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Frederick L Grover

Publications and source records attributed to Frederick L Grover.

At least 19 recordsLinked to original sources
PubMed2006

Exploring the volume-outcome relationship for off-pump coronary artery bypass graft procedures.

BACKGROUND: The relationship between the surgical case volume and risk-adjusted clinical outcomes has been examined for different surgical specialties. The purpose of this study was to explore the relationship between the off-pump coronary artery bypass graft procedure volumes (OPCABG) with risk-adjusted outcomes within the Department of Veterans Affairs (VA) 44 cardiac surgery programs. METHODS: Based on VA Continuous Improvement in Cardiac Surgery Program data, the results of 5,076 OPCABG surgical procedures performed between October 1998 and September 2003 were analyzed. Hierarchical logistic regression models evaluated the relationship between OPCABG procedure volume with risk-adjusted 30-day operative mortality, perioperative morbidity, and 180-day mortality. Both a hospital's average OPCABG volume per 6-month period and the hospital's most recent 6-month OPCABG volume were examined. RESULTS: Hospital OPCABG average volume in a 6-month period ranged from 0.2 to 47.4 procedures; whereas the most recent 6-month OPCABG hospital volume ranged from 0 to 76 OPCABG per site. No relationship between the volume measures and the outcome variables was found. CONCLUSIONS: We did not find an association between OPCABG volume with short-term mortality, perioperative morbidity, or intermediate-term (180-day) mortality.

Aged↗
PubMed2005

ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with chronic heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Heart Failure Clinical Data Standards): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Failure Society of America.

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Chronic Disease↗
PubMed2005

Simultaneous LFA-1 and CD40 ligand antagonism prevents airway remodeling in orthotopic airway transplantation: implications for the role of respiratory epithelium as a modulator of fibrosis.

Airway remodeling is a prominent feature of certain immune-mediated lung diseases such as asthma and chronic lung transplant rejection. Under conditions of airway inflammation, the respiratory epithelium may serve an important role in this remodeling process. Given the proposed role of respiratory epithelium in nonspecific injury models, we investigated the respiratory epithelium in an immune-specific orthotopic airway transplant model. MHC-mismatched tracheal transplants in mice were used to generate alloimmune-mediated airway lesions. Attenuation of this immune injury and alteration of antidonor reactivity were achieved by the administration of combined anti-LFA-1/anti-CD40L mAbs. By contrast, without immunotherapy, transplanted airways remodeled with a flattening of respiratory epithelium and significant subepithelial fibrosis. Unopposed alloimmune injury for 10 days was associated with subsequent epithelial transformation and subepithelial fibrosis that could not be reversed with immunotherapy. The relining of donor airways with recipient-derived epithelium was delayed with immunotherapy resulting in partially chimeric airways by 28 days. Partial chimerism was sufficient to prevent luminal fibrosis. However, epithelial chimerism was also associated with airway remodeling. Therefore, there appears to be an intimate relationship between the morphology and level of chimerism of the respiratory epithelium and the degree of airway remodeling following alloimmune injury.

Animals↗
PubMed2005

Depression predicts mortality following cardiac valve surgery.

BACKGROUND: Depression is associated with mortality in several cardiovascular populations, but has not been evaluated in patients undergoing cardiac valve surgery. Because identifying nonsurgical mediators of survival is important for accurate risk adjustment and the development of interventions to improve outcomes of care, we evaluated the hypothesis that depression predicts mortality following cardiac valve surgery. METHODS: This prospective cohort study enrolled 648 patients undergoing valve surgery at 14 Veteran Administration hospitals. A preoperative mental health inventory (MHI) depression screen was performed in all patients and patients were classified as depressed or not depressed using the standard MHI cutoff score of less than or equal to 52. Multivariable logistic regression was used to evaluate the association between depression and 6-month all-cause mortality, adjusting for other clinical risk variables. RESULTS: Overall, 29.2% (189/648) of the patients were depressed at baseline. Depressed patients were younger, more frequently had New York Heart Association class III/IV symptoms, and more likely required emergent surgery, preoperative intravenous nitroglycerin, or intraaortic balloon pump. Unadjusted 6-month mortality was 13.2% for depressed patients compared with 7.6% for nondepressed patients (p = 0.03). In multivariable analyses, depression remained significantly associated with mortality (odds ratio 1.90; 95% confidence interval 1.07 to 3.40, p = 0.03). These findings were consistent across subgroups of patients undergoing aortic valve replacement, mitral valve replacement and valve replacement without coronary artery bypass graft. CONCLUSIONS: Preoperative depression is an independent risk factor for mortality following cardiac valve surgery. Depression screening should be incorporated into preoperative risk stratification, and future studies are warranted to determine if preoperative or postoperative interventions to treat depression can improve outcomes.

