiotic dicloxacillin appears to markedly decrease INR levels in patients using warfarin.
Major finding: 144 patients taking warfarin (61%) had subtherapeutic international normalized ratio levels during the 2-4 weeks following a course of dicloxacillin.
Data source: An analysis of INR levels before and after antibiotic use from a Danish database of 7,400 patients taking anticoagulants.
Disclosures: No sponsor was reported for this study. Dr. Pottegard and his associates reported having no relevant financial disclosures.
Transcatheter mitral valve-in-valve implantation advantageous in failed bioprosthetic valves
PARIS – Transcatheter mitral valve-in-valve procedures in patients with a failed bioprosthetic mitral valve provide superior clinical results, compared with valve-in-ring implantations, according to the latest data from the VIVID registry.
“Obviously, these results have numerous implications for the interventional community: for surgeons, who employ bioprostheses and rings, and for the cardiovascular industry that designs transcatheter strategies for mitral valve and ring implantations,” Dr. Danny Dvir said in presenting the VIVID update at the annual congress of the European Association of Percutaneous Cardiovascular Interventio
Bioprosthetic rather than mechanical valves are increasingly popular in open-heart valve replacement operations because they avoid the need for lifelong oral anticoagulation. But over time bioprosthetic valves often fail. And that event creates a need for a high-risk, repeat open surgery or a far less invasive transcatheter valve replacement.
Lots of data are available regarding the effectiveness and limitations of transcatheter aortic valve-in-valve procedures in patients with failed bioprosthetic aortic valves, including a previous report from the VIVID (Valve-in-Valve International Data registry) by Dr. Dvir and coworkers (JAMA 2014;312:162-70). However, very little data exist about the effectiveness of mitral valve-in-valve and valve-in-ring procedures, noted Dr. Dvir of St. Paul’s Hospital and the University of British Columbia, Vancouver.
The VIVID registry is drawn from 94 sites on six continents. Dr. Dvir presented an analysis of 437 transcatheter mitral implantations in patients with failed bioprosthetic valves. The study population consisted of 349 patients with mitral valve-in-valve (VIV) and 88 with valve-in-ring (VIR) procedures.
The average Society of Thoracic Surgeons (STS) score was 12.9. “This is one of the highest-risk groups of patients that you’ll ever see,” the cardiologist commented.
Mitral regurgitation was the mechanism of bioprosthetic valve failure in 45% of cases, stenosis in 23%, and a combination of the two in the remainder. The median time from placement of the initial bioprosthetic valve to the transcatheter VIV or VIR procedure was 9 years.
Transcatheter access for the mitral VIV or VIR was transapical in 79% of cases, directly through the left atrium in 2.5%, and by the increasingly popular transseptal route in the remainder. The median follow-up post procedure was 408 days.
Mitral VIV procedures looked significantly better from the standpoint of procedural characteristics. Moderate or severe mitral regurgitation was present at the conclusion of the procedure in 2.6% of patients undergoing mitral VIV, compared with 14.8% who had a VIR procedure.
“We were a bit shocked to see that difference between the two groups,” Dr. Dvir said.
Implantation of a small surgical valve of 25 mm or less was the major independent predictor of having an elevated gradient post procedure, with an adjusted odds ratio of 3.7.
In addition, the mean valve area was 1.99 cm2 in the VIV group vs. 2.33 cm2 in the VIR group. Postinflation was employed in 3.2% of the VIV group, compared with 22.7% of the VIR group. Left ventricular outflow tract obstruction – a potentially fatal complication – occurred in 2.6% of the mitral VIV group and was significantly more common at 8% in the VIR group.
Mitral VIR procedures were associated with markedly worse clinical outcomes. Highlighting the 11.2% rate of the 30-day primary composite endpoint in the mitral VIV group, Dr. Dvir commented, “I must say, I think that is a very reasonable number given that we’re talking about a very high–risk group of patients. For this group of patients having a very high STS score, reaching good results in 30 days in the mitral valve-in-valve group is a good signal for the regulatory groups and for the community that this is a good procedure.”
In contrast, the 28.4% rate of the composite endpoint in the VIR group “is a big disappointment; almost one-third of patients undergoing mitral valve in ring experience the composite adverse event endpoint at 30 days. There is an issue there,” he added.
Dr. Dvir reported having no relevant financial conflicts.
PARIS – Transcatheter mitral valve-in-valve procedures in patients with a failed bioprosthetic mitral valve provide superior clinical results, compared with valve-in-ring implantations, according to the latest data from the VIVID registry.
“Obviously, these results have numerous implications for the interventional community: for surgeons, who employ bioprostheses and rings, and for the cardiovascular industry that designs transcatheter strategies for mitral valve and ring implantations,” Dr. Danny Dvir said in presenting the VIVID update at the annual congress of the European Association of Percutaneous Cardiovascular Interventio
Bioprosthetic rather than mechanical valves are increasingly popular in open-heart valve replacement operations because they avoid the need for lifelong oral anticoagulation. But over time bioprosthetic valves often fail. And that event creates a need for a high-risk, repeat open surgery or a far less invasive transcatheter valve replacement.
Lots of data are available regarding the effectiveness and limitations of transcatheter aortic valve-in-valve procedures in patients with failed bioprosthetic aortic valves, including a previous report from the VIVID (Valve-in-Valve International Data registry) by Dr. Dvir and coworkers (JAMA 2014;312:162-70). However, very little data exist about the effectiveness of mitral valve-in-valve and valve-in-ring procedures, noted Dr. Dvir of St. Paul’s Hospital and the University of British Columbia, Vancouver.
The VIVID registry is drawn from 94 sites on six continents. Dr. Dvir presented an analysis of 437 transcatheter mitral implantations in patients with failed bioprosthetic valves. The study population consisted of 349 patients with mitral valve-in-valve (VIV) and 88 with valve-in-ring (VIR) procedures.
The average Society of Thoracic Surgeons (STS) score was 12.9. “This is one of the highest-risk groups of patients that you’ll ever see,” the cardiologist commented.
Mitral regurgitation was the mechanism of bioprosthetic valve failure in 45% of cases, stenosis in 23%, and a combination of the two in the remainder. The median time from placement of the initial bioprosthetic valve to the transcatheter VIV or VIR procedure was 9 years.
Transcatheter access for the mitral VIV or VIR was transapical in 79% of cases, directly through the left atrium in 2.5%, and by the increasingly popular transseptal route in the remainder. The median follow-up post procedure was 408 days.
Mitral VIV procedures looked significantly better from the standpoint of procedural characteristics. Moderate or severe mitral regurgitation was present at the conclusion of the procedure in 2.6% of patients undergoing mitral VIV, compared with 14.8% who had a VIR procedure.
“We were a bit shocked to see that difference between the two groups,” Dr. Dvir said.
