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The Official Newspaper of the American Association for Thoracic Surgery
The perils of hospital air
Hospital air is a potential route of transmission of beta-lactam–resistant bacteria (BLRB), which are important causative agents of nosocomial infections, according to research published in the American Journal of Infection Control.
Dr. Mahnaz Nikaeen of the department of environmental health engineering at Isfahan (Iran) University of Medical Sciences, and his coauthors collected and tested 64 air samples from four hospital wards to determine the prevalence of airborne BLRB in different teaching hospitals, to evaluate the frequency of five common beta-lactamase–encoding genes in isolated resistant bacteria, and to identify the most predominant BLRB by 16s rRNA gene sequencing. The sampling locations in each hospital included operating rooms, ICUs, surgery wards, and internal medicine wards.
The investigators detected airborne bacteria by using culture plates with and without beta-lactams.
The prevalence of BLRB in the air samples ranged between 3% and 34%, Dr. Nikaeen said. Oxacillin-resistant bacteria had the highest prevalence, followed by ceftazidime- and cefazolin-resistant bacteria. Acinetobacter spp, Acinetobacter baumannii, and Staphylococcus spp were the most predominant BLRB.
Gene sequencing revealed that the frequency of beta-lactamase–encoding genes in isolated BLRB ranged between 0% and 47%, with the highest and lowest detection for OXA-23, commonly found in Acinetobacter spp, and CTX-m-32, a gene prevalent in extended-spectrum beta-lactamase–producing Enterobacteriaceae, respectively. MecA, a genetic element found in methicillin-resistant Staphylococcus spp, had a relatively high frequency in surgery wards and operating rooms, whereas the frequency of blaTEM, another common extended-spectrum beta-lactamase produced by Enterobacteriaceae, was higher in intensive care units and internal medicine wards. OXA-51, a chromosomally located intrinsic gene in A. baumannii, was detected in four wards.
“Isolation of beta-lactam–resistant Staphylococcus spp and A. baumannii as the most predominant BLRB indicated the potential role of airborne bacteria in dissemination of nosocomial infections,” Dr. Nikaeen and his coauthors said. “The results confirm the necessity for application of effective control measures that significantly decrease the exposure of high-risk patients to potentially airborne nosocomial infections.”
The authors reported having no conflicts.
Read the complete study in the American Journal of Infection Control (doi:10.1016/j.ajic.2016.01.041).
On Twitter @richpizzi
Hospital air is a potential route of transmission of beta-lactam–resistant bacteria (BLRB), which are important causative agents of nosocomial infections, according to research published in the American Journal of Infection Control.
Dr. Mahnaz Nikaeen of the department of environmental health engineering at Isfahan (Iran) University of Medical Sciences, and his coauthors collected and tested 64 air samples from four hospital wards to determine the prevalence of airborne BLRB in different teaching hospitals, to evaluate the frequency of five common beta-lactamase–encoding genes in isolated resistant bacteria, and to identify the most predominant BLRB by 16s rRNA gene sequencing. The sampling locations in each hospital included operating rooms, ICUs, surgery wards, and internal medicine wards.
The investigators detected airborne bacteria by using culture plates with and without beta-lactams.
The prevalence of BLRB in the air samples ranged between 3% and 34%, Dr. Nikaeen said. Oxacillin-resistant bacteria had the highest prevalence, followed by ceftazidime- and cefazolin-resistant bacteria. Acinetobacter spp, Acinetobacter baumannii, and Staphylococcus spp were the most predominant BLRB.
Gene sequencing revealed that the frequency of beta-lactamase–encoding genes in isolated BLRB ranged between 0% and 47%, with the highest and lowest detection for OXA-23, commonly found in Acinetobacter spp, and CTX-m-32, a gene prevalent in extended-spectrum beta-lactamase–producing Enterobacteriaceae, respectively. MecA, a genetic element found in methicillin-resistant Staphylococcus spp, had a relatively high frequency in surgery wards and operating rooms, whereas the frequency of blaTEM, another common extended-spectrum beta-lactamase produced by Enterobacteriaceae, was higher in intensive care units and internal medicine wards. OXA-51, a chromosomally located intrinsic gene in A. baumannii, was detected in four wards.
“Isolation of beta-lactam–resistant Staphylococcus spp and A. baumannii as the most predominant BLRB indicated the potential role of airborne bacteria in dissemination of nosocomial infections,” Dr. Nikaeen and his coauthors said. “The results confirm the necessity for application of effective control measures that significantly decrease the exposure of high-risk patients to potentially airborne nosocomial infections.”
The authors reported having no conflicts.
Read the complete study in the American Journal of Infection Control (doi:10.1016/j.ajic.2016.01.041).
On Twitter @richpizzi
Hospital air is a potential route of transmission of beta-lactam–resistant bacteria (BLRB), which are important causative agents of nosocomial infections, according to research published in the American Journal of Infection Control.
Dr. Mahnaz Nikaeen of the department of environmental health engineering at Isfahan (Iran) University of Medical Sciences, and his coauthors collected and tested 64 air samples from four hospital wards to determine the prevalence of airborne BLRB in different teaching hospitals, to evaluate the frequency of five common beta-lactamase–encoding genes in isolated resistant bacteria, and to identify the most predominant BLRB by 16s rRNA gene sequencing. The sampling locations in each hospital included operating rooms, ICUs, surgery wards, and internal medicine wards.
The investigators detected airborne bacteria by using culture plates with and without beta-lactams.
The prevalence of BLRB in the air samples ranged between 3% and 34%, Dr. Nikaeen said. Oxacillin-resistant bacteria had the highest prevalence, followed by ceftazidime- and cefazolin-resistant bacteria. Acinetobacter spp, Acinetobacter baumannii, and Staphylococcus spp were the most predominant BLRB.
Gene sequencing revealed that the frequency of beta-lactamase–encoding genes in isolated BLRB ranged between 0% and 47%, with the highest and lowest detection for OXA-23, commonly found in Acinetobacter spp, and CTX-m-32, a gene prevalent in extended-spectrum beta-lactamase–producing Enterobacteriaceae, respectively. MecA, a genetic element found in methicillin-resistant Staphylococcus spp, had a relatively high frequency in surgery wards and operating rooms, whereas the frequency of blaTEM, another common extended-spectrum beta-lactamase produced by Enterobacteriaceae, was higher in intensive care units and internal medicine wards. OXA-51, a chromosomally located intrinsic gene in A. baumannii, was detected in four wards.
“Isolation of beta-lactam–resistant Staphylococcus spp and A. baumannii as the most predominant BLRB indicated the potential role of airborne bacteria in dissemination of nosocomial infections,” Dr. Nikaeen and his coauthors said. “The results confirm the necessity for application of effective control measures that significantly decrease the exposure of high-risk patients to potentially airborne nosocomial infections.”
The authors reported having no conflicts.
Read the complete study in the American Journal of Infection Control (doi:10.1016/j.ajic.2016.01.041).
On Twitter @richpizzi
FROM AMERICAN JOURNAL OF INFECTION CONTROL
Cardioband scores hit for percutaneous direct mitral annuloplasty
CHICAGO – One-year results of a pivotal European trial of the percutaneous Cardioband mitral valve reconstruction system show a stable, consistent, and clinically meaningful reduction in mitral regurgitation coupled with significant quality of life improvements and a safety profile equivalent to that of other transcatheter valve procedures.
“The results are quite impressive. Ladies and gentlemen, I can tell you that I’ve used almost all the devices for direct and indirect annuloplasty, and this is the only device that works in a reproducible fashion,” Dr. Karl-Heinz Kuck said at the annual meeting of the American College of Cardiology.
He presented the results for the first 50 patients to reach 12 months of follow-up after undergoing the Cardioband procedure in a multicenter prospective study in which participants served as their own before-and-after controls. On the strength of these results, the Cardioband device has been approved by European Union regulatory authorities for the nonsurgical treatment of symptomatic moderate to severe secondary, or functional, mitral regurgitation. In Germany, the Cardioband procedure is now routinely reimbursed at a level similar to that of the MitraClip, according to Dr. Kuck, president of the German Cardiac Society and head of cardiology at St. Georg Hospital in Hamburg, Germany.
The Cardioband procedure essentially entails percutaneous implantation of an adjustable surgical ring designed to remodel a severely dysfunctional mitral valve by repairing the valve annulus. The implantation procedure features transfemoral venous access, which the TAVR experience has shown to be safer than transapical access. As in surgery, the percutaneous procedure utilizes supra-annular fixation. And it accomplishes a significant reduction in annular dimensions, comparable to what is achieved with a size 28 surgical ring.
“And the most important thing: Because we are not interfering with the leaflets or any other part of the mitral valve, the procedure leaves all options open for the future by preserving the native anatomy,” Dr. Kuck noted.
The procedure entails a transseptal puncture, insertion of the system, deployment of the implant, and adjustment of its size by cinching it down under echocardiographic guidance in order to reduce the septolateral valve dimension. The whole thing takes about 75 minutes.
The connection of the implant to the annulus is achieved in sutureless fashion using a series of screw-in anchors.
All 50 participants in the consecutive series were deemed by a heart team to be at unacceptably high surgical risk. They averaged 71 years of age, with an left ventricular ejection fraction of 33% and a left ventricular end diastolic diameter of 61 mm. Among them, 31 had ischemic heart disease, 11 had chronic obstructive pulmonary disease, 38 were in moderate or severe renal failure, 39 had atrial fibrillation, 12 had severe pulmonary hypertension, and 16 had previously undergone CABG surgery.
The 30-day safety adverse events consisted of one hemorrhagic stroke, a single major bleeding complication, two cases of acute renal failure, and one of cardiac tamponade. There were no MIs, and neither of the two deaths were related to the procedure.
In terms of efficacy, at baseline three-quarters of patients had grade 3-4 mitral regurgitation (MR). At discharge that was true for only 12%. At 1 year of follow-up, 90% of subjects had MR grade 2 or less, and roughly two-thirds of patients had MR grade 0-1.
The procedure did what it was designed to do: The mean valve septolateral dimension decreased by 30%, from 37 mm at baseline to 26 mm at discharge.
Dr. Kuck provided 6-month data on functional improvement. The mean 6-minute walk distance improved from 262 to 339 meters. At baseline, 87% of subjects were NYHA class III or IV; at 6 months, 77% were NYHA class I or II. Scores on the Minnesota Living with Heart Failure Questionnaire improved from a mean of 39 to 16 at follow-up.
A much larger European postmarketing commercial use study of the Cardioband system is now underway.
The Cardioband procedure addresses a major unmet need, Dr. Kuck observed. More than 4 million patients in the United States alone have mitral valve disease. When medically managed, patients with severe secondary mitral regurgitation have a poor prognosis, with 1- and 5-year mortality rates of 20% and 50%, and an extremely high rate of rehospitalization for heart failure. And yet multiple surveys have shown only a minority of these patients undergo surgery.
Discussant Dr. Spencer B. King III called the transcatheter mitral valve reconstruction system “quite fascinating.” He wondered what happens if the operator accidentally grabs the nearby circumflex artery with one of the device anchors. The answer, Dr. Kuck replied, is that the anchors can be unscrewed and repositioned at any point during the procedure.
Dr. King, president of the Heart and Vascular Institute at Saint Joseph’s Health System in Atlanta, has developed several devices widely used in interventional cardiology. He shook his head in amazement at the speed at which the European regulatory agency operated in this case, noting that EU marketing approval for the Valtech Cardioband device was granted and a payment structure was almost immediately established on the basis of a 50-patient, first-in-man study.
