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M Racz

Publications and source records attributed to M Racz.

9 recordsLinked to original sources
PubMed2001

Differential survival after coronary revascularization procedures among patients with renal insufficiency.

BACKGROUND: Acute myocardial infarction, cardiac arrest, and other cardiac events are the major cause of mortality among patients with renal insufficiency. Previous studies of interventions for coronary artery disease among patients with renal insufficiency have not controlled for potentially confounding factors such as coronary artery disease severity and left ventricular function. This study investigates the comparative survival for patients with renal insufficiency and coronary artery disease following coronary artery bypass graft (CABG) surgery as compared with percutaneous coronary artery intervention (PCI), while controlling for confounding factors. METHODS: This retrospective cohort study of patients undergoing CABG surgery or PCI discharged between 1993 and 1995 uses the New York Department of Health databases and Cox proportional hazards analyses to estimate the mortality risk associated with CABG as compared with PCI for patients with renal insufficiency. Renal function was categorized as creatinine <2.5 mg/dL (N = 58,329), creatinine > or =2.5 mg/dL (N = 840), and end-stage renal disease (ESRD) requiring dialysis (N = 407). RESULTS: Patients with either ESRD or serum creatinine > or =2.5 mg/dL had more severe coronary artery disease and a greater frequency of comorbid conditions as compared with patients with creatinine <2.5 mg/dL. Creatinine > or =2.5 mg/dL and ESRD were both associated with an increased mortality risk among all distributions of coronary artery disease anatomy. Among patients with ESRD, the risk ratio (RR) of mortality for patients undergoing CABG compared with PCI was 0.39 (95% CI, 0.22 to 0.67, P = 0.0006). Among patients with creatinine > or =2.5 mg/dL, CABG surgery did not convey a survival benefit over PCI (RR, 0.86, 95% CI, 0.56 to 1.33, P = 0.50). CONCLUSIONS: This study demonstrates a survival benefit among patients with ESRD undergoing CABG surgery as compared with PCI, while controlling for severity of coronary artery disease, left ventricular dysfunction, and other comorbid conditions. These results suggest that management decisions among patients with coronary artery disease should be made in the context of not only location and severity of coronary artery lesions, but also on the presence and severity of renal dysfunction.

Aged↗
PubMed1998

Pediatric cardiac surgery: the effect of hospital and surgeon volume on in-hospital mortality.

OBJECTIVE: To examine the relationship between annual provider (hospital and surgeon) volume of pediatric cardiac surgery and in-hospital mortality. DESIGN: Population-based retrospective cohort study using a clinical database. SETTING: The 16 acute care hospitals in New York with certificate of need approval to perform pediatric cardiac surgery. PATIENTS: All children undergoing congenital heart surgery in New York from 1992 to 1995. MAIN OUTCOME MEASURES: Risk-adjusted mortality rates for various hospital and surgeon volume ranges. Adjustments were made for severity of illness using logistic regression. RESULTS: A total of 7169 cases were analyzed. After controlling for severity of preprocedural illness using clinical risk factors, hospitals with annual pediatric cardiac surgery volumes of fewer than 100 had significantly higher mortality rates (8.26%) than hospitals with volumes of 100 or more (5.95%), and surgeons with annual volumes of fewer than 75 had significantly higher mortality rates (8.77%) than surgeons with annual volumes of 75 or more (5.90%). CONCLUSIONS: Both hospital volume and surgeon volume are significantly associated with in-hospital mortality, and these differences persist for both high-complexity and low-complexity pediatric cardiac procedures.

Cardiac Surgical Procedures↗
PubMed1997

Coronary angioplasty volume-outcome relationships for hospitals and cardiologists.

OBJECTIVE: To assess the relationship between each of 2 provider volume measures (annual hospital volume and annual cardiologist volume) for percutaneous transluminal coronary angioplasty (PTCA) and 2 outcomes of PTCA (in-hospital mortality and same-stay coronary artery bypass graft [CABG] surgery). DESIGN: Cohort study, using data from January 1, 1991, through December 31, 1994, from the Coronary Angioplasty Reporting System of the New York State Department of Health. SETTING: Thirty-one hospitals in New York State in which PTCA was performed during 1991-1994. PATIENTS: All 62670 patients discharged after undergoing PTCA in these hospitals during 1991-1994. MAIN OUTCOME MEASURES: Rates of in-hospital mortality and CABG surgery during the same stay as the PTCA. RESULTS: The overall in-hospital mortality rate for patients undergoing PTCA in New York during 1991-1994 was 0.90%, and the same-stay CABG surgery rate was 3.43%. Patients undergoing PTCA in hospitals with annual PTCA volumes less than 600 experienced a significantly higher risk-adjusted in-hospital mortality rate of 0.96% (95% confidence interval [CI], 0.91%-1.01%) and risk-adjusted same-stay CABG surgery rate of 3.92% (95% CI, 3.76%-4.08%). Patients undergoing PTCA by cardiologists with annual PTCA volumes less than 75 had mortality rates of 1.03% (95% CI, 0.91%-1.17%) and same-stay CABG surgery rates of 3.93% (95% CI, 3.65%-4.24%); both of these rates were also significantly higher than the rates for all patients. Also, same-stay CABG surgery rates for patients undergoing PTCA in hospitals with annual volumes of 600 to 999 performed by cardiologists with annual volumes of 75 to 174 (2.99%; 95% CI, 2.69%-3.31 %) and 175 or more (2.84%; 95% CI, 2.57%-3.14%) were significantly lower than the overall statewide rate (3.43%). CONCLUSIONS: In New York State, both hospital PTCA volume and cardiologist PTCA volume are significantly inversely related to in-hospital mortality rate and same-stay CABG surgery rate for patients undergoing PTCA.

