Norbert Roeder

Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence

AIMS Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and outcomes should be assessed. METHODS AND RESULTS From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41 882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21 197), 4 (n = 5353), 5 (n = 6916), and 6 (n = 8416). The proportions of patients with classical risk factors such as hypertension, dyslipidaemia, and smoking declined with higher Rutherford categories (each P < 0.001) while diabetes, chronic kidney disease, and chronic heart failure increased (each P < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each P < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each P < 0.001). Among 4298 amputated patients with CLI, 37% had not received any angiography or revascularization neither during index hospitalization nor the 24 months before. During follow-up (mean 1144 days), 7825 patients were amputated and 10 880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each P < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1days, 15.2 ± 13.8 days and 22.1 ± 20.3 days; P < 0.001) and mean case costs (3662 ± 3186 €, 5316 ± 6139 €, 6021 ± 4892 €, and 8461 ± 8515 €; P < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €). CONCLUSION Regardless of recent advances in PAD treatment, current outcomes remain poor especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations.

Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis

AIMS The prevalence of peripheral arterial disease (PAD) and especially of critical limb ischaemia (CLI) is announced to rise dramatically worldwide, with a considerable impact on the health care and socio-economic systems. We aimed to characterize the recent trends in morbidity and in-hospital outcome of PAD among all hospitalized patients in the entire German population between 2005 and 2009. METHODS AND RESULTS Nationwide data of all hospitalizations in Germany in 2005, 2007, and 2009 were analysed regarding the prevalence of PAD, comorbidities, endovascular (EVR) and surgical revascularizations (SR), major and minor amputations, in-hospital mortality, and associated costs. From 2005 to 2009, total PAD cases increased by 20.7% (from 400 928 to 483 961), with an increase of CLI subset from 40.6 to 43.5%. Total EVR increased by 46%, while thromb-embolectomy, endarterectomy, and patch plastic increased by 67, 42, and 21%, respectively. Peripheral bypasses decreased by 2%. Major amputation decreased from 4.6 to 3.5%, while minor amputation slightly increased from 4.98 to 5.11%. The crude overall in-hospital mortality remained unchanged in claudicants (2.2%), while it decreased from 9.8 to 8.4% in CLI patients. However, mortality rate according to the Poisson model (n/1000 hospital residence days) increased significantly in claudicants (P < 0.001). Total reimbursement costs for PAD in-patient care increased by 21% with an average per case costs in 2009 of €4506 in a claudicant and €6791 in a CLI patient. CONCLUSION This population-based analysis documents the significant rise of PAD, particularly of the CLI subset, and highlights the malign prognosis associated with PAD as indicated by high amputation and in-hospital mortality rates.

Emergency coronary artery bypass grafting after failed coronary angioplasty: what has changed in a decade?

BACKGROUND We assessed the impact of patient and procedural characteristics on the outcome after emergency coronary artery bypass grafting (CABG) for failed percutaneous transluminal coronary angioplasty (PTCA) and temporal changes in these factors. METHODS Patients who underwent PTCA and subsequent emergency CABG were identified from the databases of the Departments of Cardiology and Cardiothoracic Surgery. RESULTS Two periods of clinical practice were compared. In 1989 to 1993, 2,880 PTCAs were performed, 64 patients underwent emergency CABG (2.3%), and 7 patients died (10.9%). During 1994 to 1998, 46 patients of 3,801 PTCAs underwent emergency CABG (1.2%, p < 0.01), and 7 patients died (15.2%, NS). The average rate of stenting increased from 0.8% to 24% in 1994 to 1998 as well as the frequency of arterial bypass grafts (0% vs 39%). In the latter period, patients were older, were more often females, had more cardiovascular risk factors, a higher Cleveland score (each p < 0.05), and suffered more often from periprocedural myocardial infarctions (p < 0.001) and nonfatal periprocedural complications (p < 0.01). CONCLUSIONS Although the frequency of emergency CABG after failed PTCA declined, perioperative mortality tended to increase according to an unfavorable shift in patient risk factors and morbidity.