“The data are very consistent. I think that‘s what made the difference,” Dr. Kuck said.
The study was funded by Valtech. Dr. Kuck reported serving as a consultant to Biosense Webster, Edwards, and St. Jude, and on a speakers’ bureau for Medtronic.
CHICAGO – One-year results of a pivotal European trial of the percutaneous Cardioband mitral valve reconstruction system show a stable, consistent, and clinically meaningful reduction in mitral regurgitation coupled with significant quality of life improvements and a safety profile equivalent to that of other transcatheter valve procedures.
“The results are quite impressive. Ladies and gentlemen, I can tell you that I’ve used almost all the devices for direct and indirect annuloplasty, and this is the only device that works in a reproducible fashion,” Dr. Karl-Heinz Kuck said at the annual meeting of the American College of Cardiology.
He presented the results for the first 50 patients to reach 12 months of follow-up after undergoing the Cardioband procedure in a multicenter prospective study in which participants served as their own before-and-after controls. On the strength of these results, the Cardioband device has been approved by European Union regulatory authorities for the nonsurgical treatment of symptomatic moderate to severe secondary, or functional, mitral regurgitation. In Germany, the Cardioband procedure is now routinely reimbursed at a level similar to that of the MitraClip, according to Dr. Kuck, president of the German Cardiac Society and head of cardiology at St. Georg Hospital in Hamburg, Germany.
The Cardioband procedure essentially entails percutaneous implantation of an adjustable surgical ring designed to remodel a severely dysfunctional mitral valve by repairing the valve annulus. The implantation procedure features transfemoral venous access, which the TAVR experience has shown to be safer than transapical access. As in surgery, the percutaneous procedure utilizes supra-annular fixation. And it accomplishes a significant reduction in annular dimensions, comparable to what is achieved with a size 28 surgical ring.
“And the most important thing: Because we are not interfering with the leaflets or any other part of the mitral valve, the procedure leaves all options open for the future by preserving the native anatomy,” Dr. Kuck noted.
The procedure entails a transseptal puncture, insertion of the system, deployment of the implant, and adjustment of its size by cinching it down under echocardiographic guidance in order to reduce the septolateral valve dimension. The whole thing takes about 75 minutes.
The connection of the implant to the annulus is achieved in sutureless fashion using a series of screw-in anchors.
All 50 participants in the consecutive series were deemed by a heart team to be at unacceptably high surgical risk. They averaged 71 years of age, with an left ventricular ejection fraction of 33% and a left ventricular end diastolic diameter of 61 mm. Among them, 31 had ischemic heart disease, 11 had chronic obstructive pulmonary disease, 38 were in moderate or severe renal failure, 39 had atrial fibrillation, 12 had severe pulmonary hypertension, and 16 had previously undergone CABG surgery.
The 30-day safety adverse events consisted of one hemorrhagic stroke, a single major bleeding complication, two cases of acute renal failure, and one of cardiac tamponade. There were no MIs, and neither of the two deaths were related to the procedure.
In terms of efficacy, at baseline three-quarters of patients had grade 3-4 mitral regurgitation (MR). At discharge that was true for only 12%. At 1 year of follow-up, 90% of subjects had MR grade 2 or less, and roughly two-thirds of patients had MR grade 0-1.
The procedure did what it was designed to do: The mean valve septolateral dimension decreased by 30%, from 37 mm at baseline to 26 mm at discharge.
Dr. Kuck provided 6-month data on functional improvement. The mean 6-minute walk distance improved from 262 to 339 meters. At baseline, 87% of subjects were NYHA class III or IV; at 6 months, 77% were NYHA class I or II. Scores on the Minnesota Living with Heart Failure Questionnaire improved from a mean of 39 to 16 at follow-up.
A much larger European postmarketing commercial use study of the Cardioband system is now underway.
The Cardioband procedure addresses a major unmet need, Dr. Kuck observed. More than 4 million patients in the United States alone have mitral valve disease. When medically managed, patients with severe secondary mitral regurgitation have a poor prognosis, with 1- and 5-year mortality rates of 20% and 50%, and an extremely high rate of rehospitalization for heart failure. And yet multiple surveys have shown only a minority of these patients undergo surgery.
Discussant Dr. Spencer B. King III called the transcatheter mitral valve reconstruction system “quite fascinating.” He wondered what happens if the operator accidentally grabs the nearby circumflex artery with one of the device anchors. The answer, Dr. Kuck replied, is that the anchors can be unscrewed and repositioned at any point during the procedure.
Dr. King, president of the Heart and Vascular Institute at Saint Joseph’s Health System in Atlanta, has developed several devices widely used in interventional cardiology. He shook his head in amazement at the speed at which the European regulatory agency operated in this case, noting that EU marketing approval for the Valtech Cardioband device was granted and a payment structure was almost immediately established on the basis of a 50-patient, first-in-man study.
“The data are very consistent. I think that‘s what made the difference,” Dr. Kuck said.
The study was funded by Valtech. Dr. Kuck reported serving as a consultant to Biosense Webster, Edwards, and St. Jude, and on a speakers’ bureau for Medtronic.
CHICAGO – One-year results of a pivotal European trial of the percutaneous Cardioband mitral valve reconstruction system show a stable, consistent, and clinically meaningful reduction in mitral regurgitation coupled with significant quality of life improvements and a safety profile equivalent to that of other transcatheter valve procedures.
“The results are quite impressive. Ladies and gentlemen, I can tell you that I’ve used almost all the devices for direct and indirect annuloplasty, and this is the only device that works in a reproducible fashion,” Dr. Karl-Heinz Kuck said at the annual meeting of the American College of Cardiology.
He presented the results for the first 50 patients to reach 12 months of follow-up after undergoing the Cardioband procedure in a multicenter prospective study in which participants served as their own before-and-after controls. On the strength of these results, the Cardioband device has been approved by European Union regulatory authorities for the nonsurgical treatment of symptomatic moderate to severe secondary, or functional, mitral regurgitation. In Germany, the Cardioband procedure is now routinely reimbursed at a level similar to that of the MitraClip, according to Dr. Kuck, president of the German Cardiac Society and head of cardiology at St. Georg Hospital in Hamburg, Germany.
The Cardioband procedure essentially entails percutaneous implantation of an adjustable surgical ring designed to remodel a severely dysfunctional mitral valve by repairing the valve annulus. The implantation procedure features transfemoral venous access, which the TAVR experience has shown to be safer than transapical access. As in surgery, the percutaneous procedure utilizes supra-annular fixation. And it accomplishes a significant reduction in annular dimensions, comparable to what is achieved with a size 28 surgical ring.
“And the most important thing: Because we are not interfering with the leaflets or any other part of the mitral valve, the procedure leaves all options open for the future by preserving the native anatomy,” Dr. Kuck noted.
The procedure entails a transseptal puncture, insertion of the system, deployment of the implant, and adjustment of its size by cinching it down under echocardiographic guidance in order to reduce the septolateral valve dimension. The whole thing takes about 75 minutes.
The connection of the implant to the annulus is achieved in sutureless fashion using a series of screw-in anchors.
All 50 participants in the consecutive series were deemed by a heart team to be at unacceptably high surgical risk. They averaged 71 years of age, with an left ventricular ejection fraction of 33% and a left ventricular end diastolic diameter of 61 mm. Among them, 31 had ischemic heart disease, 11 had chronic obstructive pulmonary disease, 38 were in moderate or severe renal failure, 39 had atrial fibrillation, 12 had severe pulmonary hypertension, and 16 had previously undergone CABG surgery.
The 30-day safety adverse events consisted of one hemorrhagic stroke, a single major bleeding complication, two cases of acute renal failure, and one of cardiac tamponade. There were no MIs, and neither of the two deaths were related to the procedure.
In terms of efficacy, at baseline three-quarters of patients had grade 3-4 mitral regurgitation (MR). At discharge that was true for only 12%. At 1 year of follow-up, 90% of subjects had MR grade 2 or less, and roughly two-thirds of patients had MR grade 0-1.
The procedure did what it was designed to do: The mean valve septolateral dimension decreased by 30%, from 37 mm at baseline to 26 mm at discharge.
Dr. Kuck provided 6-month data on functional improvement. The mean 6-minute walk distance improved from 262 to 339 meters. At baseline, 87% of subjects were NYHA class III or IV; at 6 months, 77% were NYHA class I or II. Scores on the Minnesota Living with Heart Failure Questionnaire improved from a mean of 39 to 16 at follow-up.
A much larger European postmarketing commercial use study of the Cardioband system is now underway.
The Cardioband procedure addresses a major unmet need, Dr. Kuck observed. More than 4 million patients in the United States alone have mitral valve disease. When medically managed, patients with severe secondary mitral regurgitation have a poor prognosis, with 1- and 5-year mortality rates of 20% and 50%, and an extremely high rate of rehospitalization for heart failure. And yet multiple surveys have shown only a minority of these patients undergo surgery.
Discussant Dr. Spencer B. King III called the transcatheter mitral valve reconstruction system “quite fascinating.” He wondered what happens if the operator accidentally grabs the nearby circumflex artery with one of the device anchors. The answer, Dr. Kuck replied, is that the anchors can be unscrewed and repositioned at any point during the procedure.
Dr. King, president of the Heart and Vascular Institute at Saint Joseph’s Health System in Atlanta, has developed several devices widely used in interventional cardiology. He shook his head in amazement at the speed at which the European regulatory agency operated in this case, noting that EU marketing approval for the Valtech Cardioband device was granted and a payment structure was almost immediately established on the basis of a 50-patient, first-in-man study.
“The data are very consistent. I think that‘s what made the difference,” Dr. Kuck said.
The study was funded by Valtech. Dr. Kuck reported serving as a consultant to Biosense Webster, Edwards, and St. Jude, and on a speakers’ bureau for Medtronic.
AT ACC 16
Key clinical point: A new percutaneous repair option has been developed for patients with secondary mitral regurgitation.
Major finding: At 1 year of follow-up after receiving the Cardioband mitral reconstruction system, 90% of treated subjects with baseline severe mitral valve disease had mitral regurgitation of grade 2 or less.
Data source: A prospective, multicenter clinical trial featuring 12 months of follow-up of 50 treated patients with severe secondary mitral regurgitation.
Disclosures: The study was sponsored by Valtech, maker of the Cardioband system. The presenter reported serving as a consultant to Biosense Webster, Edwards, and St. Jude, and on a speakers bureau for Medtronic.
NIH launches research program to lower disparities in surgical care
The National Institute on Minority Health and Health Disparities (NIMHD), a division of the National Institutes of Health, has developed an initiative to conduct research on disparities in surgical care for disadvantaged populations.
Health disparities are typically associated with higher rates of chronic disabling conditions, greater comorbidity, a higher risk of premature death, lower quality of life, and longer recovery from disease. Disparities are also found in surgical outcomes.
“Disparities in surgical care can result in poorer functional outcomes, prolonged rehabilitation and recovery, and lower quality of life, particularly for disadvantaged population groups,” said Dr. Eliseo J. Pérez-Stable, NIMHD Director. “Racial and ethnic minority and low-income population groups are often times disproportionately affected by access, availability, and affordability to the most advanced health care services.”
