Natalia N. Egorova

Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals.

BACKGROUND Abdominal aortic aneurysm (AAA) disease is an insidious condition with an 85% chance of death after rupture. Ultrasound screening can reduce mortality, but its use is advocated only for a limited subset of the population at risk. METHODS We used data from a retrospective cohort of 3.1 million patients who completed a medical and lifestyle questionnaire and were evaluated by ultrasound imaging for the presence of AAA by Life Line Screening in 2003 to 2008. Risk factors associated with AAA were identified using multivariable logistic regression analysis. RESULTS We observed a positive association with increasing years of smoking and cigarettes smoked and a negative association with smoking cessation. Excess weight was associated with increased risk, whereas exercise and consumption of nuts, vegetables, and fruits were associated with reduced risk. Blacks, Hispanics, and Asians had lower risk of AAA than whites and Native Americans. Well-known risk factors were reaffirmed, including male gender, age, family history, and cardiovascular disease. A predictive scoring system was created that identifies aneurysms more efficiently than current criteria and includes women, nonsmokers, and individuals aged <65 years. Using this model on national statistics of risk factors prevalence, we estimated 1.1 million AAAs in the United States, of which 569,000 are among women, nonsmokers, and individuals aged <65 years. CONCLUSIONS Smoking cessation and a healthy lifestyle are associated with lower risk of AAA. We estimated that about half of the patients with AAA disease are not eligible for screening under current guidelines. We have created a high-yield screening algorithm that expands the target population for screening by including at-risk individuals not identified with existing screening criteria.

National Trends in Rotator Cuff Repair

BACKGROUND Recent publications suggest that arthroscopic and open rotator cuff repairs have had comparable clinical results, although each technique has distinct advantages and disadvantages. National hospital and ambulatory surgery databases were reviewed to identify practice patterns for rotator cuff repair. METHODS The rates of medical visits for rotator cuff pathology, and the rates of open and arthroscopic rotator cuff repair, were examined for the years 1996 and 2006 in the United States. The national incidence of rotator cuff repairs and related data were obtained from inpatient (National Hospital Discharge Survey, NHDS) and ambulatory surgery (National Survey of Ambulatory Surgery, NSAS) databases. These databases were queried with use of International Classification of Diseases, Ninth Revision (ICD-9) procedure codes for arthroscopic (ICD-9 codes 83.63 and 80.21) and open (code 83.63 without code 80.21) rotator cuff repair. We also examined where the surgery was performed (inpatient versus ambulatory surgery center) and characteristics of the patients, including age, sex, and comorbidities. RESULTS The unadjusted volume of all rotator cuff repairs increased 141% in the decade from 1996 to 2006. The unadjusted number of arthroscopic procedures increased by 600% while open repairs increased by only 34% during this time interval. There was a significant shift from inpatient to outpatient surgery (p < 0.001). CONCLUSIONS The increase in national rates of rotator cuff repair over the last decade has been dramatic, particularly for arthroscopic assisted repair.

Managing the Prevention of Retained Surgical Instruments: What Is the Value of Counting?

Objective:Preventing retained foreign bodies is critical for patient safety. However, the value of counting surgical instruments and the reliability of the information provided have never been quantified. This study examines the diagnostic characteristics of counting and its impact on surgical costs. Methods:We examined data from the Medical Event Reporting System-Total HealthSystem (MERS-TH), administrative hospital, and the New York State Cardiac Surgery Report databases (2000–2004). The cost per count discrepancy was examined by studying a cohort of patients undergoing coronary artery bypass graft (CABG) surgery. Linear and logistic multivariable regression models were used for statistical analysis. Results:Of 153,263 operations, there were 1062 count discrepancies. The rate of retained items was 1 of 7000 surgeries or 1 of 70 discrepancy cases. Final count discrepancies identified 77% and prevented 54% of retained items. The sensitivity of counting was 77.2%, specificity was 99.2%, but the positive predictive value was only 1.6%. Count discrepancies increased with surgery duration, late time procedures, and number of nursing teams. Bypass time, intravenous nitroglycerin injections, or myocardial infarction in the previous 24 hours were independent predictors of count discrepancies in CABG surgery. The incremental OR cost for CABG because of a count discrepancy was

National outcomes for the treatment of ruptured abdominal aortic aneurysm: Comparison of open versus endovascular repairs

932. Nationally, this would amount to an additional

An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety

24 million/yr in OR CABG cost. Conclusions:This study, for the first time, quantifies the diagnostic accuracy of counting and defines the parameters against which alternative strategies of prevention should be measured, before being adopted in standard practice.

