Briget da Graca

Trends and comparison of female first authorship in high impact medical journals: observational study (1994-2014)

Objective To examine changes in representation of women among first authors of original research published in high impact general medical journals from 1994 to 2014 and investigate differences between journals. Design Observational study. Study sample All original research articles published in Annals of Internal Medicine, Archives of Internal Medicine, The BMJ, JAMA, The Lancet, and the New England Journal of Medicine (NEJM) for one issue every alternate month from February 1994 to June 2014. Main exposures Time and journal of publication. Main outcome measures Prevalence of female first authorship and its adjusted association with time of publication and journal, assessed using a multivariable logistic regression model that accounted for number of authors, study type and specialty/topic, continent where the study was conducted, and the interactions between journal and time of publication, study type, and continent. Estimates from this model were used to calculate adjusted odds ratios against the mean across the six journals, with 95% confidence intervals and P values to describe the associations of interest. Results The gender of the first author was determined for 3758 of the 3860 articles considered; 1273 (34%) were women. After adjustment, female first authorship increased significantly from 27% in 1994 to 37% in 2014 (P<0.001). The NEJM seemed to follow a different pattern, with female first authorship decreasing; it also seemed to decline in recent years in The BMJ but started substantially higher (approximately 40%), and The BMJ had the highest total proportion of female first authors. Compared with the mean across all six journals, first authors were significantly less likely to be female in the NEJM (adjusted odds ratio 0.68, 95% confidence interval 0.53 to 0.89) and significantly more likely to be female in The BMJ (1.30, 1.01 to 1.66) over the study period. Conclusions The representation of women among first authors of original research in high impact general medical journals was significantly higher in 2014 than 20 years ago, but it has plateaued in recent years and has declined in some journals. These results, along with the significant differences seen between journals, suggest that underrepresentation of research by women in high impact journals is still an important concern. The underlying causes need to be investigated to help to identify practices and strategies to increase women’s influence on and contributions to the evidence that will determine future healthcare policies and standards of clinical practice.

Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval.

OBJECTIVEnTo report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.nnnSTUDY SETTINGnRecords from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.nnnSTUDY DESIGNnWe examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.nnnDATA COLLECTIONnProfessional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs).nnnPRINCIPAL FINDINGSnEstimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were preventable/possibly preventable. Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were preventable/possibly preventable; the most common category was surgical/procedural (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs.nnnCONCLUSIONSnAEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

Consequences for Healthcare Quality and Research of the Exclusion of Records From the Death Master File

> In November 2011, the Social Security Administration removed ≈5% of death records from its Death Master File and started excluding ≈40% of new death records, having determined that data submitted electronically by states cannot be publicly shared. Before this determination, the Death Master File provided an accessible source of national vital status data with a short time lag and high specificity and sensitivity and was routinely used by healthcare researchers and hospitals to determine study participants’ survival and to monitor postdischarge outcomes. Its effective loss means comparative effectiveness studies will be unnecessarily delayed, more costly, or unfeasible. Likewise, timely identification and correction of poor hospital performance will be more difficult, undermining the safety and quality of care and threatening hospital financing as the Centers for Medicare and Medicaid launch the Readmissions Reduction Program in October 2012 and link reimbursement to 30-day mortality under the Value-Based Purchasing Program in 2013. In summary, the action of the Social Security Administration will substantially hamper healthcare research and quality. We describe the origins of the Death Master File and the basis for excluding electronically submitted state data. We then examine the consequences for healthcare research and operations, consider alternative sources, and evaluate possible mechanisms to restore a timely national data source. nnOn November 1, 2011, the Social Security Administration (SSA) removed ≈5% of the data in its publicly available Death Master File (DMF) and stopped reporting ≈40% of new deaths.1 The SSA explained that it had determined that §205(r) of the Social Security Act (added by the Act of April 20, 1983)2 prohibits the disclosure of state records that the SSA has been including in the public version of the DMF since 2002.1 This is a “demise of a vital resource”3 that will hamper healthcare outcomes research, as well as …

