Background The purpose of this analysis was to examine the trends in patient characteristics and outcomes in patients who underwent coronary artery bypass grafting (CABG) over a 12-year period in the ...Medicare database. Methods The study included 1,264,265 isolated CABG procedures in the Medicare population from January 2000 through November 2012. Comorbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes. Trends in patient characteristics and hospital outcomes were assessed with Cochran-Armitage trend tests. Long-term survival was examined with Kaplan-Meier survival curves. Results The median age was 74 years. Comorbidity profiles increased significantly over time. The number of patients undergoing CABG decreased from 131,385 in 2000 to 71,086 in 2012. The majority of patients underwent multivessel revascularization (13.5% single-vessel CABG, 35.2% 2-vessel CABG, 32.1% 3-vessel CABG, and 15.7% ≥4-vessel CABG). The percentage of patients undergoing 1- and 2-vessel revascularization increased over time, whereas that of ≥3-vessel CABG decreased. Single internal mammary artery (IMA) use increased from 75.6% to 88.6%. Median length of stay (LOS) was 8 days. Thirty-day mortality decreased from 4.2% to 3.0%. Hospital mortality fell from 4.0% in 2000 to 2.7% in 2012 (odds ratio OR, 0.73; 95% confidence interval CI, 0.69–0.77). Survival was 93% at 6 months, 91% at 1 year, 84% at 3 years, and 76% at 5 years. Five-year survival changed little over time (range, 75%–77%). Conclusions Despite rising comorbidities in Medicare patients undergoing CABG, hospital mortality fell significantly from 2000 to 2012. When adjusted for comorbidities, this signified a 27% reduction in hospital mortality. IMA use increased during the study period, and there was a trend of decreased use of 3 or more grafts.
The short-term advantage of mitral valve repair versus replacement for degenerative disease has been extensively
documented. These advantages include lower operative mortality, improved survival, ...better preservation of leftventricular
function, shorter post-operative hospital stay, lower total costs, and fewer valve-related complications, including
thromboembolism, anticoagulation-related bleeding events and late prosthetic dysfunction. More recent written data
are available indicating the long-term advantage of repair versus replacement. While at some institutions, the repair rate
for degenerative disease may exceed 90%, the national average in 2007 was only 69%. Making direct comparisons between
mitral valve repair and replacement using the available studies does present some challenges however, as there are
often differences in baseline characteristics between patient groups as well as other dissimilarities between studies. The
purpose of this review is to systematically summarize the long-term survival and reoperation data of mitral valve repair
versus replacement for degenerative disease. A PubMed search was done and resulted in 12 studies that met our study criteria
for comparing mitral valve repair versus replacement for degenerative disease. A systematic review was then conducted
abstracting survival and reoperation data.
Abstract Background The volume-outcome relationship has been suggested as a quality metric in mitral valve surgery and would be particularly relevant in the elderly because of their greater burden of ...comorbidities and higher perioperative risk. Methods and Results The study included 1239 hospitals performing mitral valve surgery on Medicare beneficiaries from 2000 through 2009. Only 9% of hospitals performed more than 40 mitral operations per year, 29% performed 5 or less, and 51% performed 10 or less. Mitral repair rates were low; 22.7% of hospitals performed 1 or less, 65.1% performed 5 or less, and only 5.6% performed more than 20 mitral repairs per year in those aged 65 years or more. Repair rates increased with increasing volume of mitral operations per year: 5 or less, 30.5%; 6 to 10, 32.9%; 11 to 20, 34.9%; 21 to 40, 38.8%; and more than 40, 42.0% ( P = .0001). Hospitals with lower volume had significantly higher adjusted operative mortality compared with hospitals performing more than 40 cases per year: 5 or less cases per year, odds ratio (OR) 1.58 (95% confidence interval CI, 1.40-1.78); 6 to 10 cases per year, OR 1.29 (95% CI, 1.17-1.43); 11 to 20 cases per year, OR 1.17 (95% CI, 1.07-1.28); 21 to 40 cases per year, OR 1.15 (95% CI, 1.05-1.26). Hospitals with lower mitral repair rates had an increased likelihood of operative mortality relative to the top quartile: lowest quartile, OR 1.31 (95% CI, 1.20-1.44); second quartile, OR 1.18 (95% CI, 1.09-1.29); and third quartile, OR 1.14 (95% CI, 1.05-1.24). Long-term mortality beyond 6 months was also higher in low-volume hospitals: 5 or less cases year, hazard ratio (HR) 1.11 (95% CI, 1.06-1.18); 6 to 10 cases per year, OR 1.06 (95% CI, 1.02-1.10) compared with hospitals performing more than 40 cases per year. Conclusions Most hospitals perform few mitral valve operations on elderly patients. Greater volume of mitral procedures was associated with higher repair rates. Both greater volume of mitral procedures and increasing mitral repair rates were associated with decreased mortality.
