Background Robotic technology is one of the most recent technological changes in coronary artery bypass graft (CABG) operations. The current analysis was conducted to identify trends in the use and ...outcomes of robotic-assisted CABG (RA-CABG). Methods A retrospective analysis was performed using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2006 and 2012. Patient and site-level characteristics were compared between traditional CABG and RA-CABG. Operative death, postoperative length of stay, and postoperative complications were compared between the two groups. Results The number of sites using RA-CABG remained relatively constant during the study period (from 148 in 2006 to 151 in 2012). The volume of RA-CABG as a percentage of the total CABG procedures increased slightly from 0.59% (872 RA-CABG of 127,717 total CABG) in 2006 to 0.97% (1,260 RA-CABG of 97,249 total CABG) in 2012. The RA-CABG patients were significantly younger (64 vs 65 years, p < 0.0001), had fewer comorbidities, and had lower rates of cardiopulmonary bypass use (22.4% vs 80.4%, p < 0.0001). RA-CABG patients had significantly lower unadjusted major complication rates (10.2% vs 13.5%, p < 0.0001), including postoperative renal failure (2.2% vs 2.9%, p < 0.0001), and shorter length of stay (4 vs 5 days, p < 0.0001). The difference in operative death was not significant (odds ratio, 1.10; 95% confidence interval, 0.92 to 1.30, p = 0.29). Conclusions RA-CABG use remained relatively stagnant during the analysis period despite lower rates of major perioperative complications and no difference in operative deaths. Additional analysis is needed to fully understand the role that robotic technology will play in CABG operations in the future.
Background Recent clinical trials have demonstrated the safety and efficacy of several non–vitamin K oral anticoagulants (NOACs) for the treatment of atrial fibrillation (AF). However, there are ...limited data on their use and outcomes in routine clinical practice, particularly among patients newly diagnosed as having AF and patients with AF recently transitioned to a NOAC. Methods/Design ORBIT-AF II is a multicenter, national registry of patients with AF that is enrolling up to 15,000 newly diagnosed patients with AF and/or those with AF recently transitioned to a NOAC from 300 US outpatient practices. These patients will be followed for up to 2 years, including clinical status, outcomes (major adverse cardiovascular events, bleeding), and management of anticoagulation surrounding bleeding events. In addition, detailed data regarding the use of these agents in and around cardiac procedures, their complications, and management of such complications will be collected. Conclusions The ORBIT-AF II registry will provide valuable insights into the safety and effectiveness of NOACs used in AF in community practice settings.
Objectives We sought to describe real-world patterns of care in NSTEMI patients across different risk profiles for bleeding and mortality. Background The NCDR ACTION Registry–GWTG in-hospital ...mortality and major bleeding risk scores were developed to assess patient risk and optimize treatment decisions. However, little is known about the alignment of contemporary clinical management patterns with these risk estimates. Methods We studied 61,366 NSTEMI patients in the NCDR ACTION-Registry-GWTG from January 2007 to March 2009, stratifying them into four groups based on estimated risk of mortality and major bleeding. Results There were 24,709 (40.3%) patients in each of the concordant risk groups (low:low; high:high) and 5974 (9.7%) in each of the discordant risk groups (low:high; high:low). Subjects at high estimated risk for both mortality and major bleeding were least likely to receive guideline-based adjunctive pharmacotherapy or to undergo angiography within 48 hours but most likely to receive an excess dose of an antithrombotic agent. Patients at low estimated risk for mortality and bleeding received the most intensive adjunctive therapy and were most likely to undergo invasive angiography. Conclusion There are significant differences in contemporary patterns of care across varying risk profiles of mortality and major bleeding. Despite practice patterns which seem to emphasize avoiding harm with reduced use of antithrombotic therapy, patients at high risk for major bleeding continue to receive excess doses of antithrombotic therapy. Additional performance improvement efforts are needed to optimize outcomes in NSTEMI patients with high risk for both bleeding and mortality.
