Abstract Objective Substantial controversy surrounds the choice between a mechanical versus bioprosthetic prosthesis for aortic valve replacement (AVR), based on age. This study aims to investigate ...national trends and in-hospital outcomes of the 2 prosthesis choices. Methods All patients aged >18 years in the National Inpatient Sample who received an AVR between 1998 and 2011 were considered. Valve-type use was examined by patient, procedural, and hospital characteristics, after which we matched patients based on their propensity score for receiving a bioprosthetic valve and compared their in-hospital outcomes. Results Bioprosthetic valves comprised 53.3% of 767,375 implanted valves, an increase in use from 37.7% in the period 1998 to 2001 to 63.6% in the period 2007 to 2011. The median age was 74 years for patients receiving bioprosthetic valves, and 67 years for those receiving mechanical valves. Use of bioprosthetic valves increased across all age groups, most markedly in patients age 55 to 64 years. Compared with patients receiving mechanical valves, these patients had a higher incidence of renal disease (8.0% vs 4.2%), coronary artery disease (58.5% vs 50.5%), concomitant coronary artery bypass grafting (46.7% vs 41.9%), and having surgery in a high-volume (>250 cases per year) center (31.3% vs 18.5%). Patients receiving bioprosthetic valves had a higher occurrence of in-hospital complications (55.9% vs 48.6%), but lower in-hospital mortality (4.4% vs 4.9%) than patients receiving mechanical valves. This difference was confirmed in propensity-matched analyses (complications: 52.7% vs 51.5%; mortality: 4.3% vs 5.2%). Conclusions Use of bioprosthetic valves in AVR increased dramatically from 1998 to 2011, particularly in patients age 55 to 64 years. Prosthesis selection varied significantly by facility, with low-volume facilities favoring mechanical valves. Aortic valve replacement with a bioprosthetic valve, compared with a mechanical valve, was associated with lower in-hospital mortality.
Abstract BACKGROUND: Robotic-assisted lobectomy is being offered increasingly to patients. However, little is known about its safety, complication profile, or effectiveness. METHODS: Patients ...undergoing lobectomy in in the United States from 2008 to 2011 were identified in the Nationwide Inpatient Sample. In-hospital mortality, complications, length of stay, and cost for patients undergoing robotic-assisted lobectomy were compared with those for patients undergoing thoracoscopic lobectomy. RESULTS: We identified 2,498 robotic-assisted and 37,595 thoracoscopic lobectomies performed from 2008 to 2011. The unadjusted rate for any complication was higher for those undergoing robotic-assisted lobectomy than for those undergoing thoracoscopic lobectomy (50.1% vs 45.2%, P < .05). Specific complications that were higher included cardiovascular complications (23.3% vs 20.0%, P < .05) and iatrogenic bleeding complications (5.0% vs 2.0%, P < .05). The higher risk of iatrogenic bleeding complications persisted in multivariable analyses (adjusted OR, 2.64; 95% CI, 1.58-4.43). Robotic-assisted lobectomy costs significantly more than thoracoscopic lobectomy ($22,582 vs $17,874, P < .05). CONCLUSIONS: In this early experience with robotic surgery, robotic-assisted lobectomy was associated with a higher rate of intraoperative injury and bleeding than was thoracoscopic lobectomy, at a significantly higher cost.
BACKGROUND AND PURPOSE—Endovascular coiling therapy is increasingly popular for obliteration of unruptured intracranial aneurysms, but older patients face higher procedural risks and shorter periods ...during which an untreated aneurysm may rupture causing subarachnoid hemorrhage (SAH). We assessed trends in clipping and coiling of unruptured intracranial aneurysms, outcomes after clipping and coiling of unruptured intracranial aneurysms, and in SAH among Medicare beneficiaries.
METHODS—Using 2000 to 2010 Medicare Provider Analysis and Review data, we identified 2 cohorts of patients admitted electively for clipping or coiling of an unruptured aneurysm(1) utilization cohort (2000–2010)patients ≥65 years enrolled ≥1 month in a given year and (2) outcomes cohort (2001–2010)patients ≥66 years of age enrolled in Medicare for ≥1 year. We calculated rates of clipping, coiling, and SAH per 100 000 Medicare beneficiaries. We tested for trends in the risk of in-hospital mortality and complications, discharge destination, 30-day mortality, 30-day readmissions, and length of hospitalization.
RESULTS—Characteristics of patients undergoing clipping (n=4357) or coiling (n=7942) did not change appreciably. Overall, 30-day mortality, in-hospital complications, and 30-day readmissions decreased, generally reaching their lowest levels in 2008 to 2010 (1.6%, 25.0%, and 14.5% for clipping and 1.5%, 13.8%, and 11.0% for coiling, respectively). Procedural treatment rates per 100 000 beneficiaries increased from 1.4 in 2000 to 6.0 in 2010, driven mainly by increased use of coiling but SAH rates did not decrease.