Implantation of a small surgical valve of 25 mm or less was the major independent predictor of having an elevated gradient post procedure, with an adjusted odds ratio of 3.7.
In addition, the mean valve area was 1.99 cm2 in the VIV group vs. 2.33 cm2 in the VIR group. Postinflation was employed in 3.2% of the VIV group, compared with 22.7% of the VIR group. Left ventricular outflow tract obstruction – a potentially fatal complication – occurred in 2.6% of the mitral VIV group and was significantly more common at 8% in the VIR group.
Mitral VIR procedures were associated with markedly worse clinical outcomes. Highlighting the 11.2% rate of the 30-day primary composite endpoint in the mitral VIV group, Dr. Dvir commented, “I must say, I think that is a very reasonable number given that we’re talking about a very high–risk group of patients. For this group of patients having a very high STS score, reaching good results in 30 days in the mitral valve-in-valve group is a good signal for the regulatory groups and for the community that this is a good procedure.”
In contrast, the 28.4% rate of the composite endpoint in the VIR group “is a big disappointment; almost one-third of patients undergoing mitral valve in ring experience the composite adverse event endpoint at 30 days. There is an issue there,” he added.
Dr. Dvir reported having no relevant financial conflicts.
PARIS – Transcatheter mitral valve-in-valve procedures in patients with a failed bioprosthetic mitral valve provide superior clinical results, compared with valve-in-ring implantations, according to the latest data from the VIVID registry.
“Obviously, these results have numerous implications for the interventional community: for surgeons, who employ bioprostheses and rings, and for the cardiovascular industry that designs transcatheter strategies for mitral valve and ring implantations,” Dr. Danny Dvir said in presenting the VIVID update at the annual congress of the European Association of Percutaneous Cardiovascular Interventio
Bioprosthetic rather than mechanical valves are increasingly popular in open-heart valve replacement operations because they avoid the need for lifelong oral anticoagulation. But over time bioprosthetic valves often fail. And that event creates a need for a high-risk, repeat open surgery or a far less invasive transcatheter valve replacement.
Lots of data are available regarding the effectiveness and limitations of transcatheter aortic valve-in-valve procedures in patients with failed bioprosthetic aortic valves, including a previous report from the VIVID (Valve-in-Valve International Data registry) by Dr. Dvir and coworkers (JAMA 2014;312:162-70). However, very little data exist about the effectiveness of mitral valve-in-valve and valve-in-ring procedures, noted Dr. Dvir of St. Paul’s Hospital and the University of British Columbia, Vancouver.
The VIVID registry is drawn from 94 sites on six continents. Dr. Dvir presented an analysis of 437 transcatheter mitral implantations in patients with failed bioprosthetic valves. The study population consisted of 349 patients with mitral valve-in-valve (VIV) and 88 with valve-in-ring (VIR) procedures.
The average Society of Thoracic Surgeons (STS) score was 12.9. “This is one of the highest-risk groups of patients that you’ll ever see,” the cardiologist commented.
Mitral regurgitation was the mechanism of bioprosthetic valve failure in 45% of cases, stenosis in 23%, and a combination of the two in the remainder. The median time from placement of the initial bioprosthetic valve to the transcatheter VIV or VIR procedure was 9 years.
Transcatheter access for the mitral VIV or VIR was transapical in 79% of cases, directly through the left atrium in 2.5%, and by the increasingly popular transseptal route in the remainder. The median follow-up post procedure was 408 days.
Mitral VIV procedures looked significantly better from the standpoint of procedural characteristics. Moderate or severe mitral regurgitation was present at the conclusion of the procedure in 2.6% of patients undergoing mitral VIV, compared with 14.8% who had a VIR procedure.
“We were a bit shocked to see that difference between the two groups,” Dr. Dvir said.
Implantation of a small surgical valve of 25 mm or less was the major independent predictor of having an elevated gradient post procedure, with an adjusted odds ratio of 3.7.
In addition, the mean valve area was 1.99 cm2 in the VIV group vs. 2.33 cm2 in the VIR group. Postinflation was employed in 3.2% of the VIV group, compared with 22.7% of the VIR group. Left ventricular outflow tract obstruction – a potentially fatal complication – occurred in 2.6% of the mitral VIV group and was significantly more common at 8% in the VIR group.
Mitral VIR procedures were associated with markedly worse clinical outcomes. Highlighting the 11.2% rate of the 30-day primary composite endpoint in the mitral VIV group, Dr. Dvir commented, “I must say, I think that is a very reasonable number given that we’re talking about a very high–risk group of patients. For this group of patients having a very high STS score, reaching good results in 30 days in the mitral valve-in-valve group is a good signal for the regulatory groups and for the community that this is a good procedure.”
In contrast, the 28.4% rate of the composite endpoint in the VIR group “is a big disappointment; almost one-third of patients undergoing mitral valve in ring experience the composite adverse event endpoint at 30 days. There is an issue there,” he added.
Dr. Dvir reported having no relevant financial conflicts.
AT EuroPCR 2015
Key clinical point: Transcatheter mitral valve-in-valve procedures for very high surgical risk patients with a failed bioprosthetic valve yield far superior outcomes, compared with mitral valve-in-ring procedures.
Major finding: The 30-day composite adverse outcome rate comprised of death, moderate or severe mitral regurgitation, or clinically evident left ventricular outflow tract obstruction occurred in 11.2% of patients who underwent a transcatheter mitral valve-in-valve procedure, compared with 28.4% of those with a transcatheter valve-in-ring procedure.
Data source: The ongoing VIVID registry includes patients on six continents undergoing transcatheter implantation of aortic, mitral, and/or tricuspid valves after failure of an earlier bioprosthetic valve.
Disclosures: The presenter reported having no relevant financial conflicts.
Massachusetts General named top hospital for 2015-2016
Massachusetts General Hospital in Boston earned the top spot in the latest Best Hospitals ranking from U.S. News & World Report.
After finishing second in the last two rankings, Massachusetts General regained the top spot it won in 2012-2013. The Mayo Clinic in Rochester, Minn., finished second in this year’s Honor Roll after taking the top spot last year, while Johns Hopkins Hospital, Baltimore, and UCLA Medical Center tied for third and the Cleveland Clinic was fifth, U.S. News announced on July 21.
For 2015-2016, there were 15 hospitals in the Honor Roll, which is reserved for those institutions that finish at or near the top in 6 or more of the 16 specialties included in the U.S. News rankings. This year, only 137 hospitals did well enough to be nationally ranked in one or more specialties. Both of those numbers are down from a year ago, when there were 17 hospitals in the Honor Roll and 144 that were ranked nationally in at least one specialty.
The 16 specialties used in the analysis are cancer, cardiology and heart surgery, diabetes and endocrinology, otolaryngology, gastroenterology and gastrointestinal surgery, geriatrics, gynecology, nephrology, neurology and neurosurgery, ophthalmology, orthopedics, psychiatry, pulmonology, rehabilitation, rheumatology, and urology.
