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Biomedical subjects

G K Sethi

Publications and source records attributed to G K Sethi.

At least 19 recordsLinked to original sources
PubMed1995

Why it is important to demonstrate linkages between outcomes of care and processes and structures of care.

This first article of the supplement describes the rationale for the Department of Veterans Affairs Cooperative Study, Processes, Structures, and Outcomes in Cardiac Surgery, which was designed to demonstrate statistically and clinically meaningful linkages between processes and structures of care and the outcomes of that care. United States health care is in an era of great enthusiasm for the use of health care outcomes to assess and improve quality of care. An important reason for this enthusiasm is the concern that processes and structures of care, which traditionally have been selected arbitrarily without valid linkages to favorable outcomes, may not result in the desired outcomes of care. Furthermore, health care outcomes are intrinsic to the definition of quality of care and should be relatively free of preconceived biases about how care should be provided. However, the limitations to outcomes-directed quality improvement have been inadequately recognized. These limitations include the following: (1) mortality, the most commonly used outcome, is usually sufficiently rare, resulting in inadequate statistical power; (2) nonfatal outcomes are much more difficult to measure reliably; (3) outcomes may not be measurable for an extended period of time after the care episode, making linkage to quality improvement inefficient; and (4) patients often desire good processes of care as well as favorable outcomes. A review of the literature found relatively few reports linking processes and structures of care to favorable outcomes. Significant relationships between processes of care and outcomes have been reported for several medical conditions (congestive heart failure, acute myocardial infarction, pneumonia, and stroke) when the patient has been considered the unit of analysis. However, there is a paucity of published meaningful process-outcome or structure-outcome linkages for surgical conditions or for any conditions when the hospital has been the focus of analysis. The authors concluded that quality improvement will proceed most efficiently and effectively if all three elements of Donabedian's quality triad (processes, structures, and outcomes) are used and if the processes and structures chosen have been demonstrated to be associated with desired outcomes of care.

Cardiac Surgical Procedures↗
PubMed1995

The Processes, Structures, and Outcomes of Care in Cardiac Surgery study protocol.

Recently, a growing interest has arisen in defining and measuring health care outcomes. Although outcome measures may be used as potential quality-of-care screens, outcomes cannot indicate directly how care might be improved. Thus, the Processes, Structures, and Outcomes of Care in Cardiac Surgery (PSOCS) study was designed to investigate the linkages between the processes and structures of care with risk-adjusted outcomes for cardiac surgery care. Data are being collected on a comprehensive array of risk factors, processes, structures, and outcomes of care at 14 Veterans Affairs Medical Centers for this prospective, observational study. Approximately 6,000 cardiac surgery patients will be enrolled in this study over a 4.5-year period. Patient selection is based on a 6 workday rotating sampling frame with an oversampling of emergent patients. During the study, a register of all patients undergoing cardiac surgery at these centers is being maintained to assess the overall context of patient recruitment. The study will continue to enroll patients through December 1996. Major study end points extend beyond traditional measures of 30-day mortality and morbidity to encompass more innovative intermediate outcome measures, including changes in physical functional status and health-related quality of life.

Aged↗
PubMed1995

Relationships between patient-related risk factors, processes, structures, and outcomes of cardiac surgical care. Conceptual models.

The processes, Structures, and Outcomes of Care in Cardiac Surgery (PSOCS) study involves data collection on a comprehensive array of patient risk factors, processes, structures, and short-term outcomes of care at 14 participating Veterans Administration medical centers. This article summarizes the PSOCS conceptual models that serve as the theoretical framework for analyzing the hypothesized risk-process-structure-outcome relationships being investigated. The PSOCS data set includes more than 1,100 variables related to each patient and more than 300 variables related to provider-specific and facility-specific characteristics. This massive data set presents a formidable analytic challenge. The conceptual modeling process involved four-steps: 1) establishing a vision of the general conceptual model defining the overall risk-process-structure-outcome relationships, 2) developing specific hypotheses or subhypotheses, 3) visualizing a hierarchical set of dimensions and subdimensions, and 4) uniquely assigning each variable collected in the study to a dimension or subdimension for purposes of testing the study's primary hypotheses. A multidisciplinary team participated in this modeling process. The goal of the conceptual modeling process is to identify clearly the actions (ie, the changes in either processes or structures that are linked to risk-adjusted patient outcomes) that can be taken by clinicians, management, and policymakers to improve the quality of cardiac surgical care.

Cardiac Surgical Procedures↗
PubMed1995

Variations in processes and structures of cardiac surgery practice.