CONCLUSIONS—Although outcomes tended to improve over time, increased preventative treatment of unruptured intracranial aneurysms among Medicare beneficiaries did not result in a population-level decrease in SAH rates.
Objectives To compare cancer specific survival after thoracoscopic sublobar lung resection and stereotactic ablative radiotherapy (SABR) for tumors ≤2 cm in size and thoracoscopic resection (sublobar ...resection or lobectomy) and SABR for tumors ≤5 cm in size.Design National population based retrospective cohort study with propensity matched comparative analysis.Setting Surveillance, Epidemiology, and End Results (SEER) registry linked with Medicare database in the United States.Participants Patients aged ≥66 with lung cancer undergoing SABR or thoracoscopic lobectomy or sublobar resection from 1 Oct 2007 to 31 June 2012 and followed up to 31 December 2013.Main outcome measures Cancer specific survival after SABR or thoracoscopic surgery for lung cancer.Results 690 (275 (39.9%) SABR and 415 (60.1%) thoracoscopic sublobar lung resection) and 2967 (714 (24.1%) SABR and 2253 (75.9%) thoracoscopic resection) patients were included in primary and secondary analyses. The average age of the entire cohort was 76. Follow-up of the entire cohort ranged from 0 to 6.25 years, with an average of three years. In the primary analysis of patients with tumors sized ≤2 cm, 37 (13.5%) undergoing SABR and 44 (10.6%) undergoing thoracoscopic sublobar resection died from lung cancer, respectively. The cancer specific survival diverged after one year, but in the matched analysis (201 matched patients in each group) there was no significant difference between the groups (SABR v sublobar lung resection mortality: hazard ratio 1.32, 95% confidence interval 0.77 to 2.26; P=0.32). Estimated cancer specific survival at three years after SABR and thoracoscopic sublobar lung resection was 82.6% and 86.4%, respectively. The secondary analysis (643 matched patients in each group) showed that thoracoscopic resection was associated with improved cancer specific survival over SABR in patients with tumors sized ≤5 cm (SABR v resection mortality: hazard ratio 2.10, 1.52 to 2.89; P<0.001). Estimated cancer specific survival at three years was 80.0% and 90.3%, respectively.Conclusions This propensity matched analysis suggests that patients undergoing thoracoscopic surgical resection, particularly for larger tumors, might have improved cancer specific survival compared with patients undergoing SABR. Despite strategies used in study design and propensity matching analysis, there are inherent limitations to this observational analysis related to confounding, similar to most studies in healthcare of non-surgical technologies compared with surgery. As the adoption of SABR for the treatment of early stage operable lung cancer would be a paradigm shift in lung cancer care, it warrants further thorough evaluation before widespread adoption in practice.
Previous studies have shown that high-volume centers and laparoscopic techniques improve outcomes of colectomy. These evidence-based measures have been slow to be accepted, and current trends are ...unknown. In addition, the current rates and outcomes of robotic surgery are unknown.
The purpose of this study was to examine current national trends in the use of minimally invasive surgery and to evaluate hospital volume trends over time.
This was a retrospective study.
This study was conducted in a tertiary referral hospital.
Using the National Inpatient Sample, we evaluated trends in patients undergoing elective open, laparoscopic, and robotic colectomies from 2009 to 2012. Patient and institutional characteristics were evaluated and outcomes compared between groups using multivariate hierarchical-logistic regression and nonparametric tests. The National Inpatient Sample includes patient and hospital demographics, admission and treating diagnoses, inpatient procedures, in-hospital mortality, length of hospital stay, hospital charges, and discharge status.
In-hospital mortality and postoperative complications of surgery were measured.
A total of 509,029 patients underwent elective colectomy from 2009 to 2012. Of those 266,263 (52.3%) were open, 235,080 (46.2%) laparoscopic, and 7686 (1.5%) robotic colectomies. The majority of minimal access surgery is still being performed at high-volume compared with low-volume centers (37.5% vs 28.0% and 44.0% vs 23.0%; p < 0.001). A total of 36% of colectomies were for cancer. The number of robotic colectomies has quadrupled from 702 in 2009 to 3390 (1.1%) in 2012. After adjustment, the rate of iatrogenic complications was higher for robotic surgery (OR = 1.73 (95% CI, 1.20-2.47)), and the median cost of robotic surgery was higher, at $15,649 (interquartile range, $11,840-$20,183) vs $12,071 (interquartile range, $9338-$16,203; p < 0.001 for laparoscopic).
