Biomedical subjects

Steven D Culler

Publications and source records attributed to Steven D Culler.

12 recordsLinked to original sources

PubMed2006

The frequency and incremental cost of major complications among medicare beneficiaries receiving implantable cardioverter-defibrillators.

OBJECTIVES: We aimed to quantify the frequency and nature of early complications after implantable cardioverter-defibrillator (ICD) implantation in general practice, and estimate the incremental costs of those complications to the health care system. BACKGROUND: Cardioverter-defibrillator implantation rates are rising quickly. Little has been published regarding the outcomes and costs of these procedures in unselected populations. METHODS: Using Medicare Provider Analysis and Review (MedPAR) files, we identified 30,984 admissions containing procedure codes for new ICD or cardiac resynchronization therapy defibrillator implantation in fiscal year 2003. The frequencies of eight complicating diagnoses during these admissions were determined. Length of stay (LOS) and total hospital costs, derived using whole-hospital cost to charge ratios, were calculated for each admission. The incremental effects of any and each complication on LOS and hospital cost were estimated in multivariable models, adjusting for demographic factors and comorbid conditions. RESULTS: The mean cost for all admissions was 42,184 dollars (median 37,902 dollars) with mean LOS of 4.7 days (median 2.0 days). One or more complications were coded in 10.8% of admissions, most commonly "mechanical complication of the ICD" and hemorrhage/hematoma. The occurrence of any complication increased adjusted LOS by 3.4 days and costs by 7,251 dollars. Each of the individual complications was associated with highly significant increases in both LOS (1 to 10 days) and hospital cost (5,000 dollars to 20,000 dollars). CONCLUSIONS: In fiscal 2003, 10.8% of Medicare patients undergoing cardioverter-defibrillator implantation experienced one or more early complications, associated with significant increases in LOS and costs. Efforts to reduce these complications could have significant clinical and financial benefits.

Aged↗

PubMed2006

Hospital resources consumed in treating complications associated with percutaneous coronary interventions.

Nearly 9.5% of all Medicare beneficiaries who undergo a percutaneous coronary intervention (PCI) procedure develop > or =1 of 7 acute complications. This study used 2 approaches (regression analysis and propensity-matched samples) to estimate the cost of selected complications, based on administrative data from 335,477 Medicare beneficiaries who underwent PCI during a hospitalization in fiscal year 2002. Selected complications included hospital mortality, emergency/urgent coronary artery bypass surgery, postoperative stroke, acute renal failure, vascular complications, septicemia, and adult respiratory distress syndrome. The observed average cost of a PCI hospitalization for patients who did not develop complications was 13,861 dollars +/- 9,635 dollars, with an average length of stay of 3.0 +/- 3.2 days, compared with 26,807 dollars +/- 27,596 dollars and 8.0 +/- 8.9 days for patients who did develop complications. Estimates of the adjusted incremental hospital cost of treating any acute complication except death varied from a high of 33,030 dollars for patients who developed septicemia to a low of 4,278 dollars for those who developed vascular complications, whereas estimates of the incremental length of stay ranged from a high of 12.3 days for patients who had septicemia to a low of 1.8 days for patients who had vascular complications. In conclusion, we found that the incremental hospital resources that are consumed to treat patients with acute PCI complications are large compared with the cost of an uncomplicated PCI hospitalization.

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PubMed2006

Urban-rural differences in the availability of hospital information technology applications: a survey of Georgia hospitals.

CONTEXT: Information technology (IT) has been identified as a potential tool for improving the safety of health care delivery. PURPOSE: To determine if there are significant differences between urban and rural community hospitals in the availability of selected IT functional applications and technological devices. METHODS: A mailed survey of community hospitals in Georgia assessing the current availability of IT applications (54.6% response rate). FINDINGS: Georgia hospitals reported having 63.6% of 56 possible functional applications computerized but only 52.9% of 41 technological devices. Compared to rural hospitals, urban hospitals had significantly more functional applications computerized (38.0 vs 31.8, P = .031) and technological devices available (23.9 vs 18.2, P = .016). Urban hospitals had significantly (P < .05) more IT applications available in 4 areas: emergency room services (7 of 10), surgical/operating room (8 of 12), laboratory (7 of 12), and radiology (5 of 11). Overall, the availability of IT applications was bimodal in rural hospitals: over 40% of rural hospitals had adopted over 70% of all applications, while approximately 26% of rural hospitals had adopted less than 30%. CONCLUSIONS: Some of the observed urban/rural differences in availability of IT applications may be due to differences in the scope of services provided by rural hospitals, in particular laboratories, radiology departments, emergency rooms, and surgery/operating rooms. Nevertheless, the bimodal distribution of IT applications adopted in rural hospitals raises concerns about the ability of selected rural hospitals to take advantage of regional data-sharing initiatives and maintain quality of patient care in the future.

