RESUMEN
BACKGROUND: The outcomes after prolonged treatment in the intensive care unit (ICU) after surgery for Stanford type A aortic dissection (TAAD) have not been previously investigated. METHODS: This analysis included 3538 patients from a multicenter study who underwent surgery for acute TAAD and were admitted to the cardiac surgical ICU. RESULTS: The mean length of stay in the cardiac surgical ICU was 9.9±9.5 days. The mean overall costs of treatment in the cardiac surgical ICU 24086±32084 . In-hospital mortality was 14.8% and 5-year mortality was 30.5%. Adjusted analyses showed that prolonged ICU stay was associated with significantly lower risk of in-hospital mortality (adjusted OR 0.971, 95%CI 0.959-0.982), and of five-year mortality (adjusted OR 0.970, 95%CI 0.962-0.977), respectively. Propensity score matching analysis yielded 870 pairs of patients with short ICU stay (2-5 days) and long ICU stay (>5 days) with balanced baseline, operative and postoperative variables. Patients with prolonged ICU stay (>5 days) had significantly lower in-hospital mortality (8.9% vs. 17.4%, <0.001) and 5-year mortality (28.2% vs. 30.7%, P=0.007) compared to patients with short ICU-stay (2-5 days). CONCLUSIONS: Prolonged ICU stay was common after surgery for acute TAAD. However, when adjusted for multiple baseline and operative variables as well as adverse postoperative events and the cluster effect of hospitals, it was associated with favorable survival up to 5 years after surgery.
Asunto(s)
Disección Aórtica , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos , Tiempo de Internación , Humanos , Masculino , Femenino , Disección Aórtica/cirugía , Disección Aórtica/economía , Disección Aórtica/mortalidad , Tiempo de Internación/economía , Persona de Mediana Edad , Unidades de Cuidados Intensivos/economía , Anciano , Pronóstico , Aneurisma de la Aorta/cirugía , Aneurisma de la Aorta/economía , Aneurisma de la Aorta/mortalidadRESUMEN
INTRODUCTION: Stanford Type A Aortic Dissection (TAAD) is characterized by a high in-hospital mortality rate and necessitates urgent surgical intervention. While socioeconomic status is known to influence health-care outcomes, its specific association with TAAD remains underexplored. This study aimed to investigate the population-based association between socioeconomic status with TAAD repair outcomes using a national registry. METHODS: Patients who had TAAD repair were identified in National Inpatient Sample from Q4 2015-2020. National Inpatient Sample stratified estimated median household income of residents within a patient's ZIP code. Patients residing in neighborhoods of incomes in the lowest and highest quartiles were selected as the study cohorts. Multivariable logistic regressions were used to compare in-hospital outcomes, adjusted for demographics, comorbid conditions, hospital characteristics, primary payer status, and transfer status. RESULTS: Compared to patients from high-income neighborhoods, patients in low-income communities had higher risks of mortality (adjusted odds ratio [aOR] 1.45, P = 0.01), acute kidney injury (aOR 1.225, P = 0.03), and infection (aOR 1.474, P = 0.02), as well as longer wait from admission to operation (24.96 ± 2.64 versus 18.00 ± 1.92 h, P = 0.03) and longer length of stay (15.06 ± 0.38 versus 13.80 ± 0.36 d, P = 0.01). In contrast, patients from low-income communities had less risk of hemorrhage/hematoma (aOR 0.691, P < 0.01) and lower total hospital charge (428,746 ± 10,658 versus 487,017 ± 16,770 US dollars, P < 0.01). CONCLUSIONS: Evidence suggests patients from lower-income communities may have limited access to health care and treatment delays, leading to higher mortality and complications. The underlying reasons for these disparities in economically disadvantaged communities warrant further investigation, which could focus on health-care accessibility, timely detection of TAAD, and prompt transfers to specialized centers.