Abstract Background Out-of-hospital cardiac arrest (OHCA) associated with acute myocardial infarction (MI) confers high in-hospital mortality; however, among those patients who survive, little is ...known regarding their post-discharge mortality and health care use rates. Objectives The purpose of this study was to determine 1-year survival and readmission rates after hospital discharge of older MI survivors with and without OHCA. Methods Using linked Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines and Medicare data, this study analyzed 54,860 patients with MI who were older than 65 years of age and who had been discharged alive from 545 U.S. hospitals between April 2011 and December 2012. Multivariable models examined the associations between MI-associated OHCA and 1-year post-discharge mortality or all-cause readmission rates. Patients discharged to hospice were excluded, given their known poor prognosis. Results Following hospital discharge, compared with older MI survivors without OHCA (n = 54,219), those with OHCA (n = 641, 1.2%) were more likely to be younger, male, and smokers, but less likely to have diabetes, heart failure, or prior revascularization. OHCA patients presented more often with ST-segment elevation myocardial infarction (63.2% vs. 29.6%) and cardiogenic shock (29.0% vs. 2.2%); however, among in-hospital MI survivors, OHCA was not associated with 1-year post-discharge mortality (unadjusted 13.8% vs. 15.8%, p = 0.17, adjusted hazard ratio HR: 0.89; 95% confidence interval CI: 0.68 to 1.15). In contrast, MI survivors with OHCA actually had lower unadjusted and adjusted risk of the composite outcome of 1-year mortality or all-cause readmission than patients without OHCA (44.0% vs. 50.0%, p = 0.03, adjusted HR: 0.84; 95% CI: 0.72 to 0.97). Conclusions Among older patients with MI who survived to hospital discharge and were not discharged to hospice, those presenting with OHCA did not have higher 1-year mortality or health care use rates compared with those MI survivors without OHCA. These findings show that the early risk of adverse events in patients with OHCA does not persist after hospital discharge, and they support efforts to improve initial survival rates of older patients with MI and OHCA.
Objectives The purpose of this study was to describe hospital variability in the rate of finding obstructive coronary artery disease (CAD) at elective coronary angiography. Background A recent ...national study found that obstructive CAD was found in less than one-half of patients undergoing elective coronary angiography. Methods We performed a retrospective analysis of 565,504 patients without prior myocardial infarction or revascularization undergoing elective coronary angiography using CathPCI Registry data from 2005 to 2008 to evaluate the rate of finding obstructive CAD (any major epicardial vessel stenosis ≥50%) at coronary angiography at 691 U.S. hospitals. Results The rate of obstructive coronary disease found at elective coronary angiography varied from 23% to 100% among hospitals (median 45%; interquartile range: 39% to 52%), and were consistent from year to year and when alternative definitions of coronary stenosis were applied. Sites with lower rates of finding obstructive CAD were more likely to perform procedures on younger patients, those with low Framingham risk (33% in lowest yield quartile vs. 21% in highest yield quartile, p < 0.0001); with no or atypical symptoms (73% vs. 58%, p < 0.0001); and with a negative, equivocal, or unperformed functional status assessment. Hospitals with lower rates of finding obstructive CAD also less frequently prescribed aspirin, beta-blockers, platelet inhibitors, and statins (all p < 0.0001). The CAD rate was lower at facilities with small-volume catheterization laboratories and was not associated with hospital ownership or teaching program status. Conclusions The rate of finding obstructive CAD at elective coronary angiography varied considerably among reporting centers and was associated with patient selection and pre-procedure assessment strategies. This institutional variation suggests that an important opportunity may exist for quality improvement.