This years’ ranking process initially included 4,716 nonfederal community hospitals. The research organization RTI International conducted the physician survey and produced the Best Hospitals methodology and national rankings under contract with U.S. News.
Massachusetts General Hospital in Boston earned the top spot in the latest Best Hospitals ranking from U.S. News & World Report.
After finishing second in the last two rankings, Massachusetts General regained the top spot it won in 2012-2013. The Mayo Clinic in Rochester, Minn., finished second in this year’s Honor Roll after taking the top spot last year, while Johns Hopkins Hospital, Baltimore, and UCLA Medical Center tied for third and the Cleveland Clinic was fifth, U.S. News announced on July 21.
For 2015-2016, there were 15 hospitals in the Honor Roll, which is reserved for those institutions that finish at or near the top in 6 or more of the 16 specialties included in the U.S. News rankings. This year, only 137 hospitals did well enough to be nationally ranked in one or more specialties. Both of those numbers are down from a year ago, when there were 17 hospitals in the Honor Roll and 144 that were ranked nationally in at least one specialty.
The 16 specialties used in the analysis are cancer, cardiology and heart surgery, diabetes and endocrinology, otolaryngology, gastroenterology and gastrointestinal surgery, geriatrics, gynecology, nephrology, neurology and neurosurgery, ophthalmology, orthopedics, psychiatry, pulmonology, rehabilitation, rheumatology, and urology.
This years’ ranking process initially included 4,716 nonfederal community hospitals. The research organization RTI International conducted the physician survey and produced the Best Hospitals methodology and national rankings under contract with U.S. News.
Massachusetts General Hospital in Boston earned the top spot in the latest Best Hospitals ranking from U.S. News & World Report.
After finishing second in the last two rankings, Massachusetts General regained the top spot it won in 2012-2013. The Mayo Clinic in Rochester, Minn., finished second in this year’s Honor Roll after taking the top spot last year, while Johns Hopkins Hospital, Baltimore, and UCLA Medical Center tied for third and the Cleveland Clinic was fifth, U.S. News announced on July 21.
For 2015-2016, there were 15 hospitals in the Honor Roll, which is reserved for those institutions that finish at or near the top in 6 or more of the 16 specialties included in the U.S. News rankings. This year, only 137 hospitals did well enough to be nationally ranked in one or more specialties. Both of those numbers are down from a year ago, when there were 17 hospitals in the Honor Roll and 144 that were ranked nationally in at least one specialty.
The 16 specialties used in the analysis are cancer, cardiology and heart surgery, diabetes and endocrinology, otolaryngology, gastroenterology and gastrointestinal surgery, geriatrics, gynecology, nephrology, neurology and neurosurgery, ophthalmology, orthopedics, psychiatry, pulmonology, rehabilitation, rheumatology, and urology.
This years’ ranking process initially included 4,716 nonfederal community hospitals. The research organization RTI International conducted the physician survey and produced the Best Hospitals methodology and national rankings under contract with U.S. News.
SVS: AAA reimbursement needs to take anatomic complexity into account
CHICAGO – Anatomic complexity should be factored into reimbursements for abdominal aortic aneurysm repairs, University of Rochester (N.Y.) investigators concluded after they compared costs to complexity in 33 open and 107 endovascular repairs during 2007-2010.
They found that complex aneurysms – especially ones with Anatomic Severity Grade (ASG) scores above 15 – need more adjunctive procedures and cost more to repair, although at the moment, payers don’t usually take complexity directly into account.
It’s the first study to show a direct relationship between anatomic complexity and hospital cost. “Preoperative assessment with ASG scores can delineate patients at greater risk for increased resource utilization. A critical examination of the relationship between anatomic complexity and finances is required within the context of aggressive endovascular treatment strategies and shifts towards value-based reimbursement. Anatomy is related to cost. [Complexity] should be considered as a factor when calculating limited bundle reimbursements,” said investigator Dr. Khurram Rasheed, a vascular surgery resident in Rochester.
Developed by the Society for Vascular Surgery, the ASG is an assessment of the aortic neck, aneurysm body, iliac arteries, and pelvic perfusion for 16 parameters, including angles, calcifications, and tortuosity. Each parameter is scored from 0-3. Higher scores mean greater complexity, with 48 being the highest possible score (J. Vasc. Surg. 2002;35:1061-6).
An ASG of 15 proved to be a handy marker for when complexity starts to affect the bottom line. A score of 15 or higher correlated with increased costs and increased propensity for requiring intraoperative adjuncts such as renal artery stenting (odds ratio, 5.75; 95% confidence interval, 1.82-18.19). It also correlated with chronic kidney disease and end-stage renal disease, meaning that sicker patients were likely to have worse anatomy and cost more to repair, Dr. Rasheed reported at the meeting hosted by the Society for Special Surgery.
All the cases in the study were elective, and the majority of the patients were elderly white men.
The mean total-cost of endovascular aortic repair (EVAR) was $24,701, mean length of stay (LOS) of 3.0 days, and mean ASG score of 15.9. Cases below an ASG score of 15 cost a mean of $22,020 and had a mean LOS of 2.93 days. Above 15, the mean cost was $26,574 and mean LOS was 3.07 days.
About a quarter of EVAR patients required intraoperative adjuncts, most above an ASG score of 15; their cases cost a mean of $31,509, with a mean ASG score of 18.48 and LOS of 3.85 days.
For open repair, the mean total cost was $38,310, LOS of 13.5 days, and ASG score of 18.1. When five patients with unusually long hospital stays were excluded, open repair cost less than EVAR, which is consistent with previous reports. Just two open-repair patients (6%) needed adjunct procedures.
Open-repair cases with an ASG score below 15 cost a mean of $24,508 and had a mean LOS of 10 days. Cases with a higher score cost a mean of $41,071 and stayed in the hospital an average of 14.2 days. Despite trends, the ASG score differences in cost and LOS for open-repair cases did not reach statistical significance; type II error was probably to blame, Dr. Rasheed said.
The investigators have no disclosures.
CHICAGO – Anatomic complexity should be factored into reimbursements for abdominal aortic aneurysm repairs, University of Rochester (N.Y.) investigators concluded after they compared costs to complexity in 33 open and 107 endovascular repairs during 2007-2010.
They found that complex aneurysms – especially ones with Anatomic Severity Grade (ASG) scores above 15 – need more adjunctive procedures and cost more to repair, although at the moment, payers don’t usually take complexity directly into account.
It’s the first study to show a direct relationship between anatomic complexity and hospital cost. “Preoperative assessment with ASG scores can delineate patients at greater risk for increased resource utilization. A critical examination of the relationship between anatomic complexity and finances is required within the context of aggressive endovascular treatment strategies and shifts towards value-based reimbursement. Anatomy is related to cost. [Complexity] should be considered as a factor when calculating limited bundle reimbursements,” said investigator Dr. Khurram Rasheed, a vascular surgery resident in Rochester.