Asunto(s)
Disección Aórtica , Mortalidad Hospitalaria , Clase Social , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Disección Aórtica/cirugía , Disección Aórtica/mortalidad , Disección Aórtica/economía , Estados Unidos/epidemiología , Adulto , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiología , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/economía , Estatus Socioeconómico BajoRESUMEN
BACKGROUND: Several studies have reported lower mortality and morbidity after thoracic endovascular aortic repair (TEVAR) when compared to open surgical repair (OSR) in the treatment of type B aortic dissection (TbAD). However, there are few studies in the literature on the cost of both treatment options. Thus, the aim of this study is to focus on in-hospital outcomes and cost associated with TbAD repair procedures in a national database in the United States. METHODS: A retrospective review of the Premier Healthcare Database (PHD) between June 2009 and March 2015 was performed. ICD-9-CM codes were used to identify patients who underwent OSR or TEVAR for TbAD. Endpoints included in-hospital adverse events, in-hospital mortality and hospitalization cost. Logistic regression models and generalized linear models were used to assess the impact of treatment type on the main outcomes. RESULTS: Out of 1752 patients with TbAD, 54.3% underwent OSR and 45.7% underwent TEVAR. Patients in the TEVAR group were older [median age, 64 (IQR 54-73) vs. 59 (IQR 49-70), P < 1] and more likely to have preexisting comorbidities. IAE rates were 78.6% for the OSR group compared to 43.1% for the TEVAR group, P < 0.001. Patients in the OSR group showed significantly higher in-hospital mortality (15.3% vs. 5.9%, P < 0.001). After adjusting for potential confounders, OSR was associated with a 5-fold increase in IAE [aOR(95%CI): 4.8 (3.8-6.1), P < 0.001] and a 3-fold increase in in-hospital mortality [aOR(95%CI): 3.3 (2.1-5.1), P < 0.001]. In regards to charges related to the hospital stay, total cost was significantly higher among patients undergoing OSR $53,371 ($39,029-$80,471) vs. TEVAR $45,311 ($31,479-$67,960), P < 0.001. CONCLUSION: The present study shows that TEVAR presents an advantage in terms of morbidity, mortality and cost when compared to OSR in the treatment of TbAD. However, long-term cost-effectiveness of both procedures remains unknown. Further research is warranted to see whether the superiority of TEVAR is maintained over time.
Asunto(s)
Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/economía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/economía , Procedimientos Endovasculares/economía , Costos de Hospital , Anciano , Disección Aórtica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE/BACKGROUND: This study examined the 10-year hospitalization characteristics, economic patterns and early clinical outcomes of type B aortic dissection (TBAD) patients that underwent thoracic endovascular aortic repair (TEVAR) in one high-volume hospital in China. METHODS: We performed a population-based retrospective analysis based on electronic medical record system data provided by Zhongshan Hospital Fudan University from 2009 to 2018. RESULTS: We identified 1,367 cases of TBAD patients with TEVAR over the past decade. The total incidence of in-hospital complications was 7.6% (104 of 1,367), among which acute kidney injury (AKI) had the highest incidence (3.1%, 42 of 1,367). Aortic-related reintervention was performed in 7 patients (0.5%). The overall aortic-related in-hospital mortality rate was 2.7% (37 of 1,367) and had no significant time-varying trend (P = 0.2). Among these, 27% of in-hospital deaths were caused by retrograde type A dissection (RTAD). Chronic TBAD had a higher risk of in-hospital death versus acute TBAD, with a risk ratio of 2.69 (95% confidence interval [CI]: 1.19-6.09). Patients with hypertension (risk ratio 4.63, 95% CI: 1.38, 15.54) also had a higher in-hospital death risk. These 2 factors were also the predictive factors for the composite endpoint of in-hospital adverse events (risk ratio 2.17, 95% CI: 1.43, 3.29 and risk ratio 4.83, 95% CI: 1.90, 12.28, respectively), in addition to Marfan syndrome (risk ratio 4.05, 95% CI: 1.61, 10.19). The average length of hospitalization significantly declined during the past decade (annual percentage change -6.3%, 95% CI -8.2 to -4.3), and the stent-grafts (SGs) cost was the main expenditure of the total hospitalization costs. CONCLUSION: Our study showed a favorable early outcome of TEVAR over the past decade. Greater attention should be paid to certain risk factors in order to reduce the in-hospital adverse events. SG expenditure is still the primary economic burden on Chinese TBAD patients.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/economía , Disección Aórtica/mortalidad , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/mortalidad , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/economía , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , China/epidemiología , Registros Electrónicos de Salud , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Costos de Hospital , Mortalidad Hospitalaria , Humanos , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
Background Thoracic aortic dissections (TADs) and thoracic aortic aneurysms (TAAs) are resource intensive. We sought to determine economic burden and healthcare resource use to guide health policy. Methods and Results Using universal healthcare coverage data for Ontario, Canada, from 2003 to 2016, a cost-of-illness analysis was performed. From a single-payer's perspective, direct costs (hospitalization, reinterventions, readmissions, rehabilitation, extended care, home care, prescription drugs, and imaging) were assessed in 2017 Canadian dollars. Controls without TADs or TAAs were matched 10:1 on age, sex, and socioeconomic status to cases with TADs or TAAs to compare posthospital service use to the general population. Linear and spline regression were used for cost trends. Total hospital costs increased from $9 M to $20.7 M for TADs (P<0.0001) and $13 M to $18 M for TAAs (P<0.001). Costs cumulated to $587 M for 17 113 cases. Median hospital costs for TADs were $11 525 ($6102 medical, $26 896 endograft, and $30 372 surgery) with an increase over time (P=0.04). For TAAs, median costs were $16 683 ($7247 medical, $11 679 endograft, and $22 949 surgery) with a decrease over time (P=0.03). Home care was the most used posthospital service (TADs 44%, TAAs 38%), but rehabilitation had the highest median cost (TADs $11.9 M, TAAs $11 M). Men had increased median costs for indexed hospitalizations relative to women, yet women used more posthospital services with higher service costs. Conclusions Total yearly costs have increased for TADs and TAAs. Median hospital costs have increased for TADs yet decreased for TAAs. Women use posthospital healthcare services more often than men.
