RESUMEN
BACKGROUND: Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery by preserving preoperative organ function and minimizing the stress response following surgery. Few studies have assessed the association between ERAS and postoperative cardiac complications. The goal of this study is to evaluate the impact of ERAS on postoperative cardiac complications. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database of colorectal patients who underwent surgery at a tertiary colorectal cancer referral center was carried out. Preoperative, intraoperative, and postoperative factors including demographics, comorbidities, medications, and fluid administration were recorded. The primary outcome was postoperative cardiac arrhythmia, and secondary outcomes included other postoperative complications. RESULTS: A total of 800 patients who underwent elective colorectal surgery were identified. Four hundred seventeen patients (52%) were in the control group and 383 patients (48%) were in the ERAS group. Patients in both groups were similar with regard to demographics and clinical characteristics. There were significantly higher rates of cardiac arrhythmia in the control group (5.3%) compared with the ERAS group (1.8%), p = 0.009. Multivariable analysis revealed that ERAS was an independent predictor of decreased postoperative cardiac arrhythmia (OR 0.30, 95%CI 0.17-0.55, p < 0.001) while older age was an independent predictor of increased postoperative cardiac arrhythmia (OR 1.08, 95%CI 1.02-1.13, p = 0.008). Patients receiving lower amounts of intravenous fluids had significantly decreased postoperative cardiac arrhythmia (OR = 0.25, 95%CI 0.09-0.67, p = 0.006). CONCLUSIONS: ERAS and goal-directed fluid therapy are associated with significant reductions in postoperative cardiac arrhythmias.
Asunto(s)
Cirugía Colorrectal , Recuperación Mejorada Después de la Cirugía , Anciano , Arritmias Cardíacas/etiología , Arritmias Cardíacas/prevención & control , Humanos , Tiempo de Internación , Atención Perioperativa , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Estudios RetrospectivosRESUMEN
BACKGROUND: When judging the success or failure of major lower extremity (MLE) amputation, the assessment of appropriate functional and quality of life (QOL) outcomes is paramount. The heterogeneity of the scales and tests in the current literature is confusing and makes it difficult to compare results. We provide a primer for outcome assessment after amputation and assess the need for the additional development of novel instruments. METHODS: MEDLINE, EMBASE, and Google Scholar were searched for all studies using functional and QOL instruments after MLE amputation. Assessment instruments were divided into functional and QOL categories. Within each category, they were subdivided into global and amputation-specific instruments. An overall assessment of instrument quality was obtained. RESULTS: The initial search revealed 746 potential studies. After a review of abstracts, 102 were selected for full review, and 40 studies were then included in this review. From the studies, 21 different assessment instruments were used 63 times. There were 14 (67%) functional measures and 7 (33%) QOL measures identified. Five (36%) of the functional instruments and 3 (43%) of the QOL measures were specific for MLE amputees. Sixteen instruments were used >1 time, but only 5 instruments were used >3 times. An additional 5 instruments were included that were deemed important by expert opinion. The 26 assessment instruments were rated. Fourteen of the best-rated instruments were then described. CONCLUSIONS: The heterogeneity of instruments used to measure both functional and QOL outcomes make it difficult to compare MLE amputation outcome studies. Future researchers should seek to use high-quality instruments. Clinical and research societies should endorse the best validated instruments for future use in order to strengthen overall research in the field.
Asunto(s)
Amputación Quirúrgica , Amputados/rehabilitación , Evaluación de la Discapacidad , Prueba de Esfuerzo , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/cirugía , Calidad de Vida , Encuestas y Cuestionarios , Actividades Cotidianas , Amputación Quirúrgica/efectos adversos , Amputación Quirúrgica/psicología , Amputados/psicología , Humanos , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/psicología , Valor Predictivo de las Pruebas , Recuperación de la Función , Resultado del TratamientoRESUMEN
OBJECTIVE: Analysis of complex survey databases is an important tool for health services researchers. Missing data elements are challenging because the reasons for "missingness" are multifactorial, especially categorical variables such as race. We simulated missing data for race and analyzed the bias from five methods used in predicting major amputation in patients with critical limb ischemia (CLI). METHODS: Patient discharges with fully observed data containing lower extremity revascularization or major amputation and CLI were selected from the 2003 to 2007 Nationwide Inpatient Sample, a complex survey database (weighted n = 684,057). Considering several random missing data schemes, we compared five missing data methods: complete case analysis, replacement with observed frequencies, missing indicator variable, multiple imputation, and reweighted estimating equations. We created 100 simulated data sets, with 5%, 15%, or 30% of subjects' race drawn to be missing from the full data set. Bias was estimated by comparing the estimated regression coefficients averaged over 100 simulated data sets (ß(miss)) from each method vs estimates from the fully observed data set (ß(full)), with relative bias calculated as (ß(full) - ß(miss)/ß(full)) × 100%. RESULTS: Our results demonstrate that reweighted estimating equations produce the least biased and the missing indicator variable produces the most biased coefficients. Complete case analysis, replacement with observed frequencies, and multiple imputation resulted in moderate bias. Sensitivity analysis demonstrated the optimal method choice depends on the quantity and type of missing data encountered. CONCLUSIONS: Missing data are an important analytic topic in research with large databases. The commonly used missing indicator variable method introduces severe bias and should be used with caution. We present empiric evidence to guide method selection for handling missing data.