Roughly 51 million inpatient and 53 million outpatient surgical cases are performed in the United States every year, according to the Centers for Disease Control and Prevention. Research has indicated surgical care or anesthesia management or sometimes both are needed for 11%-30% of the patients suffering from the global burdens of disease, according to NIMHD. This research program, which has been approved by the National Advisory Council on Minority Health and Health Disparities, will help reduce unequal access in surgical care and improve outcomes.
Factors identified as affecting surgical outcomes include patient characteristics, healthcare system and access, clinical care and quality, and postoperative care and rehabilitation. However, for surgical disparities research, five overarching priorities have been highlighted for closer examination including improving patient-clinician communication, evaluating longer term effects, and improving patient centeredness. The NIMHD initiative will support development of a national research agenda in the area of disparities in surgical access, care, and outcomes.
Dr. Irene Dankwa-Mullan, acting deputy director, Division of Extramural Research at NIMHD, believes the program is a great chance to truly learn what are the causes and the solutions to surgical disparities. “The new research program will examine hypotheses based on published or evidence-based surgical methods that identify new indications or approaches to improving access, care coordination, outcomes, safety, and quality of surgical care for health disparity populations.”
Find the study at the National Institutes of Health here.
The National Institute on Minority Health and Health Disparities (NIMHD), a division of the National Institutes of Health, has developed an initiative to conduct research on disparities in surgical care for disadvantaged populations.
Health disparities are typically associated with higher rates of chronic disabling conditions, greater comorbidity, a higher risk of premature death, lower quality of life, and longer recovery from disease. Disparities are also found in surgical outcomes.
“Disparities in surgical care can result in poorer functional outcomes, prolonged rehabilitation and recovery, and lower quality of life, particularly for disadvantaged population groups,” said Dr. Eliseo J. Pérez-Stable, NIMHD Director. “Racial and ethnic minority and low-income population groups are often times disproportionately affected by access, availability, and affordability to the most advanced health care services.”
Roughly 51 million inpatient and 53 million outpatient surgical cases are performed in the United States every year, according to the Centers for Disease Control and Prevention. Research has indicated surgical care or anesthesia management or sometimes both are needed for 11%-30% of the patients suffering from the global burdens of disease, according to NIMHD. This research program, which has been approved by the National Advisory Council on Minority Health and Health Disparities, will help reduce unequal access in surgical care and improve outcomes.
Factors identified as affecting surgical outcomes include patient characteristics, healthcare system and access, clinical care and quality, and postoperative care and rehabilitation. However, for surgical disparities research, five overarching priorities have been highlighted for closer examination including improving patient-clinician communication, evaluating longer term effects, and improving patient centeredness. The NIMHD initiative will support development of a national research agenda in the area of disparities in surgical access, care, and outcomes.
Dr. Irene Dankwa-Mullan, acting deputy director, Division of Extramural Research at NIMHD, believes the program is a great chance to truly learn what are the causes and the solutions to surgical disparities. “The new research program will examine hypotheses based on published or evidence-based surgical methods that identify new indications or approaches to improving access, care coordination, outcomes, safety, and quality of surgical care for health disparity populations.”
Find the study at the National Institutes of Health here.
The National Institute on Minority Health and Health Disparities (NIMHD), a division of the National Institutes of Health, has developed an initiative to conduct research on disparities in surgical care for disadvantaged populations.
Health disparities are typically associated with higher rates of chronic disabling conditions, greater comorbidity, a higher risk of premature death, lower quality of life, and longer recovery from disease. Disparities are also found in surgical outcomes.
“Disparities in surgical care can result in poorer functional outcomes, prolonged rehabilitation and recovery, and lower quality of life, particularly for disadvantaged population groups,” said Dr. Eliseo J. Pérez-Stable, NIMHD Director. “Racial and ethnic minority and low-income population groups are often times disproportionately affected by access, availability, and affordability to the most advanced health care services.”
Roughly 51 million inpatient and 53 million outpatient surgical cases are performed in the United States every year, according to the Centers for Disease Control and Prevention. Research has indicated surgical care or anesthesia management or sometimes both are needed for 11%-30% of the patients suffering from the global burdens of disease, according to NIMHD. This research program, which has been approved by the National Advisory Council on Minority Health and Health Disparities, will help reduce unequal access in surgical care and improve outcomes.
Factors identified as affecting surgical outcomes include patient characteristics, healthcare system and access, clinical care and quality, and postoperative care and rehabilitation. However, for surgical disparities research, five overarching priorities have been highlighted for closer examination including improving patient-clinician communication, evaluating longer term effects, and improving patient centeredness. The NIMHD initiative will support development of a national research agenda in the area of disparities in surgical access, care, and outcomes.
Dr. Irene Dankwa-Mullan, acting deputy director, Division of Extramural Research at NIMHD, believes the program is a great chance to truly learn what are the causes and the solutions to surgical disparities. “The new research program will examine hypotheses based on published or evidence-based surgical methods that identify new indications or approaches to improving access, care coordination, outcomes, safety, and quality of surgical care for health disparity populations.”
Find the study at the National Institutes of Health here.
FROM THE NATIONAL INSTITUTES OF HEALTH
Choice of cardiac ‘operative mortality’ definition affects outcomes reporting
Reporting of outcomes has grown in importance as clinical registries collect data and establish benchmarks for quality care, but exactly what those data report can vary depending on the definition of a specific outcome, even for an outcome as seemingly straightforward as death after an intervention.
Dr. Steven Maximus of the University of California Irvine Medical Center, and colleagues reported on this phenomenon in the April issue of the Journal of Thoracic and Cardiovascular Surgery (2016;151:1101-10). Specifically, they showed how rates of postoperative mortality after five different cardiac interventions can vary within the same data set depending on the definition of postoperative mortality.
“A significant percentage of procedural deaths occur after transfer or discharge from the index hospital,” Dr. Maximus and colleagues said. “These findings illustrate the importance of the definition of ‘operative’ mortality and the need to ensure accuracy in the reporting of data to volunteer clinical registries.”
They calculated outcomes based on five different definitions of postoperative mortality for five different cardiac interventions, depending on when and where the patient died, each of which showed slightly different results. The five different definitions of postoperative mortality are: during the index hospitalization only; during the index hospitalization or in a hospital the patient was transferred to on the same day or within 24 hours of discharge; during the index hospitalization or within 30 days after the procedure; during the index hospitalization or transfer hospitalization or during readmission within 30 days; and during the index hospitalization, transfer, and within 30 days after the procedure regardless of readmission.
As an example, mortality rates for percutaneous coronary intervention (PCI) with acute coronary syndrome (ACS) ranged from 3.25% for the first definition listed to 4.51% for the fifth definition. For isolated coronary artery bypass grafting, the rates ranged from 1.71% for the first definition to 2.15% for the fifth.
The fifth definition “is the most encompassing and is the current definition used by the STS [Society of Thoracic Surgeons] and should be applied to other clinical registries, such as the American College of Cardiology National Cardiovascular Data Registry,” Dr. Maximus and colleagues said.
The study noted that the Society of Thoracic Surgeons National Database (STS-NDB) has revised its definition of operative mortality to more accurately measure outcomes. Originally, the STS-NDB definition included all deaths during the index hospitalization, even those after 30 days, and postdischarge deaths within 30 days unless the cause of death was not related to the operation. In 2011, the definition was updated to include patients transferred to other acute care facilities. STS-NDB updated the definition again in 2014 to include all deaths, regardless of cause, during the index hospitalization, even if after 30 days, and including patients transferred to other acute care facilities, and all deaths, again regardless of cause, after discharge and within 30 days of the operation.
The analyses by Dr. Maximus and colleagues used data from the California Office of Statewide Health Planning and Development hospitalized patient discharge database for the year 2009. The first analysis the researchers performed did not exclude any patients and found a significant number of cardiac procedural deaths occurred after transfer at discharge from the index hospitalization, 17% in the surgical group vs. 31% in the PCI group. In the second analysis, which excluded untrackable patients, hospital deaths included 12% for PCI and 4% for surgery.
“PCI mortality was more dependent on the method used to define mortality, compared with the surgical patients, and a larger percentage of deaths occurred after hospital discharge and within 30 days of the procedure,” Dr. Maximus and colleagues said.
Another key factor in calculating mortality rates was the ability of hospitals to follow patients. “We found that up to 20% of hospitals were not able to track their patients long-term,” Dr. Maximus and coauthors said.
Study coauthor Dr. Junaid Kahn disclosed consulting fees from Edwards Lifesciences. The other authors have no financial relationships to disclose.
“The public, our patients, and their families might be surprised to discover that doctors have difficulty tallying how many people die after cardiac interventions, and that the question merited a piece of published statistical analysis,” Dr. Tom Treasure of University College London and Dr. Samer Nashef of Papworth Hospital, Cambridge, said in their invited commentary (J Thorac Cardiovasc Surg. 2016;151:1110-1).
Dr. Maximus and colleagues showed that the wider they cast their net to account for postoperative death, the more deaths they found, Dr. Treasure and Dr. Nashef said. That may penalize institutions that are more fastidious in collecting outcomes data. “When we require institutions with scarce resources to chase long-term outcome data for the purposes of treatment quality comparison, we immediately penalize those institutions that comply; more extensive data retrieval will find more deaths,” the commentators said.
The “perfect system” would capture death following a procedure no matter where it occurs, they added. “For the sake of compliance and simplicity, and until data systems are adequately robust and comprehensive, quality monitoring of cardiac surgery may have to be based pragmatically on data that are universally available and difficult to falsify, such as death at the base hospital during the same hospital admission as the intervention.”
Dr. Treasure and Dr. Nashef also accounted for another “quirk” in measuring outcomes. “Humans make errors in data entry, transcription and transfer and computers have ‘glitches’ and ‘gremlins,’ ” they said. “An apparent improvement in clinical outcome in fact may be merely the result of better record keeping.”
The commentators reported that they had no relationships to disclose.
“The public, our patients, and their families might be surprised to discover that doctors have difficulty tallying how many people die after cardiac interventions, and that the question merited a piece of published statistical analysis,” Dr. Tom Treasure of University College London and Dr. Samer Nashef of Papworth Hospital, Cambridge, said in their invited commentary (J Thorac Cardiovasc Surg. 2016;151:1110-1).
Dr. Maximus and colleagues showed that the wider they cast their net to account for postoperative death, the more deaths they found, Dr. Treasure and Dr. Nashef said. That may penalize institutions that are more fastidious in collecting outcomes data. “When we require institutions with scarce resources to chase long-term outcome data for the purposes of treatment quality comparison, we immediately penalize those institutions that comply; more extensive data retrieval will find more deaths,” the commentators said.
The “perfect system” would capture death following a procedure no matter where it occurs, they added. “For the sake of compliance and simplicity, and until data systems are adequately robust and comprehensive, quality monitoring of cardiac surgery may have to be based pragmatically on data that are universally available and difficult to falsify, such as death at the base hospital during the same hospital admission as the intervention.”
Dr. Treasure and Dr. Nashef also accounted for another “quirk” in measuring outcomes. “Humans make errors in data entry, transcription and transfer and computers have ‘glitches’ and ‘gremlins,’ ” they said. “An apparent improvement in clinical outcome in fact may be merely the result of better record keeping.”
The commentators reported that they had no relationships to disclose.
“The public, our patients, and their families might be surprised to discover that doctors have difficulty tallying how many people die after cardiac interventions, and that the question merited a piece of published statistical analysis,” Dr. Tom Treasure of University College London and Dr. Samer Nashef of Papworth Hospital, Cambridge, said in their invited commentary (J Thorac Cardiovasc Surg. 2016;151:1110-1).