Background Since year 2000, reducing hospital readmissions has become a public health priority. In addition, there have been major changes in PCI during this period. Methods and Results The cohort ...consisted of 3,250,194 patients admitted for PCI from 1/2000 through 11/2012. Overall, 30-day readmission was 15.8%. Readmission rates declined from 16.1% in 2000 to 15.4% in 2012 (adjusted OR for for readmission 1.33 in 2000 compared to 2012). Of all readmissions after PCI, the majority were for cardiovascular-related conditions (>60%), however only small percentage (<8%) of total readmissions were for acute MI, unstable angina, or cardiac arrest/cardiogenic shock. A much larger percentage of patients were readmitted with chest pain/angina (7.9%), chronic ischemic heart disease (26.6%), and heart failure (12%). A small proportion was due to procedural complications and GI bleeding. The use of PCI with stenting during readmissions was variable, increasing from 14.2% in 2000 to 23.7% in 2006, and then declining to 12.1% in 2012. Hospital mortality during readmission was 2.5% overall and varied over time (2.8% in 2000, decreasing to 2.2% in 2006 and then rising again to 3.1% in 2012). Patients who were readmitted had >4x higher 30-day mortality than those who were not. Conclusions Among Medicare beneficiaries, readmission after PCI declined over time, despite patients having more comorbidities. This translated into a 33% lower likelihood of readmission in 2012 compared to 2000. A small proportion of readmissions were for acute coronary syndromes (ACS).
Background Gender disparities in outcomes have been documented in cardiac surgery. Gender differences in long-term survival after mitral valve operations, especially in the elderly, are less well ...studied. Methods Using Centers for Medicare and Medicaid Services data, we identified 183,792 Medicare beneficiaries aged 65 years and older who underwent mitral valve repair or replacement from 2000 through 2009. The final study population included 47,602 Medicare fee-for-service beneficiaries undergoing isolated mitral valve operations. The outcomes studied were gender-specific operative mortality and long-term survival. Results Women were less likely to receive mitral valve repair (31.9% vs 44.0%, p < 0.0001). The hospital mortality rate was 7.7% for women vs 6.1% for men ( p < 0.0001), reflective of a worse preoperative profile. Women undergoing repair had worse long-term survival than men ( p = 0.0020) but survival was similar after risk adjustment (hazard ratio, 0.97; 95% confidence interval, 0.92 to 1.02, p = 0.2106). Compared with the United States population matched for age and sex, mitral repair restored life expectancy for men but not for women. Unadjusted and adjusted long-term survival was similar for men and women undergoing mitral valve replacement ( p = 0.3653; hazard ratio, 0.99; 95% confidence interval, 0.96 to 1.02; p = 0.4847). Conclusions In this large comparative study of gender differences in mitral valve operations, elderly women had higher operative mortality and lower long-term survival. These differences appeared to be driven largely because women present for mitral valve operations later in the disease process. Mitral repair appeared to restore normal life expectancy for men but not for women. Future studies should examine the factors that influence physician referral to mitral valve operations for men and women.
Contrast-induced acute kidney injury (AKI) is a common and severe complication of percutaneous coronary intervention (PCI). Despite its substantial burden, contemporary data on the incremental costs ...of AKI are lacking. We designed this large, nationally representative study to examine: (1) the independent, incremental costs associated with AKI after PCI and (2) to identify the departmental components of cost contributing to the incremental costs associated with AKI. In this observational cross-sectional study from the Premier database, we analyzed 1,443,297 PCI patients at 518 US hospitals from 1/2006 to 12/2015. Incremental cost of AKI from a hospital perspective obtained by a microcosting approach, was estimated using mixed-effects, multivariable linear regression with hospitals as random effects. Costs were inflation-corrected to 2016 US$. AKI occurred in 82,683 (5.73%) of the PCI patients. Those with AKI had higher hospitalization cost than those without ($38,869, SD 42,583 vs $17,167 SD 13,994, p <0.001). After adjustment, the incremental cost associated with an AKI was $9,448 (95% confidence interval $9,338 to $9,558, p <0.001). AKI was also independently associated with an incremental length of stay of 3.6 days (p <0.001). Room and board costs were the largest driver of AKI costs ($4,841). Extrapolated to the United States, our findings imply an annual AKI cost burden of 411.3 million US$. In conclusion, in this national study of PCI patients, AKI was common and independently associated with ∼$10,000 incremental costs, implying a substantial burden of AKI costs in US hospitals. Successful efforts to prevent AKI in patients who underwent PCI could result in meaningful cost savings.