Asunto(s)
Minería de Datos/métodos , Minería de Datos/estadística & datos numéricos , Bases de Datos Factuales/estadística & datos numéricos , Anciano , Amputación Quirúrgica/estadística & datos numéricos , Sesgo , Simulación por Computador , Enfermedad Crítica , Interpretación Estadística de Datos , Etnicidad/estadística & datos numéricos , Femenino , Investigación sobre Servicios de Salud , Humanos , Isquemia/etnología , Isquemia/cirugía , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Alta del Paciente/estadística & datos numéricos , Reproducibilidad de los Resultados , Proyectos de Investigación , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: The share of total abdominal aortic aneurysm (AAA) repairs performed by endovascular aneurysm repair (EVAR) increased rapidly from 32% in 2001 to 65% in 2006 with considerable variation between states. We hypothesized that hospitals in competitive markets were early EVAR adopters and had improved AAA repair outcomes. METHODS: Nationwide Inpatient Sample and linked Hospital Market Structure (HMS) data was queried for patients who underwent repair for nonruptured AAA in 2003. In HMS, the Herfindahl Hirschman Index (HHI, range 0-1) is a validated and widely accepted economic measure of competition. Hospital markets were defined using a variable geographic radius that encompassed 90% of discharged patients. We conducted bivariate and multivariable linear and logistic regression analyses for the dependent variable of EVAR use. A propensity score-adjusted multivariable logistic regression model was used to control for treatment bias in the assessment of competition on AAA repair outcomes. RESULTS: A weighted total of 21,600 patients was included in our analyses. Patients at more competitive hospitals (lower HHI) were at increased odds of undergoing EVAR vs open repair (odds ratio, 1.127 per 0.1 decrease in HHI; P < .0127) after adjusting for patient demographics, comorbidities, and hospital level factors (bed size, teaching status, AAA repair volume, and ownership). Competition was not associated with differences in in-hospital mortality or vascular, neurologic, or other minor postoperative complications. CONCLUSIONS: Greater hospital competition is significantly associated with increased EVAR adoption at a time when diffusion of this technology passed its tipping point. Hospital competition does not influence post-AAA repair outcomes. These results suggest that adoption of novel vascular technology is not solely driven by clinical indications but may also be influenced by market forces.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Competencia Económica , Procedimientos Endovasculares/economía , Costos de Hospital , Hospitales , Evaluación de Procesos y Resultados en Atención de Salud/economía , Anciano , Aneurisma de la Aorta Abdominal/economía , Aneurisma de la Aorta Abdominal/mortalidad , Difusión de Innovaciones , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Modelos Lineales , Modelos Logísticos , Masculino , Análisis Multivariante , Oportunidad Relativa , Puntaje de Propensión , Indicadores de Calidad de la Atención de Salud , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: Major amputation is associated with increased short-term healthcare resource utilization (RU), early mortality, and socioeconomic status (SES) disparities. Our objective is to study patient-specific and SES-related predictors of long-term RU and survival after amputation. METHODS: This retrospective analysis identified 364 adult patients who underwent index major amputation for critical limb ischemia from January 1995 through December 2000 at two tertiary centers with outcomes through December 2010. Age, gender, SES (race, income, insurance, and marital status), comorbidities (congestive heart failure [CHF], diabetes, diabetes with complications, and renal failure [RF]), subsequent procedures, cumulative length of stay (cLOS), and mortality were analyzed. Bivariate and multivariate Poisson regression for subsequent procedures and cLOS and Cox proportional hazard modeling for all-cause mortality were undertaken. RESULTS: During a mean follow-up of 3.25 years, amputation patients had mean cLOS of 71.2 days per person-year (median, 17.6), 19.5 readmissions per person-year (median, 2.1), 0.57 amputation-related procedures (median, 0), and 0.31 cardiovascular procedures (median, 0). Below-knee amputation as the index procedure was performed in 70% of patients, and 25% had additional amputation procedures. Of readmissions at ≤ 30 days, 52% were amputation-related. Overall mortality during follow-up was 86.9%; 37 patients (10.2%) died within 30 days. Among patients surviving >30 days, multivariate Poisson regression demonstrated that younger age (incidence rate ratio [IRR], 0.98), public insurance (IRR, 1.63), CHF (IRR, 1.60), and RF (IRR, 2.12) were associated with increased cLOS. Diabetes with complications (IRR, 1.90) and RF (IRR, 2.47) affected subsequent amputation procedures. CHF (IRR, 1.83) and RF (IRR, 3.67) were associated with a greater number of cardiovascular procedures. Cox proportional hazard modeling indicated older age (hazard ratio [HR], 1.04), CHF (HR, 2.26), and RF (HR, 2.60) were risk factors for decreased survival. Factors associated with SES were not significantly related to the outcomes. CONCLUSIONS: This study found that RU is high for amputees, and increased RU persists beyond the perioperative period. Results were similar across SES indices, suggesting higher SES may not be protective against poor outcomes when limb salvage is no longer attainable. These findings support the hypothesis that SES disparities may be more modifiable during earlier stages of care for critical limb ischemia.