It is hypothesized that variations in the processes and structures of the selection of patients and the conduct of the surgical procedure may influence risk-adjusted outcome in patients undergoing cardiac surgery. For this reason, the results of the pilot phase of this Veterans Affairs cooperative study were reviewed to determine the variation in the operative practices at six pilot institutions. There were large variations in the percentage of elective, urgent, and emergent cases at each institution, ranging from 58% to 96% elective, 3% to 31% urgent, and 1% to 8% emergent. There was also a tenfold increase in the preoperative use of intra-aortic balloon pump for control of unstable angina, varying from 0.8% to 10.6%. Five of the six centers had accredited thoracic surgical residency programs. There was large variation in the preoperative participation of attending surgeons, from 100% participation at three centers to less than 5% in one. The operation was performed by the attending surgeon in 28% of cases, but this varied from 0% to 100%, depending on the hospital. Cold cardioplegia was used almost uniformly (99%) for myocardial protection; the use of retrograde cardioplegia varied from 2% to 89% among hospitals, and the use of blood cardioplegia ranged from 0% to 100%, with an average of 54% of cases. The use of myocardial temperature monitoring varied between hospitals, from 25% to 99%. The use of the cell saving devices to scavenge shed blood varied from 5% to 99%, and the frequency of the use of banked blood varied from 25% to 65%, depending on the institution. The internal mammary artery was used for 67% patients undergoing coronary artery bypass graft, with a variation between hospitals of 39% to 83%. One hospital used a single cross-clamping technique for the performance of proximal anastomoses in 95% of cases, as opposed to all other hospitals, who used this technique in less than 10% of cases. Aortic venting varied from 58% to 98% and left ventricular venting from 1% to 38%. The use of porcine valves varied approximately 15% in three hospitals to 30% to 40% in the other three hospitals. There were tremendous variations in the duration of operative procedure (5.2-7.3 hours), actual operating time (4.0-5.6 hours), total cardiopulmonary bypass duration (102-146 minutes), and ischemic time (50-87 minutes). The use of inotropic support varied from 41% to 91% between hospitals.(ABSTRACT TRUNCATED AT 400 WORDS)

Aged↗
PubMed1995

Variations in the processes and structures of cardiac surgery nursing care.

Nurses play an invaluable role as key members of the cardiac surgery patient's medical care team. Over the last century, the nursing profession has become more independent and autonomous. Despite the widespread use of nursing quality indicators, the effect of nursing-specific processes and structures of care on patient outcomes is unknown. Thus, the Processes, Structures, and Outcomes of Care in Cardiac Surgery (PSOCS) study was initiated, in part, to determine the potential effect of nursing processes and structures of care on cardiac surgery patients' risk-adjusted outcomes. In this article, the authors summarize the key components of nursing structures of care incorporated in the PSOCS study. Nursing process variables were not sufficiently designed into the study to address hypotheses relating nursing care processes to patient outcomes. An analysis of the pilot test data from September 1992 to September 1993 demonstrated potentially important variations between the six pilot centers regarding nursing care provider profiles (eg, educational preparation, specialty certification, and experience levels) and nursing staff ratios (eg, within the surgical intensive care unit). When linked to risk-adjusted patient outcomes, these variations in nursing structure of care may offer important insights toward improving the quality of care of cardiac surgery patients.

Adult↗
PubMed1995

Evaluating anesthesia health care delivery for cardiac surgery. The role of process and structure variables.

Anesthesia care is an integral component of cardiac surgery. Emphasis on cost-effectiveness and decreased hospital stay has prompted reevaluation of anesthesia practice. However, the role of anesthesia process and structure variables in relation to patient outcomes is largely unknown. Processes, Structures and Outcomes of Care in Cardiac Surgery is the first epidemiologic study to collect data on anesthesia processes, such as the pharmacologic components of anesthesia and types of cardiovascular monitors used. Structures of care, such as resident staffing, supervision, completeness of documentation, and training and experience of care providers, are also being assessed. Pilot data collected from September 1992 to September 1993 demonstrate substantial variation between the six study sites in selected processes and structures. Despite the near-universal use of narcotic anesthesia as the primary anesthetic technique, variation in the type of opioid and adjuvant benzodiazepine used was observed. Regarding invasive hemodynamic monitoring, most centers used only one type of catheter. Intraoperative transesophageal echocardiography was used commonly at several centers for valve surgery, whereas other centers did not use it at all. Its use during coronary artery bypass grafting was less common. Assessment of the preoperative anesthesia note revealed that coronary anatomy and ventricular function were noted in nearly all instances. However, a clear notation that risks and benefits of anesthesia were discussed was less frequent. Structures related to anesthesia attending staffing, board certification, and experience revealed variation. Some sites had smaller and/or more experienced attending staffs, whereas others had larger and/or less experienced staffs. These pilot findings appear to validate the authors' hypotheses that variations in anesthesia practice are present within the Veterans Affairs system. They suggest that the variable set is robust enough to relate processes and structures of anesthesia care to patient outcome.