Asunto(s)
Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/economía , Disección Aórtica/cirugía , Costos de la Atención en Salud , Recursos en Salud/economía , Procedimientos Quirúrgicos Vasculares/economía , Factores de Edad , Anciano , Disección Aórtica/epidemiología , Aneurisma de la Aorta Torácica/epidemiología , Bases de Datos Factuales , Femenino , Servicios de Atención de Salud a Domicilio/economía , Costos de Hospital , Humanos , Masculino , Persona de Mediana Edad , Ontario/epidemiología , Rehabilitación/economía , Características de la Residencia , Estudios Retrospectivos , Factores Sexuales , Factores de Tiempo , Atención de Salud Universal , Cobertura Universal del Seguro de Salud/economíaRESUMEN
The West African country of Liberia ranks as one of the lowest in the world in most measures of health. The diagnosis and management of complex surgical cases such as aortic dissection is extremely challenging, for reasons ranging from lack of diagnostic imaging capabilities to the high resources required for definitive surgical intervention. We present the first known successfully managed case of aortic dissection in the country's history and with it highlight the challenges faced and a number of lessons learned that are beneficial to anyone working in resource-limited environments.
Asunto(s)
Disección Aórtica/cirugía , Disección Aórtica/diagnóstico , Disección Aórtica/economía , Ecocardiografía , Disparidades en Atención de Salud , Humanos , Liberia , Masculino , Mediastino/diagnóstico por imagen , Persona de Mediana Edad , PobrezaRESUMEN
BACKGROUND: Despite improvements in prevention and management, aortic aneurysm repair remains a high-risk operation for patients with Marfan syndrome (MFS) and Ehlers-Danlos syndrome (EDS). The goal of this study was to examine differences in characteristics and outcomes of patients with MFS or EDS undergoing aortic aneurysm repair at teaching versus nonteaching hospitals. METHODS: We used the National Inpatient Sample to study patients with MFS or EDS undergoing open or endovascular aortic aneurysm repair from 2000 to 2014. RESULTS: Of 3487 patients (MFS = 3375, EDS = 112), 2974 (85%) had repair at a teaching hospital. Patients who underwent repair at a teaching hospital were slightly younger than those who underwent repair at a nonteaching hospital (38 vs. 43 years, P < 0.01) but otherwise were similar in gender (29% vs. 28% female), race (70% vs. 78% white), and connective tissue disorder diagnosis (97% vs. 97% MFS, all P ≥ 0.1). There were no differences in anatomy (17% vs. 19% abdominal, 67% vs. 66% thoracic, and 15% vs. 15% thoracoabdominal, all P ≥ 0.1) or type of repair (5% vs. 5% endovascular), but patients at nonteaching hospitals were more likely to have a dissection (49% vs. 38%, P = 0.02). There was no difference in perioperative mortality (4% vs. 6%, P = 0.5) or length of stay (median 8 days vs. 7 days, P = 0.3) between teaching and nonteaching hospitals. There was also no difference in hemorrhagic (47% vs. 43%), pulmonary (9% vs. 16%), renal (12% vs. 14%), or neurologic (5% vs. 6%) complications between teaching and nonteaching hospitals, respectively (all P ≥ 0.05). In analysis stratified by anatomic extent of repair, there was a lower prevalence of pulmonary complications in thoracic aorta repairs at teaching hospitals (8.1% vs. 18.4%, P = 0.01) but a higher prevalence of hemorrhage in abdominal aortic repairs at teaching hospitals (45.6% vs. 20.6%, P = 0.04) as compared with nonteaching hospitals. CONCLUSIONS: Patients with MFS and EDS who undergo aortic aneurysm repair have their operations predominantly at teaching hospitals, but those patients who undergo repair at nonteaching hospitals do not have worse mortality or morbidity despite a higher incidence of dissection.
Asunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Síndrome de Ehlers-Danlos/epidemiología , Procedimientos Endovasculares , Hospitales de Enseñanza , Síndrome de Marfan/epidemiología , Adulto , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/economía , Disección Aórtica/mortalidad , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/economía , Aneurisma de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/economía , Implantación de Prótesis Vascular/mortalidad , Bases de Datos Factuales , Síndrome de Ehlers-Danlos/diagnóstico , Síndrome de Ehlers-Danlos/economía , Síndrome de Ehlers-Danlos/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/mortalidad , Femenino , Precios de Hospital , Costos de Hospital , Hospitales de Enseñanza/economía , Humanos , Incidencia , Tiempo de Internación , Masculino , Síndrome de Marfan/diagnóstico , Síndrome de Marfan/economía , Síndrome de Marfan/mortalidad , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: The purpose of this study was to characterize utilization and outcomes of thoracic endovascular aortic aneurysm repair (TEVAR) in New York State during the first decade of commercial availability, with respect to evolving indications, results, and costs. Of specific interest was evaluation of the volume-outcome relationship for this relatively uncommon procedure. METHODS: The New York Statewide Planning and Research Cooperative System database was queried to identify patients undergoing TEVAR from 2005 to 2014 for aortic dissection (AD), non-ruptured aneurysm (NRA), and ruptured aneurysm (RA). Outcomes assessed included in-hospital mortality, complications, and costs. Linkage to the National Provider Identifier and New York Office of Professions databases facilitated comparisons by surgeon and facility volume. RESULTS: One thousand eight hundred thirty-eight patients were identified: 334 AD, 226 RA, and 1,278 NRA. Since introduction, TEVAR implantation increased significantly over the 10-year period in all groups (P < 0.01), with recent increase in utilization for AD. Increased in-hospital mortality correlated with RA (OR 5.52 [3.02-10.08], P < 0.01), coagulopathy (3.38 [2.02-5.66], P < 0.01), cerebrovascular disease (2.47 [1.17-5.22], P = 0.02), and nonwhite/nonblack race (1.74 [1.08-2.82], P = 0.02). Early in the experience (2005-2007), patients were more likely to be treated at high-volume facilities (>17 per year) and by high-volume surgeons (>5 per year), (P < 0.01). Since 2011, however, most patients (53%) have undergone TEVAR by low-volume surgeons (<3 per year). Neither surgeon nor hospital volume was associated with clinical outcomes. CONCLUSIONS: Since the introduction of TEVAR, comparable results have been obtained across hospital and surgeon volume strata. Favorable outcomes, even in low-volume settings, underscore the complexity of volume-outcome relationships in high-acuity procedures. These findings have implications for credentialing, regionalization, and future dissemination of advanced endovascular technology.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular/tendencias , Procedimientos Endovasculares/tendencias , Evaluación de Procesos, Atención de Salud/tendencias , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/economía , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/economía , Rotura de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/economía , Implantación de Prótesis Vascular/mortalidad , Bases de Datos Factuales , Difusión de Innovaciones , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/mortalidad , Femenino , Costos de la Atención en Salud/tendencias , Disparidades en Atención de Salud/tendencias , Mortalidad Hospitalaria/tendencias , Hospitales de Alto Volumen/tendencias , Hospitales de Bajo Volumen/tendencias , Humanos , Masculino , Persona de Mediana Edad , New York , Complicaciones Posoperatorias/mortalidad , Evaluación de Procesos, Atención de Salud/economía , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Background Unplanned stents in thoracic endovascular aortic repair mean additional stents implantation beyond the preoperative planning to achieve operation success. This study aimed to reveal the prevalence and consequences of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection and explore the reasons, risk factors and solutions for unplanned stents. Methods Retrospectively analysis consecutive patients diagnosed as type B aortic dissection with initial tear originating distal from the left subclavian artery and underwent thoracic endovascular aortic repair from September 1998 to June 2014 in our center. Results Under the criteria, this study enrolled 322 patients, with 83 (25.8%) patients in unplanned group. The incidence rate of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection in each year demonstrates as a bimodal curve. The curve showed that, 2003 and, 2004 was the first and highest peak and 2007 was the second peak. There was no difference in five-year survival rate between planned and unplanned patients (log-rank test, p = 0.994). The unplanned group had higher hospitalization expenses (142,699.08 ± 78,446.75 yuan vs. 175,238.58 ± 34,838.01 yuan; p = 0.019), longer operation time (104.50 ± 93.24 min vs. 179.08 ± 142.47 min; p < 0.001) and hospitalization time (17.07 ± 16.62 d vs. 24.00 ± 15.34 d; p = 0.001). The reasons for unplanned stents were type Ia endoleak (46 patients, 55.4%), bird beak (25 patients, 30.1%), and inappropriate shaping of stent (9 patients, 10.8%). Asymptomatic aortic dissection patients had higher incidence of unplanned stents. Short proximal neck length (2.66 ± 0.59 mm vs. 2.50 ± 0.51 mm; p = 0.016), short stent coverage length (154.62 ± 41.12 mm vs. 133.60 ± 44.33 mm; p = 0.002), and large distal stent oversize (75.44±10.77% vs. 82.68±15.80%; p <0.001) were risk factors for unplanned stents in thoracic endovascular aortic repair. Conclusion There are some special risk factors and reasons for unplanned stents in thoracic endovascular aortic repair for type B aortic dissection. Knowing these can we reduce the utilization of unplanned stents with appropriate methods.