Survival and Long-term Outcomes Following Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients Aged 50 to 69 Years

OBJECTIVES Endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA) has been shown to acutely decrease procedural mortality compared to open aortic repair (OAR). However, little is known about the effect of choice of procedure; EVAR vs OAR, or the impact of physician and institution volume on long-term survival and outcome. METHODS Patients hospitalized with rAAA who underwent either OAR or EVAR, were derived from the Medicare inpatient dataset (1995-2004) using ICD9 codes. We evaluated long-term survival after OAR and EVAR in the entire fee-for-service Medicare population, and then in patients matched by propensity score to create two similar cohorts for comparison with Kaplan-Meier analysis. Annual surgeon and hospital volumes of EVAR (elective and ruptured), OAR (elective and ruptured), and rAAA (EVAR and OAR) were divided into quintiles to determine if increasing volumes correlate with decreasing mortality. Predictors of survival were determined by Cox modeling. RESULTS A total of 43,033 Medicare beneficiaries had rAAA repair: 41,969 had OAR and 1,064 had EVAR. The proportions of patients with diabetes, hypertension, cardiovascular, cerebrovascular, renal disease, hyperlipidemia, and cancer were statistically higher in the EVAR than in the OAR group, whereas lower extremity vascular disease was higher in the OAR group. The initial evaluation of EVAR vs OAR, prior to propensity matching, showed no statistical advantage in EVAR-survival after 90 days. The survival analysis of patients matched by propensity score showed a benefit of EVAR over OAR that persisted throughout the 4 years of follow-up (P = .0042). Perioperative and long-term survival after rAAA repair correlated with increasing annual surgeon and hospital volume in OAR and EVAR and also with rAAA experience. EVAR repair had a protective effect (HR = 0.857, P = .0061) on long-term survival controlling for comorbidities, demographics, and hospital and surgeon volume. CONCLUSION When EVAR and OAR patients are compared using a reliable statistical technique such as propensity analysis, the perioperative survival advantage of rAAA repaired endovascularly is maintained over the long term. Institutional experience with rAAA is critical for survival after either OAR or EVAR.

Effect of gender on long-term survival after abdominal aortic aneurysm repair based on results from the Medicare national database

BACKGROUND Demographic and practice modality changes during the past decade have led to a substantial shift in the management of peripheral vascular disease. This study examined the effect of these changes using large national and regional data sets on procedure type, indications, morbidity, and on the primary target outcome: limb salvage. METHODS National Inpatient Sample (NIS) data sets and New York (NY) State inpatient hospitalizations and outpatient surgeries discharge databases from 1998 through 2007 were used to identify hospitalizations for lower extremity revascularization (LER) and major amputations. Patients were selected by cross-referencing diagnostic and procedural codes. Proportions were analyzed by chi(2) analysis, continuous variables by t test, and trends by the Poisson regression. RESULTS The national per capita (100,000 population, age >40 years) volume of major amputations decreased by 38%. The volume for national and regional use of endovascular LER doubled. The volume of open LER decreased by 67% from 1998 through 2007. Ambulatory endovascular LER grew in NY State from 7 per capita in 1998 to 22 in 2007. Interventions declined by 20% (93 to 75) for critical limb ischemia (CLI) but increased by nearly 50% for claudication. Outpatient data analysis revealed a fivefold increase in vascular interventions for CLI and claudication. Nationally, endovascular LER interventions quadrupled (8% to 32%) for CLI and doubled (26% to 61%) for claudication. A parallel reduction occurred in major amputations for patients with CLI (42% to 30%), for other PAD diagnoses (18% to 14%), and for claudication (0.9% to 0.3%). Although surgical interventions for CLI declined significantly for octogenarians from 317 to 240, outpatient interventions increased for CLI, claudication, and other diagnoses in all age groups. Comorbidities for patients treated in 2006 were substantially greater than those of a decade ago. For most procedures, cardiac and bleeding complications have significantly decreased during the last decade. Length of stay (LOS) declined from 9.5 to 7.6 days and the percentage of short (1-2 day) hospitalizations increased from 16% to 35%. CONCLUSION Although patients today, whether treated for claudication or CLI, have more comorbidities, the rates of amputation, the procedural morbidity and mortality, and LOS have all significantly decreased. Other variables, including changes in medical management and wound care, undoubtedly are important, but this change appears to be largely due to the widespread and successful use of endovascular LER or to earlier intervention, or both, driven by the safety of these techniques.

Analysis of gender-related differences in lower extremity peripheral arterial disease