Underestimation of the incidence of new-onset post–coronary artery bypass grafting atrial fibrillation and its impact on 30-day mortality

Objective: Inconsistent definitions of atrial fibrillation after coronary artery bypass grafting have caused uncertainty about its incidence and risk. We examined the extent to which limiting the definition to post–coronary artery bypass grafting atrial fibrillation events requiring treatment underestimates its incidence and impact on 30‐day mortality. Methods: We assessed in‐hospital atrial fibrillation and 30‐day mortality in 9268 consecutive patients without preoperative atrial fibrillation who underwent isolated coronary artery bypass grafting at 5 US hospitals (2004‐2010). Patients who experienced 1 or more episode of post–coronary artery bypass grafting atrial fibrillation detected via continuous in‐hospital electrocardiogram/telemetry monitoring were divided into those for whom Society of Thoracic Surgeons data (applying the definition “atrial fibrillation/flutter requiring treatment”) also indicated atrial fibrillation versus those for whom it did not. Risk‐adjusted 30‐day mortality was compared between these 2 groups and with patients without post–coronary artery bypass grafting atrial fibrillation. Results: Risk‐adjusted incidence of post–coronary artery bypass grafting atrial fibrillation incidence was 33.4% (27.0% recorded in Society of Thoracic Surgeons data, 6.4% missed). Patients with post–coronary artery bypass grafting atrial fibrillation missed by Society of Thoracic Surgeons data had a significantly greater risk of 30‐day mortality (odds ratio, 2.08, 95% confidence interval, 1.17‐3.69) than those captured. By applying the significant underestimation of post–coronary artery bypass grafting atrial fibrillation incidence we observed (odds ratio [Society of Thoracic Surgeons vs missed], 0.78; 95% confidence interval, 0.72‐0.83) to the approximately 150,000 patients undergoing isolated coronary artery bypass grafting in the United States each year estimates this increased risk of mortality is carried by 9600 patients (95% confidence interval, 9420‐9780) annually. Conclusions: Defining post–coronary artery bypass grafting atrial fibrillation as episodes requiring treatment significantly underestimates incidence and misses patients at a significantly increased risk for mortality. Further research is needed to determine whether this increased risk carries over into long‐term outcomes and whether it is mediated by differences in treatment and management.

Effect of Gender and Race on Operative Mortality After Isolated Coronary Artery Bypass Grafting

Studies examining outcomes after coronary artery bypass grafting (CABG) by gender and/or race have shown conflicting results. It remains to be determined if, or how, gender and race are independent risk factors for CABG operative mortality. Using all consecutive patients who underwent isolated CABG at Baylor University Medical Center in Dallas, Texas, from January 2004 to October 2011, the risk-adjusted associations between gender and race, respectively, and operative mortality were estimated using a generalized propensity approach, accounting for recognized Society of Thoracic Surgeons risk factors for mortality. Women were nearly 2 times more likely to die during or within 30 days of the operation than men (odds ratio 1.96, 95% confidence interval 1.44 to 2.66, p <0.0001), while no significant mortality differences were observed among races. In conclusion, these findings suggest that women face a significantly greater risk for operative death that should be taken into account during the treatment decision-making process but that race is not associated with CABG mortality and so should not be among the factors considered.

Clinical practice change requires more than comparative effectiveness evidence: abdominal aortic aneurysm management in the USA.