Developed by the Society for Vascular Surgery, the ASG is an assessment of the aortic neck, aneurysm body, iliac arteries, and pelvic perfusion for 16 parameters, including angles, calcifications, and tortuosity. Each parameter is scored from 0-3. Higher scores mean greater complexity, with 48 being the highest possible score (J. Vasc. Surg. 2002;35:1061-6).
An ASG of 15 proved to be a handy marker for when complexity starts to affect the bottom line. A score of 15 or higher correlated with increased costs and increased propensity for requiring intraoperative adjuncts such as renal artery stenting (odds ratio, 5.75; 95% confidence interval, 1.82-18.19). It also correlated with chronic kidney disease and end-stage renal disease, meaning that sicker patients were likely to have worse anatomy and cost more to repair, Dr. Rasheed reported at the meeting hosted by the Society for Special Surgery.
All the cases in the study were elective, and the majority of the patients were elderly white men.
The mean total-cost of endovascular aortic repair (EVAR) was $24,701, mean length of stay (LOS) of 3.0 days, and mean ASG score of 15.9. Cases below an ASG score of 15 cost a mean of $22,020 and had a mean LOS of 2.93 days. Above 15, the mean cost was $26,574 and mean LOS was 3.07 days.
About a quarter of EVAR patients required intraoperative adjuncts, most above an ASG score of 15; their cases cost a mean of $31,509, with a mean ASG score of 18.48 and LOS of 3.85 days.
For open repair, the mean total cost was $38,310, LOS of 13.5 days, and ASG score of 18.1. When five patients with unusually long hospital stays were excluded, open repair cost less than EVAR, which is consistent with previous reports. Just two open-repair patients (6%) needed adjunct procedures.
Open-repair cases with an ASG score below 15 cost a mean of $24,508 and had a mean LOS of 10 days. Cases with a higher score cost a mean of $41,071 and stayed in the hospital an average of 14.2 days. Despite trends, the ASG score differences in cost and LOS for open-repair cases did not reach statistical significance; type II error was probably to blame, Dr. Rasheed said.
The investigators have no disclosures.
CHICAGO – Anatomic complexity should be factored into reimbursements for abdominal aortic aneurysm repairs, University of Rochester (N.Y.) investigators concluded after they compared costs to complexity in 33 open and 107 endovascular repairs during 2007-2010.
They found that complex aneurysms – especially ones with Anatomic Severity Grade (ASG) scores above 15 – need more adjunctive procedures and cost more to repair, although at the moment, payers don’t usually take complexity directly into account.
It’s the first study to show a direct relationship between anatomic complexity and hospital cost. “Preoperative assessment with ASG scores can delineate patients at greater risk for increased resource utilization. A critical examination of the relationship between anatomic complexity and finances is required within the context of aggressive endovascular treatment strategies and shifts towards value-based reimbursement. Anatomy is related to cost. [Complexity] should be considered as a factor when calculating limited bundle reimbursements,” said investigator Dr. Khurram Rasheed, a vascular surgery resident in Rochester.
Developed by the Society for Vascular Surgery, the ASG is an assessment of the aortic neck, aneurysm body, iliac arteries, and pelvic perfusion for 16 parameters, including angles, calcifications, and tortuosity. Each parameter is scored from 0-3. Higher scores mean greater complexity, with 48 being the highest possible score (J. Vasc. Surg. 2002;35:1061-6).
An ASG of 15 proved to be a handy marker for when complexity starts to affect the bottom line. A score of 15 or higher correlated with increased costs and increased propensity for requiring intraoperative adjuncts such as renal artery stenting (odds ratio, 5.75; 95% confidence interval, 1.82-18.19). It also correlated with chronic kidney disease and end-stage renal disease, meaning that sicker patients were likely to have worse anatomy and cost more to repair, Dr. Rasheed reported at the meeting hosted by the Society for Special Surgery.
All the cases in the study were elective, and the majority of the patients were elderly white men.
The mean total-cost of endovascular aortic repair (EVAR) was $24,701, mean length of stay (LOS) of 3.0 days, and mean ASG score of 15.9. Cases below an ASG score of 15 cost a mean of $22,020 and had a mean LOS of 2.93 days. Above 15, the mean cost was $26,574 and mean LOS was 3.07 days.
About a quarter of EVAR patients required intraoperative adjuncts, most above an ASG score of 15; their cases cost a mean of $31,509, with a mean ASG score of 18.48 and LOS of 3.85 days.
For open repair, the mean total cost was $38,310, LOS of 13.5 days, and ASG score of 18.1. When five patients with unusually long hospital stays were excluded, open repair cost less than EVAR, which is consistent with previous reports. Just two open-repair patients (6%) needed adjunct procedures.
Open-repair cases with an ASG score below 15 cost a mean of $24,508 and had a mean LOS of 10 days. Cases with a higher score cost a mean of $41,071 and stayed in the hospital an average of 14.2 days. Despite trends, the ASG score differences in cost and LOS for open-repair cases did not reach statistical significance; type II error was probably to blame, Dr. Rasheed said.
The investigators have no disclosures.
AT THE 2015 VASCULAR ANNUAL MEETING
Key clinical point: Get the hang of calculating Anatomic Severity Grade scores on your triple A cases; it might one day increase your reimbursements.
Major finding: EVAR cases below an ASG score of 15 cost a mean of $22,020 and had a length of stay of 2.93 days. Above 15, the cost was $26,574 and mean LOS was 3.07 days.
Data source: Review of 33 open and 107 endovascular repairs at the University of Rochester in New York.
Disclosures: The investigators have no disclosures.
Surgical follow-up after ED cholelithiasis episode cuts long-term costs, complications
Patients who don’t receive surgical follow-up after an emergency department visit for cholelithiasis are at increased risk for further ED visits, extraneous imaging, and complications from the disease and from emergent cholecystectomy, according to the findings of a retrospective study.
“Our study identifies lack of surgical follow-up [as] a major contributor to the failure to perform cholecystecomy and highlights the importance of prompt surgical evaluation,” stated Taylor P. Williams of the University of Texas Medical Branch (UTMB), Galveston, and co-investigators.
Between August 2009 and May 2014, 71 patients were discharged from the ED at UTMB with a diagnosis of symptomatic gallstones. The study charted the care of these patients for a follow-up period of 2 years, and the findings were published the August issue of the Journal of Surgical Research (2015;197:318-23).
The mean age of patients was 41 years; 86% were women, and 49% were white. A majority of the patients (56.3%) had no health insurance, while 11.3% had Medicare, 11.3% were on Medicaid, and 21.1% had private insurance.
