Cost-effectiveness analysis--a health policy perspective.
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Axilla↗
Biomedical subjects
B S Maini
Publications and source records attributed to B S Maini.
Gastrointestinal complications following cardiac surgery. An analysis of 1477 cardiac surgery patients.
OBJECTIVE: To determine preoperative and perioperative risk factors for gastrointestinal (GI) complications following cardiac surgery. DESIGN: A database including records of patients who underwent cardiac surgery was reviewed, with univariate analysis of several variables thought to be relevant to GI complications. Using a risk-adjusted model, preoperative stratification was used to fit a logistic regression model including operative features. SETTING AND PATIENTS: All patients undergoing cardiac surgery from January 1, 1991, to December 31, 1994, at a university-affiliated teaching hospital. MAIN OUTCOME MEASURES: Incidence of GI complications, postoperative mortality, length of hospital stay, and relative risk of GI complications based on multivariate analyses. RESULTS: Gastrointestinal complications occurred in 2.1% of patients and had an associated mortality of 19.4%; this was higher than the mortality in patients without GI complications (4.1%; P < .001). Length of hospital stay was significantly longer in patients with GI complications (43 vs 13.4 days; P < .001). In patients who underwent coronary artery bypass grafting only, cardiopulmonary bypass time was significantly longer in patients with GI complications (166 vs 138 minutes; P = .004). In patients who underwent valve replacement, bypass time was not associated with GI complications. Use of a left internal mammary artery graft was associated with a lower incidence of GI complications. CONCLUSIONS: Patients who have GI complications after cardiac surgery have a higher mortality and a longer hospital stay. The use of a left internal mammary artery seems to have a protective effect against GI complications. Based on these observations, patients may be stratified into low-, medium-, and high-risk groups.
Aged↗
Outcomes and resource utilization in a managed care setting for lower extremity vein bypass grafts.
BACKGROUND: This 17-year review was undertaken to examine clinical outcomes and the changing trends in resource utilization for lower extremity bypass grafts performed in a managed care setting. PATIENTS AND METHODS: Between 1979 and 1995, 338 bypasses in 276 patients (199 men, 77 women; 62% diabetics) were carried out for limb salvage. Autogenous vein bypasses (AVB) were performed in 324 (96%) of the cases, which included 150 (43%) femoropopliteal (FP) and 174 (57%) femoro-tibial (FT) bypasses. There were 32 secondary AVB reconstructions included in the study group. RESULTS: The 30-day mortality rate was 2.2% and patient survival was 46% and 21% at 5 and 10 years. At 1 and 5 years, primary patency rates for the AVB were 87% and 79% for FP; 80% and 67% for FT AVB, whereas the limb salvage rates at those intervals were 96% and 94% for FP; 87% and 77% for FT, respectively. Despite an average annual inflation rate of 8%, significant reductions in hospital charges were noted during the study period. These were made possible by decreasing lengths of hospital stay, the development and application of guidelines and protocols for the management of leg ischemia, and the implementation of angioscopy for improving the surgical technique for in situ AVB. CONCLUSIONS: High-quality outcomes for lower extremity AVB are possible in a managed care setting with demonstrated improvements in the efficiency of resource utilization.
Aged↗
A comparison of four severity-adjusted models to predict mortality after coronary artery bypass graft surgery.
OBJECTIVE: To assess the validity of four severity-adjusted models to predict mortality following coronary artery bypass graft surgery by using an independent surgical database. DESIGN: A prospective observational study wherein predicted mortality for each patient was obtained by using four different published severity-adjusted models. SETTING: A university-affiliated teaching community hospital. PATIENTS: Eight hundred sixty-eight consecutive patients who underwent coronary artery bypass graft surgery without accompanying valve or aneurysm repair during the period from 1991 to 1993. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Predicted mortality rates for each model were obtained by averaging individual patient predictions and were compared with actual morality rates. We assessed the accuracy of overall prediction for the total series, as well as compared individual patient predictions created by each model. The discrimination of models was assessed with receiver operating characteristic curves and the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: The observed crude mortality rate was 3.7%. The predicted mortality rate ranged from 2.8% to 9.2%, despite relatively good discrimination by the models (area under the receiver operating characteristic curve, 0.70 to 0.74). The individual patient mortality predicted by different models varied by as much as a ninefold difference. CONCLUSIONS: The currently used coronary artery bypass graft predictive models, although generally accurate, have significant shortcomings and should be used with caution. The predicted mortality rate following coronary artery bypass graft surgery varied by a factor of 3.3 from lowest to highest, making the choice of model a critical factor when assessing outcome. The use of these models for individual patient risk estimations is risky because of the marked discrepancies in individual predictions created by each model.
