Coronary artery bypass operations for elderly patients in California, 2003 to 2008.

BACKGROUND: Coronary artery bypass grafting (CABG) is no longer rare for elderly patients. This study evaluates operative mortality and the effects of off-pump CABG (OPCAB) on mortality for elderly Californians between 2003 and 2008. METHODS: All isolated CABGs in California for 2003 to 2008 were classified into cohorts by age: (1) younger than 75, (2) 75 to 84, and (3) 85 or older. Multivariable logistic regression models were developed for operative mortality. Trend analyses for observed and predicted mortality, and observed-to-expected mortality ratios were performed. The "recycled predictions" method was used to assess the effect of OPCAB on operative mortality. RESULTS: Among 101,710 isolated CABGs between 2003 and 2008, 22.0% were in cohort 2 and 2.3% were in cohort 3. Predicted mortality was unchanged for cohorts 2 and 3 (all p > 0.05), but observed-to-expected mortality ratios declined from 0.958 to 0.633 for cohort 2 (p = 0.021) and from 1.027 to 0.965 for cohort 3 (p = 0.168). The proportion of OPCAB for patients aged 75 years or older increased from 25.0% to 29.1% between 2003 and 2008. The adjusted odds ratio for operative mortality for OPCAB in patients aged 75 years or older was 0.752 (95% confidence interval, 0.650 to 0.871; p < 0.001) compared with on-pump CABG for the same age cohort. CONCLUSIONS: In California, overall predicted mortality was unchanged for elderly patients between 2003 and 2008, but operative mortality significantly decreased for patients aged 75 to 84. Improvement for CABG patients aged 85 years or older was insignificant. The increase in the number of OPCAB patients was associated with decreased mortality for elderly patients.

Off-pump coronary artery bypass graft surgery in California, 2003 to 2005.

BACKGROUND: The impact of off-pump coronary artery bypass graft surgery (OPCAB) on operative mortality compared to conventional coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CCB) has not been clarified. METHOD: Patient clinical characteristics were compared between OPCAB and CCB for isolated CABG surgeries in 2003 to 2005 using data from the California CABG outcomes reporting program. A propensity score method and logistic regression models were used to compute propensity-adjusted operative mortality for patients undergoing OPCAB or CCB. RESULTS: Of 57,284 isolated CABGs, 13,515 (22.9%) were OPCAB. Compared to CCB, OPCAB patients were older, more females/nonwhite, and had a higher prevalence of certain noncardiac risk factors but were fewer with diabetes, acute myocardial infarction, New York Heart Association class IV heart failure or angina, cardiogenic shock, prior cardiac surgery, left main coronary disease, or > or =3-vessel coronary disease (all P < .01). Overall, the propensity-adjusted operative mortalities (PAOMRs) were significantly lower in OPCAB patients compared to CCB patients (OPCAB 2.59% [95% CI 2.52%-2.67%] vs CCB 3.22% [95% CI 3.17%-3.27%]). Off-pump CABG had a protective advantage for all quintile subgroups (all P < .05). However, within the OPCAB cohort, those who converted to CCB intraoperately had higher PAOMR (converters 3.47% [95% CI 3.16%-3.77%] vs nonconverters 2.53% [95% CI 2.46%-2.61%]). Age, female sex, nonwhite race, diabetes, congestive heart failure, prior cadiac surgery, left main disease, and with > or =3 diseased coronary arteries were associated with a higher risk of intraoperative conversion from OPCAB to CCB (all <0.05). CONCLUSION: OPCAB and CCB patients had significantly different preoperative risk profiles, and OPCAB was associated with lower operative mortality compared to CCB.

The treatment of hip fractures: variations in care.

UNLABELLED: The purpose of this descriptive study was to identify the ranges of operative treatment, perioperative management, and mortality rate of elderly patients with hip fractures. We retrospectively identified 1001 elderly patients who had operative treatment for a fractured hip in 49 medium- and high-volume California hospitals using a two-stage stratified cluster sample of hospitalizations for hip fractures. This sampling method allowed for generation of weighted estimates that described the overall care of all patients with hip fractures in California from 1995 to 1996. The in-hospital, 30-day, and 6-month mortality rates were 1.7%, 5%, and 12% respectively. Bipolar hemiarthroplasties were used more often than unipolar implants (73% versus 26%). There were some deviations from generally accepted guidelines for care of patients with hip fractures particularly related to administration of antibiotic and deep vein thrombosis prophylaxis. Fourteen percent of patients did not receive any antibiotic prophylaxis before and during surgery, and 24% did not receive prophylaxis within 4 hours of the beginning of the surgical procedure. Twenty-four percent of patients received no prophylaxis for deep vein thrombosis, and 81% of patients did not receive prophylaxis after hospital discharge. Surgeons need to continually evaluate the treatment regimens for patients with hip fractures to optimize care. LEVEL OF EVIDENCE: Descriptive Study, Level II (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.