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Adulto , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/economía , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/economía , Implantación de Prótesis Vascular/mortalidad , China , Endofuga/etiología , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/mortalidad , Femenino , Costos de Hospital , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Tempo Operativo , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Previous studies have demonstrated that patients undergoing complex surgical procedures at high-volume centers have improved outcomes. The goal of this study was to determine if this volume-outcomes relationship persists at a national level among patients undergoing emergent open repair for thoracic aortic dissection. METHODS: De-identified patient-level data were obtained from the Nationwide Inpatient Sample (2005 to 2008). Patients undergoing emergent aortic surgery for thoracic aortic dissection (n = 1230) were identified by ICD-9 codes and stratified by annual center volume into low volume (≤5 cases/year), intermediate volume (6 to 10 cases/year), and high volume (≥11 cases/year). The Deyo-Charlson co-morbidity score was used to adjust for differences in comorbidity between groups. Major outcomes of interest included: in-hospital morbidity and mortality, length of hospitalization, total hospital costs, and discharge disposition. RESULTS: There was a significant association between in-hospital mortality and center volume (p = 0.014), with low, intermediate, and high-volume centers having mortality rates of 23.4% (n = 187), 20.1% (n = 62), and 12.1% (n = 15), respectively. This relationship persisted when controlling for severity of co-morbid illness (p = 0.007). The number of complications per patient varied significantly by center volume (p = 0.044), with a higher proportion of patients at high-volume centers having no complications. Also, the highest proportion of home discharges was observed among patients at high-volume centers (p = 0.011). CONCLUSIONS: Survival following emergent open repair for thoracic aortic dissection was significantly greater at high-volume centers. These findings suggest that understanding the processes at high-volume centers that underlie this volume-outcomes relationship may improve in-hospital survival and postoperative complications.
Asunto(s)
Aneurisma de la Aorta Torácica/epidemiología , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/epidemiología , Disección Aórtica/cirugía , Servicios Médicos de Urgencia/estadística & datos numéricos , Servicio de Cirugía en Hospital/estadística & datos numéricos , Enfermedad Aguda , Adulto , Anciano , Disección Aórtica/economía , Aneurisma de la Aorta Torácica/economía , Estudios de Cohortes , Comorbilidad , Servicios Médicos de Urgencia/economía , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Servicio de Cirugía en Hospital/economía , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: The epidemiology of aortic dissection (AD) has not been well described among older persons in the United States. It is not known whether advancements in AD care over the last decade have been accompanied by changes in outcomes. METHODS AND RESULTS: The Inpatient Medicare data from 2000 to 2011 were used to determine trends in hospitalization rates for AD. Mortality rates were ascertained through corresponding vital status files. A total of 32 057 initial AD hospitalizations were identified. The overall hospitalization rate for AD remained unchanged at 10 per 100 000 person-years. For 30-day and 1-year mortality associated with AD, the observed rate decreased from 31.8% to 25.4% (difference, 6.4%; 95% confidence interval [CI], 6.2-6.5; adjusted, 6.4%; 95% CI, 5.7-6.9) and from 42.6% to 37.4% (difference, 5.2%; 95% CI, 5.1-5.2; adjusted, 6.2%; 95% CI, 5.3-6.7), respectively. For patients undergoing surgical repair for type A dissections, the observed 30-day mortality decreased from 30.7% to 21.4% (difference, 9.3%; 95% CI, 8.3-10.2; adjusted, 7.3%; 95% CI, 5.8-7.8) and the observed 1-year mortality decreased from 39.9% to 31.6% (difference, 8.3%; 95% CI, 7.5-9.1%; adjusted, 8.2%; 95% CI, 6.7-9.1). The 30-day mortality decreased from 24.9% to 21% (difference, 3.9%; 95% CI, 3.5-4.2; adjusted, 2.9%; 95% CI, 0.7-4.4) and 1-year decreased from 36.4% to 32.5% (difference, 3.9%; 95% CI, 3.3-4.3; adjusted, 3.9%; 95% CI, 2.5-6.3) for surgical repair of type B dissection. CONCLUSIONS: Although AD hospitalization rates remained stable, improvement in mortality was noted, particularly in patients undergoing surgical repair.
