RESUMEN

BACKGROUND: Data on the longitudinal impact of surgical ablation (SA) for atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) remain limited. This study examined 2-year risk-adjusted mortality and total hospital costs in Medicare beneficiaries with AF requiring CABG with or without SA. METHODS: CABG was performed in 3745 Medicare beneficiaries with AF in 2013, with concomitant SA in 17% (626 of 3745). Risk-adjusted mortality, morbidity, and cost during the first 2 postoperative years for patients with SA and those without SA were compared. A piecewise Cox proportional hazard model (0-90 days and 91-729 days) was used to risk-adjust mortality. RESULTS: Compared with the no SA group, the SA group had lower rates of heart failure before surgery (31% vs 36%), chronic lung disease (27% vs 33%), renal failure (4% vs 7%), and urgent or emergent presentation (34% vs 49%) (all P < .05). Risk-adjusted index admission costs were higher with SA (rate ratio [RR], 1.11; P < .01), as were readmissions for AF (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.00-1.29; P = .04) and pacemaker/defibrillator implantation (HR, 1.37; 95%, 1.08-1.74; P = .01). Risk-adjusted inpatient days and inpatient costs were similar after 2 years (RR, 0.97; P = .31 and RR = 1.04; P = .17, respectively); however, the risk-adjusted hazard for late mortality (91-729 days) was significantly lower with SA (HR, 0.71; 95% CI, 0.52-0.97; P = .03). CONCLUSIONS: In patients with AF requiring CABG, SA was associated with a 29% lower risk-adjusted hazard for late mortality. Index hospital costs were higher with SA, but total inpatient costs were not different in the 2 groups after 2 years. SA appears to be a cost-effective intervention to enhance late 2-year survival in patients with AF undergoing CABG.

Asunto(s)

Fibrilación Atrial , Ablación por Catéter , Puente de Arteria Coronaria , Anciano , Fibrilación Atrial/epidemiología , Fibrilación Atrial/mortalidad , Fibrilación Atrial/cirugía , Ablación por Catéter/economía , Ablación por Catéter/mortalidad , Estudios de Cohortes , Comorbilidad , Puente de Arteria Coronaria/economía , Puente de Arteria Coronaria/mortalidad , Análisis Costo-Beneficio , Femenino , Humanos , Masculino , Medicare , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Estados Unidos

RESUMEN

OBJECTIVE: Surgical ablation for atrial fibrillation concomitant with cardiac surgery is now a Class I recommendation for selected patients. Understanding how the revised recommendations will affect appropriate use of surgical ablation is challenging because the reported prevalence of preoperative atrial fibrillation depends on the definition used. The objective was to determine the prevalence of atrial fibrillation in the 3 years before cardiac surgery and the rate of concomitant surgical ablation. METHODS: Patients with and without a diagnosis of atrial fibrillation in the 3 years before surgical coronary artery bypass, aortic valve replacement, or mitral valve replacement/repair were identified in the 2014 Medicare Standard Analytical File. RESULTS: Patients had prior atrial fibrillation in 28.4% of 79,134 cardiac surgeries. Prior atrial fibrillation was associated with risk factors for increased cardiac surgical morbidity/mortality, including recent heart failure, renal failure, and lung disease. Black patients were less likely to have prior atrial fibrillation but more likely to have had infrequent care for it. Isolated coronary artery bypass had the lowest prevalence but highest absolute number of prior atrial fibrillation cases. Concomitant surgical ablation was performed in 22.1% of patients with prior atrial fibrillation. Patients with mitral valve surgery were 3-fold more likely to receive surgical ablation. Women were less likely to have prior atrial fibrillation but less likely to have surgical ablation when they did. CONCLUSIONS: Medicare beneficiaries had a substantially higher prevalence of atrial fibrillation diagnoses in the 3 years before cardiac surgery than previously published rates of preoperative atrial fibrillation. Concomitant surgical ablation was performed in less than one-quarter of patients with atrial fibrillation undergoing cardiac surgery for other indications.