Of the 71 patients, 18 (25.4%) had outpatient surgical follow-up after an ED visit for a cholelithiasis episode, and they saw the surgeon an average of 7.7 days after the initial ED visit. In the 9 patients who then had an elective cholecystectomy, 8 of these operations occurred within a month of the initital ED visit.
A total of 53 (74.6%) had no immediate surgical follow-up after their ED visit.
The 62 patients who did not have a cholecystectomy had a different trajectory of care than did those who had surgery soon after their ED visit. Of the non-cholecystectomy group, 14.5% of this group eventually had outpatient surgical follow-up within a mean time of 137 days and 37.1% had repeat visits to the ED for gallstone symptoms (17.7% had two or more additional ED visits). Over half of those visits resulted in additional CT or ultrasound imaging. A total of 8 (12.9%) of the total group ended up with an emergent cholecystectomy.
The investigators looked at factors associated with surgical follow-up and eventual or emergent cholecystectomy. Laboratory values, demographics, and radiographic findings were similar between those who underwent cholecystectomy and those who did not. Patients with insurance were more likely to achieve surgical follow-up and more likely to have an elective cholecystectomy. Nausea and vomiting on presentation at the initial ED visit were associated with a greater likelihood of having a cholecystectomy.
The study showed that the 71 patients who presented at the ED with symptoms of cholelithiasis had a similar number of elective and emergent cholecystectomies. But those who did not pursue follow-up and delayed in having surgery incurred additional risks and costs.
A limitation of the study, according to the investigators, is that it involves a small sample from a single center in a community with a high proportion of patients who lack health insurance. In addition, UTMB protocol for acute gallbladder disease leads to a higher rate of admissions than is typical in the United States.
The investigators concluded that “lack of appropriate follow-up leads to multiple ED visits, high rates of emergent cholecystectomy, and redundant radiographic studies, increasing the cost of care and quality of life of those patients. Our data contribute to the literature supporting early surgical follow-up and elective cholecystectomy in preventing repeat ED visits and development of gallstone-related complications in patients presenting to the ED with symptomatic gallstones not severe enough to require emergency admission.”
The investigators had no relevant disclosures.
Patients who don’t receive surgical follow-up after an emergency department visit for cholelithiasis are at increased risk for further ED visits, extraneous imaging, and complications from the disease and from emergent cholecystectomy, according to the findings of a retrospective study.
“Our study identifies lack of surgical follow-up [as] a major contributor to the failure to perform cholecystecomy and highlights the importance of prompt surgical evaluation,” stated Taylor P. Williams of the University of Texas Medical Branch (UTMB), Galveston, and co-investigators.
Between August 2009 and May 2014, 71 patients were discharged from the ED at UTMB with a diagnosis of symptomatic gallstones. The study charted the care of these patients for a follow-up period of 2 years, and the findings were published the August issue of the Journal of Surgical Research (2015;197:318-23).
The mean age of patients was 41 years; 86% were women, and 49% were white. A majority of the patients (56.3%) had no health insurance, while 11.3% had Medicare, 11.3% were on Medicaid, and 21.1% had private insurance.
Of the 71 patients, 18 (25.4%) had outpatient surgical follow-up after an ED visit for a cholelithiasis episode, and they saw the surgeon an average of 7.7 days after the initial ED visit. In the 9 patients who then had an elective cholecystectomy, 8 of these operations occurred within a month of the initital ED visit.
A total of 53 (74.6%) had no immediate surgical follow-up after their ED visit.
The 62 patients who did not have a cholecystectomy had a different trajectory of care than did those who had surgery soon after their ED visit. Of the non-cholecystectomy group, 14.5% of this group eventually had outpatient surgical follow-up within a mean time of 137 days and 37.1% had repeat visits to the ED for gallstone symptoms (17.7% had two or more additional ED visits). Over half of those visits resulted in additional CT or ultrasound imaging. A total of 8 (12.9%) of the total group ended up with an emergent cholecystectomy.
The investigators looked at factors associated with surgical follow-up and eventual or emergent cholecystectomy. Laboratory values, demographics, and radiographic findings were similar between those who underwent cholecystectomy and those who did not. Patients with insurance were more likely to achieve surgical follow-up and more likely to have an elective cholecystectomy. Nausea and vomiting on presentation at the initial ED visit were associated with a greater likelihood of having a cholecystectomy.
The study showed that the 71 patients who presented at the ED with symptoms of cholelithiasis had a similar number of elective and emergent cholecystectomies. But those who did not pursue follow-up and delayed in having surgery incurred additional risks and costs.
A limitation of the study, according to the investigators, is that it involves a small sample from a single center in a community with a high proportion of patients who lack health insurance. In addition, UTMB protocol for acute gallbladder disease leads to a higher rate of admissions than is typical in the United States.
The investigators concluded that “lack of appropriate follow-up leads to multiple ED visits, high rates of emergent cholecystectomy, and redundant radiographic studies, increasing the cost of care and quality of life of those patients. Our data contribute to the literature supporting early surgical follow-up and elective cholecystectomy in preventing repeat ED visits and development of gallstone-related complications in patients presenting to the ED with symptomatic gallstones not severe enough to require emergency admission.”
The investigators had no relevant disclosures.
Patients who don’t receive surgical follow-up after an emergency department visit for cholelithiasis are at increased risk for further ED visits, extraneous imaging, and complications from the disease and from emergent cholecystectomy, according to the findings of a retrospective study.
“Our study identifies lack of surgical follow-up [as] a major contributor to the failure to perform cholecystecomy and highlights the importance of prompt surgical evaluation,” stated Taylor P. Williams of the University of Texas Medical Branch (UTMB), Galveston, and co-investigators.
Between August 2009 and May 2014, 71 patients were discharged from the ED at UTMB with a diagnosis of symptomatic gallstones. The study charted the care of these patients for a follow-up period of 2 years, and the findings were published the August issue of the Journal of Surgical Research (2015;197:318-23).
The mean age of patients was 41 years; 86% were women, and 49% were white. A majority of the patients (56.3%) had no health insurance, while 11.3% had Medicare, 11.3% were on Medicaid, and 21.1% had private insurance.
Of the 71 patients, 18 (25.4%) had outpatient surgical follow-up after an ED visit for a cholelithiasis episode, and they saw the surgeon an average of 7.7 days after the initial ED visit. In the 9 patients who then had an elective cholecystectomy, 8 of these operations occurred within a month of the initital ED visit.
A total of 53 (74.6%) had no immediate surgical follow-up after their ED visit.
The 62 patients who did not have a cholecystectomy had a different trajectory of care than did those who had surgery soon after their ED visit. Of the non-cholecystectomy group, 14.5% of this group eventually had outpatient surgical follow-up within a mean time of 137 days and 37.1% had repeat visits to the ED for gallstone symptoms (17.7% had two or more additional ED visits). Over half of those visits resulted in additional CT or ultrasound imaging. A total of 8 (12.9%) of the total group ended up with an emergent cholecystectomy.