In vitro testing of bioprostheses: influence of mechanical stresses and lipids on calcification

BACKGROUND Structural valve deterioration of bioprostheses is mainly caused by the progressive development of calcification. Mechanical stresses or lipid deposits in porcine aortic leaflets have been proposed as major factors contributing to the calcification process. METHODS A new test protocol consisting of nondestructive holographic interferometry, which allows a quantitative deformation analysis of heart valves, and accelerated dynamic in vitro calcification was used. The rapid calcification fluid contained a final combined calcium and phosphorus concentration of 130 (mg/dL)2 in barbital buffer solution. The calcification of 32 bioprostheses donated by different manufacturers (SJM Bioimplant, Biocor standard, Biocor No-React, Carpentier-Edwards SAV, Bravo, pericardial prototype) was assessed after up to 25 x 10(6) cycles by microradiography and the areas of calcification were compared with the holographic interferograms. The distribution of lipid droplets of four porcine prostheses were visualized by Sudan III stain before the calcification process. RESULTS Most of the tested bioprostheses had areas presenting with stress concentrations, and the dynamic in vitro testing resulted in leaflet calcification corresponding to the holographic irregularities. A strong correlation between calcification and stress distribution or lipid accumulation was found (r = 0.72; r = 0.81, respectively). After 19 x 10(6) cycles, the Carpentier-Edwards SAV and the pericardial valves had significantly less calcification than other prostheses tested (p = 0.003), but the variation among individual prostheses from the same manufacturer was even more pronounced. CONCLUSIONS Mechanical stresses or lipid accumulation seems to play an important role in the calcification process of bioprostheses. Quality control of bioprosthetic valves using holographic interferometry has the potential to predict calcification before implantation.

Heart transplant candidates at high risk can be identified at the time of initial evaluation

The increasing discrepancy between the numbers of patients selected for cardiac transplantation and the available donor organs requires validation of markers of high risk at the time of initial evaluation that may help to determine which patients profit from aggressive therapy. We retrospectively examined the case records of 91 heart transplant caddidates selected out of a total of 140 consecutive patients referred for evaluation. Of these 91 patients, 48 were transplanted during follow-up. Of the remaining 43 patients, 25 died after a mean survival time of 1.6±2.5 months. The causes of death were pump failure in 18 (72%) and sudden cardiac death in 7 (28%). Multivariate analysis identified 4 out of 26 parameters at initial evaluation that distinguished the 25 nonsurvivors from the 18 survivors. These were: mean arterial pressure (P=0.03), pulmonary capillary wedge pressure (P=0.002), mean pulmonary artery pressure (P=0.007). The mode of death could not be predicted. We conclude that there are prognostic markers at initial evaluation that allow more restrictive selection of patients for cardiac transplantation and mechanical bridging.

Case mix measures and diagnosis‐related groups: opportunities and threats for inpatient dermatology

Objective  The changing healthcare environment world‐wide is leading to extensive use of per case payment systems based on diagnosis‐related groups (DRG). The aim of this study was to examine the impact of application of different DRG systems used in the German healthcare system.

DRGs in der Dermatologie: Ergebnisse des DRG‐Evaluationsprojektes der Deutschen Dermatologischen Gesellschaft

Hintergrund: Die Einführung des DRG‐Systems in Deutschland optional ab dem 1. 1. 2003 und für alle Krankenhäuser verpflichtend ab dem 1. 1. 2004 hat zu einer großen Verunsicherung v. a. auf der Krankenhausseite geführt, da befürchtet wird, daß die in Deutschland praktizierten diagnostischen und therapeutischen Maßnahmen sich nicht sachgerecht mit einem DRG‐System abbilden und vergüten lassen. Daher hat die Deutsche Dermatologische Gesellschaft ein DRG‐Evaluationsprojekt in Zusammenarbeit mit der DRG‐Research‐Group des Universitätsklinikums Münster und der Bundesärztekammer mit dem Ziel durchgeführt, die medizinische und ökonomische Homogenität der Fallgruppen zu überprüfen.

G‐DRG Version 2004: Veränderungen aus Sicht der Dermatologie

Die Finanzierung der stationären Krankenhausleistungen über ein DRG‐basiertes Vergütungssystem wird ab 2004 für alle Krankenhäuser verpflichtend eingeführt. Nachdem mit der Krankenhausfallpauschalenverordnung 2004 (KFPV 2004) die zentralen Punkte der G‐DRG‐Systemversion bekannt geworden sind, stellt sich die Frage nach den Konsequenzen. Festzustellen ist, daß der erste deutsche DRG‐Fallpauschalenkatalog sich sehr deutlich von dem bisherigen Optionskatalog unterscheidet, so daß eine intensive Auseinandersetzung mit den neuen Bedingungen erforderlich wird. Medizinökonomisches Handeln wird stärker als bisher den Krankenhausalltag prägen und Einfluß nehmen auf sich verändernde Versorgungsstrukturen. Die wesentlichen Grundlagen und die Anwendung der neuen Bestimmungen müssen deshalb bekannt sein. Neben den allgemeinen Abrechnungsregeln werden vor allem die Veränderungen im neuen Fallpauschalenkatalog erläutert und Auswirkungen für die Dermatologie beispielhaft beleuchtet. Weiterhin müssen die Klassifikationssysteme in den Versionen OPS‐301 SGB V und ICD‐10‐GM 2004 sowie die Deutschen Kodierrichtlinien Version 2004 Berücksichtigung finden. Daher werden ebenso die wesentlichen Neuerungen im Verwendungszusammenhang für die Dermatologie vorgestellt.

