Financial Impact of Deep Sternal Wound Infections After Coronary Surgery: A Microcosting Analysis

ABSTRACT Introduction: Deep sternal wound infections (DSWI) are so serious and costly that hospital services continue to strive to control and prevent these outcomes. Microcosting is the more accurate approach in economic healthcare evaluation, but there are no studies in this field applying this method to compare DSWI after isolated coronary artery bypass grafting (CABG). This study aims to evaluate the incremental risk-adjusted costs of DSWI on isolated CABG. Methods: This is a retrospective, single-center observational cohort study with a propensity score matching for infected and non-infected patients to compare incremental risk-adjusted costs between groups. Data to homogeneity sample was obtained from a multicentric database, REPLICCAR II, and additional sources of information about costs were achieved with the electronic hospital system (Si3). Inflation variation and dollar quotation in the study period were corrected using the General Market Price Index. Groups were compared using analysis of variance, and multiple linear regression was performed to evaluate the cost drivers related to the event. Results: As expected, infections were costly; deep infection increased the costs by 152% and mediastinitis by 188%. Groups differed among hospital stay, exams, medications, and multidisciplinary labor, and hospital stay costs were the most critical cost driver. Conclusion: In summary, our results demonstrate the incremental costs of a detailed microcosting evaluation of infections on CABG patients in São Paulo, Brazil. Hospital stay was an important cost driver identified, demonstrating the importance of evaluating patients' characteristics and managing risks for a faster, safer, and more effective discharge.

Impacto Atual da Circulação Extracorpórea na Cirurgia de Revascularização Miocárdica no Estado de São Paulo / Current Impact of Cardiopulmonary Bypass in Coronary Artery Bypass Grafting in São Paulo State

Resumo Fundamento Resultados prévios com o uso de circulação extracorpórea (CEC) geram dificuldades na escolha do melhor tratamento para cada paciente na cirurgia de revascularização miocárdica (CRM) no contexto atual. Objetivo Avaliar o impacto da CEC no cenário atual da CRM no estado de São Paulo. Métodos Foram analisados 2.905 pacientes submetidos à CRM de forma consecutiva em 11 centros do estado de São Paulo pertencentes ao Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) I. Dados perioperatórios e de seguimento foram colocados via on-line por especialistas treinados e capacitados em cada hospital. Foram analisadas as associações das variáveis perioperatórias com o tipo de procedimento (com ou sem CEC) e com os desfechos. A mortalidade esperada foi calculada por meio do EuroSCORE II (ESII). Os valores de p menores de 5% foram considerados significativos. Resultados Não houve diferença significativa em relação à idade dos pacientes entre os grupos (p=0,081). Dentre os pacientes, 72,9% eram de sexo masculino; 542 pacientes foram operados sem CEC (18,7%). Das características pré-operatórias, pacientes com infarto agudo do miocárdio (IAM) prévio (p=0,005) e disfunção ventricular (p=0,031) foram operados com CEC; no entanto, pacientes de emergência ou em classe funcional New York Heart Association (NYHA) IV foram operados sem CEC (p<0,001). O valor do ESII foi semelhante para ambos os grupos (p=0,427). Na CRM sem CEC, houve preferência pelo uso do enxerto radial (p<0,001) e com CEC pela artéria mamária direita (p<0,001). No pós-operatório, o uso de CEC esteve associado com reoperação por sangramento (p=0,012). Conclusão Atualmente, no REPLICCAR, reoperação por sangramento foi o único desfecho associado ao uso da CEC na CRM. (Arq Bras Cardiol. 2020; 115(4):595-601)

Abstract Background Previous results on the use of cardiopulmonary bypass (CPB) have generated difficulties in choosing the best treatment for each patient undergoing myocardial revascularization surgery (CABG) in the current context. Objective Evaluate the current impact of CPB in CABG in São Paulo State. Methods A total of 2905 patients who underwent CABG were consecutively analyzed in 11 São Paulo State centers belonging to the São Paulo Registry of Cardiovascular Surgery (REPLICCAR) I. Perioperative and follow-up data were included online by trained specialists in each hospital. Associations of the perioperative variables with the type of procedure and with the outcomes were analyzed. The study outcomes were morbidity and operative mortality. The expected mortality was calculated using EuroSCORE II (ESII). The values of p <5% were considered significant. Results There were no significant differences concerning the patients' age between the groups (p=0.081). 72.9% of the patients were males. Of the patients, 542 underwent surgery without CPB (18.7%). Of the preoperative characteristics, patients with previous myocardial infarction (p=0.005) and ventricular dysfunction (p=0.031) underwent surgery with CPB. However, emergency or New York Heart Association (NYHA) class IV patients underwent surgery without CPB (p<0.001). The ESII value was similar in both groups (p=0.427). In CABG without CPB, the radial graft was preferred (p<0.001), and in CABG with CPB the right mammary artery was the preferred one (p<0.001). In the postoperative period, CPB use was associated with reoperation for bleeding (p=0.012). Conclusion Currently in the REPLICCAR, reoperation for bleeding was the only outcome associated with the use of CPB in CABG. (Arq Bras Cardiol. 2020; 115(4):595-601)

Level of physical activity and quality of life: a comparative study among the elderly of rural and urban areas / Nível de atividade física e qualidade de vida: um estudo comparativo entre idosos dos espaços rural e urbano