The investigators looked at factors associated with surgical follow-up and eventual or emergent cholecystectomy. Laboratory values, demographics, and radiographic findings were similar between those who underwent cholecystectomy and those who did not. Patients with insurance were more likely to achieve surgical follow-up and more likely to have an elective cholecystectomy. Nausea and vomiting on presentation at the initial ED visit were associated with a greater likelihood of having a cholecystectomy.
The study showed that the 71 patients who presented at the ED with symptoms of cholelithiasis had a similar number of elective and emergent cholecystectomies. But those who did not pursue follow-up and delayed in having surgery incurred additional risks and costs.
A limitation of the study, according to the investigators, is that it involves a small sample from a single center in a community with a high proportion of patients who lack health insurance. In addition, UTMB protocol for acute gallbladder disease leads to a higher rate of admissions than is typical in the United States.
The investigators concluded that “lack of appropriate follow-up leads to multiple ED visits, high rates of emergent cholecystectomy, and redundant radiographic studies, increasing the cost of care and quality of life of those patients. Our data contribute to the literature supporting early surgical follow-up and elective cholecystectomy in preventing repeat ED visits and development of gallstone-related complications in patients presenting to the ED with symptomatic gallstones not severe enough to require emergency admission.”
The investigators had no relevant disclosures.
FROM JOURNAL OF SURGICAL RESEARCH
Key clinical point: Surgical follow-up after a patient presents at the ED with symptomatic cholelithiasis is critical in reducing ED visits, complications, and costs for gallbladder disease.
Major finding: Of those patients who did not have elective surgery, 37.1% had repeat visits to the ED for gallstone symptoms, 17.7% of which had two or more additional ED visits, and over half of those additional visits resulted in CT or ultrasound imaging.
Data source: A single-center study of 71 patients presenting to the emergency department with symptomatic cholelithiasis and followed for up to 2 years.
Disclosures: The investigators had no relevant disclosures.
SVS: Cryoallografts, NAIS best to reconstruct infected aortic grafts
CHICAGO – Neoaortoiliac system reconstruction or cryopreserved allografts should be used first-line to replace infected aortic endografts, followed by antibiotic-soaked prosthetic grafts, according to a review of 206 cases from vascular surgery centers across the United States.
In the study, 75 patients had cryoallograft reconstruction, mostly cryoartery, or neoaortoiliac system (NAIS) reconstruction with femoral vein; 53 (71%) were alive at 5 years. Forty-nine of the 92 (53%) patients reconstructed with antibiotic-soaked prosthetic grafts also made it to 5 years, while two of 19 (11%) reconstructed with untreated prosthetic grafts survived that long.
The cases were reconstructed inline. The index procedure had been endovascular aortic repair (EVAR) in 165, and thoracic EVAR (TEVAR) in 21, with a better 5-year survival for the EVAR group. Another 11 patients had extra-anatomic reconstruction after initial EVAR, and their 5-year survival was comparable to inline reconstruction at about 50% overall. Nine other patients were managed medically; the majority died soon after being diagnosed with an infected graft.
“Clinicians should have a high index of suspicion to diagnose symptomatic postop EVAR and TEVAR patients with graft infection, especially in those patients with chronic infections or contaminated index procedures. NAIS and cryopreserved allografts require longer procedure times” – about 500 minutes versus about 350 minutes for prosthetic grafts – “but offer improved survival, while prosthetics soaked in antibiotic do better than prosthetic grafts alone,” said lead investigator Dr. Audra Duncan, professor of surgery at the Mayo Clinic in Rochester, Minn.
Patients were treated at the Mayo Clinic, the Cleveland Clinic in Ohio, Johns Hopkins University in Baltimore, the University of California, Los Angeles, and 15 other vascular centers around the country during 2004-2014. They were 68 years old on average, and 78% were men. Comorbidities included hypertension in 84%, smoking in 58%, and renal insufficiency in 30%.
On multivariate analysis, chronic infection, polymicrobial infection, and prosthetic reconstruction, among other things, predicted mortality after reconstruction.
Graft infections were primarily polymicrobial and fungal, and were diagnosed a mean of 716 days after the initial implant, generally by CT. Symptoms included pain in 66%, mostly in the back and abdomen, and fever and chills, also in 66%. Streptococcus, Escherichia coli, and both methicillin-sensitive and -resistant Staphylococcus aureus were among the most commonly isolated organisms. No particular type of graft seemed more likely to get infected.
The sources of infection are unknown, but index procedures were complicated by urinary tract, groin, and other infections in about one-third of patients. About one-third also had interval procedures, including endoleak intervention. About 14% of patients were thought to have had a contaminated index procedure.
Patients stayed in the hospital a mean of 24 days after reconstruction. Early complications included persistent sepsis in 27 patients, myocardial infarction in 9, recurrent infection in 9, and pneumonia in 8. Mortality at 30 days was 11%.
Nineteen replacement grafts – mostly unsoaked Dacron – were explanted after a mean of 540 days. Persistent sepsis after reconstruction was associated with unsoaked Dacron and polytetrafluoroethylene (PTFE) grafts.
To prevent graft infections, Mayo patients “take an antibiotic for any invasive procedure,” including dental work. “I am not sure we have data to support that, but it is something we do,” Dr. Duncan said.
Dr. Duncan has no relevant disclosures.
CHICAGO – Neoaortoiliac system reconstruction or cryopreserved allografts should be used first-line to replace infected aortic endografts, followed by antibiotic-soaked prosthetic grafts, according to a review of 206 cases from vascular surgery centers across the United States.
In the study, 75 patients had cryoallograft reconstruction, mostly cryoartery, or neoaortoiliac system (NAIS) reconstruction with femoral vein; 53 (71%) were alive at 5 years. Forty-nine of the 92 (53%) patients reconstructed with antibiotic-soaked prosthetic grafts also made it to 5 years, while two of 19 (11%) reconstructed with untreated prosthetic grafts survived that long.
The cases were reconstructed inline. The index procedure had been endovascular aortic repair (EVAR) in 165, and thoracic EVAR (TEVAR) in 21, with a better 5-year survival for the EVAR group. Another 11 patients had extra-anatomic reconstruction after initial EVAR, and their 5-year survival was comparable to inline reconstruction at about 50% overall. Nine other patients were managed medically; the majority died soon after being diagnosed with an infected graft.
“Clinicians should have a high index of suspicion to diagnose symptomatic postop EVAR and TEVAR patients with graft infection, especially in those patients with chronic infections or contaminated index procedures. NAIS and cryopreserved allografts require longer procedure times” – about 500 minutes versus about 350 minutes for prosthetic grafts – “but offer improved survival, while prosthetics soaked in antibiotic do better than prosthetic grafts alone,” said lead investigator Dr. Audra Duncan, professor of surgery at the Mayo Clinic in Rochester, Minn.
