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David M Shahian

Publications and source records attributed to David M Shahian.

12 recordsLinked to original sources
PubMed2005

Implementation of a cardiac surgery report card: lessons from the Massachusetts experience.

Demand is increasing for public accountability in health care. In 2000, the Massachusetts legislature mandated a state report card for cardiac surgery and percutaneous coronary interventions. During the planning and implementation of this report card, a number of observations were made that may prove useful to other states faced with similar mandates. These include the necessity for constructive, nonadversarial collaboration between regulators, clinicians, and statisticians; the advantages of preemptive adoption of The Society of Thoracic Surgeons [STS] National Cardiac Database, preferably before a report card is mandated; the support and resources available to cardiac surgeons through the STS, the National Cardiac Database Committee, and the Duke Clinical Research Institute; the value of a state STS organization; and the importance of media education to facilitate fair and dispassionate press coverage. Some important features of report cards may vary from state to state depending on the legislative mandate, local preferences, and statistical expertise. These include the choice of a statistical model and analytical technique, national versus regional reference population, and whether individual surgeon profiling is required.

Data Collection↗
PubMed2005

Gender-specific practice guidelines for coronary artery bypass surgery: perioperative management.

Gender differences in coronary bypass surgery have been the focus of numerous publications in recent years. Unfortunately these publications have contradictions that leave surgeons with conflicting recommendations for care. To help resolve these inconsistencies, The Society of Thoracic Surgeons (STS) Workforce on Evidence-Based Surgery has carried out an objective review of published information in this field. The STS Workforce recognizes that there are important gender issues associated with referral bias, the impact of body size, psychosocial factors, and postoperative support, but the intent of this guideline is to focus specifically on perioperative management. As with all practice guidelines, our goal is to gather the most important information, analyze the information in a logical and unbiased fashion, and make recommendations based solely on the available evidence.

Anemia↗
PubMed2005

Massachusetts cardiac surgery report card: implications of statistical methodology.

BACKGROUND: Choice of statistical methodology may significantly impact the results of provider profiling, including cardiac surgery report cards. Because of sample size and clustering issues, logistic regression may overestimate systematic interprovider variability, leading to false outlier classification. Theoretically, the use of hierarchical models should result in more accurate representation of provider performance. METHODS: Extensively validated and audited data were available for all 4,603 isolated coronary artery bypass grafting procedures performed at 13 Massachusetts hospitals during 2002. To produce the official Massachusetts cardiac surgery report card, a 19-variable predictor set and a hierarchical generalized linear model were employed. For the current study, this same analysis was repeated with the 14 predictors used in the New York Cardiac Surgery Reporting System. Two additional analyses were conducted using each set of predictor variables and applying standard logistic regression. For each of the four combinations of predictors and models, the point estimates of risk-adjusted 30-day mortality, 95% confidence or probability intervals, and outlier status were determined for each hospital. RESULTS: Overall unadjusted mortality for coronary bypass operations was 2.19%. For most hospitals, there was wide variability in the point estimates and confidence or probability intervals of risk-adjusted mortality depending on statistical model, but little variability relative to the choice of predictors. There were no hospital outliers using hierarchical models, but there was one outlier using logistic regression with either predictor set. CONCLUSIONS: When used to compare provider performance, logistic regression increases the possibility of false outlier classification. The use of hierarchical models is recommended.

Aged↗
PubMed2004

The Society of Thoracic Surgeons practice guideline series: transmyocardial laser revascularization.

BACKGROUND: Patients with chronic severe angina refractory to medical therapy who cannot be completely revascularized with either percutaneous catheter intervention or coronary artery bypass graft surgery present clinical challenges. Transmyocardial laser revascularization, either as sole therapy or as an adjunct to coronary artery bypass graft surgery, may be appropriate for some of these patients. Although transmyocardial revascularization has consistently been demonstrated as an efficacious means of relieving angina, the mechanism of its effects are still debated, and criteria for the selection of patients for this novel therapy have not been adequately defined. METHODS: We reviewed the available evidence to allow us to make recommendations for the appropriate therapeutic applications of transmyocardial revascularization following the format of the American Heart Association and the American College of Cardiology guidelines for diagnostic and therapeutic procedures. Our recommendations were classified as class I, IIA, IIB, or III. For each recommendation we defined the level of supporting evidence as A, B, or C. RESULTS: We identified class I indications for transmyocardial revascularization as sole therapy and class IIA indications for transmyocardial revascularization as an adjunct to coronary artery bypass graft surgery with levels of evidence A and B, respectively. CONCLUSIONS: Transmyocardial laser revascularization may be an acceptable form of therapy for selected patients: as sole therapy for a subset of patients with refractory angina and as an adjunct to coronary artery bypass graft surgery for a subset of patients with angina who cannot be completely revascularized surgically.