Background Prior studies have shown a treatment gap in oral anticoagulation (OAC) use among patients with atrial fibrillation yet have incompletely characterized factors associated with failure to ...treat and subsequent outcomes in contemporary practice. Methods Using data collected between June 2010 and August 2011 from 174 ambulatory care sites in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we identified factors associated with absence of OAC via stratified logistic regression. Using weighted Cox regression, we assessed the association between OAC non-use and subsequent outcomes over 2.5 years. Results Among 9553 patients, 2202 (23.0%) were not on OAC. Among OAC non-recipients, 1846 (83.8%) had a CHA₂DS₂-VASc score > 2. Factors independently associated with OAC non-use included atrial fibrillation type (paroxysmal odds ratio (OR) 0.73, 95% confidence interval (CI) 0.54-0.99; persistent OR 0.14, 95% CI 0.10-0.21; permanent OR 0.35, 0.25-0.49; reference = new-onset), left atrial diameter enlargement (mild OR 0.80, 0.66-0.97, moderate 0.58, 0.47-0.73, severe 0.53, 0.42-0.68; reference=normal diameter) and age > 80 years (OR 1.04, 95% CI 1.02-1.08). Untreated patients had a higher risk of death (adjusted hazard ratio (HR) 1.22, 95% CI 1.05-1.41), a lower bleeding risk (adjusted HR 0.35, 95% CI 0.15-0.81) and a nonsignificant trend toward higher risk of stroke/non-central nervous system embolism/transient ischemic attack than those treated (adjusted HR 1.18, 95% CI 0.91-1.54). Conclusions A majority of atrial fibrillation patients not treated with an OAC in current community practice meet guideline indications for treatment. Atrial fibrillation burden, chronicity, and comorbidity are associated with non-treatment. Untreated patients are at increased risk for adverse outcomes.
Objectives This study sought to examine trends in mortality, readmission, and costs among Medicare beneficiaries receiving ventricular assist devices (VADs) and associations between hospital-level ...procedure volume and outcomes. Background VADs are an option for patients with advanced heart failure, but temporal changes in outcomes and associations between facility-level volume and outcomes are poorly understood. Methods This is a population-based, retrospective cohort study of all fee-for-service Medicare beneficiaries with heart failure who received an implantable VAD between 2006 and 2011. We used Cox proportional hazards models to examine temporal changes in mortality, readmission, and hospital-level procedure volume. Results Among 2,507 patients who received a VAD at 103 centers during the study period, the in-hospital mortality decreased from 30% to 10% (p < 0.001), the 1-year mortality decreased from 42% to 26% (p < 0.001), and the all-cause readmission was frequent (82% and 81%; p = 0.70). After covariate adjustment, in-hospital and 1-year mortality decreased (p < 0.001 for both), but the all-cause readmission did not change (p = 0.82). Hospitals with a low procedure volume had higher risks of in-hospital mortality (risk ratio: 1.72; 95% confidence interval CI: 1.28 to 2.33) and 1-year mortality (risk ratio: 1.55; 95% CI: 1.24 to 1.93) than high-volume hospitals. Procedure volume was not associated with risk of readmission. The greatest cost was from the index hospitalization and remained unchanged ($204,020 in 2006 and $201,026 in 2011; p = 0.21). Conclusions Short- and long-term mortality after VAD implantation among Medicare beneficiaries improved, but readmission remained similar over time. A higher volume of VAD implants was associated with lower risk of mortality but not readmission. Costs to Medicare have not changed in recent years.
Background There is an increasing focus on optimizing health care quality and reducing costs. The care of children undergoing heart surgery requires significant investment of resources, and it ...remains unclear how costs of care relate to quality. We evaluated this relationship across a multicenter cohort. Methods Clinical data from The Society of Thoracic Surgeons Database were merged with cost data from the Pediatric Health Information Systems Database for children undergoing heart surgery (2006 to 2010). Hospital-level costs were modeled using Bayesian hierarchical methods adjusting for case-mix, and hospitals were categorized into cost tertiles. The primary quality metric evaluated was in-hospital mortality. Results Overall, 27 hospitals (30,670 patients) were included. Median adjusted cost per case was $82,360 and varied fivefold across hospitals, while median adjusted mortality was 3.4% and ranged from 2.4% to 5.0% across hospitals. Overall, hospitals in the lowest cost tertile had significantly lower adjusted mortality rates compared with the middle and high cost tertiles (2.5% vs 3.8% and 3.5%, respectively, both p < 0.001). When assessed at the individual hospital level, most (75%) but not all hospitals in the lowest cost tertile were also in the lowest mortality tertile. Similar relationships were seen across the spectrum of surgical complexity. Lower cost hospitals also had shorter length of stay and trends toward fewer major complications. Conclusions Lowest cost hospitals generally deliver the highest quality care for children undergoing heart surgery, although there is some variation in this relationship. This information is important in the design of initiatives aiming to optimize health care value in this population.
