Predictors of mortality for patients undergoing cardiac valve replacements in New York State

BACKGROUND: The objective of this study was to identify the mortality rates and significant independent risk factors for mortality for each of six valve replacement groups. METHODS: A total of 14,190 patients who underwent valve replacement in New York State from 1995 to 1997 were classified into six major groups and significant independent risk factors for inpatient mortality were identified for each of the groups using stepwise logistic regression. RESULTS: Mortality rates ranged from 3.33% for isolated aortic valve surgical procedures to 18.72% for multiple valve replacements with coronary artery bypass graft operations. The number of years in excess of age 55 was a significant multivariate predictor of mortality for all six groups of patients. Shock was a significant predictor for five of the six groups, and in each of those groups it was the risk factor with the highest odds ratio. CONCLUSIONS: Significant patient risk factors are relatively consistent across different types of valve replacement procedures. The probability of survival from valve surgical procedures is highly dependent on the patient's preoperative profile and the type of valve operation.     

Laparoscopic and open cholecystectomy in New York State: mortality, complications, and choice of procedure

BACKGROUND: With the advent of laparoscopic cholecystectomy patient outcomes and choice of procedure (laparoscopic vs open) are of vital interest. The purpose of this study was to examine the mortality and complication rates for patients undergoing laparoscopic and open cholecystectomy in New York State and to test for differences among hospital peer groups and regions of the state in the tendency to use the laparoscopic approach. METHODS: A population-based, retrospective cohort study of laparoscopic and open cholecystectomy was conducted in which data were analyzed on all 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996. RESULTS: A total of 78.7% of the 30,968 patients who underwent cholecystectomy as a principal procedure in New York State in 1996 underwent laparoscopic cholecystectomy. The mortality rate was lower for laparoscopic cholecystectomy than for the open procedure (0.23% vs 1.90%, P < .0001) and remained significantly lower after patient characteristics related to patient survival (odds ratio 0.34, P < .0001) were controlled for. The prevalence rate of the 8 most common complications among cholecystectomy patients was also much lower among patients undergoing laparoscopic cholecystectomy. Patients undergoing cholecystectomy in public hospitals, Bronx County, and Kings County were found to be significantly less likely to have laparoscopic procedures, and patients undergoing cholecystectomy on Long Island were found to be significantly more likely to have laparoscopic procedures than were other patients in the state. CONCLUSIONS: There are reasonably large differences among hospitals, hospital groups, and regions of the state in the type of cholecystectomy used, even after adjustment for differences in patient comorbidities and indications for type of procedure.     

Utilization of peritoneal dialysis in the United States: Reasons for underutilization,specifically in New York State and the boroughs of New York City

Peritoneal dialysis (PD) is currently underutilized in the United States (US), even within resource-rich neighborhoods. We analyzed data from US Renal Data Service to determine PD utilization within the US, New York State (NYS), selected boroughs within New York City (NYC), and Boston, Massachusetts. We then compared the odds of selecting PD with hemodialysis (HD) and analyzed how diabetes mellitus status, age >65 years, gender, and race influenced PD utilization between 2010 and 2016. We then compared a high-volume PD center (HVC) with a low-volume PD center (LVC). The odds of starting PD vs HD were as follows: Brooklyn 0.30 (0.25-0.36; <0.0001), Bronx 0.56 (0.47-0.67; <0.0001), Queens 0.66 (0.54-0.80; <0.0001), and Manhattan 0.61 (0.52-0.71; <0.0001). In 2016, the odds of starting PD compared with the rest of the US were as follows: Brooklyn 0.14 (0.08-0.22; <0.0001), Bronx 0.39 (0.27-0.56; <0.0001), Queens 0.32 (0.23-0.45; <0.0001), Manhattan 0.54 (0.36-0.79; 0.002), and Boston 0.89 (0.58-1.4; 0.624). Analysis of influencing factors showed that only age >65 significantly (<0.0001) influenced PD modality selection in Brooklyn and Boston. Differences between HVC and LVC in terms of modality transition, peritonitis rate, or provider:patient ratio were not statistically significant. Factors that influence PD utilization in urban neighborhoods are discussed and remediation measures are proposed.     

Same-Day Thyroidectomy: A Review of Practice Patterns and Outcomes for 1,168 Procedures in New York State

Background

There has been a shift of procedures from the inpatient to the outpatient setting. Same-day thyroidectomy (SDT) has been reported in high-volume single-institution series, but few studies have evaluated its widespread use.

Methods

Patients undergoing thyroidectomy for benign and malignant thyroid disease were abstracted from the 2004 New York State inpatient (SID) and ambulatory surgery (SASD) databases. SDTs were discharged on the same day as their surgery. Patient and provider (surgeon and hospital volume) characteristics were associated with outcomes, including probability of SDT versus hospital admission and 30-day rehospitalization, by bivariate and multivariate analyses.

