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Edward L Hannan

Publications and source records attributed to Edward L Hannan.

At least 19 recordsLinked to original sources
PubMed2007

Is early too early? Effect of shorter stays after bypass surgery.

BACKGROUND: Postoperative stays after coronary artery bypass graft surgery (CABG) decreased substantially in the 1990s. Although shorter stays offer clinical benefits, premature discharge could increase adverse events and offset initial savings. This study examined the effect of early discharge after CABG on readmission/death and cost within 60 days of discharge home. Variability in hospitals' tendencies for early discharge and adverse outcomes was also explored. METHODS: Analyses were based on clinical and claims data for 55,889 New York CABG patients discharged home 1995 to 1998. Early discharge was defined as a postoperative stay below the 15th percentile for patients with similar risk. The likelihood of early discharge and its effect on readmission/death were examined using hierarchical logistic regression, accounting for patient risk and within-hospital correlation. The correlation between early discharge and adverse outcomes at the hospital level was assessed. The effect of early discharge on subsequent inpatient, outpatient, skilled nursing, and home health costs was examined in the Medicare subset. RESULTS: Overall, 17% of patients were discharged early, with increasing prevalence over time. The tendency to discharge early varied widely among hospitals (2% to 42% of patients). We found no association between hospitals' tendencies for early discharge and adverse outcomes. Lower postdischarge costs among patients discharged early (mean = 3,491 dollars versus 5,246 dollars for typical stays) resulted in average cumulative savings of 6,309 dollars. CONCLUSIONS: Patients selected for earlier discharge after CABG did not have increased adverse event rates or higher costs. Variation among hospitals in early discharge suggests that more efficient patient management could be achieved at some hospitals.

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PubMed2006

Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era.

BACKGROUND: The importance of completeness of revascularization by percutaneous coronary intervention in patients with multivessel disease is unclear in that there is little information on the impact of incomplete revascularization outside of randomized trials. The objective of this study is to compare long-term mortality and subsequent revascularization for percutaneous coronary intervention patients receiving stents who were completely revascularized (CR) with those who were incompletely revascularized (IR). METHODS AND RESULTS: Patients from New York State's Percutaneous Coronary Interventions Reporting System were subdivided into patients who were CR and IR. Then subsets of IR patients were contrasted with CR patients. Differences in long-term survival and subsequent revascularization for CR and IR patients were compared after adjustment for differences in preprocedural risk. A total of 68.9% of all stent patients with multivessel disease who were studied were IR, and 30.1% of all patients had total occlusions and/or > or =2 IR vessels. At baseline, the following patients were at higher risk: those who were older and those with more comorbid conditions, worse ejection fraction, and more renal disease and stroke. After adjustment for these baseline differences, IR patients were significantly more likely to die at any time (adjusted hazard ratio=1.15; 95% confidence interval, 1.01 to 1.30) than CR patients. IR patients with total occlusions and a total of > or =2 IR vessels were at the highest risk compared with CR patients (hazard ratio=1.36; 95% confidence interval, 1.12 to 1.66). CONCLUSIONS: IR with stenting is associated with an adverse impact on long-term mortality, and consideration should be given to either achieving CR, opting for surgery, or monitoring percutaneous coronary intervention patients with IR more closely after discharge.

Adult↗
PubMed2006

Differences in per capita rates of revascularization and in choice of revascularization procedure for eleven states.

BACKGROUND: A few studies have investigated differences in elective procedure rates across small and medium sized referral regions. The purposes of this study are to investigate differences in revascularizations across 11 entire states and to investigate differences in choice of revascularization procedure (percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG) surgery). METHODS: Age-sex adjusted rates per 100,000 population who were 20 or older were calculated for PCI, CABG surgery, and total revascularization for each state. Also, the risk-adjusted proportion of revascularized patients who underwent PCI was calculated for each state and differences were compared. RESULTS: We found variations in procedures performed per capita of 1.83-fold for PCI, 1.54-fold for CABG surgery, and 1.54-fold for total revascularization. For patients undergoing revascularization of two or more vessels, the age/sex adjusted maximum rate of 224 per 100,000 population over 20 years old in Florida was 53% higher than the minimum rate of 146 in Colorado. Higher catheterization rates per 1,000 Medicare enrollees and higher percent of white patients were significant predictors of higher revascularization rates, and density of specialists was a significant predictor of catheterization rate. The risk-adjusted percentage of revascularized patients with two or more arteries attempted who underwent PCI ranged from 10.4% in Oregon to 29.0% in Iowa. CONCLUSION: There are reasonably large differences among states in total revascularization rates and in type of revascularization among revascularization. These differences appear to be related to practice pattern differences. Future effort should be devoted to understanding the reason for these differences and the impact on patients' health and survival.