Angioplasty, Balloon, Coronary↗
PubMed1997

Assessment of coronary artery bypass graft surgery performance in New York. Is there a bias against taking high-risk patients?

OBJECTIVES: The purpose of this study was to determine whether performing coronary artery bypass surgery on high-risk patients adversely affects the risk-adjusted mortality rates for patients of surgeons and hospitals in New York State compared with the impact of performing surgery on more routine patients. METHODS: Risk-adjusted mortality-rates were calculated for 31 hospitals and 87 surgeons for high-risk (a predicted mortality rate of at least 7.5%) and low-risk patients during the time period 1990 to 1992. RESULTS: The risk-adjusted mortality for all high-risk patients was lower (2.94%) than the risk-adjusted mortality for other patients (3.02%). Fifteen of the 31 hospitals had a lower risk-adjusted mortality for all patients than they did for low-risk patients only, and no differences in either direction were statistically significant. Forty-one of 87 surgeons (47%) had risk-adjusted mortality for all patients that was at least as low as the risk-adjusted mortality for low-risk patients. In general, hospitals and surgeons with the lowest risk-adjusted mortality for all cases also had the lowest risk-adjusted mortality for high-risk cases. CONCLUSIONS: The authors conclude that there is no systematic bias against operating on high-risk coronary artery bypass graft patients in the risk-adjusted performance system in New York.

Bias↗
PubMed1996

Reduction in angioplasty complications after the introduction of coronary stents: results from a consecutive series of 2242 patients.

The introduction of coronary stents for the treatment of acute vessel closure has probably improved the safety of angioplasty, but little data are available regarding angioplasty complication rates when bailout stenting is available. Therefore baseline and patient outcome data for 2242 consecutive patients treated at a single tertiary referral center were compared before and after bailout coronary stenting was introduced. Patients treated after stents became available were more likely to have diabetes (16% prestent availability vs 19% poststent, p < 0.05), unstable angina (61% prestent vs 70% poststent, p < 0.01), and to have received intravenous nitroglycerin before the procedure (22% prestent vs 28% poststent, p < 0.01). Major complications occurred in 4.1% of patients before stent availability and 2.0% afterwards (p < 0.01). These complications included in-hospital death (1.1% prestent vs 0.7% poststent, p = not significant [NS]), Q wave myocardial infarction (0.5% prestent vs 0.3% poststent, p = NS), and emergency bypass surgery (2.9% prestent vs 1.1% poststent, p < 0.01). The introduction of coronary stents was associated with a > 50% reduction in major complications despite greater patient acuity. The traditionally reported complication rates for angioplasty appear not to apply when ballout stenting is available.

Angina, Unstable↗
PubMed1994

Improving the outcomes of coronary artery bypass surgery in New York State.

OBJECTIVE: To assess changes in outcomes of coronary artery bypass graft (CABG) surgery in New York since 1989, when the State Department of Health began collecting, analyzing, and disseminating information regarding risk factors, mortality, and complications of CABG surgery. These new data stimulated specific quality improvement activities at hospitals throughout the state. DESIGN: A clinical database was used to identify significant independent risk factors and to assess risk-adjusted provider mortality rates. SETTING: All 30 hospitals performing CABG surgery in New York during the period 1989 through 1992. PATIENTS: All 57,187 patients undergoing isolated CABG surgery who were discharged from New York State hospitals in 1989 through 1992. MAIN OUTCOME MEASURES: Actual, expected (from a logistic regression model), and risk-adjusted in-hospital mortality. RESULTS: Actual mortality decreased from 3.52% in 1989 to 2.78% in 1992. Because average patient severity of illness increased, risk-adjusted mortality decreased even more--a decrease of 41% from 4.17% in 1989 to 2.45% in 1992. The risk-adjustment model performed well; there were no clinically or statistically significant differences between actual and predicted numbers of deaths at any of 10 levels of patient severity. CONCLUSIONS: We believe that this quality improvement program, based on the collection and dissemination of risk-adjusted mortality data for CABG surgery, played a significant role in the observed decline in the death rate from this procedure. Quality improvement programs based on similar principles for other procedures and conditions should be undertaken.

Actuarial Analysis↗
PubMed1994

New York State's Cardiac Surgery Reporting System: four years later.

This study examined changes in the risk-adjusted mortality associated with coronary artery bypass grafting procedures performed in New York State during the first 4 years of New York's Cardiac Surgery Reporting System (1989 to 1992). To track performance over time, surgeons and hospitals were subdivided into three groups on the basis of their performance in 1989. The risk-adjusted mortality for each of the three groups was computed for 1992 and compared with their 1989 mortality. The results indicate that all groups of providers exhibited large reductions in the risk-adjusted mortalities, with the groups that showed the highest initial mortalities manifesting the most improvement. However, the group rankings remained the same in 1992 as they were in 1989. For example, when the hospital groups were based on the terciles of risk-adjusted mortality observed in 1989, the risk-adjusted mortality decreased from 2.72% to 2.19% for group 1, from 4.24% to 2.51% for group 2, and from 7.12% to 2.77% for group 3. Notably, the risk-adjusted mortalities of the three groups were all significantly different from one another in 1989, but were not significantly different from one another in 1992. Another interesting finding was that the volume of operations performed by the various provider groups did not change substantially in the 4-year period.

Coronary Artery Bypass↗
PubMed1967

AID to Vietnam.

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Humans↗