Dr. Maximus and colleagues showed that the wider they cast their net to account for postoperative death, the more deaths they found, Dr. Treasure and Dr. Nashef said. That may penalize institutions that are more fastidious in collecting outcomes data. “When we require institutions with scarce resources to chase long-term outcome data for the purposes of treatment quality comparison, we immediately penalize those institutions that comply; more extensive data retrieval will find more deaths,” the commentators said.
The “perfect system” would capture death following a procedure no matter where it occurs, they added. “For the sake of compliance and simplicity, and until data systems are adequately robust and comprehensive, quality monitoring of cardiac surgery may have to be based pragmatically on data that are universally available and difficult to falsify, such as death at the base hospital during the same hospital admission as the intervention.”
Dr. Treasure and Dr. Nashef also accounted for another “quirk” in measuring outcomes. “Humans make errors in data entry, transcription and transfer and computers have ‘glitches’ and ‘gremlins,’ ” they said. “An apparent improvement in clinical outcome in fact may be merely the result of better record keeping.”
The commentators reported that they had no relationships to disclose.
Reporting of outcomes has grown in importance as clinical registries collect data and establish benchmarks for quality care, but exactly what those data report can vary depending on the definition of a specific outcome, even for an outcome as seemingly straightforward as death after an intervention.
Dr. Steven Maximus of the University of California Irvine Medical Center, and colleagues reported on this phenomenon in the April issue of the Journal of Thoracic and Cardiovascular Surgery (2016;151:1101-10). Specifically, they showed how rates of postoperative mortality after five different cardiac interventions can vary within the same data set depending on the definition of postoperative mortality.
“A significant percentage of procedural deaths occur after transfer or discharge from the index hospital,” Dr. Maximus and colleagues said. “These findings illustrate the importance of the definition of ‘operative’ mortality and the need to ensure accuracy in the reporting of data to volunteer clinical registries.”
They calculated outcomes based on five different definitions of postoperative mortality for five different cardiac interventions, depending on when and where the patient died, each of which showed slightly different results. The five different definitions of postoperative mortality are: during the index hospitalization only; during the index hospitalization or in a hospital the patient was transferred to on the same day or within 24 hours of discharge; during the index hospitalization or within 30 days after the procedure; during the index hospitalization or transfer hospitalization or during readmission within 30 days; and during the index hospitalization, transfer, and within 30 days after the procedure regardless of readmission.
As an example, mortality rates for percutaneous coronary intervention (PCI) with acute coronary syndrome (ACS) ranged from 3.25% for the first definition listed to 4.51% for the fifth definition. For isolated coronary artery bypass grafting, the rates ranged from 1.71% for the first definition to 2.15% for the fifth.
The fifth definition “is the most encompassing and is the current definition used by the STS [Society of Thoracic Surgeons] and should be applied to other clinical registries, such as the American College of Cardiology National Cardiovascular Data Registry,” Dr. Maximus and colleagues said.
The study noted that the Society of Thoracic Surgeons National Database (STS-NDB) has revised its definition of operative mortality to more accurately measure outcomes. Originally, the STS-NDB definition included all deaths during the index hospitalization, even those after 30 days, and postdischarge deaths within 30 days unless the cause of death was not related to the operation. In 2011, the definition was updated to include patients transferred to other acute care facilities. STS-NDB updated the definition again in 2014 to include all deaths, regardless of cause, during the index hospitalization, even if after 30 days, and including patients transferred to other acute care facilities, and all deaths, again regardless of cause, after discharge and within 30 days of the operation.
The analyses by Dr. Maximus and colleagues used data from the California Office of Statewide Health Planning and Development hospitalized patient discharge database for the year 2009. The first analysis the researchers performed did not exclude any patients and found a significant number of cardiac procedural deaths occurred after transfer at discharge from the index hospitalization, 17% in the surgical group vs. 31% in the PCI group. In the second analysis, which excluded untrackable patients, hospital deaths included 12% for PCI and 4% for surgery.
“PCI mortality was more dependent on the method used to define mortality, compared with the surgical patients, and a larger percentage of deaths occurred after hospital discharge and within 30 days of the procedure,” Dr. Maximus and colleagues said.
Another key factor in calculating mortality rates was the ability of hospitals to follow patients. “We found that up to 20% of hospitals were not able to track their patients long-term,” Dr. Maximus and coauthors said.
Study coauthor Dr. Junaid Kahn disclosed consulting fees from Edwards Lifesciences. The other authors have no financial relationships to disclose.
Reporting of outcomes has grown in importance as clinical registries collect data and establish benchmarks for quality care, but exactly what those data report can vary depending on the definition of a specific outcome, even for an outcome as seemingly straightforward as death after an intervention.
Dr. Steven Maximus of the University of California Irvine Medical Center, and colleagues reported on this phenomenon in the April issue of the Journal of Thoracic and Cardiovascular Surgery (2016;151:1101-10). Specifically, they showed how rates of postoperative mortality after five different cardiac interventions can vary within the same data set depending on the definition of postoperative mortality.
“A significant percentage of procedural deaths occur after transfer or discharge from the index hospital,” Dr. Maximus and colleagues said. “These findings illustrate the importance of the definition of ‘operative’ mortality and the need to ensure accuracy in the reporting of data to volunteer clinical registries.”
They calculated outcomes based on five different definitions of postoperative mortality for five different cardiac interventions, depending on when and where the patient died, each of which showed slightly different results. The five different definitions of postoperative mortality are: during the index hospitalization only; during the index hospitalization or in a hospital the patient was transferred to on the same day or within 24 hours of discharge; during the index hospitalization or within 30 days after the procedure; during the index hospitalization or transfer hospitalization or during readmission within 30 days; and during the index hospitalization, transfer, and within 30 days after the procedure regardless of readmission.
As an example, mortality rates for percutaneous coronary intervention (PCI) with acute coronary syndrome (ACS) ranged from 3.25% for the first definition listed to 4.51% for the fifth definition. For isolated coronary artery bypass grafting, the rates ranged from 1.71% for the first definition to 2.15% for the fifth.
The fifth definition “is the most encompassing and is the current definition used by the STS [Society of Thoracic Surgeons] and should be applied to other clinical registries, such as the American College of Cardiology National Cardiovascular Data Registry,” Dr. Maximus and colleagues said.
The study noted that the Society of Thoracic Surgeons National Database (STS-NDB) has revised its definition of operative mortality to more accurately measure outcomes. Originally, the STS-NDB definition included all deaths during the index hospitalization, even those after 30 days, and postdischarge deaths within 30 days unless the cause of death was not related to the operation. In 2011, the definition was updated to include patients transferred to other acute care facilities. STS-NDB updated the definition again in 2014 to include all deaths, regardless of cause, during the index hospitalization, even if after 30 days, and including patients transferred to other acute care facilities, and all deaths, again regardless of cause, after discharge and within 30 days of the operation.
The analyses by Dr. Maximus and colleagues used data from the California Office of Statewide Health Planning and Development hospitalized patient discharge database for the year 2009. The first analysis the researchers performed did not exclude any patients and found a significant number of cardiac procedural deaths occurred after transfer at discharge from the index hospitalization, 17% in the surgical group vs. 31% in the PCI group. In the second analysis, which excluded untrackable patients, hospital deaths included 12% for PCI and 4% for surgery.
“PCI mortality was more dependent on the method used to define mortality, compared with the surgical patients, and a larger percentage of deaths occurred after hospital discharge and within 30 days of the procedure,” Dr. Maximus and colleagues said.
Another key factor in calculating mortality rates was the ability of hospitals to follow patients. “We found that up to 20% of hospitals were not able to track their patients long-term,” Dr. Maximus and coauthors said.
Study coauthor Dr. Junaid Kahn disclosed consulting fees from Edwards Lifesciences. The other authors have no financial relationships to disclose.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Mortality rates for various coronary procedures can vary depending on the definition chosen.
Major finding: The mortality rate for percutaneous coronary intervention with acute coronary syndrome ranged from 3.25% to 4.51% depending on which of five definitions was used.
Data source: California Office of Statewide Health Planning and Development Hospitalized Patient Discharge Data Base for 2009.
Disclosures: Study coauthor Dr. Junaid Kahn reports receiving consulting fees for Edwards Lifesciences. The other authors have no financial relationships to disclose.
Ripple effect of complications in lung transplant
As the frequency of lung transplants rises, so too has the strain on resources to manage in-hospital complications after those operations. Researchers from the University of Pittsburgh have identified independent predictors of short-term complications that can compromise long-term survival in these patients in what they said is the first study to systematically evaluate and profile such complications.
“These results may identify important targets for best practice guidelines and quality-of-care measures after lung transplantation,” reported Dr. Ernest G. Chan and colleagues (J Thorac Cardiovasc Surg 2016 April;151:1171-80).
The study involved 748 patients in the University of Pittsburgh Medical Center Transplant Patient Management System database who had in-hospital complications after single- or double-lung transplant from January 2007 to October 2013. The researchers analyzed 3,381 such complications in 92.78% of these patients, grading the complications via the extended Accordion Severity Grading System (ASGS). The median follow-up of the cohort was 5.4 years.
The researchers also classified complications that carried significant decrease in 5-year survival into three categories: renal complications, with a hazard ratio (HR) of 2.58; hepatic, with an HR of 4.08; and cardiac, with an HR of 1.95.
“Multivariate analysis identified a weighted ASGS sum of greater than 10 and renal, cardiac, and vascular complications as predictors of decreased long-term survival,” Dr. Chan and colleagues noted.
In-hospital complications are important predictors of long-term survival, Dr. Chan and coauthors wrote, citing studies from Memorial Sloan-Kettering Cancer Center in New York and the University of Minnesota. (N Engl J Med. 2001;345:181-8;Ann Surg. 2011;254:368-74). They also noted variable findings of several studies with regard to the impact center volume can have on long-term survival, particularly because high-volume centers may be better prepared to manage those complications.
“These important finding highlight the need for further in-depth analysis into an intriguing aspect of surgical management of complications after high-risk procedures,” the researchers wrote. Their goal was to create a postoperative complication profile for lung transplant patients.
Of the 748 patients in the study, 7.22% (54) had an uneventful postoperative course. The noncomplication group had a cumulative 5-year survival of around 73.8% vs. 53.3% for the complications group. On average, each patient in the complication group had almost five different complications. The most common were pulmonary in nature (71.66%), followed by infections (69.52%), pleural space–related problems (46.12%), renal complications (36.23%), and cardiac (35.83%). Renal complications accounted for the greatest decrease in 5-year survival at 35.4% vs. 64.4% in patients who did not have renal complications.
Survival rates for other categories of complications vs. the absence of those complications were: hepatic, 18.1% vs. 57.3%; cardiac, 39.5% vs. 62.3%; vascular, 29.4% vs. 58.5%; neurologic, 32.6% vs. 57.1%; musculoskeletal, 27.4% vs. 56.8%; and pleural-space complications, 48.7% vs. 60.3%.
The multivariate analysis assigned hazard ratios to these predictors: age older than 65 years, 1.01; renal events, 1.70; cardiac events, 1.29; vascular events, 1.33; and weighted ASGS sum, 1.08. Besides ASGS severity, the researchers considered Charlson Comorbidity Index analysis, but found that it had no significant effect on hazard ratio, the researchers said.