IMPORTANCE The choice between bioprosthetic and mechanical aortic valve replacement in younger patients is controversial because long-term survival and major morbidity are poorly characterized. OBJECTIVE To quantify survival and major morbidity in patients aged 50 to 69 years undergoing aortic valve replacement. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort analysis of 4253 patients aged 50 to 69 years who underwent primary isolated aortic valve replacement using bioprosthetic vs mechanical valves in New York State from 1997 through 2004, identified using the Statewide Planning and Research Cooperative System. Median follow-up time was 10.8 years (range, 0 to 16.9 years); the last follow-up date for mortality was November 30, 2013. Propensity matching yielded 1001 patient pairs. MAIN OUTCOMES AND MEASURES Primary outcome was all-cause mortality; secondary outcomes were stroke, reoperation, and major bleeding. RESULTS No differences in survival or stroke rates were observed in patients with bioprosthetic compared with mechanical valves. Actuarial 15-year survival was 60.6% (95% CI, 56.3%-64.9%) in the bioprosthesis group compared with 62.1% (95% CI, 58.2%-66.0%) in the mechanical prosthesis group (hazard ratio, 0.97 [95% CI, 0.83-1.14]). The 15-year cumulative incidence of stroke was 7.7% (95% CI, 5.7%-9.7%) in the bioprosthesis group and 8.6% (95% CI, 6.2%-11.0%) in the mechanical prosthesis group (hazard ratio, 1.04 [95% CI, 0.75-1.43). The 15-year cumulative incidence of reoperation was higher in the bioprosthesis group (12.1% [95% CI, 8.8%-15.4%] vs 6.9% [95% CI, 4.2%-9.6%]; hazard ratio, 0.52 [95% CI, 0.36-0.75]). The 15-year cumulative incidence of major bleeding was higher in the mechanical prosthesis group (13.0% [95% CI, 9.9%-16.1%] vs 6.6% [95% CI, 4.8%-8.4%]; hazard ratio, 1.75 [95% CI, 1.27-2.43]). The 30-day mortality rate was 18.7% after stroke, 9.0% after reoperation, and 13.2% after major bleeding. CONCLUSIONS AND RELEVANCE Among propensity-matched patients aged 50 to 69 years who underwent aortic valve replacement with bioprosthetic compared with mechanical valves, there was no significant difference in 15-year survival or stroke. Patients in the bioprosthetic valve group had a greater likelihood of reoperation but a lower likelihood of major bleeding. These findings suggest that bioprosthetic valves may be a reasonable choice in patients aged 50 to 69 years.

Defining high-risk patients for endovascular aneurysm repair

OBJECTIVES Historically, women have higher procedurally related mortality rates than men for abdominal aortic aneurysm (AAA) repair. Although endovascular aneurysm repair (EVAR) has improved these rates for men and women, effects of gender on long-term survival with different types of AAA repair, such as EVAR vs open aneurysm repair (OAR), need further investigation. To address this issue, we analyzed survival in matched cohorts who received EVAR or OAR for both elective (eAAA) and ruptured AAA (rAAA). METHODS Using the Medicare Beneficiary Database (1995-2006), we compiled a cohort of patients who underwent OAR or EVAR for eAAA (n = 322,892) or rAAA (n = 48,865). Men and women were matched by propensity scores, accounting for baseline demographics, comorbid conditions, treating institution, and surgeon experience. Frailty models were used to compare long-term survival of the matched groups. RESULTS Perioperative mortality for eAAAs was significantly lower among EVAR vs OAR recipients for both men (1.84% vs 4.80%) and women (3.19% vs 6.37%, P < .0001). One difference, however, was that the survival benefit of EVAR was sustained for the 6 years of follow-up in women but disappeared in 2 years in men. Similarly, the survival benefit of men vs women after elective EVAR disappeared after 1.5 to 2 years. For rAAAs, 30-day mortality was significantly lower for EVAR recipients compared with OAR recipients, for both men (33.43% vs 43.70% P < .0001) and women (41.01% vs 48.28%, P = .0201). Six-year survival was significantly higher for men who received EVAR vs those who received OAR (P = .001). However, the survival benefit for women who received EVAR compared with OAR disappeared in 6 months. Survival was also substantially higher for men than women after emergent EVAR (P = .0007). CONCLUSIONS Gender disparity is evident from long-term outcomes after AAA repair. In the case for rAAA, where the long-term outcome for women was significantly worse than for men, the less invasive EVAR treatment did not appear to benefit women to the same extent that it did for men. Although the long-term outcome after open repair for elective AAA was also worse for women, EVAR benefit for women was sustained longer than for men. These associations require further study to isolate specific risk factors that would be potential targets for improving AAA management.

National trends in the repair of ruptured abdominal aortic aneurysms

INTRODUCTION Gender-related differences continue to challenge the management of lower extremity (LE) peripheral arterial disease (PAD) in women. We analyzed the time-trends in hospital care of such differences. METHODS Data for patients with PAD from New York, New Jersey, and Florida state hospital inpatient discharge databases (1998-2007) were analyzed using univariate and multivariate regression analyses. RESULTS The 2.4 million PAD-related inpatient discharge records analyzed showed a slight decrease of inpatient procedures for both genders. Compared with men, women had 18% to 27% fewer PAD and 33% to 49% fewer vascular procedural hospitalizations (P < .0001). They were persistently more likely than men to be admitted emergently (56% vs 51% in 1998 and 57% vs 53% in 2007) and discharged to a nursing home. During the study period, the amputation rate declined by 36% in women and 21% in men with PAD, and similarly, open procedures decreased by 36% and 30%. Endovascular procedures, however, increased by 150% in women and 144% in men. Procedural mortality was 4.95% vs 4.37% for men (P < .0001). Female mortality rates were persistently higher after amputations (9.89% vs 8.90%, P < .0001), open (5.49% vs 4.00%, P < .0001), and endovascular procedures (2.87% vs 2.10%, P < .0001). Time trends showed improved mortality for men and women, with a stable difference between the two. CONCLUSION The analysis of representative state administrative databases of inpatient care records demonstrated improvements in mortality and amputation rates over time. However, a gender-related disparity in PAD outcomes remains that merits further investigation.