Asunto(s)
Disección Aórtica/economía , Hospitalización/economía , Pacientes Internos , Medicare/economía , Estados Unidos , Procedimientos Quirúrgicos Vasculares/economía , Anciano , Anciano de 80 o más Años , Disección Aórtica/epidemiología , Disección Aórtica/terapia , Costo de Enfermedad , Femenino , Mortalidad Hospitalaria/tendencias , Hospitalización/tendencias , Humanos , Tiempo de Internación/economía , Masculino , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
The E-vita open plus is a one-stage endoluminal stent graft system used for treating complex aneurysms and dissections of the thoracic aorta. The National Institute for Health and Care Excellence (NICE), as a part of its Medical Technologies Evaluation Programme (MTEP), selected this device for evaluation and invited the manufacturer, JOTEC GmbH, to submit clinical and economic evidence. King's Technology Evaluation Centre (KiTEC), an External Assessment Centre (EAC) commissioned by the NICE, independently critiqued the manufacturer's submissions. The EAC considered that the manufacturer had included most of the relevant evidence for the E-vita open plus, based on international E-vita open registry data for 274 patients, but had provided only limited evidence for the comparators. The EAC therefore conducted a systematic review and meta-analysis of all comparators to supplement the information, and found ten additional studies providing outcome data for the three two-stage comparators. The EAC noted that the cost model submitted by the manufacturer did not include key complications during the procedures. The EAC developed a new economic model incorporating data on complications along with their long-term costs. The revised model indicated that the E-vita open plus might not provide cost savings when compared with some of the comparators in the short-term (1 year), but would have high cost savings in the long-term, from the second year onwards. The NICE Medical Technologies Guidance MTG 16, issued in December 2013, recommended the adoption of the E-vita open plus in selected patients within the National Health Service in England.
Asunto(s)
Comités Consultivos , Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/terapia , Disección Aórtica/economía , Disección Aórtica/terapia , Stents/economía , Adulto , Anciano , Anciano de 80 o más Años , Análisis Costo-Beneficio , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Económicos , Complicaciones Posoperatorias/economía , Evaluación de la Tecnología Biomédica/economía , Resultado del Tratamiento , Reino UnidoRESUMEN
OBJECTIVE: This study weighed the cost and benefit of thoracic endovascular aortic repair (TEVAR) vs open repair (OR) in the treatment of an acute complicated type B aortic dissection by (TBAD) estimating the cost-effectiveness to determine an optimal treatment strategy based on the best currently available evidence. METHODS: A cost-utility analysis from the perspective of the health system payer was performed using a decision analytic model. Within this model, the 1-year survival, quality-adjusted life-years (QALYs), and costs for a hypothetical cohort of patients with an acute complicated TBAD managed with TEVAR or OR were evaluated. Clinical effectiveness data, cost data, and transitional probabilities of different health states were derived from previously published high-quality studies or meta-analyses. Probabilistic sensitivity analyses were performed on uncertain model parameters. RESULTS: The base-case analysis showed, in terms of QALYs, that OR appeared to be more expensive (incremental cost of 17,252.60) and less effective (-0.19 QALYs) compared with TEVAR; hence, in terms of the incremental cost-effectiveness ratio, OR was dominated by TEVAR. As a result, the incremental cost-effectiveness ratio (ie, the cost per life-year saved) was not calculated. The average cost-effectiveness ratio of TEVAR and OR per QALY gained was 56,316.79 and 108,421.91, respectively. In probabilistic sensitivity analyses, TEVAR was economically dominant in 100% of cases. The probability that TEVAR was economically attractive at a willingness-to-pay threshold of 50,000/QALY gained was 100%. CONCLUSIONS: The present results suggest that TEVAR yielded more QALYs and was associated with lower 1-year costs compared with OR in patients with an acute complicated TBAD. As a result, from the cost-effectiveness point of view, TEVAR is the dominant therapy over OR for this disease under the predefined conditions.
Asunto(s)
Aneurisma de la Aorta/economía , Aneurisma de la Aorta/cirugía , Disección Aórtica/economía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/economía , Procedimientos Endovasculares/economía , Costos de Hospital , Enfermedad Aguda , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico , Disección Aórtica/mortalidad , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Humanos , Modelos Económicos , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Años de Vida Ajustados por Calidad de Vida , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/terapia , Disección Aórtica/economía , Disección Aórtica/terapia , Cuidados Críticos/economía , Cuidados Críticos/organización & administración , Current Procedural Terminology , Documentación/normas , Medicare , Humanos , MasculinoRESUMEN
Because there is increasing demand for critical care providers in the United States, many medical ICUs for adults have begun to integrate nurse practitioners and physician assistants into their medical teams. Studies suggest that such advanced practice providers (APPs), when appropriately trained in acute care, can be highly effective in helping to deliver high-quality medical critical care and can be important elements of teams with multiple providers, including those with medical house staff. One aspect of building an integrated team is a practice model that features appropriate coding and billing of services by all providers. Therefore, it is important to understand an APP's scope of practice, when they are qualified for reimbursement, and how they may appropriately coordinate coding and billing with other team providers. In particular, understanding when and how to appropriately code for critical care services (Current Procedural Terminology [CPT] code 99291, critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 min; CPT code 99292, critical care, each additional 30 min) and procedures is vital for creating a sustainable program. Because APPs will likely play a growing role in medical critical care units in the future, more studies are needed to compare different practice models and to determine the best way to deploy this talent in specific ICU settings.