Results

A total of 6,762 thyroidectomies were identified; 17% (1,168) were SDTs. Patients undergoing SDT compared to thyroidectomy with admission were more often white (80 vs. 65%, P < 0.001), with private insurance (80 vs. 70%, P < 0.001) and fewer comorbidities (96 vs. 89% with Charlson scores of none/low, P < 0.001). SDT was performed more often by high-volume surgeons (48 vs. 31%, P < 0.001) and at high-volume hospitals (61 vs. 35%, P < 0.001). Rehospitalization rates of 1.4 and 2.4% were observed for SDT and inpatient thyroidectomy, respectively (P = NS). In multivariate analysis, thyroidectomy by a high-volume surgeon was associated with a higher chance of same-day discharge (odds ratio = 2.3, P < 0.001).

Conclusion

Nearly 20% of thyroidectomy patients undergo SDT in New York State. They have different demographic and clinical characteristics than patients undergoing thyroidectomy who are admitted. There seem to be a few high-volume surgeons and centers with extensive SDT experience. More research is needed to explore optimized patient triage and patterns of referral to centers of excellence.     

Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly

Aim Emergency surgery is associated with higher mortality rates, especially in elderly patients presenting with emergent colorectal disease. The aim of this study was to determine the outcomes in elderly patients following emergency colorectal resection, with particular focus on octogenarians who presented a sixfold higher mortality rate with respect to other patients. Method This study examined 355 patients who underwent surgery at an Emergency Department for complications of colorectal disease between January 2007 and December 2009. Morbidity and mortality were analyzed on the basis of patients’ characteristics and presentation. Univariate and logistic regression analyses were performed on morbidity and mortality risk factors. Results Two‐hundred and fifteen patients of > 65 years of age were included, 93 of whom were ≥ 80 years of age. The global mortality rate was 16%. In patients ≥ 80 years of age the mortality rate was 30%. The difference in mortality rate between patients < 80 years of age vs patients ≥ 80 years of age was 24%. In resected patients ≥ 80 years of age, American Society of Anesthesiology grade, colonic ischaemia, neurological comorbidity and anastomotic dehiscence were identified as independent risk factors in both univariate and logistic regression analyses. The morbidity rate was approximately 17%, and no significant difference in morbidity was found between the two groups. Conclusion The results of this study show that fitness status and micro vascular impairment impact significantly on mortality in the elderly, particularly in octogenarians. Although the outcomes observed were compatible with the literature, the six fold higher mortality rate observed in the most elderly patients identifies a group for which death prevention is best achieved with aggressive resuscitation and intensive postoperative care, rather than timing of surgery.     

Quality of life, morbidity, and mortality after surgical intensive care: a follow-up study of patients treated for abdominal sepsis in the surgical intensive care unit.

OBJECTIVE: To evaluate the long-term outcome of patients treated in the surgical intensive care unit (SICU) for abdominal sepsis. DESIGN: Retrospective study. SETTING: University hospital, Sweden. SUBJECTS: 210 consecutive patients treated for abdominal sepsis in the SICU at Lund University Hospital during the period January 1983 to December 1995. MAIN OUTCOME MEASURES: Background information, morbidity, and mortality. Follow-up of surviving patients with interview and completion of a quality of life (QoL) assessment. Information collected postmortem from the registers of the Swedish National Board of Health and Welfare. RESULTS: At follow-up, 45 patients of the 151 who survived the initial hospital stay had died, 41 were lost to follow up and 16 chose not to participate in the study; 49 patients completed the study. Median QoL scores were significantly impaired (p < 0.01) although subjective QoL did not change significantly. In-hospital mortality was 28% (59/210) and total mortality over the time period 50% (104/210). CONCLUSION: Most patients who survived after treatment of abdominal sepsis in the SICU regained good health and their functional status was restored. Subjective QoL remained unchanged.     

The reliability and validity of three‐item screening measures for burnout: Evidence from group‐employed health care practitioners in upstate New York

We investigate the psychometric validity and reliability of three‐item screening measures for emotional exhaustion, depersonalization, and personal achievement comprising an abbreviated version of the Maslach Burnout Inventory®. Despite its utilization in multiple studies, the shortened instrument has not been sufficiently validated in diverse settings, populations, and organizational contexts. We examine its ability to assess burnout accruing from patient care practice in a rural, underserved area. Utilizing data from a cross‐sectional survey of 308 rural‐based medical professionals, we investigate how the three short‐form subscales of the nine‐item abbreviated inventory compare with their gold‐standard parent subscales from the original 22‐item human services scale in measuring corresponding dimensions of burnout. The findings provide significant evidence that the three‐item measures are valid and reliable proxies for the long‐form subscales. The short‐form measures are highly correlated with the original subscales and display high convergent and discriminant validity. Each of the abbreviated subscales manifests the kind of high sensitivity with adequate specificity that one would expect to see in a good screening instrument. We conclude that the short‐form measures can be utilized to rapidly screen human service professionals such as rural health care practitioners for symptoms of each of the three dimensions of burnout.