“With appropriate patients selection and contemporary surgical techniques, vigilant postoperative management and avoidance of adverse events may potentially offer patients better long-term outcomes,” Dr. Chan and colleagues noted. “The overall 90-day postoperative course has an influence on long-term survival.”
Among those factors that influence survival are the severity of the intervention to treat the complication and the occurrence of less-severe complications, they added. “The next step is to identify interventions that effectively reduce the incidence, as well as severity, of in-hospital, postoperative complications.”
The researchers had no financial relationships to disclose.
The study findings show not only that complications after lung transplantation “are nearly ubiquitous” but also that clinicians need better management strategies to address them, Katie Kinaschuk and Dr. Jayan Nagendran said in their invited commentary (J Thorac Cardiovasc Surg. 2016;151:1181-2).
The multivariate analysis by Dr. Chan and colleagues shows a strong correlation between nonpulmonary complications and decreased long-term survival in patients who have had lung transplants, but this does not downplay the significance of pulmonary and infectious complications, Ms. Kinaschuk and Dr. Nagendran noted. “Thus, despite the need to improve treatment algorithms of highly predictive non–allograft-related complications, the greatest opportunity to decrease the overall rates of complications still exists within pulmonary and infectious etiologies.”
Noteworthy among the study findings was that the Charlson Comorbidity Index values were not a predictor for long-term survival, they wrote. That may suggest that factors of the operation itself, along with donor tissue, may have important roles in the link between postoperative complications and decreased long-term survival. “This may represent the need for careful reporting and consideration of non–allograft-related postoperative complications in assessing new technologies for donor lung management,” they said.
The “ripple effect” of early postoperative complications “may warrant more vigilant long-term surveillance once a complication has occurred,” the commentators noted. “Ultimately, determination of preventive measures by identifying predictors of complications will have the greatest positive effect on survival,” an area that needs further investigation, they wrote.
Ms. Kinaschuk and Dr. Nagendran had no relationships to disclose.
The study findings show not only that complications after lung transplantation “are nearly ubiquitous” but also that clinicians need better management strategies to address them, Katie Kinaschuk and Dr. Jayan Nagendran said in their invited commentary (J Thorac Cardiovasc Surg. 2016;151:1181-2).
The multivariate analysis by Dr. Chan and colleagues shows a strong correlation between nonpulmonary complications and decreased long-term survival in patients who have had lung transplants, but this does not downplay the significance of pulmonary and infectious complications, Ms. Kinaschuk and Dr. Nagendran noted. “Thus, despite the need to improve treatment algorithms of highly predictive non–allograft-related complications, the greatest opportunity to decrease the overall rates of complications still exists within pulmonary and infectious etiologies.”
Noteworthy among the study findings was that the Charlson Comorbidity Index values were not a predictor for long-term survival, they wrote. That may suggest that factors of the operation itself, along with donor tissue, may have important roles in the link between postoperative complications and decreased long-term survival. “This may represent the need for careful reporting and consideration of non–allograft-related postoperative complications in assessing new technologies for donor lung management,” they said.
The “ripple effect” of early postoperative complications “may warrant more vigilant long-term surveillance once a complication has occurred,” the commentators noted. “Ultimately, determination of preventive measures by identifying predictors of complications will have the greatest positive effect on survival,” an area that needs further investigation, they wrote.
Ms. Kinaschuk and Dr. Nagendran had no relationships to disclose.
The study findings show not only that complications after lung transplantation “are nearly ubiquitous” but also that clinicians need better management strategies to address them, Katie Kinaschuk and Dr. Jayan Nagendran said in their invited commentary (J Thorac Cardiovasc Surg. 2016;151:1181-2).
The multivariate analysis by Dr. Chan and colleagues shows a strong correlation between nonpulmonary complications and decreased long-term survival in patients who have had lung transplants, but this does not downplay the significance of pulmonary and infectious complications, Ms. Kinaschuk and Dr. Nagendran noted. “Thus, despite the need to improve treatment algorithms of highly predictive non–allograft-related complications, the greatest opportunity to decrease the overall rates of complications still exists within pulmonary and infectious etiologies.”
Noteworthy among the study findings was that the Charlson Comorbidity Index values were not a predictor for long-term survival, they wrote. That may suggest that factors of the operation itself, along with donor tissue, may have important roles in the link between postoperative complications and decreased long-term survival. “This may represent the need for careful reporting and consideration of non–allograft-related postoperative complications in assessing new technologies for donor lung management,” they said.
The “ripple effect” of early postoperative complications “may warrant more vigilant long-term surveillance once a complication has occurred,” the commentators noted. “Ultimately, determination of preventive measures by identifying predictors of complications will have the greatest positive effect on survival,” an area that needs further investigation, they wrote.
Ms. Kinaschuk and Dr. Nagendran had no relationships to disclose.
As the frequency of lung transplants rises, so too has the strain on resources to manage in-hospital complications after those operations. Researchers from the University of Pittsburgh have identified independent predictors of short-term complications that can compromise long-term survival in these patients in what they said is the first study to systematically evaluate and profile such complications.
“These results may identify important targets for best practice guidelines and quality-of-care measures after lung transplantation,” reported Dr. Ernest G. Chan and colleagues (J Thorac Cardiovasc Surg 2016 April;151:1171-80).
The study involved 748 patients in the University of Pittsburgh Medical Center Transplant Patient Management System database who had in-hospital complications after single- or double-lung transplant from January 2007 to October 2013. The researchers analyzed 3,381 such complications in 92.78% of these patients, grading the complications via the extended Accordion Severity Grading System (ASGS). The median follow-up of the cohort was 5.4 years.
The researchers also classified complications that carried significant decrease in 5-year survival into three categories: renal complications, with a hazard ratio (HR) of 2.58; hepatic, with an HR of 4.08; and cardiac, with an HR of 1.95.
“Multivariate analysis identified a weighted ASGS sum of greater than 10 and renal, cardiac, and vascular complications as predictors of decreased long-term survival,” Dr. Chan and colleagues noted.
In-hospital complications are important predictors of long-term survival, Dr. Chan and coauthors wrote, citing studies from Memorial Sloan-Kettering Cancer Center in New York and the University of Minnesota. (N Engl J Med. 2001;345:181-8;Ann Surg. 2011;254:368-74). They also noted variable findings of several studies with regard to the impact center volume can have on long-term survival, particularly because high-volume centers may be better prepared to manage those complications.
“These important finding highlight the need for further in-depth analysis into an intriguing aspect of surgical management of complications after high-risk procedures,” the researchers wrote. Their goal was to create a postoperative complication profile for lung transplant patients.
Of the 748 patients in the study, 7.22% (54) had an uneventful postoperative course. The noncomplication group had a cumulative 5-year survival of around 73.8% vs. 53.3% for the complications group. On average, each patient in the complication group had almost five different complications. The most common were pulmonary in nature (71.66%), followed by infections (69.52%), pleural space–related problems (46.12%), renal complications (36.23%), and cardiac (35.83%). Renal complications accounted for the greatest decrease in 5-year survival at 35.4% vs. 64.4% in patients who did not have renal complications.
Survival rates for other categories of complications vs. the absence of those complications were: hepatic, 18.1% vs. 57.3%; cardiac, 39.5% vs. 62.3%; vascular, 29.4% vs. 58.5%; neurologic, 32.6% vs. 57.1%; musculoskeletal, 27.4% vs. 56.8%; and pleural-space complications, 48.7% vs. 60.3%.
The multivariate analysis assigned hazard ratios to these predictors: age older than 65 years, 1.01; renal events, 1.70; cardiac events, 1.29; vascular events, 1.33; and weighted ASGS sum, 1.08. Besides ASGS severity, the researchers considered Charlson Comorbidity Index analysis, but found that it had no significant effect on hazard ratio, the researchers said.
“With appropriate patients selection and contemporary surgical techniques, vigilant postoperative management and avoidance of adverse events may potentially offer patients better long-term outcomes,” Dr. Chan and colleagues noted. “The overall 90-day postoperative course has an influence on long-term survival.”
Among those factors that influence survival are the severity of the intervention to treat the complication and the occurrence of less-severe complications, they added. “The next step is to identify interventions that effectively reduce the incidence, as well as severity, of in-hospital, postoperative complications.”
The researchers had no financial relationships to disclose.
As the frequency of lung transplants rises, so too has the strain on resources to manage in-hospital complications after those operations. Researchers from the University of Pittsburgh have identified independent predictors of short-term complications that can compromise long-term survival in these patients in what they said is the first study to systematically evaluate and profile such complications.
“These results may identify important targets for best practice guidelines and quality-of-care measures after lung transplantation,” reported Dr. Ernest G. Chan and colleagues (J Thorac Cardiovasc Surg 2016 April;151:1171-80).
The study involved 748 patients in the University of Pittsburgh Medical Center Transplant Patient Management System database who had in-hospital complications after single- or double-lung transplant from January 2007 to October 2013. The researchers analyzed 3,381 such complications in 92.78% of these patients, grading the complications via the extended Accordion Severity Grading System (ASGS). The median follow-up of the cohort was 5.4 years.
The researchers also classified complications that carried significant decrease in 5-year survival into three categories: renal complications, with a hazard ratio (HR) of 2.58; hepatic, with an HR of 4.08; and cardiac, with an HR of 1.95.
“Multivariate analysis identified a weighted ASGS sum of greater than 10 and renal, cardiac, and vascular complications as predictors of decreased long-term survival,” Dr. Chan and colleagues noted.
In-hospital complications are important predictors of long-term survival, Dr. Chan and coauthors wrote, citing studies from Memorial Sloan-Kettering Cancer Center in New York and the University of Minnesota. (N Engl J Med. 2001;345:181-8;Ann Surg. 2011;254:368-74). They also noted variable findings of several studies with regard to the impact center volume can have on long-term survival, particularly because high-volume centers may be better prepared to manage those complications.
“These important finding highlight the need for further in-depth analysis into an intriguing aspect of surgical management of complications after high-risk procedures,” the researchers wrote. Their goal was to create a postoperative complication profile for lung transplant patients.
Of the 748 patients in the study, 7.22% (54) had an uneventful postoperative course. The noncomplication group had a cumulative 5-year survival of around 73.8% vs. 53.3% for the complications group. On average, each patient in the complication group had almost five different complications. The most common were pulmonary in nature (71.66%), followed by infections (69.52%), pleural space–related problems (46.12%), renal complications (36.23%), and cardiac (35.83%). Renal complications accounted for the greatest decrease in 5-year survival at 35.4% vs. 64.4% in patients who did not have renal complications.
Survival rates for other categories of complications vs. the absence of those complications were: hepatic, 18.1% vs. 57.3%; cardiac, 39.5% vs. 62.3%; vascular, 29.4% vs. 58.5%; neurologic, 32.6% vs. 57.1%; musculoskeletal, 27.4% vs. 56.8%; and pleural-space complications, 48.7% vs. 60.3%.
The multivariate analysis assigned hazard ratios to these predictors: age older than 65 years, 1.01; renal events, 1.70; cardiac events, 1.29; vascular events, 1.33; and weighted ASGS sum, 1.08. Besides ASGS severity, the researchers considered Charlson Comorbidity Index analysis, but found that it had no significant effect on hazard ratio, the researchers said.
“With appropriate patients selection and contemporary surgical techniques, vigilant postoperative management and avoidance of adverse events may potentially offer patients better long-term outcomes,” Dr. Chan and colleagues noted. “The overall 90-day postoperative course has an influence on long-term survival.”