Angina Pectoris↗
PubMed2004

Cardiac surgery risk models: a position article.

Differences in medical outcomes may result from disease severity, treatment effectiveness, or chance. Because most outcome studies are observational rather than randomized, risk adjustment is necessary to account for case mix. This has usually been accomplished through the use of standard logistic regression models, although Bayesian models, hierarchical linear models, and machine-learning techniques such as neural networks have also been used. Many factors are essential to insuring the accuracy and usefulness of such models, including selection of an appropriate clinical database, inclusion of critical core variables, precise definitions for predictor variables and endpoints, proper model development, validation, and audit. Risk models may be used to assess the impact of specific predictors on outcome, to aid in patient counseling and treatment selection, to profile provider quality, and to serve as the basis of continuous quality improvement activities.

Bayes Theorem↗
PubMed2003

The volume-outcome relationship: from Luft to Leapfrog.

Numerous reports have documented a volume-outcome relationship for complex medical and surgical care, although many such studies are compromised by the use of discharge abstract data, inadequate risk adjustment, and problematic statistical methodology. Because of the volume-outcome association, and because valid outcome measurements are unavailable for many procedures, volume-based referral strategies have been advocated as an alternative approach to health-care quality improvement. This is most appropriate for procedures with the greatest outcome variability between low-volume and high-volume providers, such as esophagectomy and pancreatectomy, and for particularly high-risk subgroups of patients. Whenever possible, risk-adjusted outcome data should supplement or supplant volume standards, and continuous quality improvement programs should seek to emulate the processes of high-volume, high-quality providers. The Leapfrog Group has established a minimum volume requirement of 500 procedures for coronary artery bypass grafting. In view of the questionable basis for this recommendation, we suggest that it be reevaluated.

Hospital Mortality↗
PubMed2003

Contemporary management of superior pulmonary sulcus (Pancoast) lung tumors.

For more than three decades following the initial report by Shaw et al. in 1961, the standard treatment of Pancoast lung tumors consisted of induction radiotherapy followed by en bloc resection through a posterolateral thoracotomy. Overall 5-year survival rates with this regime were typically 30 to 40%, with poor prognosis in patients with positive mediastinal lymph nodes, T4 involvement, or incomplete resection. During the past decade, advancements in surgical technique and adjuvant therapy have improved the safety and completeness of resection as well as the probability of long-term survival. Alternative surgical approaches have been developed to facilitate more complete resection of tumors involving subclavian vessels and brachial plexus, and aggressive vertebral body resection has been performed in conjunction with neurosurgeons. Arguably the most important advance in the treatment of Pancoast tumors has been the recognition that induction chemoradiation substantially improves both the rate of complete resection and medium-term survival.

Combined Modality Therapy↗
PubMed2002

Pulmonary myelolipoma.

Myelolipoma is an extremely rare, benign pulmonary lesion, usually presenting as an asymptomatic pulmonary nodule. We describe myelolipoma of the lung in a 54-year-old man, present on roentgenogram for 20 years, and we review the natural history, pathology, diagnosis, and management of such lesions.

Humans↗
PubMedDate not supplied

Measuring performance for treating heart attacks and heart failure: the case for outcomes measurement.

To complement the current process measures for treating patients with heart attacks and with heart failure, which target gaps in quality but do not capture patient outcomes, the Centers for Medicare and Medicaid Services (CMS) has proposed the public reporting of hospital-level thirty-day mortality for these conditions in 2007. We present the case for including measurements of outcomes in the assessment of hospital performance, focusing on the care of patients with heart attacks and with heart failure. Recent developments in the methodology and standards for outcomes measurement have laid the groundwork for incorporating outcomes into performance monitoring efforts for these conditions.

Cardiology Service, Hospital↗