Adult↗
PubMed2006

A risk score to predict in-hospital mortality for percutaneous coronary interventions.

OBJECTIVES: Our purpose was to develop a risk score to predict in-hospital mortality for percutaneous coronary intervention (PCI) using a statewide population-based PCI registry. BACKGROUND: Risk scores predicting adverse outcomes after PCI have been developed from a single or a small group of hospitals, and their abilities to be generalized to other patient populations might be affected. METHODS: A logistic regression model was developed to predict in-hospital mortality for PCI using data from 46,090 procedures performed in 41 hospitals in the New York State Percutaneous Coronary Intervention Reporting System in 2002. A risk score was derived from this model and was validated using 2003 data from New York. RESULTS: The risk score included nine significant risk factors (age, gender, hemodynamic state, ejection fraction, pre-procedural myocardial infarction, peripheral arterial disease, congestive heart disease, renal failure, and left main disease) that were consistent with other reports. The point values for risk factors range from 1 to 9, and the total risk score ranges from 0 to 40. The observed and recalibrated predicted risks in 2003 were highly correlated for all PCI patients as well as for those in the higher-risk subgroup who suffered myocardial infarctions within 24 h before the procedure. The total risk score for mortality is strongly associated with complication rates and length of stay in the 2003 PCI data. CONCLUSIONS: The risk score accurately predicted in-hospital death for PCI procedures using future New York data. Its performance in other patient populations needs to be further studied.

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PubMed2006

Risk stratification of in-hospital mortality for coronary artery bypass graft surgery.

OBJECTIVES: The purpose of this research was to develop a risk index for in-hospital mortality for coronary artery bypass graft (CABG) surgery. BACKGROUND: Risk indexes for CABG surgery are used to assess patients' operative risk as well as to profile hospitals and surgeons. None has been developed using data from a population-based region in the U.S. for many years. METHODS: Data from New York's Cardiac Surgery Reporting System in 2002 were used to develop a statistical model that predicts mortality and to create a risk index based on a relatively small number of patient risk factors. The fit of the index was tested by applying it to another year (2003) of New York data and testing the correspondence of expected and observed mortality rates for each risk score in the index. RESULTS: The risk index contains a total of 10 risk factors (age, female gender, hemodynamic state, ejection fraction, pre-procedural myocardial infarction, chronic obstructive pulmonary disease, calcified ascending aorta, peripheral arterial disease, renal failure, and previous open heart operations). The score possible for each variable ranges from 0 to 5, and total risk scores possible range from 0 to 34. The highest score observed for any patient was 22, and 93% of the patients had scores of 8 or lower. When the risk index was applied to another year of New York data with a considerably lower mortality rate, the C-statistic was 0.782. CONCLUSIONS: The risk index appears to be a valuable tool for predicting patient risk when applied to another year of New York data. It should now be tested against other risk indexes in a variety of geographical regions.

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PubMed2006

Trends in postoperative length of stay after bypass surgery.

BACKGROUND: Although single-site studies have reported reductions in coronary artery bypass graft (CABG) surgery length of stay (LOS) over the last 15 years, less information is available regarding overall temporal trends and interhospital variability. This study examined trends in postoperative LOS, associated rates of transfer at discharge and variation among hospitals in LOS at CABG hospitals in New York State. METHODS: Trends in postoperative LOS and transfers at discharge for 105,842 CABG patients treated in 30 hospitals in New York between 1992 and 1998 were first described graphically. Mixed models were then used to assess temporal trends and interhospital variability in LOS, accounting for differences in patient risk and within-hospital correlation in outcomes. Clinical and LOS data were obtained from the Cardiac Surgery Reporting System. Additional information was extracted from the New York Statewide Planning and Research Cooperative System. RESULTS: Postoperative LOS decreased 30% between 1992 and 1998 after adjusting for patient risk. A concurrent increase in the probability of nonacute patient transfers occurred over time, with the most pronounced increase in patients with stays exceeding 5 days. Underlying the downward trend in LOS was substantial interhospital variability that peaked in 1994 and remained significant in 1998. Stays were longer at hospitals located in New York City. CONCLUSIONS: The downward shift in LOS observed in the 1990s was achieved in part by an increase in nonacute care transfers, reflecting a shift in care setting. After decreasing trends in postoperative stays tapered off, significant variability among hospitals remained.