Background Cognitive impairment without dementia (CIND) and acute myocardial infarction (AMI) are prevalent in older adults; however, the association of CIND with outcomes after AMI is unknown. ...Methods We used a multicenter registry to study 772 patients ≥65 years with AMI, enrolled between April 2005 and December 2008, who underwent cognitive function assessment with the Telephone Interview for Cognitive Status-modified (TICS-m) 1 month after AMI. Patients were categorized by cognitive status to describe characteristics and in-hospital treatment, including quality of life and survival 1 year after AMI. Results Mean age was 73.2 ± 6.3 years; 58.5% were men, and 78.2% were white. Normal cognitive function (TICS-m >22) was present in 44.4%; mild CIND (TICS-m 19-22) in 29.8%; and moderate/severe CIND (TICS-m <19) in 25.8% of patients. Rates of hypertension (72.6%, 77.4%, and 81.9%), cerebrovascular accidents (3.5%, 7.0%, and 9.0%), and myocardial infarction (20.1%, 22.2%, and 29.6%) were higher in those with lower TICS-m scores ( P < .05 for comparisons). AMI medications were similar by cognitive status; however, CIND was associated with lower cardiac catheterization rates ( P = .002) and cardiac rehabilitation referrals ( P < .001). Patients with moderate/severe CIND had higher risk-adjusted 1-year mortality that was nonstatistically significant (adjusted hazard ratio 1.97, 95% CI 0.99-3.94, P = .054; referent normal, TICS-m >22). Quality of life across cognitive status was similar at 1 year. Conclusions Most older patients surviving AMI have measurable CIND. Cognitive impairment without dementia was associated with less invasive care, less referral and participation in cardiac rehabilitation, and worse risk-adjusted 1-year survival in those with moderate/severe CIND, making it an important condition to consider in optimizing AMI care.
Objectives The authors sought to describe the association between post-procedural bleeding and long-term recurrent bleeding, major adverse cardiac events (MACE), and mortality among older patients ...undergoing percutaneous coronary intervention (PCI). Background Bleeding complications after PCI are associated with an increased risk for acute morbidity and long-term mortality, but the association of these bleeding complications with other events is unknown. Methods Patients entered into the National Cardiovascular Data Registry (NCDR) CathPCI Registry (n = 461,311; 946 sites) from January 2004 to December 2008 were linked with claims from the Centers for Medicare & Medicaid Services and grouped according to in-hospital post-PCI bleeding. The association between post-PCI bleeding and 1-, 12-, and 30-month readmission for bleeding, MACE, and all-cause mortality was examined with Cox regression that included patient and procedural characteristics using no bleeding as the reference. Results Overall, 3.1% (n = 14,107) of patients experienced post-PCI bleeding. Patients who bled were older, more often female, had more medical comorbidities, less often received bivalirudin, and more often underwent PCI via the femoral approach. After adjustment, bleeding after the index procedure was significantly associated with readmission for bleeding (adjusted hazard ratios 95% confidence interval: 1 month, 1.54 1.42 to 1.67; 12 months, 1.52 1.40 to 1.66; 30 months, 1.29 1.11 to 1.50), MACE (1 month, 1.11 1.07 to 1.15; 12 months, 1.17 1.13 to 1.21; 30 months, 1.12 1.06 to 1.19) and all-cause mortality (1 month, 1.32 1.26 to 1.38; 12 months, 1.33 1.27 to 1.40); 30 months, 1.22 1.15 to 1.30). Conclusions Post-PCI bleeding complications are associated with an increased risk for short- and long-term recurrent bleeding, MACE, and all-cause mortality. These data underscore the prognostic importance of periprocedural bleeding and the need for identifying strategies to reduce long-term bleeding risk among patients undergoing PCI.
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