CKD and Acute and Long-Term Outcome of Patients with Peripheral Artery Disease and Critical Limb Ischemia

BACKGROUND AND OBJECTIVES Despite the many studies showing an association between CKD and a high risk of ischemic events and mortality, the association of CKD with peripheral arterial disease (PAD) still has not been well described. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This large cohort study assessed the association of CKD, even in the earlier stages, with morbidity, short- and long-term outcome, and costs among patients with PAD. RESULTS We identified 41,882 patients with PAD who had an index hospitalization between January 1, 2009, and December 31, 2011. Of these, 8470 (20.2%) also had CKD (CKD stage 2: n=2158 [26%]; stage 3: n=3941 [47%]; stage 4: n=935 [11%]; stage 5: n=1436 [17%]). The ratio of women to men was 1:1.2. Compared with patients without known CKD, those with CKD had higher frequencies of coronary artery disease (1.8-fold higher; P<0.001), chronic heart failure (3.3-fold higher; P<0.001), and Rutherford PAD categories 5 and 6 (1.8-fold higher; P<0.001); underwent significantly fewer revascularizations (0.9-fold fewer; P<0.001); had a nearly two-fold higher amputation rate (P<0.001); had higher frequencies of in-hospital infections (2.1-fold higher; P<0.001), acute renal failure (2.8-fold higher; P<0.001), and sepsis (1.9-fold higher; P<0.001); had a 2.5-fold higher frequency of myocardial infarction (P<0.001); and had a nearly three-fold higher in-hospital mortality rate (P<0.001). In an adjusted multivariable Cox regression model, CKD remained a significant predictor of long-term outcome of patients with PAD during follow-up for up to 4 years (until December 31, 2012; median, 775 days; 25th-75th percentiles, 469-1120 days); the hazard ratio was 2.59 (95% confidence interval, 2.21 to 2.78; P<0.001). The projected mortality rates after 4 years were 27% in patients without known CKD and 46%, 52%, 72%, and 78% in those with CKD stages 2, 3, 4, and 5, respectively. Lengths of hospital stay and reimbursement costs were on average nearly 1.4-fold higher (P<0.001) in patients who also had CKD. CONCLUSIONS This analysis illustrates the significant and important association of CKD with in-hospital and long-term mortality, morbidity, amputation rates, duration and costs of hospitalization, in-hospital treatment, and complications in patients with PAD.

Retrospective Analysis of the Blood Component Utilization in a University Hospital of Maximum Medical Care

Background: Demographic data illustrate clearly that people in highly developed countries get older, and the elderly need more blood transfusions than younger patients. Additionally, special extensive therapies result in an increased consumption of blood components. Beyond that the aging of the population reduces the total number of preferably young and healthy blood donors. Therefore, Patient Blood Management will become more and more important in order to secure an increasing blood supply under fair-minded conditions. Methods: At the University Hospital of Münster (UKM) a comprehensive retrospective analysis of the utilization of all conventional blood components was performed including all medical and surgical disciplines. In parallel, a new medical reporting system was installed to provide a monthly analysis of the transfusional treatments in the whole infirmary, in every department, and in special blood-consuming cases of interest, as well. Results: The study refers to all UKM in-patient cases from 2009 to 2011. It clearly demonstrates that older patients (>60 years, 35.2–35.7% of all cases, but 49.4–52.6% of all cases with red blood cell (RBC) transfusions, 36.4–41. 6% of all cases with platelet (PTL, apheresis only) transfusions, 45.2– 48.0% of all cases with fresh frozen plasma (FFP) transfusions) need more blood products than younger patients. Male patients (54.4–63.9% of all cases with transfusions) are more susceptible to blood transfusions than female patients (36.1–45.6% of all cases with transfusions). Most blood components are used in cardiac, visceral, and orthopedic surgery (49.3–55.9% of all RBC units, 45.8–61.0% of all FFP units). When regarding medical disciplines, most transfusions are administered to hematologic and oncologic patients (12.9–17.7% of all RBC units, 9.2– 12.0% of all FFP units). The consumption of PTL in this special patient cohort (40.6–50.9% of all PTL units) is more pronounced than in all other surgical or in non-surgical disciplines. Conclusion: The results obtained from our retrospective analysis may help to further optimize the responsible and medical indication-related utilization of blood transfusions as well as the recruitment of blood donors and their timing. It may be also a helpful tool in order to avoid needless transfusions and transfusion-associated adverse events.