Among those factors that influence survival are the severity of the intervention to treat the complication and the occurrence of less-severe complications, they added. “The next step is to identify interventions that effectively reduce the incidence, as well as severity, of in-hospital, postoperative complications.”
The researchers had no financial relationships to disclose.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Early complications after lung transplant surgery can negatively impact survival and long-term outcomes.
Major finding: Postoperative complications occurred in 92.78% of patients. Median follow-up was 5.4 years.
Data source: Retrospective analysis of 748 patients in the University of Pittsburgh Medical Center Transplant Patient Management System who had lung transplants from January 2007 to October 2013.
Disclosures: The study investigators had no relationships to disclose.
Hybrid option ‘reasonable’ for HLHS?
Although the classic Norwood palliation for infants with hypoplastic left heart syndrome (HLHS) has been well established, the procedure has had its drawbacks, namely the need for cardiopulmonary bypass with hypothermia and a because it rules out biventricular correction months later. A hybrid procedure avoids the need for bypass and accommodates short-term biventricular correction, but it has lacked strong evidence.
Researchers from Justus-Liebig University Giessen, Germany, reported on 182 patients with HLHS who had the three-stage Giessen hybrid procedure, noting 10-year survival of almost 80% with almost a third of patients requiring no artery intervention in that time (J Thorac Cardiovasc Surg. 2016 April;151:1112-23).
“In view of the early results and long-term outcome after Giessen hybrid palliation, the hybrid approach has become a reasonable alternative to the conventional strategy to treat neonates with HLHS and variants,” wrote Dr. Can Yerebakan and colleagues. “Further refinements are warranted to decrease patient morbidity.”
The Giessen hybrid procedure uses a technique to control pulmonary blood flow that is different from the Norwood procedure. The hybrid approach involves stenting of the arterial duct or prostaglandin therapy to maintain systemic perfusion combined with off-pump bilateral banding of the pulmonary arteries (bPAB) in the neonatal period. The Giessen hybrid operation defers the Norwood-type palliation using cardiopulmonary bypass that involves an aortic arch reconstruction, including a superior cavopulmonary connection or a biventricular correction, if indicated, until the infant is 4-8 months of age.
“In recent years, hybrid treatment has moved from a myth to an alternative modality in a growing number of institutions globally,” Dr. Yerebakan and colleagues said. The hybrid procedure has been used in high-risk patients. One report claimed higher morbidity in the hybrid procedure due to bPAB (Ann Thorac Surg. 2013;96:1382-8). Another study raised concerns about an adequate pulmonary artery rehabilitation at the time of the Fontan operation, the third stage in the hybrid strategy (J Thorac Cardiovasc Surg. 2014;147:706-12).
But with the hybrid approach, patients retain the potential to receive a biventricular correction up to 8 months later without compromising survival, “postponing an immediate definitive decision in the newborn period in comparison with the classic Norwood palliation,” Dr. Yerebakan and coauthors noted.
The doctors at the Pediatric Heart Center Giessen treat all types and variants of HLHS with the modified Giessen hybrid strategy. Between 1998 and 2015, 182 patients with HLHS had the Giessen hybrid stage I operation, including 126 patients who received univentricular palliation or a heart transplant. The median age of stage I recipients was 6 days, and median weight 3.2 kg. The stage II operation was performed at 4.5 months, with a range of 2.9 to 39.5 months, and Fontan completion was established at 33.7 months, with a range of 21 to 108 months.
Median follow-up after the stage I procedure was 4.6 years, and the death rate was 2.5%. After stage II, mortality was 4.9%; no deaths were reported after Fontan completion. Body weight less than 2.5 kg and aortic atresia had no significant effect on survival. Mortality rates were 8.9% between stages I and II and 5.3% between stage II and Fontan completion. “Cumulative interstage mortality was 14.2%,” Dr. Yerebakan and colleagues noted. “At 10 years, the probability of survival is 77.8%.”
Also at 10 years, 32.2% of patients were free from further pulmonary artery intervention, and 16.7% needed aortic arch reconstruction. Two patients required reoperations for aortic arch reconstruction.
Dr. Yerebakan and colleagues suggested several steps to improve outcomes with the hybrid approach: “intense collaboration” with anesthesiology and pediatric cardiology during and after the procedure to risk stratify individual patients; implementation of standards for management of all stages, including out-of-hospital care, in all departments that participate in a case; and liberalized indications for use of MRI before the stage II and Fontan completion.
Among the limitations of the study the authors noted were its retrospective nature and a median follow-up of only 5 years when the center has some cases with up to 15 years of follow-up. But Dr. Yerebakan and coauthors said they could not determine if the patients benefit from the hybrid treatment in the long-term.
The researchers had no disclosures.
The study by Dr. Yerebakan and colleagues is one of the largest single-center series of patients with HLHS who routinely undergo a hybrid palliation to date, and while the study is open to criticisms, “the authors should be applauded,” Dr. Ralph S. Mosca of New York University said in his invited commentary (J Thorac Cardiovasc Surg. 2016;151:1123-25).
Among the criticisms Dr. Mosca mentioned are that the hybrid approach requires a more extensive stage II reconstruction, “often further complicated by the presence of significant branch PA stenosis and a difficult aortic arch reconstruction”; that there is “appreciable” interstage mortality at 12.2%; and that there is an absence of data on renal or respiratory insufficiency, infection rates, and neurologic outcomes.
Dr. Mosca cited the cause for applause, however: “Through their persistence and collective experience, [the authors] have achieved commendable results in this difficult patient population.”
Yet, Dr. Mosca also noted a number of “potential problems” with the hybrid approach: bilateral banding of the pulmonary artery is a “crude procedure”; arterial duct stenting can lead to retrograde aortic arch reduction; and the interstage mortality “remains significant.”
Results of the hybrid and Norwood procedures are “strikingly similar,” Dr. Mosca said. While the hybrid approach may lower neonatal mortality, it may also carry longer-term consequences “predicated upon the need to closely observe and intervene,” he said. Clinicians need more information on hybrid outcomes, but in time it will likely take its place as an option for HLHS alongside the Norwood procedure, Dr. Mosca said.
The study by Dr. Yerebakan and colleagues is one of the largest single-center series of patients with HLHS who routinely undergo a hybrid palliation to date, and while the study is open to criticisms, “the authors should be applauded,” Dr. Ralph S. Mosca of New York University said in his invited commentary (J Thorac Cardiovasc Surg. 2016;151:1123-25).
Among the criticisms Dr. Mosca mentioned are that the hybrid approach requires a more extensive stage II reconstruction, “often further complicated by the presence of significant branch PA stenosis and a difficult aortic arch reconstruction”; that there is “appreciable” interstage mortality at 12.2%; and that there is an absence of data on renal or respiratory insufficiency, infection rates, and neurologic outcomes.
Dr. Mosca cited the cause for applause, however: “Through their persistence and collective experience, [the authors] have achieved commendable results in this difficult patient population.”
Yet, Dr. Mosca also noted a number of “potential problems” with the hybrid approach: bilateral banding of the pulmonary artery is a “crude procedure”; arterial duct stenting can lead to retrograde aortic arch reduction; and the interstage mortality “remains significant.”
Results of the hybrid and Norwood procedures are “strikingly similar,” Dr. Mosca said. While the hybrid approach may lower neonatal mortality, it may also carry longer-term consequences “predicated upon the need to closely observe and intervene,” he said. Clinicians need more information on hybrid outcomes, but in time it will likely take its place as an option for HLHS alongside the Norwood procedure, Dr. Mosca said.
The study by Dr. Yerebakan and colleagues is one of the largest single-center series of patients with HLHS who routinely undergo a hybrid palliation to date, and while the study is open to criticisms, “the authors should be applauded,” Dr. Ralph S. Mosca of New York University said in his invited commentary (J Thorac Cardiovasc Surg. 2016;151:1123-25).
Among the criticisms Dr. Mosca mentioned are that the hybrid approach requires a more extensive stage II reconstruction, “often further complicated by the presence of significant branch PA stenosis and a difficult aortic arch reconstruction”; that there is “appreciable” interstage mortality at 12.2%; and that there is an absence of data on renal or respiratory insufficiency, infection rates, and neurologic outcomes.
Dr. Mosca cited the cause for applause, however: “Through their persistence and collective experience, [the authors] have achieved commendable results in this difficult patient population.”
Yet, Dr. Mosca also noted a number of “potential problems” with the hybrid approach: bilateral banding of the pulmonary artery is a “crude procedure”; arterial duct stenting can lead to retrograde aortic arch reduction; and the interstage mortality “remains significant.”
Results of the hybrid and Norwood procedures are “strikingly similar,” Dr. Mosca said. While the hybrid approach may lower neonatal mortality, it may also carry longer-term consequences “predicated upon the need to closely observe and intervene,” he said. Clinicians need more information on hybrid outcomes, but in time it will likely take its place as an option for HLHS alongside the Norwood procedure, Dr. Mosca said.
Although the classic Norwood palliation for infants with hypoplastic left heart syndrome (HLHS) has been well established, the procedure has had its drawbacks, namely the need for cardiopulmonary bypass with hypothermia and a because it rules out biventricular correction months later. A hybrid procedure avoids the need for bypass and accommodates short-term biventricular correction, but it has lacked strong evidence.
Researchers from Justus-Liebig University Giessen, Germany, reported on 182 patients with HLHS who had the three-stage Giessen hybrid procedure, noting 10-year survival of almost 80% with almost a third of patients requiring no artery intervention in that time (J Thorac Cardiovasc Surg. 2016 April;151:1112-23).
“In view of the early results and long-term outcome after Giessen hybrid palliation, the hybrid approach has become a reasonable alternative to the conventional strategy to treat neonates with HLHS and variants,” wrote Dr. Can Yerebakan and colleagues. “Further refinements are warranted to decrease patient morbidity.”
The Giessen hybrid procedure uses a technique to control pulmonary blood flow that is different from the Norwood procedure. The hybrid approach involves stenting of the arterial duct or prostaglandin therapy to maintain systemic perfusion combined with off-pump bilateral banding of the pulmonary arteries (bPAB) in the neonatal period. The Giessen hybrid operation defers the Norwood-type palliation using cardiopulmonary bypass that involves an aortic arch reconstruction, including a superior cavopulmonary connection or a biventricular correction, if indicated, until the infant is 4-8 months of age.
“In recent years, hybrid treatment has moved from a myth to an alternative modality in a growing number of institutions globally,” Dr. Yerebakan and colleagues said. The hybrid procedure has been used in high-risk patients. One report claimed higher morbidity in the hybrid procedure due to bPAB (Ann Thorac Surg. 2013;96:1382-8). Another study raised concerns about an adequate pulmonary artery rehabilitation at the time of the Fontan operation, the third stage in the hybrid strategy (J Thorac Cardiovasc Surg. 2014;147:706-12).
But with the hybrid approach, patients retain the potential to receive a biventricular correction up to 8 months later without compromising survival, “postponing an immediate definitive decision in the newborn period in comparison with the classic Norwood palliation,” Dr. Yerebakan and coauthors noted.
The doctors at the Pediatric Heart Center Giessen treat all types and variants of HLHS with the modified Giessen hybrid strategy. Between 1998 and 2015, 182 patients with HLHS had the Giessen hybrid stage I operation, including 126 patients who received univentricular palliation or a heart transplant. The median age of stage I recipients was 6 days, and median weight 3.2 kg. The stage II operation was performed at 4.5 months, with a range of 2.9 to 39.5 months, and Fontan completion was established at 33.7 months, with a range of 21 to 108 months.