Adult↗
PubMed2005

The identification and development of Canadian coronary artery bypass graft surgery quality indicators.

OBJECTIVE: The study objective was to develop quality indicators for coronary artery bypass graft surgery that relate to quality of care, associate with preventable death, and could be reported on performance reports. METHODS: A comprehensive list of quality indicators was collected from quality improvement organizations including the Society For Thoracic Surgery, Northern New England Cardiovascular Disease Study Group, and Veteran's Affairs System. Indicators were collated from practice guidelines from the American College of Cardiology and the American Heart Association. A MEDLINE search using the keywords "quality indicators" and "coronary bypass" was completed. A 17-member multidisciplinary international expert panel was assembled, who voted using a 2-step Delphi process regarding association with quality of care, risk adjustment, association with preventable death, and inclusion on performance reports. RESULTS: A total of 149 quality indicators were examined. This list was distilled to 33 indicators related to quality of care, 10 indicators that could be adequately risk adjusted, 34 indicators related to preventable death, and 18 indicators to be included on performance reports. These selected indicators consisted of 19 outcome variables, 23 process of care variables, and 4 structure variables. The quality indicators believed to be useful on a Canadian institutional coronary artery bypass graft surgery report card included the following: 30-day mortality, in-hospital mortality, electrocardiographic myocardial infarction, red cell transfusion, allogeneic blood product transfusion, deep sternal wound infection, postoperative stroke, postoperative dialysis, intensive care unit readmission, intensive care unit length of stay, ventilation time, repeat cardiac operation, repeat surgery with cardiopulmonary bypass, repeat revascularization, waiting time to surgery, completion of surgery within a recommended waiting time, use of left internal thoracic artery graft, and institutional volume. CONCLUSIONS: This set of consensus quality indicators can be used as a standard list to be monitored by providers of coronary artery bypass graft surgery in an effort to continuously evaluate and improve their performance.

Canada↗
PubMed2005

Mortality after cardiac bypass surgery: prediction from administrative versus clinical data.

BACKGROUND: Risk-adjusted outcome rates frequently are used to make inferences about hospital quality of care. We calculated risk-adjusted mortality rates in veterans undergoing isolated coronary artery bypass surgery (CABS) from administrative data and from chart-based clinical data and compared the assessment of hospital high and low outlier status for mortality that results from these 2 data sources. STUDY POPULATION: We studied veterans who underwent CABS in 43 VA hospitals between October 1, 1993, and March 30, 1996 (n=15,288). METHODS: To evaluate administrative data, we entered 6 groups of International Classification of Diseases (ICD)-9-CM codes for comorbid diagnoses from the VA Patient Treatment File (PTF) into a logistic regression model predicting postoperative mortality. We also evaluated counts of comorbid ICD-9-CM codes within each group, along with 3 common principal diagnoses, weekend admission or surgery, major procedures associated with CABS, and demographic variables. Data from the VA Continuous Improvement in Cardiac Surgery Program (CICSP) were used to create a separate clinical model predicting postoperative mortality. For each hospital, an observed-to-expected (O/E) ratio of mortality was calculated from (1) the PTF model and (2) the CICSP model. We defined outlier status as an O/E ratio outside of 1.0 (based on the hospital's 90% confidence interval). To improve the statistical and predictive power of the PTF model, selected clinical variables from CICSP were added to it and outlier status reassessed. RESULTS: Significant predictors of postoperative mortality in the PTF model included 1 group of comorbid ICD-9-CM codes, intraortic balloon pump insertion before CABS, angioplasty on the day of or before CABS, weekend surgery, and a principal diagnosis of other forms of ischemic heart disease. The model's c-index was 0.698. As expected, the CICSP model's predictive power was significantly greater than that of the administrative model (c=0.761). The addition of just 2 CICSP variables to the PTF model improved its predictive power (c=0.741). This model identified 5 of 6 high mortality outliers identified by the CICSP model. Additional CICSP variables were statistically significant predictors but did not improve the assessment of high outlier status. CONCLUSIONS: Models using administrative data to predict postoperative mortality can be improved with the addition of a very small number of clinical variables. Limited clinical improvements of administrative data may make it suitable for use in quality improvement efforts.