Adoption of healthcare innovations frequently outpaces the evidence of effectiveness. Endovascular repair (EVAR) for abdominal aortic aneurysms in the USA demonstrates how comparative effectiveness research without evidence-based reimbursement changes may fail to influence clinical practice. Randomized controlled trials for small abdominal aortic aneurysms demonstrate no lasting benefits of EVAR or open surgical repair (OSR) compared with surveillance, and for large abdominal aortic aneurysms demonstrate no lasting survival benefit of EVAR over OSR, and do show poorer durability and higher costs for EVAR. Nonetheless, >50% of elective abdominal aortic aneurysm repairs in the USA use EVAR. Factors that may be driving the high use of EVAR include patient preference, surgeons desire to appear up-to-date in the procedures they offer, higher hourly surgeon reimbursement for EVAR than OSR, and the expansion of physician specialties able to perform abdominal aortic aneurysm repair from only vascular surgeons with OSR, to vascular surgeons and interventional radiologists/cardiologists with EVAR. By comparison, in Canada, where government health insurance restricts EVAR coverage to high surgical risk patients, only approximately 25% of abdominal aortic aneurysm repairs are performed using EVAR. Country-specific cost studies and a prospective population-based study collecting detailed clinical data to identify patient subgroups that truly benefit from a particular management strategy are needed to inform policy regarding EVAR availability and reimbursement.

Excess short-term mortality in women after isolated coronary artery bypass graft surgery

Objective Female sex is considered a risk factor for adverse outcomes following isolated coronary artery bypass graft (CABG) surgery. We assessed the association between sex and short-term mortality following isolated CABG, and estimated the ‘excess’ deaths occurring in women. Methods Short-term mortality was investigated in 13u2005327 consecutive isolated CABG patients in North Texas between January 2008 and December 2012. The association between sex and CABG short-term mortality, and the excess deaths among women were assessed via a propensity-adjusted (by Society of Thoracic Surgeons-recognised risk factors) generalised estimating equations model approach. Results Short-term mortality was significantly higher in women than men (adjusted OR=1.39; 95% CI 1.04 to 1.86; p=0.027). This significantly greater risk translates into 35 ‘excess’ deaths among women included in this study (>10% of the total 343 deaths in the study cohort) and into 392 ‘excess’ deaths among the ∼40u2005000 women undergoing isolated CABG in the USA each year. Conclusions The higher risk associated with female sex lead to 35 ‘excess’ deaths in women in this study cohort (over 10% of the total deaths) and to 392 ‘excess’ deaths among women undergoing isolated CABG in the USA each year. Further research is needed to assess the causal mechanisms underlying this sex-related difference. Results of such work could inform the development and implementation of sex-specific treatment and management strategies to reduce womens mortality following CABG. Based on our results, if such work brought womens short-term mortality into line with mens, total short-term mortality could be reduced by up to 10%.

Sex Differences in the Epidemiology of New-Onset In-Hospital Post–Coronary Artery Bypass Graft Surgery Atrial Fibrillation: A Large Multicenter Study

Background—New-onset atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG) is associated with increased morbidity and poorer long-term survival. Although many studies show differences in outcome in women versus men after CABG, little is known about the sex-specific incidence and characteristics of post-CABG AF. Methods and Results—Overall, 11u2009236 consecutive patients without preoperative AF underwent isolated CABG from 2002 to 2010 at 4 US academic medical centers and 1 high-volume specialty cardiac hospital. Data routinely collected for the Society of Thoracic Surgeons database were augmented with details on new-onset post-CABG AF events detected via continuous in-hospital ECG/telemetry monitoring. Unadjusted incidence of post-CABG AF was 29.5% (3312/11u2009236) overall, 30.2% (2485/8214) in men, and 27.4% (827/3022) in women. After adjustment for Society of Thoracic Surgeons–recognized risk factors, women had significantly lower risk for post-CABG AF (odds ratio [95% confidence interval]=0.75 [0.64–0.89]), shorter first, longest, and total duration of AF episodes (mean difference [95% confidence interval]=−2.7 [−4.7 to −0.8] hours; −4.1 [−6.9 to −1.2] hours; −2.4 [−2.5 to −2.3] hours, respectively). At 48 hours, AF-free probabilities were 77% for women and 72% for men (P<0.001). Number of episodes (P=0.18), operative mortality (P=0.048), stroke (P=0.126), and discharge in AF (P=0.234) did not differ significantly by sex. Conclusions—These novel data on sex-specific characteristics of new-onset AF after isolated CABG show that women had lower adjusted risk for post-CABG AF and experienced shorter episodes. Investigation of sex-specific impacts on outcomes is needed to identify optimal strategies for prevention and management to ensure all patients achieve the best possible outcomes.