Asunto(s)

Técnicas de Ablación , Fibrilación Atrial/cirugía , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Técnicas de Ablación/efectos adversos , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Comorbilidad , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/epidemiología , Bases de Datos Factuales , Femenino , Estado de Salud , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/epidemiología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Masculino , Medicare , Prevalencia , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiología

RESUMEN

The most common fracture in primary care is metatarsal fracture, but it is controversial whether to treat this fracture conservatively or surgically. We performed a cohort study to contrast metatarsal fractures that heal normally with fractures that show delayed healing. We analyzed 5% Medicare Standard Analytic Files, selecting all metatarsal fractures in 2011 to 2013, excluding patients with multiple fractures. Delayed healing was defined as treatment >14 days postfracture with either low-intensity pulsed ultrasound or surgery. Treatment for delayed healing was identified using the Current Procedural Terminology and International Classification of Diseases, Revision 9, Clinical Modification codes. Among 9482 metatarsal fractures, 256 (2.7%) showed delayed healing. Patients with delayed healing were younger (p < .0001); more likely to receive specialist referral (p < .001); more likely to have obesity (p = .005), psychosis (p = .003), chronic lung disease (p = .012), or iron deficiency anemia (p = .016); and more likely to receive surgery before ultrasound (p < .0001). Patients more likely to be treated with surgery than ultrasound included younger patients (p < .0001), obese patients (p = .02), and patients who first see a specialist (p < .05).

Asunto(s)

Curación de Fractura , Fracturas no Consolidadas/terapia , Huesos Metatarsianos/diagnóstico por imagen , Terapia por Ultrasonido/métodos , Anciano , Femenino , Estudios de Seguimiento , Fracturas no Consolidadas/diagnóstico , Humanos , Masculino , Huesos Metatarsianos/lesiones , Radiografía , Estudios Retrospectivos , Resultado del Tratamiento , Ondas Ultrasónicas

RESUMEN

BACKGROUND: Enteral nutrition (EN) supports many older and disabled Americans. This study describes the frequency and cost of acute care hospitalization with dehydration and/or malnutrition of Medicare beneficiaries receiving EN, focusing on those receiving home EN. METHODS: Medicare 5% Standard Analytic Files were used to determine Medicare spending for EN supplies and the proportion and cost of beneficiaries receiving EN, specifically home EN, admitted to the hospital with dehydration and/or malnutrition. RESULTS: In 2013, Medicare paid $370,549,760 to provide EN supplies for 125,440 beneficiaries, 55% of whom were also eligible for Medicaid. Acute care hospitalization with dehydration and/or malnutrition occurred in 43,180 beneficiaries receiving EN. The most common principal diagnoses were septicemia (21%), aspiration pneumonitis (9%), and pneumonia (5%). In beneficiaries receiving EN at home, >one-third (37%) were admitted with dehydration and/or malnutrition during a mean observation interval of 231 ± 187 days. Admitted patients were usually hospitalized more than once with dehydration and/or malnutrition (1.73 ± 1.30 admissions) costing $23,579 ± 24,966 per admitted patient, totaling >$129,685,622 during a mean observation interval of 276 ± 187 days. Mortality in the year following enterostomy tube placement was significantly higher for admitted compared with nonadmitted patients (40% vs 33%; P = .05). CONCLUSION: Acute care hospitalizations with dehydration and/or malnutrition in Medicare beneficiaries receiving EN were common and expensive. Additional strategies to reduce these, with particular focus on vulnerable populations such as Medicaid-eligible patients, are needed.

Asunto(s)

Deshidratación , Nutrición Enteral/efectos adversos , Servicios de Atención de Salud a Domicilio , Costos de Hospital , Hospitalización/economía , Desnutrición , Medicare , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Deshidratación/economía , Deshidratación/epidemiología , Deshidratación/etiología , Femenino , Humanos , Masculino , Desnutrición/economía , Desnutrición/epidemiología , Desnutrición/etiología , Persona de Mediana Edad , Admisión del Paciente , Neumonía/terapia , Neumonía por Aspiración/terapia , Prevalencia , Sepsis/terapia , Estados Unidos/epidemiología , Poblaciones Vulnerables