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PubMed2006

Relationship between provider volume and postoperative complications for bariatric procedures in New York State.

BACKGROUND: Although the number of bariatric procedures has grown recently, few studies have focused on the relationship between provider volume and outcomes among patients undergoing a bariatric procedure. STUDY DESIGN: Using New York State's inpatient discharge database, we identified adults undergoing a bariatric procedure in New York State between January 1, 2003 and December 31, 2003 (n=7,868). Separate multivariable statistical models were constructed to examine the relationship between surgeon volume and hospital volume and postoperative complications (using surgeon volume cutpoints of 25, 50, 100, 150 and hospital volume cutpoints of 100, 125, 150, 200) while controlling for demographic characteristics and comorbidity. RESULTS: There was a considerably higher likelihood of postoperative complications among surgeons performing 100 or fewer bariatric procedures compared with those performing more than 100 procedures (odds ratio [OR]: 2.39, 95% CI: 1.59 to 3.59) and for those performing 150 or fewer procedures compared with those performing more than 150 procedures (odds ratio: 2.05, 95% CI: 1.29 to 3.25) after risk adjustment. Likewise, for each of the four hospital volume cutpoints, there was a notably higher likelihood of postoperative complications in the lower volume hospitals. Analyses of the interaction between surgeon and hospital volume indicated a markedly higher likelihood of postoperative complications among patients operated on by a low-volume surgeon (100 procedures or fewer) in a low-volume hospital (150 procedures or fewer) or a low-volume surgeon in a high-volume hospital than among patients operated on by a high-volume surgeon in a high-volume hospital. CONCLUSIONS: The likelihood of postoperative complications from bariatric procedures is greater for patients with low-volume surgeons or in low-volume hospitals.

Adult↗
PubMed2006

Veterans Health Administration patients' use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals.

OBJECTIVE: We sought to quantify Veterans Health Administration (VA) patients' utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n=6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals. RESULTS: VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal. CONCLUSIONS: For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.

Angioplasty, Balloon, Coronary↗
PubMed2006

Predictors of in-hospital postoperative complications among adults undergoing bariatric procedures in New York state, 2003.

BACKGROUND: Our aim was to determine the relationship between patient level characteristics and in-hospital postoperative complications among obese adults who underwent a bariatric procedure in New York state in 2003. Understanding patient level factors that predict or are associated with adverse outcomes among bariatric surgery patients can help to identify patients who need to be monitored particularly carefully. METHODS: Using New York's inpatient discharge database, we identified adults who underwent a bariatric operation between January 1, 2003 and December 31, 2003 (n=7,868). Following preliminary descriptive analyses, a stepwise logistic regression model was constructed to identify significant patient level predictors of postoperative complications. Patient level risk factors included age, gender, race/ethnicity, and 24 co-morbid conditions. RESULTS: 6.8% of adults undergoing a bariatric procedure in New York in 2003 experienced one or more of the postoperative complications included in the study. Respiratory complications were the most common type of complication, with >2% of patients experiencing pneumonia, collapsed lung, and/or respiratory complications secondary to the operation. Multivariate analyses by stepwise logistic regression identified age > or =50 years, male gender, Hispanic ethnicity, congestive heart failure, cardiac arrhythmia, other neurological disorders, and peptic ulcer as predictors of complications. CONCLUSIONS: Certain subpopulations of persons undergoing bariatric procedures may be at increased risk for adverse events and will need to be monitored carefully.

Adult↗
PubMed2005

Preoperative status and risk of complications in patients with hip fracture.