Asunto(s)
Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/terapia , Disección Aórtica/economía , Disección Aórtica/terapia , Cuidados Críticos/economía , Cuidados Críticos/organización & administración , Current Procedural Terminology , Documentación/normas , Medicare , Humanos , MasculinoRESUMEN
This article explores the rules and regulations from Current Procedural Terminology (CPT) code set and US Medicare and Medicaid Services (Medicare) regarding multiple physicians reporting critical care services during the global period. The article takes into account the critical care definitions, regulations, documentation requirements, and services each provider can report to Medicare. A clinical scenario based on literature supporting the types of complications and care that might typically be included in the post-operative period for a patient who is surgically treated for a type A aortic dissection was analyzed. It was determined that multiple physicians may provide critical care services to a single patient during the global period. The physician who performed the primary procedure cannot report critical care separately unless documentation supporting use of modifier 25 (significant, separately identifiable services) or 24 (unrelated services) supports that critical care is unrelated to the global period. Other physicians may report critical care services separately if specific criteria are met. To report critical care services to Medicare, the patient's condition must meet the Medicare definition of critical care and the physicians should generally represent different specialties providing different aspects of care to the critically ill or injured patient as defined by Medicare. There should be no overlap in time of services provided by each physician. Each physician's documentation should clearly support medical necessity with the diagnosis demonstrating the critical nature of the patients' illness, the total time spent providing critical care, the critical care service provided, and other contributing factors.
Asunto(s)
Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/terapia , Disección Aórtica/economía , Disección Aórtica/terapia , Cuidados Críticos/economía , Cuidados Críticos/organización & administración , Current Procedural Terminology , Documentación/normas , Medicare , Anciano , Servicios Médicos de Urgencia , Episodio de Atención , Humanos , Masculino , Medicare/economía , Enfermeras Practicantes/economía , Grupo de Atención al Paciente/economía , Grupo de Atención al Paciente/organización & administración , Asistentes Médicos/economía , Médicos/economía , Procedimientos Quirúrgicos Operativos/economía , Estados UnidosRESUMEN
OBJECTIVE: Endovascular treatment is increasingly used to treat complicated aortic pathology. The aim of the study was to assess if compared with operative repair, thoracic endovascular repair of aorta (TEVAR) was associated with a cost benefit in management of diseases affecting the descending thoracic aorta. We also compared early and mid-term outcomes between the two groups. METHODS: Clinical characteristics, outcomes and hospitalisation costs of 84 consecutive patients undergoing intervention for conditions affecting the descending thoracic aorta were reviewed retrospectively. Hospitalisation costs were calculated from National Health Service (NHS) reference costs for staff time, consumables, transfusion and length of stay. RESULTS: Apart from a higher frequency of acute type B dissection (16/45 vs 5/39, p = 0.047) in the TEVAR group, the baseline characteristics were similar. TEVAR was associated with significant reductions in morbidity (renal dysfunction 11 (31%) vs 5 (10%) p=0.025; in-hospital death 7 (20%) vs 3 (6%), p = 0.03; median intensive therapy unit (ITU) stay 6 (3-11) vs 1 (1-4), p < 0.0001). TEVAR was associated with significantly increased procedural costs (£2468 (2961) vs £9581 (11495) p ≤ 0.0001). This was chiefly attributable to the cost of endovascular stents. There was no significant difference in overall hospitalisation costs. TEVAR was associated with significantly lower freedom from death or re-operation (log rank p=0.048). CONCLUSIONS: TEVAR is associated with reduced morbidity and mortality in the short term. However, no cost benefit was seen with TEVAR even in the short term. In the long term, due to increased risk of re-interventions TEVAR may actually prove to be a more expensive therapeutic option.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/economía , Procedimientos Endovasculares/economía , Adulto , Anciano , Disección Aórtica/economía , Disección Aórtica/cirugía , Aneurisma de la Aorta Torácica/economía , Implantación de Prótesis Vascular/métodos , Análisis Costo-Beneficio , Procedimientos Endovasculares/métodos , Inglaterra , Femenino , Costos de Hospital/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Medicina Estatal/economía , Resultado del TratamientoRESUMEN