Cardiopulmonary Bypass↗
PubMed2004

Prescription-filling rates for key medications in Veterans Affairs patients after coronary artery bypass grafting.

PURPOSE: The six-month prescription-filling rates for key secondary-prevention drugs in Department of Veterans Affairs (VA) patients who had undergone coronary artery bypass grafting (CABG) were studied. METHODS: Patient records for elective CABG from April 2000 through March 2002 (divided into four six-month periods) were analyzed. The study population included 8925 CABG-only patients surviving to hospital discharge. For each six-month period and in aggregate, the primary study endpoint was the six-month prescription-filling rate. RESULTS: Across the four six-month periods, prescription-filling rates increased for all categories of medications studied. There were modest progressive increases for lipid-lowering agents, statins, -blockers, angiotensin-converting-enzyme Inhibitors, and angiotensin-receptor blockers. The antithrombotic-filling rate averaged 88.5%. Filling rates for aspirin were much higher than for aspirin alternatives. CONCLUSION: Prescription-filling rates for post-CABG medications in VA facilities were generally high and suggested compliance with guidelines for the prevention of cardiovascular events.

Adrenergic beta-Antagonists↗
PubMed2004

Predictors of health-related quality of life after coronary artery bypass surgery.

BACKGROUND: Little is known about the determinants of health-related quality of life after coronary artery bypass surgery. We determined the predictors of overall physical and mental health status 6 months after the operation. METHODS: We evaluated 1,973 patients enrolled in a multicenter Veterans Affairs prospective cohort study who completed preoperative and 6-month postoperative Short Form-36 (SF-36) health status surveys. Multiple linear regression was used to identify the significant independent predictors of 6-month physical and mental component summary scores from the SF-36. RESULTS: In multivariable analyses adjusting for baseline health status, significant predictors of postoperative physical health status were a history of neurologic disease, peripheral vascular disease, chronic obstructive pulmonary disease, hypertension, current smoking, forced expiratory volume, left ventricular ejection fraction, and serum creatinine. Significant predictors of postoperative mental health status were a history of psychiatric disease, chronic obstructive pulmonary disease, current smoking, age, and New York Heart Association functional class. CONCLUSIONS: These predictors of health-related quality of life after coronary artery bypass surgery may be useful for preoperative risk assessment and counseling of patients with regard to anticipated health status outcomes. Factors such as current smoking and psychiatric disease may be targets for interventions to improve health-related quality of life outcomes.

Coronary Artery Bypass↗
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↗
PubMed2004

Predictors of cognitive decline following coronary artery bypass graft surgery.

BACKGROUND: A significant number of patients develop cognitive impairment that persists for months following coronary artery bypass grafting (CABG) surgery. Our objectives were to identify patient-related risk factors, processes of care, and the occurrence of any perioperative complications associated with cognitive decline. METHODS: Nine hundred thirty-nine patients enrolled in the Processes, Structures, and Outcomes of Care in Cardiac Surgery study undergoing CABG-only surgery at 14 Veterans Administration medical centers between 1992 and 1996 completed a short battery of cognitive tests at baseline and 6-months post-CABG. The composite cognitive score was based on the sum of errors for each individual item in the battery. Multiple linear regression analyses were used to identify independent predictors of the 6-month composite cognitive score. RESULTS: In multivariable analyses, patient characteristics associated with cognitive decline included cerebrovascular disease (p = 0.009), peripheral vascular disease (p = 0.007), history of chronic disabling neurologic illness (p = 0.016), and living alone (p = 0.049), while the number of years of education (p = 0.001) was inversely related to cognitive decline. After adjustment for baseline patient risk factors, the presence of any postoperative complication(s) (p = 0.001) was also associated with cognitive decline while cardiopulmonary bypass time (p = 0.008) was inversely related to cognitive decline. CONCLUSIONS: Patients with noncoronary manifestations of atherosclerosis, chronic disabling neurologic illness, or limited social support are at risk for cognitive decline after CABG surgery. In contrast, more years of education were associated with less cognitive decline. Preoperative assessment of risk factors identified in this study may be useful when counseling patients about the risk for cognitive decline following CABG surgery.