BACKGROUND: Limited information is available on preoperative status and risks for complications for older patients having surgery for hip fracture. Our objective was to identify potentially modifiable clinical findings that should be considered in decisions about the timing of surgery. METHODS: We conducted a prospective cohort study with data obtained from medical records and through structured interviews with patients. A total of 571 adults with hip fracture who were admitted to 4 metropolitan hospitals were included. RESULTS: Multiple logistic regression was used to identify risk factors (including 11 categories of physical and laboratory findings, classified as mild and severe abnormalities) for in-hospital complications. The presence of more than 1 (odds ratio [OR] 9.7, 95% confidence interval [CI] 2.8 to 33.0) major abnormality before surgery or the presence of major abnormalities on admission that were not corrected prior to surgery (OR 2.8, 95% CI 1.2 to 6.4) was independently associated with the development of postoperative complications. We also found that minor abnormalities, while warranting correction, did not increase risk (OR 0.70, 95% CI 0.28 to 1.73). CONCLUSIONS: In this study of older adults undergoing urgent surgery, potentially reversible abnormalities in laboratory and physical examination occurred frequently and significantly increased the risk of postoperative complications. Major clinical abnormalities should be corrected prior to surgery, but patients with minor abnormalities may proceed to surgery with attention to these medical problems perioperatively.

Adult↗
PubMed2005

A multistate comparison of patient characteristics, outcomes, and treatment practices in acute myocardial infarction.

The primary purpose of this study was to examine variations in patient characteristics, outcomes, and treatment practices in acute myocardial infarction (AMI) across 11 states. Data from 11 states were extracted from the Healthcare Cost and Utilization Project State Inpatient Dataset. Patients who had a primary diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification, code 410.x1) from 11 states were extracted from the Healthcare Cost and Utilization Project 1999 dataset. Bivariate comparisons were conducted to examine the characteristics, treatment practices, and outcomes of patients who had AMI. Multivariate regression models were used to examine the association between geographic location (and other factors) and the likelihood of in-hospital mortality, undergoing coronary artery bypass grafting (CABG), or percutaneous coronary interventions (PCIs). Results revealed considerable variations across states in practice patterns and treatment outcomes. New York had the highest average length of stay (8.2 days, p <0.01), rate of patients who had AMI being transferred (20.7%, p <0.01), and in-hospital case fatality rate (10.7%, p <0.01) and the lowest rate of alive discharges being routine (65.6%, p <0.01). PCI was performed 2 times as often as CABG for patients who had AMI (23.9% vs 11.3%, p <0.01), with patients who underwent CABG being transferred more often. Multivariate analyses showed that state of residence, age, female gender, transfer status, and number of co-morbidities were predictors of in-hospital mortality and the likelihood of undergoing CABG or PCI. In conclusion, large differences in practice patterns and treatment outcomes exist across states.

Age Distribution↗
PubMed2005

Volume-outcome relationships for percutaneous coronary interventions in the stent era.

BACKGROUND: Most studies that are the basis of recommended volume thresholds for percutaneous coronary interventions (PCIs) predate the routine use of stent placement. METHODS AND RESULTS: Data from New York's Percutaneous Coronary Interventions Reporting System in 1998 to 2000 (n=107 713) were used to examine the impact of annual hospital volume and annual operator volume on in-hospital mortality, same-day coronary artery bypass graft (CABG) surgery, and same-stay CABG surgery after adjustment for differences in patients' severity of illness. For a hospital-volume threshold of 400, the odds ratios for low-volume hospitals versus high-volume hospitals were 1.98 (95% CI, 1.17, 3.35) for in-hospital mortality, 2.07 (95% CI, 1.36, 3.15) for same-day CABG surgery, and 1.51 (95% CI, 1.03, 2.21) for same-stay CABG surgery. For an operator-volume threshold of 75, the odds ratios for low-volume versus high-volume operators were 1.65 (95% CI, 1.05, 2.60) for same-day CABG surgery and 1.55 (95% CI, 1.10, 2.18) for same-stay CABG surgery. Operator volume was not significantly associated with mortality. Also, for hospital volumes below 400 and operator volumes below 75, the respective odds of mortality, same-day CABG surgery, and same-stay CABG surgery were 5.92, 4.02, and 3.92 times the odds for hospital volumes of 400 or higher and operator volumes of 75 or higher. CONCLUSIONS: Higher-volume operators and hospitals continue to experience lower risk-adjusted PCI outcome rates.

Angioplasty, Balloon, Coronary↗
PubMed2005

Long-term outcomes of coronary-artery bypass grafting versus stent implantation.