Patients were treated at the Mayo Clinic, the Cleveland Clinic in Ohio, Johns Hopkins University in Baltimore, the University of California, Los Angeles, and 15 other vascular centers around the country during 2004-2014. They were 68 years old on average, and 78% were men. Comorbidities included hypertension in 84%, smoking in 58%, and renal insufficiency in 30%.
On multivariate analysis, chronic infection, polymicrobial infection, and prosthetic reconstruction, among other things, predicted mortality after reconstruction.
Graft infections were primarily polymicrobial and fungal, and were diagnosed a mean of 716 days after the initial implant, generally by CT. Symptoms included pain in 66%, mostly in the back and abdomen, and fever and chills, also in 66%. Streptococcus, Escherichia coli, and both methicillin-sensitive and -resistant Staphylococcus aureus were among the most commonly isolated organisms. No particular type of graft seemed more likely to get infected.
The sources of infection are unknown, but index procedures were complicated by urinary tract, groin, and other infections in about one-third of patients. About one-third also had interval procedures, including endoleak intervention. About 14% of patients were thought to have had a contaminated index procedure.
Patients stayed in the hospital a mean of 24 days after reconstruction. Early complications included persistent sepsis in 27 patients, myocardial infarction in 9, recurrent infection in 9, and pneumonia in 8. Mortality at 30 days was 11%.
Nineteen replacement grafts – mostly unsoaked Dacron – were explanted after a mean of 540 days. Persistent sepsis after reconstruction was associated with unsoaked Dacron and polytetrafluoroethylene (PTFE) grafts.
To prevent graft infections, Mayo patients “take an antibiotic for any invasive procedure,” including dental work. “I am not sure we have data to support that, but it is something we do,” Dr. Duncan said.
Dr. Duncan has no relevant disclosures.
CHICAGO – Neoaortoiliac system reconstruction or cryopreserved allografts should be used first-line to replace infected aortic endografts, followed by antibiotic-soaked prosthetic grafts, according to a review of 206 cases from vascular surgery centers across the United States.
In the study, 75 patients had cryoallograft reconstruction, mostly cryoartery, or neoaortoiliac system (NAIS) reconstruction with femoral vein; 53 (71%) were alive at 5 years. Forty-nine of the 92 (53%) patients reconstructed with antibiotic-soaked prosthetic grafts also made it to 5 years, while two of 19 (11%) reconstructed with untreated prosthetic grafts survived that long.
The cases were reconstructed inline. The index procedure had been endovascular aortic repair (EVAR) in 165, and thoracic EVAR (TEVAR) in 21, with a better 5-year survival for the EVAR group. Another 11 patients had extra-anatomic reconstruction after initial EVAR, and their 5-year survival was comparable to inline reconstruction at about 50% overall. Nine other patients were managed medically; the majority died soon after being diagnosed with an infected graft.
“Clinicians should have a high index of suspicion to diagnose symptomatic postop EVAR and TEVAR patients with graft infection, especially in those patients with chronic infections or contaminated index procedures. NAIS and cryopreserved allografts require longer procedure times” – about 500 minutes versus about 350 minutes for prosthetic grafts – “but offer improved survival, while prosthetics soaked in antibiotic do better than prosthetic grafts alone,” said lead investigator Dr. Audra Duncan, professor of surgery at the Mayo Clinic in Rochester, Minn.
Patients were treated at the Mayo Clinic, the Cleveland Clinic in Ohio, Johns Hopkins University in Baltimore, the University of California, Los Angeles, and 15 other vascular centers around the country during 2004-2014. They were 68 years old on average, and 78% were men. Comorbidities included hypertension in 84%, smoking in 58%, and renal insufficiency in 30%.
On multivariate analysis, chronic infection, polymicrobial infection, and prosthetic reconstruction, among other things, predicted mortality after reconstruction.
Graft infections were primarily polymicrobial and fungal, and were diagnosed a mean of 716 days after the initial implant, generally by CT. Symptoms included pain in 66%, mostly in the back and abdomen, and fever and chills, also in 66%. Streptococcus, Escherichia coli, and both methicillin-sensitive and -resistant Staphylococcus aureus were among the most commonly isolated organisms. No particular type of graft seemed more likely to get infected.
The sources of infection are unknown, but index procedures were complicated by urinary tract, groin, and other infections in about one-third of patients. About one-third also had interval procedures, including endoleak intervention. About 14% of patients were thought to have had a contaminated index procedure.
Patients stayed in the hospital a mean of 24 days after reconstruction. Early complications included persistent sepsis in 27 patients, myocardial infarction in 9, recurrent infection in 9, and pneumonia in 8. Mortality at 30 days was 11%.
Nineteen replacement grafts – mostly unsoaked Dacron – were explanted after a mean of 540 days. Persistent sepsis after reconstruction was associated with unsoaked Dacron and polytetrafluoroethylene (PTFE) grafts.
To prevent graft infections, Mayo patients “take an antibiotic for any invasive procedure,” including dental work. “I am not sure we have data to support that, but it is something we do,” Dr. Duncan said.
Dr. Duncan has no relevant disclosures.
AT THE 2015 VASCULAR ANNUAL MEETING
Key clinical point: Neoaortoiliac system reconstruction or cryopreserved allografts perform best in replacing infected aortic endografts, but if you have to use prosthetics, use ones soaked in antibiotics.
Major finding: Seventy-five patients had cryoallograft reconstruction, mostly cryoartery, or neoaortoiliac system (NAIS) reconstruction with femoral vein; 53 (71%) were alive at 5 years. Two of 19 (11%) patients reconstructed with untreated prosthetic grafts survived that long.
Data source: Review of 206 patients at 19 vascular surgery centers in the United States.
Disclosures: The lead investigator has no relevant disclosures.
SVS: Beta-blockers cut stroke, death risk in carotid stenting
CHICAGO – Carotid artery stenting is safer if patients have been on beta-blockers for at least a month beforehand, according to a review of 5,248 stent cases during 2005-2014.
“Compared to non-users, patients on long-term beta-blockers are at 34% less risk of stroke and death after carotid artery stenting [odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P = .025], and this risk reduction is amplified to 65% in patients with postop hypertension [OR, 0.35; 95% CI, 0.17-0.73; P = .005]. Beta-blockers significantly reduce the stroke and death risk ... and should be investigated prospectively for potential use during” carotid artery stenting (CAS), said senior investigator Dr. Mahmoud Malas, director of endovascular surgery and associate professor of surgery at Johns Hopkins Bayview Medical Center in Baltimore.
In the study, long-term beta-blocker use was not associated with post-procedure hypotension in the study. Among patients who developed it, however, beta-blockers were associated with a 48% reduction in the risk of stroke or death at 30 days (OR, 0.52; 95% CI, 0.28-0.98; P = .43).