RESUMEN

OBJECTIVES: While surgical ablation (SA) for persistent atrial fibrillation (AF) can reduce recurrence of AF, its impact on longitudinal survival and health-care costs remains controversial. This study defines the clinical outcomes and costs associated with SA in patients with prior AF undergoing coronary artery bypass grafting (CABG). METHODS: A total of 3745 Medicare beneficiaries with prior AF who underwent CABG in 2013 were divided into 2 groups: those with and those without concomitant SA. Risk-adjusted early (0-90 days) and late (91-364 days) postoperative outcomes and inpatient costs were compared. RESULTS: SA was performed in 17% of CABG patients with prior AF. Preoperative characteristics favoured patients with SA: emergent presentation (15% vs 22%), heart failure in the 2 weeks prior to CABG (31% vs 36%), chronic lung disease (27% vs 33%) and renal failure (4% vs 7%) (all P < 0.05). Risk-adjusted operative mortality and perioperative stroke rates were similar in the 2 groups. Risk-adjusted survival was similar through 90 days, but significantly better with SA after 90 days [hazard ratio (HR) = 0.58; P = 0.03]. At 1 year, the risk-adjusted incidence of cardiovascular implantable electronic device implantation was greater with SA (HR = 1.20; P = 0.01). Risk-adjusted costs for the CABG admission (HR = 1.11; P < 0.01) and inpatient care through 1 year (HR = 1.06; P = 0.02) were also greater with SA. CONCLUSIONS: In the US Medicare population, SA was performed in 17% of CABG-AF patients in 2013. Operative risks for mortality and stroke did not increase with SA but costs did. Patients receiving SA, however, had significantly better risk-adjusted late survival.

Asunto(s)

Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Medicare/economía , Complicaciones Posoperatorias/sangre , Medición de Riesgo/métodos , Anciano , Fibrilación Atrial/complicaciones , Fibrilación Atrial/epidemiología , Ablación por Catéter/economía , Causas de Muerte/tendencias , Comorbilidad/tendencias , Puente de Arteria Coronaria/economía , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/epidemiología , Costos y Análisis de Costo , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de Tiempo , Estados Unidos/epidemiología

RESUMEN

BACKGROUND: Fracture nonunion risk is related to severity of injury and type of treatment, yet fracture healing is not fully explained by these factors alone. We hypothesize that patient demographic factors assessable by the clinician at fracture presentation can predict nonunion. METHODS: A prospective cohort study design was used to examine ~2.5 million Medicare patients nationwide. Patients making fracture claims in the 5% Medicare Standard Analytic Files in 2011 were analyzed; continuous enrollment for 12months after fracture was required to capture the ICD-9-CM nonunion diagnosis code (733.82) or any procedure codes for nonunion repair. A stepwise regression analysis was used which dropped variables from analysis if they did not contribute sufficient explanatory power. In-sample predictive accuracy was assessed using a receiver operating characteristic (ROC) curve approach, and an out-of-sample comparison was drawn from the 2012 Medicare 5% SAF files. RESULTS: Overall, 47,437 Medicare patients had 56,492 fractures and 2.5% of fractures were nonunion. Patients with healed fracture (age 75.0±12.7SD) were older (p<0.0001) than patients with nonunion (age 69.2±13.4SD). The death rate among all Medicare beneficiaries was 4.8% per year, but fracture patients had an age- and sex-adjusted death rate of 11.0% (p<0.0001). Patients with fracture in 14 of 18 bones were significantly more likely to die within one year of fracture (p<0.0001). Stepwise regression yielded a predictive nonunion model with 26 significant explanatory variables (all, p≤0.003). Strength of this model was assessed using an area under the curve (AUC) calculation, and out-of-sample AUC=0.710. CONCLUSIONS: A logistic model predicted nonunion with reasonable accuracy (AUC=0.725). Within the Medicare population, nonunion patients were younger than patients who healed normally. Fracture was associated with increased risk of death within 1year of fracture (p<0.0001) in 14 different bones, confirming that geriatric fracture is a major public health issue. Comorbidities associated with increased risk of nonunion include past or current smoking, alcoholism, obesity or morbid obesity, osteoarthritis, rheumatoid arthritis, type II diabetes, and/or open fracture (all, multivariate p<0.001). Nonunion prediction requires knowledge of 26 patient variables but predictive accuracy is currently comparable to the Framingham cardiovascular risk prediction.