BACKGROUND: Several studies have compared outcomes for coronary-artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), but most were done before the availability of stenting, which has revolutionized the latter approach. METHODS: We used New York's cardiac registries to identify 37,212 patients with multivessel disease who underwent CABG and 22,102 patients with multivessel disease who underwent PCI from January 1, 1997, to December 31, 2000. We determined the rates of death and subsequent revascularization within three years after the procedure in various groups of patients according to the number of diseased vessels and the presence or absence of involvement of the left anterior descending coronary artery. The rates of adverse outcomes were adjusted by means of proportional-hazards methods to account for differences in patients' severity of illness before revascularization. RESULTS: Risk-adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. For example, the adjusted hazard ratio for the long-term risk of death after CABG relative to stent implantation was 0.64 (95 percent confidence interval, 0.56 to 0.74) for patients with three-vessel disease with involvement of the proximal left anterior descending coronary artery and 0.76 (95 percent confidence interval, 0.60 to 0.96) for patients with two-vessel disease with involvement of the nonproximal left anterior descending coronary artery. Also, the three-year rates of revascularization were considerably higher in the stenting group than in the CABG group (7.8 percent vs. 0.3 percent for subsequent CABG and 27.3 percent vs. 4.6 percent for subsequent PCI). CONCLUSIONS: For patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting.

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PubMed2005

Physiologic trauma triage criteria in adult trauma patients: are they effective in saving lives by transporting patients to trauma centers?

BACKGROUND: Trauma triage criteria have been in place for many years and were updated in 1999 by the American College of Surgeons. We are unaware of any studies that have directly examined the ability of these criteria to reduce short-term mortality by transporting patients to trauma centers rather than to noncenters. STUDY DESIGN: Retrospective observational cohort study of adult patients meeting physiologic triage criteria who were transported to 9 regional (Level I) trauma centers, 21 area (Level II) trauma centers, and 119 noncenters in New York in 1996 to 1998. For each triage criterion and for one or more of the criteria, odds ratios and their confidence intervals for mortality in regional and area trauma centers versus noncenters and odds ratios and their confidence intervals for mortality in regional centers versus area centers and noncenters were used to measure performance. RESULTS: Patients in regional trauma centers had considerably lower mortality than patients in area trauma centers and noncenters for two individual triage criteria and for patients with one or more triage criteria (odds ratio, 0.75; 95% CI, 0.63-0.90 for one or more criteria). Also, patients with head injuries who were treated in regional centers had notably lower mortality than patients in other hospitals (odds ratio, 0.67; 95% CI, 0.53-0.85). CONCLUSIONS: In New York, regional trauma centers exhibit considerably lower mortality than area trauma centers or noncenters for adult patients meeting specific physiologic triage criteria. It is important that population-based trauma systems with data from centers and noncenters be developed for the purpose of evaluating and redesigning trauma systems.

Adolescent↗
PubMed2005

Clinical and operative predictors of outcomes of carotid endarterectomy.

OBJECTIVE: The net benefit for patients undergoing carotid endarterectomy is critically dependent on the risk of perioperative stroke and death. Information about risk factors can aid appropriate selection of patients and inform efforts to reduce complication rates. This study identifies the clinical, radiographic, surgical, and anesthesia variables that are independent predictors of deaths and stroke following carotid endarterectomy. METHODS: A retrospective cohort study of patients undergoing carotid endarterectomy in 1997 and 1998 by 64 surgeons in 6 hospitals was performed (N = 1972). Detailed information on clinical, radiographic, surgical, anesthesia, and medical management variables and deaths or strokes within 30 days of surgery were abstracted from inpatient and outpatient records. Multivariate logistic regression models identified independent clinical characteristics and operative techniques associated with risk-adjusted rates of combined death and nonfatal stroke as well as all strokes. RESULTS: Death or stroke occurred in 2.28% of patients without carotid symptoms, 2.93% of those with carotid transient ischemic attacks, and 7.11% of those with strokes (P < .0001). Three clinical factors increased the risk-adjusted odds of complications: stroke as the indication for surgery (odds ratio [OR], 2.84; 95% confidence interval [CI] = 1.55-5.20), presence of active coronary artery disease (OR, 3.58; 95% CI = 1.53-8.36), and contralateral carotid stenosis > or =50% (OR, 2.32; 95% CI = 1.33-4.02). Two surgical techniques reduced the risk-adjusted odds of death or stroke: use of local anesthesia (OR, 0.30; 95% CI = 0.16-0.58) and patch closure (OR, 0.43; 95% CI = 0.24-0.76). CONCLUSIONS: Information about these risk factors may help physicians weigh the risks and benefits of carotid endarterectomy in individual patients. Two operative techniques (use of local anesthesia and patch closure) may lower the risk of death or stroke.

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