“We think” the benefits are due to “up-regulation of adrenergic receptors. We think also there is better baroreceptor reflex sensitivity.” Long-term use of beta-blockers reduces heart rate variability, as well, and decreases the risk of hyperperfusion fourfold, Dr. Malas said at the meeting hosted by the Society for Vascular Surgery.
The researchers looked into the issue because they are trying to find a way to make CAS safer in the wake of the Carotid Revascularization Endarterectomy versus Stent Trial (CREST) and others that have shown increased risk compared with carotid endarterectomy.
The subjects were all captured in SVS’s Vascular Quality Initiative database; 2,152 were not on beta-blockers before CAS, 259 were on them for less than 30 days, and 2,837 were on them for more than 30 days. There were no statistical between-group differences in lesion sites, approach (femoral in almost all the cases), or contrast volume used in surgery, a marker of case complexity.
Long-term users had more diabetes, hypertension, coronary artery disease, and congestive heart failure, whereas short term users were more symptomatic; those and other differences were controlled for on multivariate analysis. Aspirin, clopidogrel, and statin use were similar between the groups. About two-thirds of the subjects were men, and the average age in the study was about 70 years old.
Overall, the 30-day stroke and death rate was 3.4% (minor stroke 1.5%, major 0.9%, and death 1.2%).
Predictors of postoperative stroke or death at 30 days included symptomatic status, age, diabetes, and perioperative hypotension and hypertension. Prior carotid endarterectomy and distal embolic protection were both protective.
The investigators have no disclosures.
CHICAGO – Carotid artery stenting is safer if patients have been on beta-blockers for at least a month beforehand, according to a review of 5,248 stent cases during 2005-2014.
“Compared to non-users, patients on long-term beta-blockers are at 34% less risk of stroke and death after carotid artery stenting [odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P = .025], and this risk reduction is amplified to 65% in patients with postop hypertension [OR, 0.35; 95% CI, 0.17-0.73; P = .005]. Beta-blockers significantly reduce the stroke and death risk ... and should be investigated prospectively for potential use during” carotid artery stenting (CAS), said senior investigator Dr. Mahmoud Malas, director of endovascular surgery and associate professor of surgery at Johns Hopkins Bayview Medical Center in Baltimore.
In the study, long-term beta-blocker use was not associated with post-procedure hypotension in the study. Among patients who developed it, however, beta-blockers were associated with a 48% reduction in the risk of stroke or death at 30 days (OR, 0.52; 95% CI, 0.28-0.98; P = .43).
“We think” the benefits are due to “up-regulation of adrenergic receptors. We think also there is better baroreceptor reflex sensitivity.” Long-term use of beta-blockers reduces heart rate variability, as well, and decreases the risk of hyperperfusion fourfold, Dr. Malas said at the meeting hosted by the Society for Vascular Surgery.
The researchers looked into the issue because they are trying to find a way to make CAS safer in the wake of the Carotid Revascularization Endarterectomy versus Stent Trial (CREST) and others that have shown increased risk compared with carotid endarterectomy.
The subjects were all captured in SVS’s Vascular Quality Initiative database; 2,152 were not on beta-blockers before CAS, 259 were on them for less than 30 days, and 2,837 were on them for more than 30 days. There were no statistical between-group differences in lesion sites, approach (femoral in almost all the cases), or contrast volume used in surgery, a marker of case complexity.
Long-term users had more diabetes, hypertension, coronary artery disease, and congestive heart failure, whereas short term users were more symptomatic; those and other differences were controlled for on multivariate analysis. Aspirin, clopidogrel, and statin use were similar between the groups. About two-thirds of the subjects were men, and the average age in the study was about 70 years old.
Overall, the 30-day stroke and death rate was 3.4% (minor stroke 1.5%, major 0.9%, and death 1.2%).
Predictors of postoperative stroke or death at 30 days included symptomatic status, age, diabetes, and perioperative hypotension and hypertension. Prior carotid endarterectomy and distal embolic protection were both protective.
The investigators have no disclosures.
CHICAGO – Carotid artery stenting is safer if patients have been on beta-blockers for at least a month beforehand, according to a review of 5,248 stent cases during 2005-2014.
“Compared to non-users, patients on long-term beta-blockers are at 34% less risk of stroke and death after carotid artery stenting [odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P = .025], and this risk reduction is amplified to 65% in patients with postop hypertension [OR, 0.35; 95% CI, 0.17-0.73; P = .005]. Beta-blockers significantly reduce the stroke and death risk ... and should be investigated prospectively for potential use during” carotid artery stenting (CAS), said senior investigator Dr. Mahmoud Malas, director of endovascular surgery and associate professor of surgery at Johns Hopkins Bayview Medical Center in Baltimore.
In the study, long-term beta-blocker use was not associated with post-procedure hypotension in the study. Among patients who developed it, however, beta-blockers were associated with a 48% reduction in the risk of stroke or death at 30 days (OR, 0.52; 95% CI, 0.28-0.98; P = .43).
“We think” the benefits are due to “up-regulation of adrenergic receptors. We think also there is better baroreceptor reflex sensitivity.” Long-term use of beta-blockers reduces heart rate variability, as well, and decreases the risk of hyperperfusion fourfold, Dr. Malas said at the meeting hosted by the Society for Vascular Surgery.
The researchers looked into the issue because they are trying to find a way to make CAS safer in the wake of the Carotid Revascularization Endarterectomy versus Stent Trial (CREST) and others that have shown increased risk compared with carotid endarterectomy.
The subjects were all captured in SVS’s Vascular Quality Initiative database; 2,152 were not on beta-blockers before CAS, 259 were on them for less than 30 days, and 2,837 were on them for more than 30 days. There were no statistical between-group differences in lesion sites, approach (femoral in almost all the cases), or contrast volume used in surgery, a marker of case complexity.
Long-term users had more diabetes, hypertension, coronary artery disease, and congestive heart failure, whereas short term users were more symptomatic; those and other differences were controlled for on multivariate analysis. Aspirin, clopidogrel, and statin use were similar between the groups. About two-thirds of the subjects were men, and the average age in the study was about 70 years old.
Overall, the 30-day stroke and death rate was 3.4% (minor stroke 1.5%, major 0.9%, and death 1.2%).
Predictors of postoperative stroke or death at 30 days included symptomatic status, age, diabetes, and perioperative hypotension and hypertension. Prior carotid endarterectomy and distal embolic protection were both protective.
The investigators have no disclosures.
AT THE 2015 VASCULAR ANNUAL MEETING
Key clinical point: Carotid artery stenting is safer if patients have been on beta-blockers for at least a month beforehand.
Major finding: The risk of stroke or death after carotid artery stenting is reduced by 34% when patients are on long-term beta-blockers preoperatively.
Data source: Review of 5,248 stent cases during 2005-2014
Disclosures: The investigators have no disclosures.