This study may be limited by selection bias by surgeons regarding the choice of patient management. In addition, there are limitations in the measures of disease severity and, because the database relies on billing codes, there may be inaccuracies such as underreporting.
Our results show that the majority of colectomies in the United States are still performed open, although rates of laparoscopy continue to increase. There is a trend toward increased volume of laparoscopic procedures at specialty centers. The role of robotics is still being defined, in light of higher cost, lack of clinical benefit, and increased iatrogenic complications, albeit comparable overall complications, as compared with laparoscopic colectomy.
IMPORTANCE: For early-stage breast cancer, breast conservation surgery (BCS) is a conservative option for women and involves removing the tumor with a margin of surrounding breast tissue. If margins ...are not tumor free, patients undergo additional surgery to avoid local recurrence. OBJECTIVES: To investigate the use of BCS in New York State and to determine rates of reoperation, procedure choice, and the effect of surgeon experience on the odds of a reoperation 90 days after BCS. DESIGN, SETTING, AND PARTICIPANTS: A population-based sample of 89 448 women undergoing primary BCS for cancer were selected and examined from January 1, 2003, to December 31, 2013, in New York State mandatory reporting databases. All hospitals and ambulatory surgery centers in New York State were included. Data were analyzed from December 15, 2014, to November 1, 2015. MAIN OUTCOMES AND MEASURES: Rate of reoperations within 90 days of the initial BCS procedure. RESULTS: During the study period, 89 448 women 20 years or older (mean SD age, 61.7 13.7 years) underwent primary BCS. In 2013, 1416 women in New York aged 20 to 49 years underwent BCS compared with 3068 women aged 50 to 64 years and 3644 women 65 years or older. These numbers represent a significant decrease from 1960 women younger than 50 years in 2003 who underwent BCS (P < .001 for trend) but little change from the 2899 women aged 50 to 64 years and 3270 women 65 years or older who underwent BCS in 2003. Mean overall rate of 90-day reoperation was 30.9% (27 010 of 87 499 patients) and decreased over time from 39.5% (6630 of 16 805 patients) in 2003 to 2004 to 23.1% (5148 of 22 286 patients) in 2011 to 2013. Rates of reoperation were highest in women aged 20 to 49 years (37.7% 6990 of 18 524) and lowest in women 65 years or older (26.3% 9656 of 36 691) (P < .001 for trend). Over time, more patients underwent BCS as a subsequent procedure, from 4237 of 6630 patients (63.9%) in 2003 to 2004 to 4258 of 5148 (82.7%) in 2011 to 2013 (P < .001 for trend). Among the 19 466 women who underwent BCS as a second procedure, 2429 (12.5%) required a third intervention (2.7% of all women included). Significant surgeon-level variation was found in the data; 90-day rates of reoperations by surgeon ranged from 0% to 100%. Low-volume surgeons (<14 cases per year) had an unadjusted rate of 35.2% compared with 29.6% in middle-volume (14-33 cases per year) and 27.5% in high-volume (≥34 cases per year) surgeons. The difference persisted in adjusted analyses (odds ratio for low-volume surgeons, 1.49 95% CI, 1.19-1.87; for middle-volume surgeons, 1.20 95% CI, 0.93-1.56) compared with high-volume surgeons (used as the reference category). CONCLUSIONS AND RELEVANCE: Use of BCS has decreased overall, most steeply in younger women. Nearly 1 in 4 women underwent a reoperation within 90 days of BCS across New York State from 2011 to 2013, compared with 2 in 5 from 2003 to 2004. Rates vary significantly by surgeon, and initial BCS performed by high-volume surgeons was associated with a 33% lower risk for a reoperation.
Objective To compare long term survival after minimally invasive lobectomy and thoracotomy lobectomy.Design Propensity matched analysis.Setting Surveillance, Epidemiology and End Results ...(SEER)-Medicare database.Participants All patients with lung cancer from 2007 to 2009 undergoing lobectomy.Main outcome measure Influence of less invasive thoracoscopic surgery on overall survival, disease-free survival, and cancer specific survival.Results From 2007 to 2009, 6008 patients undergoing lobectomy were identified (n=4715 (78%) thoracotomy). The median age of the entire cohort was 74 (interquartile range 70-78) years. The median length of follow-up for entire group was 40 months. In a matched analysis of 1195 patients in each treatment category, no statistical differences in three year overall survival, disease-free survival, or cancer specific survival were found between the groups (overall survival: 70.6% v 68.1%, P=0.55; disease-free survival: 86.2% v 85.4%, P=0.46; cancer specific survival: 92% v 89.5%, P=0.05).Conclusion This propensity matched analysis showed that patients undergoing thoracoscopic lobectomy had similar overall, cancer specific, and disease-free survival compared with patients undergoing thoracotomy lobectomy. Thoracoscopic techniques do not seem to compromise these measures of outcome after lobectomy.