Anesthesiology↗
PubMed1995

Self-report measures for assessing treatment outcomes in cardiac surgery patients.

Patient self-report measures are increasingly valued as outcome variables in health services research studies. In this article, the authors describe the Functional Status, Health Related Quality of Life, Life Satisfaction, and Patient Satisfaction scales included in the Processes, Structures, and Outcomes of Cardiac Surgery (PSOCS) cooperative study underway within the Department of Veterans Affairs health care system. In addition to reporting on the baseline psychometric characteristics of these instruments, the authors compared preoperative Medical Outcomes Study SF-36 data from the study patients with survey data from a probability sample of the US population and with preoperative data on cardiac surgery patients from a high volume private sector surgical practice. Descriptive analyses indicate that the SF-36 profiles for all of the cardiac patients are highly similar. The Veterans Affairs and private sector patients report diminished physical functioning, physical role functioning, and emotional role functioning as well as reduced energy relative to an age-matched comparison sample. At the same time, however, the Veterans Affairs patients evidenced lower levels of capacity on most of the SF-36 dimensions relative to the private sector patients.

Cardiac Surgical Procedures↗
PubMed1995

An analysis of interobserver reliability and representativeness of data from the Veterans Affairs Cooperative Study on Processes, Structures, and Outcomes in Cardiac Surgery.

The authors made some preliminary judgments regarding the reliability and representativeness of the data in the early stages of the Veterans Affairs Cooperative Study entitled Processes, Structures, and Outcomes of Care in Cardiac Surgery (PSOCS). Preliminary PSOCS interobserver reliability and potential patient and site selection bias reported were based on comparisons with identical risk, procedure, and outcome data items collected independently in the Continuous Improvement in Cardiac Surgery Study. PSOCS interobserver reliability for this limited set of variables was good to excellent. At the six pilot centers, there were few important differences between patients entered into PSOCS and those not entered. The 14 Veterans Affairs medical centers that will participate in the full-scale PSOCS study and the 29 nonparticipating centers exhibited similar patient populations. will be valuable.

Cardiac Surgical Procedures↗
PubMed1995

Development of an interactive data base management system for capturing large volumes of data.

Accurate collection and successful management of data are problems common to all scientific studies. For studies in which large quantities of data are collected by means of questionnaires and/or forms, data base management becomes quite laborious and time consuming. Data base management comprises data collection, data entry, data editing, and data base maintenance. In this article, the authors describe the development of an interactive data base management (IDM) system for the collection of more than 1,400 variables from a targeted population of 6,000 patients undergoing heart surgery requiring cardiopulmonary bypass. The goals of the IDM system are to increase the accuracy and efficiency with which this large amount of data is collected and processed, to reduce research nurse work load through automation of certain administrative and clerical activities, and to improve the process for implementing a uniform study protocol, standardized forms, and definitions across sites.

Cardiac Surgical Procedures↗
PubMed1992

Implications of third heart sounds in patients with valvular heart disease. The Veterans Affairs Cooperative Study on Valvular Heart Disease.

BACKGROUND: The presence of third heart sounds in patients with valvular heart disease is often regarded as a sign of heart failure, but it may also depend on the type of valvular disease. METHODS: We assessed the prevalence of third heart sounds and the relation between third heart sounds and cardiac function in 1281 patients with six types of valvular heart disease. RESULTS: The prevalence of third heart sounds was higher in patients with mitral regurgitation (46 percent) or aortic regurgitation (28 percent) than in those with aortic stenosis (11 percent) or mitral stenosis (8 percent). The left ventricular ejection fraction was significantly lower (P less than 0.001) when a third heart sound was detected in patients with aortic stenosis (0.38, vs. 0.56 in those without third heart sounds) or mixed aortic valve disease (0.40 vs. 0.55). However, the ejection fraction was only slightly lower in patients with mitral regurgitation and third heart sounds (0.51 vs. 0.57, P = 0.03). The pulmonary-capillary wedge pressure was higher (P less than 0.001) when a third heart sound was detected in patients with aortic stenosis (18.6 mm Hg, vs. 12.1 mm Hg in those without third heart sounds). There was no association between the wedge pressure and third heart sounds in patients with mitral regurgitation. The prevalence of third heart sounds increased with the severity of mitral regurgitation. CONCLUSIONS: In patients with mitral regurgitation, third heart sounds are common but do not necessarily reflect left ventricular systolic dysfunction or increased filling pressure. In patients with aortic stenosis, third heart sounds are uncommon but usually indicate the presence of systolic dysfunction and elevated filling pressure.