Aged↗
PubMed2004

Comparison of short-term mortality risk factors for valve replacement versus coronary artery bypass graft surgery.

BACKGROUND: Risk factors for 30-day operative (short-term) mortality following coronary artery bypass graft (CABG only) procedures are well established. However, little is known about how the risk factors for short-term mortality following valve replacement procedures (with or without a CABG procedure performed) compare with CABG only risk factors. METHODS: Department of Veterans Affairs (VA) records (65,585 records) were collected from October 1991 through March 2001 and analyzed. Risk factors for short-term mortality were compared across three subgroups of patients: CABG only surgery (n = 56,318), aortic valve replacement (AVR) with or without CABG (n = 7450), and mitral valve replacement (MVR) with or without CABG (n = 1817). Multivariable logistic regression analyses were used to compare the relative magnitude of risk for 19 candidate predictor variables across subgroups. RESULTS: Only three patient baseline characteristics differed significantly in magnitude of risk between the procedure groups. Partially or totally dependent functional status significantly increased the risk of short-term mortality for AVR patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.29-2.09) and MVR patients (OR 2.21, 95% CI 1.48-3.30), but not for CABG only patients (OR 1.04, 95% CI 0.93-1.16). Conversely, previous heart surgery and New York Heart Association functional class III or IV symptoms conferred greater magnitude of risk for CABG only patients compared with the valve subgroups. CONCLUSIONS: Overall, the risk factors for short-term mortality following valve replacement and CABG surgery appear to be relatively consistent. However, clinicians should be aware of the importance of preoperative functional status as a unique predictor of mortality following valve surgery.

Aged↗
PubMed2004

Relationship between processes of care and coronary bypass operative mortality and morbidity.

BACKGROUND: Information is limited regarding the effects of processes of care on cardiac surgical outcomes. Correspondingly, many recommended cardiac surgical processes of care are derived from animal experiments or clinical judgment. This report from the VA Cooperative Study in Health Services, "Processes, Structures, and Outcomes of Cardiac Surgery," focuses on the relationships between 3 process groups (preoperative evaluation, intraoperative care, and supervision by senior physicians) and a composite outcome, perioperative mortality and morbidity. METHODS: Data on 734 risk, process, and structure variables were collected prospectively on 3,988 patients who underwent coronary artery bypass grafting at 14 VA medical centers between 1992 and 1996. Data reduction was accomplished by examining data completeness and variation across sites and surgeon, using previously published data and clinical judgment. We then applied multivariable logistic regression to the 39 remaining processes of care to determine which were related to the composite outcome after adjusting for 17 patient-related risk factors and controlling for intraoperative complications. RESULTS: Our first analysis showed several measures of operative duration, the use of inotropic agents, transesophageal echo, lowest systemic temperature, and hemoconcentration/ultrafiltration, to be powerful predictors of the composite outcome. Because the use of inotropic agents and operative duration may be related to an intermediate outcome (eg, intraoperative complications), we performed a second analysis omitting these processes. The use of intraoperative transesophageal echo and hemoconcentration/ultrafiltration remained significantly associated with an increased risk of an event (odds ratios 1.60 and 1.36, respectively). CONCLUSIONS: Our results viewed in the context of past studies suggest the possibility that inotropic use, TEE, and hemoconcentration/ultrafiltration may have adverse effects on operative outcome. Further evaluation of these processes of care using observational data, as well as randomized trials when feasible, would be of interest.

Coronary Artery Bypass↗