BACKGROUND: The use of stent grafts and mortality of stent graft repair of type B thoracic aortic dissection (T(B)AD) is not well defined. We sought to determine national estimates for the use and mortality of thoracic endovascular aortic repair (TEVAR) for T(B)AD in the United States. METHODS: Records of the Nationwide Inpatient Sample (NIS) database between 2005 and 2007 were examined. International Classification of Diseases, 9th edition (ICD-9) diagnosis codes were used to select patients who underwent open or TEVAR with a stent graft for a diagnosis of thoracic aortic dissection or thoracoabdominal aortic dissection. We excluded patients with a diagnosis code for aortic aneurysm and those with procedure codes for cardioplegia or for operations on heart vessels or valves, which were considered type A dissections (T(A)AD). The remaining patients were considered as T(B)AD. We compared demographics and comorbidities, as well as adjusted complications and mortality rates, between patients undergoing TEVAR vs open repair. RESULTS: We identified an estimated 10,466 repairs for dissection of the thoracic or thoracoabdominal aorta (open, 8659; TEVAR, 1818). Of these, 464 had a diagnosis of aortic aneurysm, and 5002 patients were considered T(A)AD. Of nonaneurysmal dissections, 5000 repairs were considered T(B)AD (open, 3619; TEVAR, 1381). The endovascular patients were older and had greater comorbidities, although only cardiac disease, renal failure, hypertension, and peripheral vascular disease were statistically significant. In-hospital mortality was 19% for open repair vs 10.6% for TEVAR (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.36-3.67; P < .01). In-hospital mortality was significantly higher with open repairs coded as emergent admissions (20.1% vs 13.1%; P = .03), but did not reach statistical significance for elective admissions (12.3% vs 4.8%; P = .09). Cardiac complications (12.4% vs 4.9%, P < .01), respiratory complications (7.7% vs 4.3%, P = .02), genitourinary complications (9.0% vs 2.5%, P < .01), hemorrhage (14.0% vs 2.8%, P < .01), and acute renal failure (32.1% vs 17.2%, P < .01) were more frequent in the open repair group. Median length of stay was greater in the open repair group (10.7 vs 8.3 days, P < .01). CONCLUSION: For patients with a diagnosis of T(B)AD who undergo repair, the endovascular approach is being used for older patients with greater comorbidities, yet has reduced morbidity and in-hospital mortality. The use of endovascular stent graft repair for type B thoracic aortic dissection merits further longitudinal analysis.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Pacientes Internos , Anciano , Disección Aórtica/economía , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/economía , Aneurisma de la Aorta Torácica/mortalidad , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/economía , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Bases de Datos como Asunto , Femenino , Costos de Hospital , Mortalidad Hospitalaria , Humanos , Pacientes Internos/estadística & datos numéricos , Tiempo de Internación , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Selección de Paciente , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: The traditional medical treatment for type B acute aortic dissection (AAD) is widely accepted, but the optimal clinical pathway has not been confirmed. Methods and Results From admissions over the past 12 years, 210 patients with uncomplicated type B AAD were divided into 2 groups: Conventional therapy group (CG) of 90 who were treated by 7 days of bed rest and intravenous antihypertensive agents and the Clinical pathway group (CPG) of 120 who were treated by early rehabilitation. In the CPG, patients were administered oral medication from the first day after onset and took a short walk from the third day after onset. The incidence of respiratory complications, and of delirium, was significantly decreased in the CPG. Early mortality was similar: 3.3% and 2.5%, respectively. The diameter of the aorta had not enlarged in either group 1 month later. Conclusions The clinical pathway of treatment for uncomplicated type B AAD was safer and better for preventing early complications and cost benefit.
Asunto(s)
Aneurisma de la Aorta/rehabilitación , Aneurisma de la Aorta/terapia , Disección Aórtica/rehabilitación , Disección Aórtica/terapia , Vías Clínicas , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/economía , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Aneurisma de la Aorta/economía , Bloqueadores de los Canales de Calcio/uso terapéutico , Análisis Costo-Beneficio , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , CaminataRESUMEN
PURPOSE: To report our experience using a commercially available catheter-based system equipped with an intravascular ultrasound (IVUS) transducer to achieve controlled true lumen re-entry in patients undergoing subintimal angioplasty for chronic total occlusions (CTO) or aortic dissections. METHODS: During an 8-month period, 10 patients (6 men; mean age 73.4 years) with lower extremity (LE) ischemia from CTOs (n=7) or true lumen collapse from aortic dissections (n=3) were treated. Subintimal access and controlled re-entry of the CTOs were performed with a commercially available 6.2-F dual-lumen catheter, which contained an integrated 64-element phased-array IVUS transducer and a deployable 24-G needle through which a guidewire was passed once the target lumen was reached. The occluded segments were balloon dilated; self-expanding nitinol stents were deployed. In the aortic dissections, fenestrations were performed using the same device, with the IVUS unit acting as the guide. The fenestrations were balloon dilated and stented to support the true lumen. RESULTS: Time to effective re-entry ranged from 6 to 10 minutes (mean 7) in the CTOs; antegrade flow was restored in all 7 CTOs, and the patients were free of ischemic symptoms at up to 8-month follow-up. In the aortic dissection cases, the fenestrations equalized pressures between the lumens and restored flow into the compromised vessels. There were no complications related to the use of this device in any of the 10 patients. CONCLUSIONS: Our preliminary results demonstrate the feasibility of using this catheter-based system for subintimal recanalization with controlled re-entry in CTOs and for aortic flap fenestrations in aortic dissections. This approach can improve the technical success rate, reduce the time of the procedure, and minimize potential complications.