Adult↗
PubMed1992

Improved sterile technique diminishes the incidence of positive line cultures in cardiovascular patients.

In order to determine the incidence of positive line cultures, especially as affected by differing protocols for line insertion, cultures were obtained from lines in residence for up to 4 days from cardiac patients (who received Cefuroxime) and vascular patients (who received Cefazolin) as prophylaxis perioperatively. Positive cultures were obtained from 95 (19%) of 496 lines in cardiac patients and 83 (31%) of 261 lines in vascular patients. There was a linear relationship between duration of line residence and the incidence of positive line cultures, increasing from 14% on Day 1 to 33% on Day 4. The use of full sterile technique at the time of insertion halved the incidence of subsequent positive line cultures. Four of the 403 (1%) patients each had a single episode of postoperative line sepsis. Another four patients developed wound infections with the same organisms as cultured from their lines. One patient has had a vascular graft infection with the same organism cultured as was isolated from a Swan-Ganz line 1 year previously. These data suggest that monitoring lines should be inserted using full sterile technique and removed as soon as the patient is hemodynamically stable.

Cardiac Surgical Procedures↗
PubMed1992

Peripheral vascular disease in heart transplant recipients.

The improved longevity of heart transplant recipients demands heightened awareness of the long-term complications of the procedure. Between 1979 and 1990, 232 patients received 241 heart transplants at our institution. Accelerated coronary atherosclerosis occurred in 45 (19%) of the 232 patients, typically appearing within 2 years of transplantation, whereas peripheral vascular disease (PVD) appeared in 23 (10%) of the 232 patients, usually within 3 years of transplantation. In the patients with PVD, 13 had occlusive disease, nine had aneurysms, and one patient suffered a vertebral artery dissection. Accelerated coronary atherosclerosis afflicted 12 (52%) of the 23 patients affected by PVD (p < 0.05) and preceded the development of PVD in all 12. Logistic regression analysis revealed risk factors predictive of the development of PVD after transplantation to be a pretransplant history of ischemic cardiomyopathy and posttransplant hypertension and hypertriglyceridemia (p < 0.05), with the presence of more than one risk factor increasing the probability of development of PVD. Those patients thus identified as at risk should be closely monitored for the development of PVD. Aggressive medical management of hypertension and hyperlipidemia in this subpopulation may forestall or prevent the development of peripheral vascular disease after heart transplantation.

Adult↗
PubMed1992

Futility of yearly heart biopsies in patients undergoing heart transplantation.

Three hundred thirty-eight endomyocardial biopsies, performed as part of the routine annual evaluation at 1 or more years after transplantation in 211 patients, were reviewed. In only two instances (0.6%) were the histologic findings suggestive, but not pathognomonic, of acute rejection. Both patients were treated for rejection and are doing well at 4 and 6 years postoperatively. On the basis of the results of this study, we believe that routine yearly heart biopsies in asymptomatic patients are not necessary for long-term care of patients after heart transplantation, and we believe they should be performed only if there is clinical suspicion of rejection or as part of a research protocol.

Actuarial Analysis↗
PubMed1991

Lipid peroxidation: a possible factor in late graft failure of coronary artery bypass grafts.

Atherosclerosis is the paramount cause of late vein graft failure after coronary artery bypass grafting. Lipid peroxidation, which may play a significant role in the initiation and progression of atherosclerosis, was examined in segments of vein grafts (n = 6) harvested at reoperation for coronary disease. These were analyzed for cholesterol, phospholipid, triglyceride, and lipid peroxides. Nonatherosclerotic vascular tissues, including coronary arteries (n = 6), saphenous veins (n = 9), and donor aortic specimens (n = 11) were analyzed for comparison. Risk factors for atherosclerosis including elevated serum cholesterol and triglycerides, smoking, and hypertension were more frequent in patients with coronary artery disease compared to organ donors. Lipid peroxides were elevated in explanted vein grafts when compared to either saphenous vein, coronary artery or donor aorta. Lipid peroxides were not significantly different in saphenous vein when compared to coronary artery, but levels in both of these tissues were greater than in donor aorta. Although increased levels of lipid peroxides in explanted veins may simply reflect morphologic changes in these grafts, the known effects of lipid peroxides on a number of biochemical events suggest that they may contribute directly to graft failure after coronary artery bypass grafting.