Effect of Age on Survival Between Open Repair and Surveillance for Small Abdominal Aortic Aneurysms

Randomized controlled trials have shown no significant difference in survival between immediate open repair and surveillance with selective repair for asymptomatic abdominal aortic aneurysms of 4.0 to 5.5 cm in diameter. This lack of difference has been shown to hold true for all diameters in this range, in men and women, but the question of whether patients of different ages might obtain different benefits has remained unanswered. Using the pooled patient-level data for the 2,226 patients randomized to immediate open repair or surveillance in the United Kingdom Small Aneurysm Trial (UKSAT; September 1, 1991, to July 31, 1998; follow-up 2.6 to 6.9 years) or the Aneurysm Detection and Management (ADAM) trial (August 1, 1992, to July 31, 2000; follow-up 3.5 to 8.0 years), the adjusted effect of age on survival in the 2 treatment groups was estimated using a generalized propensity approach, accounting for a comprehensive array of clinical and nonclinical risk factors. No significant difference in survival between immediate open repair and surveillance was observed for patients of any age, overall (p = 0.606) or in men (p = 0.371) or women separately (p = 0.167). In conclusion, survival did not differ significantly between immediate open repair and surveillance for patients of any age, overall or in men or women. Combined with the previous evidence regarding diameter, and the lack of benefit of immediate endovascular in trials comparing it with surveillance repair for small abdominal aortic aneurysms, these results suggest that surveillance should be the first-line management strategy of choice for asymptomatic abdominal aortic aneurysms of 4.0 to 5.5 cm.

Predicting New-Onset Post-Coronary Artery Bypass Graft Atrial Fibrillation With Existing Risk Scores

BACKGROUNDnNew-onset atrial fibrillation (AF) after coronary artery bypass graft (CABG) operation is associated with poorer survival. Blanket prophylaxis efforts have not appreciably decreased incidence, making targeted prevention for high-risk patients desirable. We compared predictive abilities of existing scores developed/used to predict adverse CABG outcomes (Society of Thoracic Surgeons [STS] risk of mortality) or AF not associated with cardiac operation (the Cohorts for Heart and Aging Research in Genomic Epidemiology [CHARGE]-AF score, the CHA2DS2-VASc score), and a risk model for predicting postoperative AF following cardiac operations (POAF score), with age (the most consistently identified post-CABG AF risk factor).nnnMETHODSnData submitted to the STS Adult Cardiac Surgery Database were used to assess new-onset AF in 8,976 consecutive patients without preoperative AF undergoing isolated CABG from 2004 to 2010 at five participating centers. Five logistic regression models (for CHA2DS2-VASc score, CHARGE-AF score, POAF score, STS risk score, and age, respectively, all modeled with restricted cubic splines) with a random effect for site were fitted to predict post-CABG AF. Estimates were used to compute and compare receiver operating characteristic (ROC) areas.nnnRESULTSnNew-onset AF occurred in 2,141 patients (23.9%). The ROC area was greatest for CHARGE-AF (0.68, 95% confidence interval [CI]: 0.67-0.69), followed by age (0.66, 95% CI: 0.65-0.68), POAF score (0.65, 95% CI: 0.64-0.66), CHA2DS2-VASc (0.59, 95% CI: 0.58 to 0.60), and STS risk of mortality (0.58, 95% CI: 0.56-0.59). CHARGE-AF was significantly more predictive than age (p < 0.0001); the other scores were significantly less predictive (p < 0.0001).nnnCONCLUSIONSnOnly CHARGE-AF performed better than age alone. Its performance was moderate and comparable with published risk models specifically targeted at new-onset post-isolated CABG AF. Future research should continue to focus on developing better predictive models.