Aged↗
Laparoscopic adrenal surgery.
Laparoscopic adrenalectomy (LA) was performed in 6 patients (4 right and 2 left). A transperitoneal approach in a lateral position was used. Pheochromocytoma was present in two patients and Conn's syndrome, with a solitary functioning adenoma, was the diagnosis in four. Early vascular control was obtained in the two patients with pheochromocytoma, resulting in very stable intraoperative blood pressure. Operative time for LA was 152 +/- 26 min and was associated with a short length of stay (2.0 +/- 0.6 days) and minimal intraoperative blood loss (82 +/- 30 ml). There were no conversions to laparotomy and one complication was noted. LA is a safe and effective operation for patients requiring adrenalectomy for hormone-secreting tumors.
Adrenal Gland Diseases↗
Evaluation of right ventricular function during aortic operations.
The simultaneous measurements of mixed venous oxygen saturation (SvO2) and right ventricular ejection fraction (RVEF) have now made it possible to precisely define and correlate the various hemodynamic changes that occur during abdominal aortic operations. Twenty-five patients undergoing infrarenal abdominal aortic aneurysm repair were examined with a pulmonary artery catheter capable of continuously measuring SvO2 and RVEF. With aortic clamping, significant reductions in cardiac index, stroke volume index, and right ventricular end-diastolic volume index (RVEDVI) were noted, while RVEF remained unchanged. Following unclamping of the aorta, a significant reduction in SvO2 occurred, accompanied by an increase in mean pulmonary artery pressure and in pulmonary vascular resistance. Despite the increase in afterload, RVEDVI and RVEF did not change after unclamping. These preliminary data suggest that right ventricular function is preserved during abdominal aortic aneurysm repair.
Aged↗
A modified, angioscopically assisted technique for in situ saphenous vein bypass: impact on patency, complications, and length of stay.
PURPOSE: The impact of preoperative saphenous vein mapping and intraoperative angioscopy on the results of in situ saphenous vein bypass is analyzed in this study. METHODS: A new technique developed for in situ saphenous vein bypass (ISVB) was used in 26 patients (group I) and consisted of (1) preoperative duplex scanning and mapping of the saphenous vein and its tributaries, (2) small incisions for dissecting the proximal and distal arteries and veins, (3) ligation of marked tributaries through small incisions, (4) angioscopically directed incision of venous valves with a flexible-tipped valvulotome, and (5) femoral and distal anastomoses. The results were compared with those of 14 patients (group II) in whom the technique was similar except that venous tributaries were identified angioscopically and then ligated and 24 patients (group III) who underwent standard "open" ISVB through one long incision without angioscopy or vein mapping and in whom valvulotomy was carried out with a rigid valvulotome passed through tributaries. RESULTS: In comparing the results of groups I and III, significant reductions in operative intravenous fluid requirements (1930 ml vs 2675 ml; p = 0.04), postoperative length of stay (4.4 days vs 9.1 days; p < 0.001), and wound complications (1 vs 9; p = 0.01) were observed. Angioscopic irrigation fluid volume in group I was less than that in group II (360 ml vs 1014 ml; p < 0.001). At 12 months, the primary graft patency rate in all 64 patients was 91% for femoropopliteal and 89% for femoral-infrapopliteal ISBV and 84% for the 40 patients in groups I and II. CONCLUSIONS: This report demonstrates the effectiveness of our modified technique for ISVB, which helped reduce wound complications and length of stay while satisfactory early graft patency was also maintained.
Aged↗
Laparoscopic cholecystectomy. A clinical and financial analysis of 280 operations.