Asunto(s)

Envejecimiento/patología , Fracturas no Consolidadas/epidemiología , Adulto , Factores de Edad , Anciano , Área Bajo la Curva , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Biológicos , Probabilidad , Estudios Prospectivos , Estados Unidos/epidemiología

RESUMEN

Device infection is a complication of implantable cardioverter-defibrillator (ICD) therapy that significantly increases mortality. Risk factors associated with death and ICD infection are poorly understood. The purpose of this study was to identify patient characteristics associated with death after cardiovascular implantable electronic device (CIED) infection. This is a retrospective cohort study of 64,903 Medicare fee-for-service patients who received an ICD in 2007, including 1,855 with device infection. Long-term survival was significantly reduced with CIED infection (71.6% vs 85.0%, p <0.001). Regression analysis accounting for age, race, gender, and 28 co-morbidities identified only 2 patient characteristics associated with decreased long-term survival with CIED infection: female gender and human immunodeficiency virus/acquired immunodeficiency syndrome. In patients with CIED infection, women had substantially reduced long-term survival compared with men (67.3% vs 72.9%, p <0.02). The risk-adjusted hazard ratio for long-term mortality with device infection in women compared with that in men increased significantly from 0.86 (95% confidence interval [CI] 0.82 to 0.91) to 1.25 (95% CI 1.02 to 1.53), corresponding to a risk increase of >45%. Importantly, a substantial portion of this excess mortality occurred after the index admission for infection, when the hazard ratio for death in women compared with that in men increased from 0.86 (95% CI 0.82 to 0.91) to 1.20 (95% CI 0.96 to 1.51) with CIED infection, despite little gender difference in admission length of stay, disposition, and cost. In conclusion, women are significantly more likely than men to die with CIED infection. A substantial part of this excess mortality occurs after discharge. It will be important to identify and address the cause(s) of this gender difference in mortality.

Asunto(s)

Enfermedades Cardiovasculares/terapia , Desfibriladores Implantables/efectos adversos , Infecciones Relacionadas con Prótesis/mortalidad , Distribución por Edad , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/mortalidad , Intervalos de Confianza , Femenino , Estudios de Seguimiento , Humanos , Masculino , Oportunidad Relativa , Estudios Retrospectivos , Distribución por Sexo , Tasa de Supervivencia/tendencias , Factores de Tiempo , Estados Unidos/epidemiología

RESUMEN

STUDY DESIGN: Retrospective observational cohort analysis of administrative claims. OBJECTIVE: Estimate readmission rates after spine stenosis decompression surgery in a 5% randomly selected sample of Medicare beneficiaries. SUMMARY OF BACKGROUND DATA: Operative management of lumbar spinal stenosis has significant and measurable benefits compared with nonoperative care. Revision rates for lumbar decompression with and without fusion have been reported with significant variability. An understanding of readmission and reoperation rates informs decisions regarding the cost-effective management of lumbar stenosis. METHODS: Patients were identified in 2005-2009 Medicare claims who had both a procedure code for decompression (03.09), and a diagnosis of lumbar spinal stenosis (724.02). Patients diagnosed with spondylolisthesis, and those receiving revision surgery or fusion of more than 3 segments were excluded. Kaplan-Meier product limit method was used to estimate univariate rates of readmission for fusion, decompression, or injection and Cox proportional hazards to examine whether fusion decreased the likelihood of readmission. RESULTS: The overall 1-year readmission rate was slightly higher in patients undergoing fusion with decompression (9.7%) than patients who underwent decompression alone (7.2%, P = 0.03). Rates at 2 years were 14.6% and 12.5%, respectively. Patients receiving decompression with fusion were slightly younger and more likely female. Procedures performed during readmission were similar for the fusion and no fusion cohorts with 56% receiving fusion, 23% decompression, and 22% injection for pain management. Of the patients who were not readmitted, more than 25% of patients received outpatient injections for pain management during the 3-month quarter of their surgery and approximately 20% in the subsequent quarter. CONCLUSION: Readmission rates for spinal stenosis decompression were approximately 8% to 10% per year. Fusion at the index procedure did not protect against subsequent readmission. Large databases can inform choice of surgical options by focusing examination on indications for surgery and reasons for readmission. Fusion along with decompression does not seem to impact readmission rates.