Objective : To investigate if the relationship between physical activity level (PAL) and quality of life (QOL) is affected by living environment (rural or urban). Method : A quantitative, observational and cross-sectional study was performed. Of the 40 participants of both genders, 20 were residents of urban areas and 20 were residents of rural areas in the town of Pimenta Bueno (RO), Brazil. The WHOQOL BREF and IPAQ Long Version questionnaires were used to assess QOL and PAL, respectively. Mann Whitney and Fisher's Exact were used to statistically compare groups for QOL and PAL scores. The correlation between the two was tested by the Spearman test. A significance level of p<0.05 was used. Results : No differences between the rural and urban areas for QOL or PAL were found. In the rural group a positive and significant correlation was found between PAL and the physical, psychological and complete QOL domains. In terms of PAL, elderly persons from the rural area who were regularly active had higher total QOL and physical domain scores than insufficiently active elderly individuals from the rural area. When place of residence was compared, insufficiently active elderly in the urban area had higher scores on the social component of QOL than insufficiently active elderly from the rural group. Among regularly active seniors, those living in the rural area had higher physical QOL scores. Conclusion : According to the results, level of physical activity exerts a differential influence on the QOL of elderly people from rural and urban areas.

Objetivo : Investigar se, entre idosos, a relação nível de atividade física (NAF) e qualidade de vida (QV) é afetada pelo ambiente de moradia (rural ou urbano). Método : Estudo de abordagem quantitativa, natureza observacional e delineamento transversal. Participaram 40 idosos de ambos os sexos, 20 residentes em espaço urbano e 20, em espaço rural na cidade de Pimenta Bueno-RO. Os questionários WHOQOL BREF e IPAQ versão longa foram utilizados para avaliação da QV e do NAF, respectivamente. Os testes estatísticos de Mann Withney e Exato de Fischer para comparação dos grupos quanto aos escores de QV e NAF. A correlação entre esses foi testada pelo teste de Spearman. Foi utilizado como valor de significância p<0,05. Resultados : Não foram encontradas diferenças para QV ou NAF entre idosos moradores do espaço rural e urbano. No grupo de idosos moradores do espaço rural foi encontrada correlação positiva, significativa, entre o NAF e os domínios físico, psicológico e total da QV. Quando comparados ao NAF, os idosos do espaço rural regularmente ativos apresentaram maior QV no escore total e no domínio físico, em comparação aos insuficientemente ativos do espaço rural. Quando comparados segundo local de moradia, idosos insuficientemente ativos do espaço urbano apresentaram maior escore no componente social da QV, em comparação ao grupo de idosos insuficientemente ativos do espaço rural. Entre os idosos regularmente ativos, aqueles residentes em espaço rural apresentaram maior escore no domínio físico da QV. Conclusão : Com base nos idosos pesquisados, o nível de atividade física exerce influência diferenciada na QV de idosos do espaço rural e urbano.

Determinação do risco cardiovascular em população de check-up espontâneo através do escore de Framingham / Determination of cardiovascular risk in spontaneous check-up population through the Framingham score

Fundamentos: As doenças cardiovasculares (DCV) estão entre as principais causas de morte em todo o mundo. Muitos dos pacientes que sofrem morte súbita são previamente assintomáticos, o que torna relevante a preocupação com a triagem da doença cardiovascular. A probabilidade de doença coronariana na população em geral pode ser calculada com base nos resultados do Framingham Heart Study. Objetivo: Determinar o risco cardiovascular em população assintomática de check-up espontâneo, utilizando o escore de Framingham. Métodos: Foram coletadas através de estudo de coorte retrospectivo, informações do prontuário de 83 indivíduos, 50 homens e 33 mulheres, com idade entre 30-79 anos, assintomáticos, que realizaram a primeira consulta nos últimos dois anos. Os dados de sedentarismo, tabagismo e presença de diabetes mellitus foram analisados de forma separada, utilizando-se o teste do qui-quadrado. As variáveis da escala de Framingham foram analisadas em escala numérica através do teste de Mann-Whitney. Resultados: Procuraram avaliação cardiológica 52,0 % dos homens quando estavam na faixa de risco moderado a alto e escore de Framingham médio de 9,8, com risco cardiovascular de 14,2 % para o desenvolvimento de doença cardiovascular em cinco anos; 72,7 % das mulheres procuraram avaliação cardiológica quando estavam na faixa de risco baixo, e escore de Framingham médio de 7,2 com risco cardiovascular de 8,3 % para o desenvolvimento de doença cardiovascular em cinco anos. Conclusão: Na população assintomática que fez check-up espontâneo, utilizando-se o escore de Framingham, os homens apresentaram risco moderado e alto de DCV, enquanto que esse risco foi muito reduzido entre as mulheres.

Background: Cardiovascular diseases (CVD) are among the leading causes of death all over the world. Many sudden deaths occur among formerly asymptomatic patients, underscoring the importance of concern over screening for cardiovascular disease. The probability of coronary disease among the general population may be calculated on the basis of the Framingham Heart Study findings. Objective: To determine the cardiovascular risk in an asymptomatic spontaneous check-up population, using the Framingham score.Methods: Information was collected from the medical records of 83 asymptomatic individuals (50 men and 33 women) between 30 and 79 years old having their first consultation in the past two years. Data on sedentary lifestyles, smoking and diabetes mellitus were analyzed separately though the chi-square test. The Framingham scale variables were analyzed on a numerical scale through the Mann-Whitney test. Results: Cardiological evaluations were sought by 52 % of men in the moderate to high risk range with an average Framingham score of 9.8 and cardiovascular risk of 14.2 % for developing cardiovascular disease within five years, with 72.7 % of the women seeking cardiological evaluations when in the low risk range and an average Framingham score of 7.2 with a cardiovascular risk of 8.3 % for developing cardiovascular disease within five years.Conclusion: In an asymptomatic spontaneous check-up population, using the Framingham score, the men presented moderate to high cardiovascular risks, with these risks being far lower among the women.