Two hundred eighty patients underwent laparoscopic cholecystectomy (LC) and were compared with 304 patients who underwent traditional "open" cholecystectomy (OC). Laparoscopic cholecystectomy was performed electively in 72.5% of cases and urgently in 27.5% of cases. Conversion from LC to OC was required in 14 patients (5%), six of whom required common bile duct exploration. Common bile duct stones were managed with video-laparoscopic techniques in 11 patients, with percutaneous transhepatic laser lithotripsy in three patients, and with laparotomy in six patients. Hospital stay was significantly shorter and complications were significantly fewer for LC compared with OC. Hospital expenses for LC were significantly higher than for OC because of longer duration of operation and higher operating room expenses. Patients who underwent elective LC returned to work an average of 31 days earlier than patients who underwent OC (10 days vs 41 days). These data indicate that LC can be performed safely although at a higher cost than OC, and that patients as well as employers benefit from a short length of hospital stay.
Adult↗
Continuous monitoring of mixed venous oxygen saturation during aortic operations.
OBJECTIVE: To systematically analyze the changes in mixed venous oxygen saturation (delta SvO2) during aortic operations with tube, aortobi-iliac, and aortobifemoral grafts. DESIGN: Survey of consecutive patients. SETTING: Teaching community hospital. PATIENTS: Thirty-one patients (22 male, 9 female, mean age 67 +/- 10 yrs), undergoing elective operations for aortic aneurysms (n = 25) and aortoiliac occlusive disease (n = 6). INTERVENTIONS: SvO2 was recorded throughout the operation. Cardiac output, mean pulmonary arterial pressure, arterial oxygen saturation (SaO2), and arterial pH were measured before and immediately after the unclamping of the aortic graft. RESULTS: In all patients, unclamping the aorta resulted in a marked reduction of mean SvO2, with no change in the cardiac output or SaO2. The unclamping of tube grafts was associated with a significant reduction in arterial pH (p less than .01) and in SvO2 (p less than .001), when compared with unclamping of bifurcation grafts. A significant (p less than .05) increase in mean pulmonary arterial pressure was observed after unclamping the aorta in patients with tube grafts. Despite a longer clamp time, unclamping the second limb of a bifurcation graft resulted in a smaller delta SvO2, when compared with that observed after unclamping the first limb (12% vs. 6%; p less than .01). The delta SvO2 after unclamping limb II was only 2% in aortobifemoral grafts and 9% in aortobi-iliac grafts. CONCLUSIONS: Reperfusion via extensive pelvic and lumbar collaterals in patients with aortoiliac occlusive disease reduces the delta SvO2 after aortic unclamping. Monitoring the changes in SvO2 during different types of aortic reconstruction helps to define precisely the physiologic alterations that occur in the course of these operations.
Aged↗
Laparoscopic common bile duct exploration.
Operative common bile duct exploration, performed in conjunction with cholecystectomy, has been considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. With the advent of laparoscopic cholecystectomy, the management of common bile duct stones has been affected. More emphasis is being placed on endoscopic sphincterotomy and options other than operative common duct exploration. Because of this increasing demand, we have developed a new technique for laparoscopic common bile duct exploration performed in the same operative setting as laparoscopic cholecystectomy. A series of five patients who successfully underwent common bile duct exploration, flexible choledochoscopy with stone extraction, and T-tube drainage, all using laparoscopic technique, is reported. Mean postoperative length of hospital stay was 4.6 days. Outpatient T-tube cholangiography was performed in all cases and revealed normal ductal anatomy with no retained stones. Follow-up ranged from 6 weeks to 4 months, and all patients were asymptomatic and had normal liver function tests.
Adolescent↗
Carotid endarterectomy: a ten-year analysis of outcome and cost of treatment.
Between 1978 and 1988, 215 patients with an average age of 67 years, underwent 246 carotid endarterectomies. Two hundred ten (85.4%) patients were symptomatic, and 36 (14.6%) were asymptomatic. Six patients (2.4%) had a postoperative stroke, and all had immediate reoperation. One of these patients died (30 day mortality rate, 0.4% for the series), and two (0.8%) recovered completely, whereas three (1.2%) had a mild permanent neurologic deficit. Two patients (0.8%) had nonfatal myocardial infarction. Mean follow-up of 42.2 months (range, 1 to 126 months) was achieved. At 5 and 8 years actuarial survival rates of 82% and 66% and stroke-free survival rates of 67% and 37% were observed. Actuarial stroke free rates of 90% at 5 and 8 years were noted. By introducing and observing guidelines that required preoperative study of most clearly defined classes of patients before admission for surgical treatment, the average length of stay for carotid endarterectomy was lowered from 9.5 days in the first 5 years of the study to 5.8 days in the second 5 years (p = 0.001). Average hospital charges, expressed in constant dollars, decreased from $3113 in the first 5 years to $2620 in the second 5 years (p = 0.02) despite an 88% inflationary increase in medical consumer price index. This experience shows that the length of hospitalization of patients with carotid endarterectomy can be reduced and the cost of admission lowered without untoward effect on perioperative morbidity and mortality rates.