Asunto(s)

Descompresión Quirúrgica/estadística & datos numéricos , Vértebras Lumbares/cirugía , Medicare/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Fusión Vertebral/estadística & datos numéricos , Estenosis Espinal/cirugía , Adolescente , Corticoesteroides/administración & dosificación , Corticoesteroides/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Analgesia Epidural/economía , Analgesia Epidural/estadística & datos numéricos , Analgésicos/administración & dosificación , Analgésicos/uso terapéutico , Niño , Preescolar , Análisis Costo-Beneficio , Descompresión Quirúrgica/economía , Femenino , Estudios de Seguimiento , Humanos , Lactante , Inyecciones , Estimación de Kaplan-Meier , Masculino , Medicare/economía , Persona de Mediana Edad , Bloqueo Nervioso/economía , Bloqueo Nervioso/estadística & datos numéricos , Manejo del Dolor/economía , Manejo del Dolor/estadística & datos numéricos , Readmisión del Paciente/economía , Complicaciones Posoperatorias/economía , Modelos de Riesgos Proporcionales , Reoperación/economía , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Fusión Vertebral/economía , Estenosis Espinal/economía , Estados Unidos/epidemiología , Adulto Joven

RESUMEN

BACKGROUND: Cardiovascular implantable electronic device (CIED) therapy can reduce morbidity and mortality, but this benefit can be diminished by CIED infection. Currently, there are limited published data on the mortality and cost associated with CIED infection. METHODS: We analyzed the risk-adjusted total and incremental admission mortality, long-term mortality, admission length of stay (LOS), and admission cost associated with infection in a retrospective cohort of 200 219 Medicare fee-for-service patients admitted for CIED generator implantation, replacement, or revision between January 1, 2007, and December 31, 2007. RESULTS: There were a total of 5817 admissions with infection. Infection was associated with significant increases in adjusted admission mortality (rate ratios, 4.8-7.7; standardized rates, 4.6%-11.3%) and long-term mortality (rate ratios, 1.6-2.1; standardized rates, 26.5%-35.1%), depending on CIED type. Importantly, approximately half of the incremental long-term mortality occurred after discharge. The adjusted LOS was significantly longer with infection (length of stay mean ratios, 2.5-4.0; standardized length of stay, 15.5-24.3 days), depending on CIED type. The standardized adjusted incremental and total admission costs with infection were $14 360 to $16 498 and $28 676 to $53 349, respectively, depending on CIED type. The largest incremental cost with infection was intensive care, which accounted for more than 40% of the difference. Adjusted long-term mortality rate and cost ratios with infection were significantly greater for pacemakers than for implantable cardioverter/defibrillators or cardiac resynchronization therapy/defibrillator devices. CONCLUSIONS: Infection associated with CIED procedures resulted in substantial incremental admission mortality and long-term mortality that varied with the CIED type and occurred, in part, after discharge. Almost half of the incremental admission cost was for intensive care.

Asunto(s)

Dispositivos de Terapia de Resincronización Cardíaca/efectos adversos , Enfermedades Cardiovasculares/cirugía , Procedimientos Quirúrgicos Cardiovasculares/efectos adversos , Cuidados Críticos/economía , Desfibriladores Implantables/efectos adversos , Infecciones Relacionadas con Prótesis , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardiovasculares/instrumentación , Procedimientos Quirúrgicos Cardiovasculares/mortalidad , Costos y Análisis de Costo , Femenino , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Medicare/estadística & datos numéricos , Persona de Mediana Edad , Readmisión del Paciente/economía , Infecciones Relacionadas con Prótesis/economía , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/etiología , Reoperación/economía , Medición de Riesgo , Tasa de Supervivencia , Estados Unidos