Abstract Introduction Robot-assisted surgery has been rapidly adopted in the U.S. for prostate cancer (PCa). Its adoption has been driven by market forces and patient preference, and debate continues ...regarding whether it offers improved outcomes to justify higher cost relative to open surgery. We examined comparative effectiveness of robot assisted (RARP) versus open radical prostatectomy (ORP) in cancer control and survival in a nationally representative population. Materials and Methods Population based observational cohort study of PCa patients undergoing RARP and ORP during 2003-2012 captured in Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Propensity score matching and time to event analysis was used to compare all-cause mortality, prostate cancer-specific mortality and use of additional treatment following surgery. Results 6,430 RARP and 9,161 ORP performed during 2003-2012 were identified. RARP increased in use from 13.6% to 72.6% in 2003-2004 to 72.6% in 2011-2012. After median follow-up of 6.5 years (IQR 5.2-7.9), RARP was associated with equivalent risk of all-cause mortality (Hazard Ratio HR 0.85, 0.72-1.01) and similar cancer-specific mortality (HR 0.85, 0.50-1.43) versus ORP. RARP was also associated with less use of additional treatment (HR 0.78, 0. 70-0.86). Conclusions RARP has comparable intermediate cancer control, as evidenced by less use of additional postoperative cancer therapies and equivalent cancer-specific and overall survival. Longer-term follow-up is needed to assess for differences in PCa-specific survival, which was similar during intermediate follow-up. Our findings have significant quality and cost implications and provide reassurance regarding the adoption of more expensive technology in absence of randomized controlled trials.
Background We aimed to determine the relationship between hospital volume and use of dual aortic and mitral valve surgical procedures. Methods Patients who underwent both aortic and mitral valve ...repair or replacement during the same hospital stay were identified from the Nationwide Inpatient Sample (NIS). We compared patients’ characteristics and in-hospital outcomes by the average annual center volume for multiple–heart valve surgical procedures, grouped into tertiles of patients with low (1 to 8), medium (9 to 18), and high (19+) volume categories using χ2 tests and adjusted hierarchical logistic regression models. Results From 1998 to 2011 an estimated total of 87,675 patients underwent combined aortic and mitral valve surgical procedures across the United States. Although most patients’ characteristics were similar across volume groups, high-volume centers were more likely to treat older patients with coronary artery disease and to perform concomitant tricuspid valve operations. Low-volume centers replaced the aortic and mitral valves concomitantly more frequently with mechanical valves compared with high-volume centers (66.1% vs 45.5%), and this difference persisted across age groups. Compared with low-volume centers, the risk-adjusted odds ratios for in-hospital mortality at medium- and high-volume centers were 0.85 (95% confidence interval CI: 0.74 to 0.99) and 0.66 (95% CI: 0.55 to 0.80), respectively. No significant interaction was found between overall facility major cardiac surgery volume and multiple–valve procedure volume with respect to mortality ( p = 0.143). Conclusions Hospital volume remains an important factor influencing risk-adjusted mortality after combined aortic and mitral valve surgical procedures. Hospitals that perform more than eight combined aortic and mitral heart valve operations demonstrate a superior statistical hospital survival compared with those that perform less than eight multiple–heart valve operations a year. Further policy interventions aimed to lower hospital mortality in low-volume centers may offer possibilities for quality improvement in the field of valve surgery.
Background Robotic-assisted mitral valve repair is becoming more frequently performed in cardiac surgery. However, little is known about its utilization and safety at a national level. Methods ...Patients undergoing mitral valve repair in the United States from 2008 to 2012 were identified in the National Inpatient Sample. Inhospital mortality, complications, length of stay, and cost for patients undergoing robotic-assisted mitral valve repair were compared with patients undergoing nonrobotic procedures. Results We identified 50,408 isolated mitral valve repair surgeries, of which 3,145 were done with robotic assistance. In a propensity score matched analysis of 631 pairs of patients, we found no difference between patients undergoing robotic-assisted and nonrobotic-assisted mitral valve repair with respect to inhospital mortality, complications, or composite outcomes in unadjusted or multivariable analyses. Robotic-assisted mitral valve repair surgery was associated with a shorter median length of stay (4 versus 6 days, p < 0.001), and there was no difference in median total costs between the two procedures. Conclusions In our analysis of a large national database with its inherent limitations, robotic-assisted mitral valve repair was found to be safe, with an acceptable morbidity and mortality profile.
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