Adolescent↗
PubMed1991

Abdominal aortic aneurysm in the patient undergoing cardiac transplantation.

In the past 3 years at our institution 130 patients have undergone cardiac transplantation for ischemic cardiomyopathy in 49 (38%), idiopathic cardiomyopathy in 42 (32%), viral cardiomyopathy in 9 (6.9%), pulmonary hypertension in 8 (6%), and graft atherosclerosis in 2 (1.5%). Routine preoperative abdominal ultrasonography was performed on 98 (75%) of these patients with specific visualization of the abdominal aorta in 93 (95%). Abdominal aortic aneurysms (all infrarenal) were found before operation in four patients and only in the subgroup undergoing transplantation for ischemic heart disease (10.5%). They measured 3.4, 4.5, 3.6, and 3.8 cm before transplantation. Periodic evaluation by ultrasonography was carried out after transplantation during the 3-year period of this study. One aneurysm that was initially 3.6 cm increased to 4.0 cm and ruptured 2 months after transplantation. The patient died despite emergent surgery. Aneurysms in three patients who demonstrated rapid aneurysm expansion after transplantation were successfully repaired at 5, 20, and 33 months after transplantation when the lesions reached 5.5, 5.9, and 4.8 cm. A fifth patient with an initially normal (1.5 cm) aorta developed a symptomatic aneurysm of 4.1 cm, which was repaired uneventfully. The average expansion rate of these aneurysms after transplantation was 0.74 +/- 0.15 cm/year. This experience suggests that aneurysms are limited to patients undergoing transplantation for ischemic heart disease. Ultrasound examination may be appropriate for preoperative screening. Careful aortic surveillance after transplantation is important in patients having transplantation for ischemic cardiomyopathy because of the apparent rapid expansion rate compared to aneurysms in the population not receiving transplants.

Aorta, Abdominal↗
PubMed1991

Comparison of postoperative complications between saphenous vein and IMA grafts to left anterior descending coronary artery.

Considerable controversy exists regarding relative morbidity associated with the saphenous vein graft (SVG) and internal mammary artery (IMA) graft in patients undergoing myocardial revascularization. As a part of the cooperative study on use of antiplatelet drugs for graft patency, operative and postoperative data were prospectively collected on 1,150 patients who underwent either SVG (n = 656) or IMA anastomosis (n = 494) to the left anterior descending coronary artery. There were no differences in baseline characteristics of patients, distribution of randomization among treatment groups, and total number of distal anastomoses performed between the two groups. The aortic cross-clamp time, cardiopulmonary bypass duration, operative time, and chest tube drainage were greater (p = 0.0001) in the patients with IMA grafts compared with SVG. However, there was no difference in the operative mortality rate, the amount of blood and blood products received, the reoperation rate for control of postoperative bleeding, and incidence of wound complications between the two groups. The early and 1-year patency rates for the IMA were slightly but not significantly better than the SVG patency rates (92.8% versus 90.1% for 1-year patency; p = 0.309). In conclusion, use of IMA is associated with a longer operative time as well as increased postoperative bleeding compared with the SVG. It, however, does not increase operative mortality or postoperative morbidity.

Aged↗
PubMed1991

Impact of resident training on postoperative morbidity in patients undergoing single valve replacement. Department of Veterans Affairs Cooperative Study on Valvular Heart Disease.

As one of the requirements of the Department of Veterans Affairs cooperative study on valvular heart disease, operative and postoperative data were prospectively collected in 964 patients undergoing single valve replacement. The procedure was performed either by a resident under the direct supervision of an attending surgeon (49.5%) or by an attending surgeon (50.5%). There was no difference in operative mortality between the two groups of surgeons when adjusted for patient-related and disease-related risk factors. The proportion of patients who had at least one postoperative complication was slightly but not significantly higher in the attending group (35.8% versus 30.4% for aortic valve replacement, 38% versus 28% for mitral valve replacement, and 36% versus 30% for all single valve replacement procedures). As the significance of each complication varies, we weighted each complication to the associated operative mortality to formulate the morbidity score. An expected complication rate for each group was derived from a multivariate logistic model, and the ratio of observed to expected morbidity was calculated to adjust observed morbidity according to the risk of patients. There was no difference in the observed/expected morbidity ratio between the two groups of surgeons. We conclude that currently used teaching techniques and philosophy to educate cardiac surgical residents, which allow them to take progressive responsibility for cardiac surgical procedures, are well justified, and patient care does not suffer when resident training is enhanced.

Aortic Valve↗