Median follow-up after the stage I procedure was 4.6 years, and the death rate was 2.5%. After stage II, mortality was 4.9%; no deaths were reported after Fontan completion. Body weight less than 2.5 kg and aortic atresia had no significant effect on survival. Mortality rates were 8.9% between stages I and II and 5.3% between stage II and Fontan completion. “Cumulative interstage mortality was 14.2%,” Dr. Yerebakan and colleagues noted. “At 10 years, the probability of survival is 77.8%.”
Also at 10 years, 32.2% of patients were free from further pulmonary artery intervention, and 16.7% needed aortic arch reconstruction. Two patients required reoperations for aortic arch reconstruction.
Dr. Yerebakan and colleagues suggested several steps to improve outcomes with the hybrid approach: “intense collaboration” with anesthesiology and pediatric cardiology during and after the procedure to risk stratify individual patients; implementation of standards for management of all stages, including out-of-hospital care, in all departments that participate in a case; and liberalized indications for use of MRI before the stage II and Fontan completion.
Among the limitations of the study the authors noted were its retrospective nature and a median follow-up of only 5 years when the center has some cases with up to 15 years of follow-up. But Dr. Yerebakan and coauthors said they could not determine if the patients benefit from the hybrid treatment in the long-term.
The researchers had no disclosures.
Although the classic Norwood palliation for infants with hypoplastic left heart syndrome (HLHS) has been well established, the procedure has had its drawbacks, namely the need for cardiopulmonary bypass with hypothermia and a because it rules out biventricular correction months later. A hybrid procedure avoids the need for bypass and accommodates short-term biventricular correction, but it has lacked strong evidence.
Researchers from Justus-Liebig University Giessen, Germany, reported on 182 patients with HLHS who had the three-stage Giessen hybrid procedure, noting 10-year survival of almost 80% with almost a third of patients requiring no artery intervention in that time (J Thorac Cardiovasc Surg. 2016 April;151:1112-23).
“In view of the early results and long-term outcome after Giessen hybrid palliation, the hybrid approach has become a reasonable alternative to the conventional strategy to treat neonates with HLHS and variants,” wrote Dr. Can Yerebakan and colleagues. “Further refinements are warranted to decrease patient morbidity.”
The Giessen hybrid procedure uses a technique to control pulmonary blood flow that is different from the Norwood procedure. The hybrid approach involves stenting of the arterial duct or prostaglandin therapy to maintain systemic perfusion combined with off-pump bilateral banding of the pulmonary arteries (bPAB) in the neonatal period. The Giessen hybrid operation defers the Norwood-type palliation using cardiopulmonary bypass that involves an aortic arch reconstruction, including a superior cavopulmonary connection or a biventricular correction, if indicated, until the infant is 4-8 months of age.
“In recent years, hybrid treatment has moved from a myth to an alternative modality in a growing number of institutions globally,” Dr. Yerebakan and colleagues said. The hybrid procedure has been used in high-risk patients. One report claimed higher morbidity in the hybrid procedure due to bPAB (Ann Thorac Surg. 2013;96:1382-8). Another study raised concerns about an adequate pulmonary artery rehabilitation at the time of the Fontan operation, the third stage in the hybrid strategy (J Thorac Cardiovasc Surg. 2014;147:706-12).
But with the hybrid approach, patients retain the potential to receive a biventricular correction up to 8 months later without compromising survival, “postponing an immediate definitive decision in the newborn period in comparison with the classic Norwood palliation,” Dr. Yerebakan and coauthors noted.
The doctors at the Pediatric Heart Center Giessen treat all types and variants of HLHS with the modified Giessen hybrid strategy. Between 1998 and 2015, 182 patients with HLHS had the Giessen hybrid stage I operation, including 126 patients who received univentricular palliation or a heart transplant. The median age of stage I recipients was 6 days, and median weight 3.2 kg. The stage II operation was performed at 4.5 months, with a range of 2.9 to 39.5 months, and Fontan completion was established at 33.7 months, with a range of 21 to 108 months.
Median follow-up after the stage I procedure was 4.6 years, and the death rate was 2.5%. After stage II, mortality was 4.9%; no deaths were reported after Fontan completion. Body weight less than 2.5 kg and aortic atresia had no significant effect on survival. Mortality rates were 8.9% between stages I and II and 5.3% between stage II and Fontan completion. “Cumulative interstage mortality was 14.2%,” Dr. Yerebakan and colleagues noted. “At 10 years, the probability of survival is 77.8%.”
Also at 10 years, 32.2% of patients were free from further pulmonary artery intervention, and 16.7% needed aortic arch reconstruction. Two patients required reoperations for aortic arch reconstruction.
Dr. Yerebakan and colleagues suggested several steps to improve outcomes with the hybrid approach: “intense collaboration” with anesthesiology and pediatric cardiology during and after the procedure to risk stratify individual patients; implementation of standards for management of all stages, including out-of-hospital care, in all departments that participate in a case; and liberalized indications for use of MRI before the stage II and Fontan completion.
Among the limitations of the study the authors noted were its retrospective nature and a median follow-up of only 5 years when the center has some cases with up to 15 years of follow-up. But Dr. Yerebakan and coauthors said they could not determine if the patients benefit from the hybrid treatment in the long-term.
The researchers had no disclosures.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: A hybrid operation for hypoplastic left heart syndrome (HLHS) and variants in neonates is emerging as an alternative to the Norwood palliation.
Major finding: At 10 years, the probability of survival with the hybrid procedure was 77.8%. Low body weight (less than 2.5 kg) and aortic atresia had no significant impact on survival.
Data source: Retrospective study of 182 patients who had the hybrid procedure at a single center between June 1998 and February 2015.
Disclosures: The study investigators had no relationships to disclose.
Medicare delays plans for new star ratings on hospitals
Bowing to pressure from the hospital industry and Congress, the Obama administration on April 20 delayed releasing its new hospital quality rating measure just a day before its planned launch.
The new “overall hospital quality” star rating aimed to combine the government’s disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare & Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others. The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best.
But this month, 60 senators and 225 members of the House of Representatives signed letters urging the CMS to delay releasing the star ratings. “We have heard from hospitals in our districts that they do not have the necessary data to replicate or evaluate the CMS’s work to ensure that the methodology is accurate or fair,” the letter from the House members said.
In a notice sent April 20, the CMS told Congress it would delay release of the star ratings on its Hospital Compare website until July 2016. The “CMS is committed to working with hospitals and associations to provide further guidance about star ratings,” the notice said. “After the star ratings go live in their first iteration, we will refine and improve the site as we work together and gain experience.”
But in a conference call with hospital representatives, the CMS officials said they might delay release of the ratings past July if they are still analyzing or revising the methodology, according to people who participated in the call.
Mortality, readmissions, patient experience, and safety of care metrics each accounted for 22% of the star rating, while measures of effectiveness of care, timeliness of care, and efficient use of medical imaging made up 12% in total.
The hospital industry for months has been urging this delay, arguing that many of the measures will not be relevant to patients seeking a specific service. For instance, a hospital’s death rate for Medicare patients might be irrelevant for a woman trying to decide where to give birth.
The industry’s major trade groups said in a letter to the CMS that some hospitals perform poorly because their patients tend to be lower income and don’t have the support at home. Many of the nation’s most prestigious hospitals have been bracing for middling or poor ratings.
Rick Pollack, president of the American Hospital Association, said in a statement that “the delay is a necessary step as hospitals and health systems work with CMS to improve the ratings for patients, and the AHA commends CMS for their decision.”
Last year, the CMS created a star rating to represent the views of patients in surveys. Two sets of researchers recently determined that hospitals with more stars in patient experience tended to have lower death and readmission rates.
Hospital Compare received 3.7 million unique page views last year, according to an April 2016 paper published in the journal Health Affairs. The author, analyst Steven D. Findlay, called the traffic “not at a level commensurate with [the] stature and potential” of the federal government’s health care facility comparison sites.
Dr. Ashish Jha, a Harvard School of Public Health researcher, said consumers will be more likely to use the unified star ratings, but this specific mix of measures raises concerns. “The idea that dying and being readmitted to the hospital are equally important to patients seems funny to me,” he said.
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Bowing to pressure from the hospital industry and Congress, the Obama administration on April 20 delayed releasing its new hospital quality rating measure just a day before its planned launch.
The new “overall hospital quality” star rating aimed to combine the government’s disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare & Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others. The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best.
But this month, 60 senators and 225 members of the House of Representatives signed letters urging the CMS to delay releasing the star ratings. “We have heard from hospitals in our districts that they do not have the necessary data to replicate or evaluate the CMS’s work to ensure that the methodology is accurate or fair,” the letter from the House members said.
In a notice sent April 20, the CMS told Congress it would delay release of the star ratings on its Hospital Compare website until July 2016. The “CMS is committed to working with hospitals and associations to provide further guidance about star ratings,” the notice said. “After the star ratings go live in their first iteration, we will refine and improve the site as we work together and gain experience.”
But in a conference call with hospital representatives, the CMS officials said they might delay release of the ratings past July if they are still analyzing or revising the methodology, according to people who participated in the call.
Mortality, readmissions, patient experience, and safety of care metrics each accounted for 22% of the star rating, while measures of effectiveness of care, timeliness of care, and efficient use of medical imaging made up 12% in total.
The hospital industry for months has been urging this delay, arguing that many of the measures will not be relevant to patients seeking a specific service. For instance, a hospital’s death rate for Medicare patients might be irrelevant for a woman trying to decide where to give birth.
The industry’s major trade groups said in a letter to the CMS that some hospitals perform poorly because their patients tend to be lower income and don’t have the support at home. Many of the nation’s most prestigious hospitals have been bracing for middling or poor ratings.
Rick Pollack, president of the American Hospital Association, said in a statement that “the delay is a necessary step as hospitals and health systems work with CMS to improve the ratings for patients, and the AHA commends CMS for their decision.”
Last year, the CMS created a star rating to represent the views of patients in surveys. Two sets of researchers recently determined that hospitals with more stars in patient experience tended to have lower death and readmission rates.
Hospital Compare received 3.7 million unique page views last year, according to an April 2016 paper published in the journal Health Affairs. The author, analyst Steven D. Findlay, called the traffic “not at a level commensurate with [the] stature and potential” of the federal government’s health care facility comparison sites.
Dr. Ashish Jha, a Harvard School of Public Health researcher, said consumers will be more likely to use the unified star ratings, but this specific mix of measures raises concerns. “The idea that dying and being readmitted to the hospital are equally important to patients seems funny to me,” he said.
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Bowing to pressure from the hospital industry and Congress, the Obama administration on April 20 delayed releasing its new hospital quality rating measure just a day before its planned launch.
The new “overall hospital quality” star rating aimed to combine the government’s disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare & Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others. The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best.
But this month, 60 senators and 225 members of the House of Representatives signed letters urging the CMS to delay releasing the star ratings. “We have heard from hospitals in our districts that they do not have the necessary data to replicate or evaluate the CMS’s work to ensure that the methodology is accurate or fair,” the letter from the House members said.
In a notice sent April 20, the CMS told Congress it would delay release of the star ratings on its Hospital Compare website until July 2016. The “CMS is committed to working with hospitals and associations to provide further guidance about star ratings,” the notice said. “After the star ratings go live in their first iteration, we will refine and improve the site as we work together and gain experience.”