Background Survival and other outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) in the Medicare population are unclear. Methods Patients aged 65 years and older who ...underwent TAVR from November 2011 through 2013 were considered for inclusion. Results The study consisted of 18,283 patients and 19.3% were aged 90 years or older. Compared with patients younger than 90 years, patients 90 years or older were less likely to have a number of comorbidities, including previous myocardial infarction (17.5% versus 21.8%), previous coronary artery bypass grafting (20.0% versus 35.0%), and chronic obstructive pulmonary disease (25.4% versus 39.0%) among others. The 30-day and 1-year mortality rates were 8.4% versus 5.9% ( p = 0.0001) and 25.4% versus 21.5% ( p = 0.0001) in the older and younger groups, respectively (odds ratio OR 1.47, 95% confidence interval CI: 1.28 to 1.70, p = 0.0001). Patients 90 years and older were more likely to undergo pacemaker insertion (11.1% versus 8.3%, p = 0.0001). Among nonagenarians, compared with the transapical group, patients undergoing transfemoral TAVR had lower 30-day (7.2% versus 13.6%, p = 0.0001) and 1-year (23.8% versus 31.6%, p = 0.0001) mortality rates, were more likely to be discharged home (54.4% versus 34.1%, p = 0.0001), and had lower 30-day readmission rates (23.8% versus 31.8%, p = 0.0001). After adjustment for patient characteristics, transapical TAVR was an independent predictor of 30-day mortality rate (OR 1.94, 95% CI: 1.48 to 2.56, p = 0.0001) and readmission (OR 1.46, 95% CI: 1.19 to 1.80, p = 0.0003). Conclusions In patients undergoing TAVR, although 30-day and 1-year mortality rates were slightly worse for nonagenarians than their younger counterparts, long-term survival was still encouraging, with 75% of nonagenarians living to 1 year. Transapical TAVR was associated with worse outcomes in nonagenarians.
Background This study was designed to examine the effect of hospital procedural volume on outcomes in aortic valve replacement (AVR) in the elderly. Methods The study included 277,928 Medicare ...beneficiaries who underwent AVR from 2000 through 2009 at one of 1,255 participating hospitals. Operative mortality and the use of mechanical prostheses were analyzed according to hospital annual procedural volume. Annual AVR volume was divided into 5 different categories: the smallest volume group with less than 10 AVRs per year to the largest group averaging more than 70 AVRs per year. Results The overall observed operative mortality rate was 7.3%; for isolated AVR it was 5.5%. Lower-volume hospitals exhibited increased adjusted operative mortality: 10 cases or fewer per year—odds ratio (OR), 1.55; 95% confidence interval (CI), 1.39 to 1.72; 11 to 20 cases per year—OR, 1.35; 95% CI, 1.23 to 1.47; 21 to 40 cases per year—OR, 1.15; 95% CI, 1.06 to 1.25; 41 to 70 cases per year—OR, 1.10; 95% CI, 1.01 to 1.20 relative to those hospitals performing more than 70 cases per year. The discrepancy in operative mortality between low- and high-volume hospitals diverged during the study. Mechanical valve use decreased with increasing hospital volume ( p = 0.0001). Mechanical valves were used in 64.5% of AVRs in hospitals with an annual AVR volume less than 10 in contrast to only 25.4% in hospitals with an annual AVR volume more than 70. After adjustment, the use of mechanical valves was independently associated with increased operative mortality (OR, 1.15; 95% CI, 1.11–1.19). Conclusions Low-volume centers were characterized by increased adjusted operative mortality and greater use of mechanical prostheses, a trend that persisted during the 10-year course of the study. These data would support the center-of-excellence concept for AVR and may be particularly relevant in the elderly population.
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