Regional variation in prosthesis choice for aortic valve replacement in older patients.

BACKGROUND AND AIM OF THE STUDY: The study aim was to investigate regional practice patterns regarding aortic valve replacement (AVR) by comparing bioprosthetic versus mechanical valve usage in patients aged > or = 65 years, and to determine whether the choice of valve type for AVR in these patients varied by geographic region. METHODS: The details were acquired of all mechanical and bioprosthetic AVRs performed in patients aged > or = 65 years between 1999 and 2006, as contained in the Florida State Inpatient Database. By using a small area analysis, the patients' zip codes were aggregated into hospital referral regions based on where they were most likely to receive AVR. The regional rates of both mechanical and bioprosthetic AVR were then determined. RESULTS: Of 23,925 AVRs performed during this period, 15,368 involved a bioprosthetic aortic valve and 8,557 a mechanical aortic valve. Statewide, 64% of AVRs in these patients involved a bioprosthesis. Regional rates of mechanical AVRs varied widely, from 10% to 81%. CONCLUSION: Substantial regional differences were identified in practice patterns for AVR in patients aged > or = 65 years. This suggested that provider preference, in addition to patient pathology, would often determine the type of valve implanted.

Geography or pathology? Regional variation in atrial septal defect closure rates and techniques.

BACKGROUND: Since the introduction of percutaneous closure in the United States, rates of secundum atrial septal defect and patent foramen ovale closures have increased substantially. Whether or not closure rates are uniform or vary due to differences in regional practice patterns is unknown. We sought to investigate this by comparing regional rates of closure across Florida. METHODS: We identified all atrial septal defect closures from 2001 to 2006 in the Florida State Inpatient Database. Using small area analysis, zip codes were assigned to Hospital Referral Regions based on where patients were most likely to go for closure. We obtained population-normalised rates of overall, percutaneous, and surgical closure. RESULTS: Of 1830 atrial septal defect and patent foramen ovale closures from 2001 to 2006, 751 were surgical and 1004 were percutaneous. The statewide closure rate was 1.91 per 100,000 people per year; regional rates varied 3.8-fold from 0.78 to 2.94 per 100,000 people per year. Percutaneous rates varied sevenfold from 0.25 to 1.75 per 100,000 people per year, while surgical rates varied 2.71-fold from 0.53 to 1.44 per 100,000 people per year. CONCLUSIONS: Despite a consistent prevalence of atrial septal defects, and patent foramens ovale, rates of repair vary across regions, suggesting that closure is driven by provider practice patterns rather than patient pathology. Efforts should be directed towards increasing consensus regarding the appropriate, evidence-based indications for closure so as to avoid the costs and potential negative sequelae of over- or undertreatment.

Can the intestinal dysmotility of critical illness be differentiated from postoperative ileus?

Gastrointestinal dysmotility is commonly noted in the intensive care unit and postoperative settings. Characterized by delayed passage of stool and flatus, nausea, vomiting, and abdominal distention, the condition is associated with nutritional deficiencies, risk of aspiration, and considerable allocation of health care resources. Knowledge of gastrointestinal function in health and illness continues to expand. While the factors that precipitate ileus differ between postoperative and critically ill patients, the two clinical scenarios seem to have similar mechanisms and share many of the same pathophysiologic patterns. By reviewing and comparing the literature on the respective mechanisms and contributing factors generated in these separate clinical settings, a common more comprehensive management strategy may be derived with the potential for newer innovative therapeutic options.

Common ground: measuring intrainstitutional mortality among pediatric surgical procedures.