Adult↗
Primary sarcoma of the aorta associated with a vascular prosthesis: a case report.
A case of a primary malignant fibrous histiocytoma of the aorta, arising at the site of a woven Dacron thoracic aortic graft is described. Hypertension was a prominent clinical feature. Compression and distortion of the aortic graft by tumor complicated later surgical repair of an adjacent aortic aneurysm, resulting in death. At autopsy, the tumor was shown to have arisen in a portion of aortic wall surrounding the graft material. Tumor emboli were present in several distal arteries, with complete occlusion of the right renal artery by invasive tumor embolus. Primary tumors of the aorta are rare; 16 such cases have been reported in the literature. Only 2 previous cases of tumors associated with vascular prostheses have been reported. The occurrence of tumor in this case adjacent to an aortic graft raises the possibility that the graft material played a role in tumor induction.
Aorta↗
Nutritional assessment and treatment of hospital malnutrition.
A thorough awareness of the nutritional and metabolic status of the hospitalized patient is crucial for all persons directly involved in patient care. The catabolic nature of the body's response to illness or injury induces a serious drain on vital organs and tissues. Therefore, a complete assessment of the body's various compartments must be carefully taken, and any nutritional depletion must be quickly alleviated. Due to the alarming incidence of often undetected severe malnutrition in hospitalized patients, if becomes imperative that attention be paid to nutritional status, to decrease unnecessary morbidity and mortality.
Anthropometry↗
Effect of arterial reconstruction on limb salvage: a ten-year appraisal.
Two hundred forty-four consecutive patients were reviewed who presented themselves over a ten-year period (1967 to 1977) with threatened limb loss secondary to arteriosclerosis involving the arteries supplying the lower extremities. Patients with claudication as the presenting complaint were not included. Primary amputation was performed in 14 patients (6%), with an operative mortality of 21%, whereas arterial reconstructive surgery was carried out in 230 patients (94%) with an operative mortality of 2.7% One hundred eleven femoral-popliteal vein grafts in 101 patients showed a cumulative five-year graft patency of 78% with a limb salvage rate of 73%. Twenty-eight femoral-femoral grafts and 21 axillary-bilateral femoral grafts yielded five-year graft patency rates of 91% and 77%, respectively: the limb salvage rates were 91% and 86%. Inclusive of the 14 patients undergoing primary amputation, the overall five-year cumulative limb salvage in the entire group was 76%.
Adult↗
Femorofemoral grafting: indications and late results.
Experience with fifty-three femorofemoral grafts performed as the initial operation for iliac occlusive disease over a ten year period is reviewed. There was one operative death (2 per cent). There were two early and three late graft failures, for a five year cumulative graft patency rate of 80 per cent. Of the twenty-eight patients in whom the femorofemoral graft was performed for limb salvage, the five year cumulative limb salvage rate was 91 per cent. During the follow-up period, two grafts were converted to axillobilateral femoral grafts because of recurrent symptoms of claudication caused by progression of disease in the iliac system from which the femorofemoral graft originated. All other patients with patent grafts have had satisfactory relief of symptoms throughout the follow-up period.
Aged↗
Nutrition in the critically ill patient.
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Amino Acids↗
Nutritional and metabolic assessment of the hospitalized patient.
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Anthropometry↗
Recurring infection and "shunt nephritis" in home hyperalimentation.
A patient on home hyperalimentation after a series of infections, developed a "shunt nephritis" not unlike the nephritis reported in patients with hydrocephalus undergoing ventriculoatriostomy. Permanent eradication of infection and reversal of kidney damage required removal of indwelling catheter.
Adult↗