But in a conference call with hospital representatives, the CMS officials said they might delay release of the ratings past July if they are still analyzing or revising the methodology, according to people who participated in the call.
Mortality, readmissions, patient experience, and safety of care metrics each accounted for 22% of the star rating, while measures of effectiveness of care, timeliness of care, and efficient use of medical imaging made up 12% in total.
The hospital industry for months has been urging this delay, arguing that many of the measures will not be relevant to patients seeking a specific service. For instance, a hospital’s death rate for Medicare patients might be irrelevant for a woman trying to decide where to give birth.
The industry’s major trade groups said in a letter to the CMS that some hospitals perform poorly because their patients tend to be lower income and don’t have the support at home. Many of the nation’s most prestigious hospitals have been bracing for middling or poor ratings.
Rick Pollack, president of the American Hospital Association, said in a statement that “the delay is a necessary step as hospitals and health systems work with CMS to improve the ratings for patients, and the AHA commends CMS for their decision.”
Last year, the CMS created a star rating to represent the views of patients in surveys. Two sets of researchers recently determined that hospitals with more stars in patient experience tended to have lower death and readmission rates.
Hospital Compare received 3.7 million unique page views last year, according to an April 2016 paper published in the journal Health Affairs. The author, analyst Steven D. Findlay, called the traffic “not at a level commensurate with [the] stature and potential” of the federal government’s health care facility comparison sites.
Dr. Ashish Jha, a Harvard School of Public Health researcher, said consumers will be more likely to use the unified star ratings, but this specific mix of measures raises concerns. “The idea that dying and being readmitted to the hospital are equally important to patients seems funny to me,” he said.
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
FROM KAISER HEALTH NEWS
AATS Graham Foundation Programs Open with July Deadlines
Two AATS Graham Foundation programs are now open for application.
Third John Alexander Research Scholarship provides research, training and experience for North American surgeons committed to pursuing an academic career in cardiothoracic surgery. This two-year scholarship will run from July 1, 2017 - June 30, 2019 and provides an annual $80,000 stipend to the host institution.
* Applications must be submitted during the candidate’s first two years in an academic position.
* Research must occur within the first three years after completion of an approved North American cardiothoracic residency.
Deadline: July 1, 2016
Evarts A. Graham Memorial Traveling Fellowship supports training of international surgeons with the potential for future thoracic surgical leadership. The fellowship will run from 2017-2018 and provide a stipend of $75,000 to help cover living and travel expenses for fellows while visiting North American medical centers.
* Candidates must be from other than North America, who have not limited (six months or less) clinical training in North American prior to submitting their application.
* Candidates must have completed their formal training in general and thoracic/cardiovascular surgery but not yet reached a senior position.
Deadline: July 1, 2016
Two AATS Graham Foundation programs are now open for application.
Third John Alexander Research Scholarship provides research, training and experience for North American surgeons committed to pursuing an academic career in cardiothoracic surgery. This two-year scholarship will run from July 1, 2017 - June 30, 2019 and provides an annual $80,000 stipend to the host institution.
* Applications must be submitted during the candidate’s first two years in an academic position.
* Research must occur within the first three years after completion of an approved North American cardiothoracic residency.
Deadline: July 1, 2016
Evarts A. Graham Memorial Traveling Fellowship supports training of international surgeons with the potential for future thoracic surgical leadership. The fellowship will run from 2017-2018 and provide a stipend of $75,000 to help cover living and travel expenses for fellows while visiting North American medical centers.
* Candidates must be from other than North America, who have not limited (six months or less) clinical training in North American prior to submitting their application.
* Candidates must have completed their formal training in general and thoracic/cardiovascular surgery but not yet reached a senior position.
Deadline: July 1, 2016
Two AATS Graham Foundation programs are now open for application.
Third John Alexander Research Scholarship provides research, training and experience for North American surgeons committed to pursuing an academic career in cardiothoracic surgery. This two-year scholarship will run from July 1, 2017 - June 30, 2019 and provides an annual $80,000 stipend to the host institution.
* Applications must be submitted during the candidate’s first two years in an academic position.
* Research must occur within the first three years after completion of an approved North American cardiothoracic residency.
Deadline: July 1, 2016
Evarts A. Graham Memorial Traveling Fellowship supports training of international surgeons with the potential for future thoracic surgical leadership. The fellowship will run from 2017-2018 and provide a stipend of $75,000 to help cover living and travel expenses for fellows while visiting North American medical centers.
* Candidates must be from other than North America, who have not limited (six months or less) clinical training in North American prior to submitting their application.
* Candidates must have completed their formal training in general and thoracic/cardiovascular surgery but not yet reached a senior position.
Deadline: July 1, 2016
Housing & Registration Open: Inaugural Patient Safety Course
June 24-25, 2016
Renaissance Boston Waterfront Hotel
Boston, MA
Co-Directors
Thoralf M. Sundt, III, MD
Steven Yule, PhD
Program Committee
David J. Bunnell, PA-C, APACVS
David C. Fitzgerald, CCP, AMSECT
Jake Jaquiss, MD
M. Blair Marshall, MD
Shannon Pengel, RN
Kenneth Shann, CCP, LP, AMSECT
Marco Zenati, MD
Patient Safety is essential for successful surgical care — in cardiothoracic surgery — and all disciplines. In the more than 10 years since the Institute of Medicine made patient safety a priority, little progress has been made in changing culture and practice on the front lines.
This two-day course — including team training and simulation experiences — will make a difference, offering surgical team members practical safety behaviors for improving patient outcomes.
Special Benefits for Team Registration
The Patient Safety program includes team training and simulation experiences. Register three or more members from the same institution and receive one Healthcare Professional registration COMPLIMENTARY. We encourage you to send the entire team to join us in Boston this June.
June 24-25, 2016
Renaissance Boston Waterfront Hotel
Boston, MA
Co-Directors
Thoralf M. Sundt, III, MD
Steven Yule, PhD
Program Committee
David J. Bunnell, PA-C, APACVS
David C. Fitzgerald, CCP, AMSECT
Jake Jaquiss, MD
M. Blair Marshall, MD
Shannon Pengel, RN
Kenneth Shann, CCP, LP, AMSECT
Marco Zenati, MD
Patient Safety is essential for successful surgical care — in cardiothoracic surgery — and all disciplines. In the more than 10 years since the Institute of Medicine made patient safety a priority, little progress has been made in changing culture and practice on the front lines.
This two-day course — including team training and simulation experiences — will make a difference, offering surgical team members practical safety behaviors for improving patient outcomes.
Special Benefits for Team Registration
The Patient Safety program includes team training and simulation experiences. Register three or more members from the same institution and receive one Healthcare Professional registration COMPLIMENTARY. We encourage you to send the entire team to join us in Boston this June.
June 24-25, 2016
Renaissance Boston Waterfront Hotel
Boston, MA
Co-Directors
Thoralf M. Sundt, III, MD
Steven Yule, PhD
Program Committee
David J. Bunnell, PA-C, APACVS
David C. Fitzgerald, CCP, AMSECT
Jake Jaquiss, MD
M. Blair Marshall, MD
Shannon Pengel, RN
Kenneth Shann, CCP, LP, AMSECT
Marco Zenati, MD
Patient Safety is essential for successful surgical care — in cardiothoracic surgery — and all disciplines. In the more than 10 years since the Institute of Medicine made patient safety a priority, little progress has been made in changing culture and practice on the front lines.
This two-day course — including team training and simulation experiences — will make a difference, offering surgical team members practical safety behaviors for improving patient outcomes.
Special Benefits for Team Registration
The Patient Safety program includes team training and simulation experiences. Register three or more members from the same institution and receive one Healthcare Professional registration COMPLIMENTARY. We encourage you to send the entire team to join us in Boston this June.
IDSA, SHEA release inpatient antibiotic stewardship guidelines
The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have jointly released evidence-based guidelines for implementing an inpatient antibiotic stewardship program.
The guidelines, published April 13 online in Clinical Infectious Diseases, address the optimal use of antibiotics in inpatient populations, and were prepared by a multidisciplinary expert panel of the IDSA and the SHEA, which included representation from the specialties of internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases.
Antibiotic stewardship has been defined by IDSA, SHEA, and the Pediatric Infectious Diseases Society as “coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration.” The new guidelines discuss a broad range of possible interventions, but the authors emphasize the need “for each site to assess its clinical needs and available resources and individualize its [antibiotic stewardship program] with that assessment in mind.”
The process used in the development of the guidelines included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, according to Dr. Tamar F. Barlam of the section of infectious diseases at Boston University, and her colleagues.
“The benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events including Clostridium difficile infection, improvement in rates of antibiotic susceptibilities to targeted antibiotics, and optimization of resource utilization across the continuum of care,” Dr. Barlam and her coauthors wrote.
A complete list of any potential conflicts of interest for the multiple coauthors is provided with the full stewardship guidelines, which can be reviewed in Clinical Infectious Diseases (doi: 10.1093/cid/ciw118).
On Twitter @richpizzi
The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have jointly released evidence-based guidelines for implementing an inpatient antibiotic stewardship program.
The guidelines, published April 13 online in Clinical Infectious Diseases, address the optimal use of antibiotics in inpatient populations, and were prepared by a multidisciplinary expert panel of the IDSA and the SHEA, which included representation from the specialties of internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases.
Antibiotic stewardship has been defined by IDSA, SHEA, and the Pediatric Infectious Diseases Society as “coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration.” The new guidelines discuss a broad range of possible interventions, but the authors emphasize the need “for each site to assess its clinical needs and available resources and individualize its [antibiotic stewardship program] with that assessment in mind.”
The process used in the development of the guidelines included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, according to Dr. Tamar F. Barlam of the section of infectious diseases at Boston University, and her colleagues.
“The benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events including Clostridium difficile infection, improvement in rates of antibiotic susceptibilities to targeted antibiotics, and optimization of resource utilization across the continuum of care,” Dr. Barlam and her coauthors wrote.
A complete list of any potential conflicts of interest for the multiple coauthors is provided with the full stewardship guidelines, which can be reviewed in Clinical Infectious Diseases (doi: 10.1093/cid/ciw118).
On Twitter @richpizzi
The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have jointly released evidence-based guidelines for implementing an inpatient antibiotic stewardship program.
The guidelines, published April 13 online in Clinical Infectious Diseases, address the optimal use of antibiotics in inpatient populations, and were prepared by a multidisciplinary expert panel of the IDSA and the SHEA, which included representation from the specialties of internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases.
Antibiotic stewardship has been defined by IDSA, SHEA, and the Pediatric Infectious Diseases Society as “coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration.” The new guidelines discuss a broad range of possible interventions, but the authors emphasize the need “for each site to assess its clinical needs and available resources and individualize its [antibiotic stewardship program] with that assessment in mind.”
The process used in the development of the guidelines included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, according to Dr. Tamar F. Barlam of the section of infectious diseases at Boston University, and her colleagues.
“The benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events including Clostridium difficile infection, improvement in rates of antibiotic susceptibilities to targeted antibiotics, and optimization of resource utilization across the continuum of care,” Dr. Barlam and her coauthors wrote.
A complete list of any potential conflicts of interest for the multiple coauthors is provided with the full stewardship guidelines, which can be reviewed in Clinical Infectious Diseases (doi: 10.1093/cid/ciw118).
On Twitter @richpizzi
FROM CLINICAL INFECTIOUS DISEASES