BACKGROUND: For adult populations, hospitals that have low mortality rates for one surgical discipline tend to have low mortality rates for other surgical disciplines. We sought to determine to what degree mortality rates for high-risk pediatric surgical procedures were correlated within institutions. METHODS: High-risk operations performed on patients ≤ 10 years of age were identified in the 2003/2006 Kids' Inpatient Databases and grouped into cardiac surgical, neurosurgical, and general surgical categories. We calculated the hospital-level risk-adjusted mortality rates of each category ("categorical mortality") and of the other 2 categories combined ("other mortality"); then we calculated the correlation between these groups. Hospitals also were placed into quintiles based on excess other mortality and grouped categorical mortality were estimated. RESULTS: Categorical mortality was correlated with other mortality (R = 0.22-0.26) for all 3 categories. Other mortality was a good predictor of categorical mortality, with categorical mortality rates at hospitals in the bottom quintile of other mortality, on average 1.58 times greater than those in the top quintile (P < .001). Correlations of categorical mortality with other mortality were significantly greater for the subgroup of Children's General Hospitals (R = 0.43-0.57). CONCLUSION: Hospitals with low mortality rates for 1 high-risk pediatric surgical specialty tended to have low rates for other specialties. This observation suggests that diverse surgical fields share institutional resources and processes that affect their mutual performance. Implementation of these common pillars may lead to broader improvements in quality than efforts focused on individual disciplines.

Patient-specific insulin-resistance-guided infusion improves glycemic control in cardiac surgery.

BACKGROUND: Maintenance of appropriate capillary blood glucose in cardiovascular surgery patients has been associated with improved outcomes, including lower mortality. Interpatient variability in insulin resistance can make management difficult, leading to unexpected episodes of hypoglycemia and hyperglycemia. To improve postoperative glucose control at our institution, a patient-specific insulin-resistance-guided (IRG) protocol was developed. METHODS: Prospective data were gathered on 100 consecutive cardiovascular surgery patients managed with our standard insulin infusion protocol and 100 patients managed using the IRG protocol. Clinical characteristics and glycemic indices were analyzed for the two groups. Primary endpoints included (1) percentage of time spent in the target range, (2) number of hypoglycemic and hyperglycemic episodes, (3) time to achievement of target blood glucose, and (4) the total daily dose of insulin required. RESULTS: The IRG protocol resulted in significant improvements, including increased percentage of time spent in the normoglycemic range (82.5% versus 65.8%, p < 0.001), reduced rate of hypoglycemic episodes (0.12 versus 0.99, p < 0.01), reduced rate of hyperglycemic episodes (capillary blood glucose >126 mg/dL: 4.8 versus 8.2, p < 0.01), and a reduced time to the first measurement in the target range. Total daily dose of insulin was mildly increased, but failed to reach statistical significance (92.48 versus 82.64 units, p = 0.32). CONCLUSIONS: Use of the IRG protocol led to improved glycemic indices while reducing episodes of hypoglycemia in both diabetic and nondiabetic patients. The ability to adjust a patient's insulin dosing based upon factors related to their insulin resistance results in improved blood glucose control and safety in cardiovascular surgery patients.

Favorable early outcomes for patients with extended indications for thoracic endografting.

BACKGROUND: Endografts originally designed and approved for the treatment of thoracic aortic aneurysms have rapidly been adopted for nonapproved use in the treatment of disorders of the thoracic aorta, including aortic transection, dissection, pseudoaneurysms, and thoracoabdominal aneurysms. The purpose of this study was to evaluate the early outcomes of patients treated with thoracic endografts for nonapproved indications at our institution. METHODS: The medical records of patients undergoing thoracic endografting at our institution from August 2005 until March 2008 were reviewed. Patients undergoing endografting for uncomplicated thoracic aortic aneurysms were excluded. The outcomes of patients with extended indications for thoracic endografting were studied. RESULTS: During the study period, endografting was performed in 31 patients for nonapproved aortic conditions. Patients underwent endografting for a spectrum of indications, including aortic transection (n = 12), complications of type B aortic dissection including rupture (n = 9), thoracoabdominal aneurysm with visceral debranching (n = 6), aortic arch debranching (n = 2), and pseudoaneurysm associated with prior coarctation repair (n = 2). Early outcomes were favorable. All patients had successful endograft repair of their anatomic lesion. There were no endoleaks. There was no hospital mortality. Average hospitalization was 15 days for patients with aortic transection and 9 days for all other patients. CONCLUSIONS: Thoracic endografts are versatile devices that with appropriate expertise can be used effectively to treat a spectrum of disorders of the thoracic aorta, including acute emergencies. Early outcomes of patients with extended indications for thoracic endografting compare favorably to published series of patients treated with open procedures. Further study is required to assess the long-term efficacy of these devices.