Asunto(s)
Amputación Quirúrgica/mortalidad , Recursos en Salud/estadística & datos numéricos , Isquemia/cirugía , Sobrevivientes , Factores de Edad , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica/efectos adversos , Boston , Comorbilidad , Enfermedad Crítica , Diabetes Mellitus/mortalidad , Femenino , Insuficiencia Cardíaca/mortalidad , Humanos , Isquemia/mortalidad , Tiempo de Internación , Masculino , Persona de Mediana Edad , Análisis Multivariante , Readmisión del Paciente , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Modelos de Riesgos Proporcionales , Sistema de Registros , Insuficiencia Renal/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Factores Socioeconómicos , Sobrevivientes/estadística & datos numéricos , Centros de Atención Terciaria , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Disparities in limb salvage procedures may be driven by socioeconomic status (SES) and access to high-volume hospitals. We sought to identify SES factors associated with major amputation in the setting of critical limb ischemia (CLI). METHODS: The 2003-2007 Nationwide Inpatient Sample was queried for discharges containing lower extremity revascularization (LER) or major amputation and chronic CLI (N = 958,120). The Elixhauser method was used to adjust for comorbidities. Significant predictors in bivariate logistic regression were entered into a multivariate logistic regression for the dependent variable of amputation vs LER. RESULTS: Overall, 24.2% of CLI patients underwent amputation. Significant differences were seen between both groups in bivariate and multivariate analysis of SES factors, including race, income, and insurance status. Lower-income patients were more likely to be treated at low-LER-volume institutions (odds ratio [OR], 1.74; P < .001). Patients at higher-LER-volume centers (OR, 15.16; P <.001) admitted electively (OR, 2.19; P < .001) and evaluated with diagnostic imaging (OR, 10.63; P < .001) were more likely to receive LER. CONCLUSIONS: After controlling for comorbidities, minority patients, those with lower SES, and patients with Medicaid were more likely receive amputation for CLI in low-volume hospitals. Addressing SES and hospital factors may reduce amputation rates for CLI.
Asunto(s)
Amputación Quirúrgica/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Isquemia/cirugía , Recuperación del Miembro/estadística & datos numéricos , Extremidad Inferior/irrigación sanguínea , Factores Socioeconómicos , Anciano , Diagnóstico por Imagen/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Femenino , Capacidad de Camas en Hospitales/estadística & datos numéricos , Humanos , Seguro de Salud/estadística & datos numéricos , Isquemia/diagnóstico , Isquemia/etnología , Modelos Logísticos , Masculino , Medicaid/estadística & datos numéricos , Grupos Minoritarios/estadística & datos numéricos , Oportunidad Relativa , Características de la Residencia/estadística & datos numéricos , Medición de Riesgo , Factores de Riesgo , Estados UnidosRESUMEN
Disparities in health care are well documented for several racial, ethnic, and gender groups. In peripheral arterial disease, differences in prevalence, treatment selection, treatment outcomes, and resulting quality of life have negative effects on some minority groups and women. It may be easy to document disparities, but it is harder to understand their underlying causes. Are there biologic differences between members of racial and ethnic groups that influence disease presentation and outcomes? Or is the socioeconomic environment that surrounds them the true driver of observed differences? This article reviews the evidence for racial and gender disparities in vascular surgery and presents some potential mechanisms that may explain the disparities.
Asunto(s)
Etnicidad , Disparidades en Atención de Salud , Evaluación de Procesos y Resultados en Atención de Salud , Enfermedades Vasculares Periféricas/cirugía , Grupos Raciales , Procedimientos Quirúrgicos Vasculares , Femenino , Investigación sobre Servicios de Salud , Humanos , Masculino , Selección de Paciente , Enfermedades Vasculares Periféricas/diagnóstico , Enfermedades Vasculares Periféricas/etnología , Prevalencia , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores Socioeconómicos , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
All gastrointestinal (GI) disorders can present during pregnancy, and in fact 0.2% to 1.0% of all pregnant women require non-obstetrical general surgery. All of the clinical decision-making skills of the experienced surgeon must come into play in order to make the correct therapeutic decisions when evaluating the pregnant patient with a GI disorder that potentially requires surgery. While in general the principles of diagnosing and treating a pregnant woman with an acute surgical abdominal problem remain the same as those governing the treatment of the non-pregnant patient, some important differences are present and can pose problems. As a general rule the condition of the mother should always take priority because proper treatment of surgical diseases in the mother will usually benefit the fetus as well as the mother.