Georgia↗

PubMed2006

The relationship between ex ante mortality risk and end-of-life medical costs.

BACKGROUND: Spending on medical care for patients in their last year of life accounts for over one-quarter of US Medicare programme outlays. While the magnitude of spending on end-of-life care is striking, it is difficult to determine if expenditures are wasteful or simply reflect the inherent uncertainty facing physicians. METHODS: Using a sample of fee-for-service Medicare beneficiaries, we document the association between mortality risk and end-of-life medical spending. Mortality risk at 1 year before death was estimated using a logistic model with age, sex and co-morbidities as covariates. RESULTS: We found that, among decedents, end-of-life spending is inversely related to predicted mortality risk, ranging from Dollars US 23,000 for decedents with mortality risk in the interval 0.00-0.05 to Dollars US 16,000 for decedents with mortality risk > 0.25 (1999 dollar values). In aggregate, > 50% of Medicare spending on medical care in the last year of life is for beneficiaries with below-median mortality risk. CONCLUSIONS: We conclude that physicians treat patients who are likely to die differently than those who are not. Substituting palliative for curative care for patients with unfavourable prognoses may lower total expenditures, but probably not as much as commonly expected.

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PubMed2004

Economic analysis of a transesophageal echocardiography-guided approach to cardioversion of patients with atrial fibrillation: the ACUTE economic data at eight weeks.

OBJECTIVES: The aim of this study was to compare the relative cost of a transesophageal echocardiography (TEE)-guided strategy versus conventional strategy for patients with atrial fibrillation (AF) >2 days duration undergoing electrical cardioversion over an eight-week period. BACKGROUND: The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial found no difference in embolic rates between the two approaches. However, the TEE-guided strategy had a shorter time to cardioversion and a lower rate of composite bleeding. While similar clinical efficacy was concluded, the relative cost of these two strategies has not been explored. METHODS: Two economic approaches were employed in the ACUTE trial. The first approach was based on hospital charge data from complete hospital Universal Billing Code of 1992 forms, a detailed hospital charge questionnaire, or imputation. Regression analysis was used to investigate the added cost of adverse events. The second economic approach involved the development of an independent analytic model simulating treatment and actual ACUTE outcome costs as a validation of clinically derived data. Sensitivity analysis was performed on the analytic model to investigate the potential range in cost differences between the strategies. RESULTS: A total of 833 of the 1,222 patients were enrolled from 53 U.S. sites; TEE-guided (n = 420) and conventional (n = 413). At eight-week follow-up, total mean costs did not significantly differ between the two groups, respectively (6,508 dollars vs. 6,239 dollars; difference of 269 dollars; p = 0.50). Cumulative costs were 24% higher in the conventional group, primarily due to increased incidence of bleeding and hospital costs associated with bleeding. A separate analytic model showed that treatment costs were higher for the TEE-guided strategy, but outcome costs were higher for the conventional strategy. Sensitivity analysis of the analytic model illustrated that varying the incidence and cost of major bleeding and the cost of TEE had the greatest impact on cost differences between the two groups. CONCLUSIONS: In patients with AF >2 days duration undergoing electrical cardioversion, the TEE-guided group showed little difference in patient costs compared with the conventional group. The TEE strategy had higher initial treatment costs but lower outcome-associated costs. Cumulative costs were 24% higher in the conventional group, primarily due to bleeding. The TEE-guided strategy is an economically feasible approach compared with the conventional strategy.

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PubMed2004

Evaluating alternative risk-adjustment strategies for surgery.

BACKGROUND: Comparison of institutional health care outcomes requires risk adjustment. Risk-adjustment methodology may influence the results of such comparisons. METHODS: We compared 3 risk-adjustment methodologies used to assess the quality of surgical care. Nurse reviewers abstracted data from a continuous sample of 2,167 surgical patients at 3 academic institutions. One risk adjustor was based on medical record data (National Surgical Quality Improvement Program [NSQIP]) whereas the other 2, the DxCG and Charlson Comorbidity Index (CCI), primarily used International Classification of Disease-9 (ICD-9) codes. Risk-assessment scores from the 3 systems were compared with each other and with mortality. RESULTS: Substantial disagreement was found in the risk assessment calculated by the 3 methodologies. Although there was a weak association between the CCI and DxCG, neither correlated well with the NSQIP. The NSQIP was best able to predict mortality, followed by the DxCG and CCI. CONCLUSION: In surgical patients, different risk-adjustment methodologies afford divergent estimates of mortality risk.

Evidence-Based Medicine↗

PubMed2004

Current status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures.

BACKGROUND: Current practice, trends, and early outcomes in patients undergoing surgical and percutaneous coronary interventions (PCI) are changing and subject to speculation. METHODS: 148,396 consecutive patients in 69 HCA, Inc hospitals who underwent either PCI or coronary artery bypass grafting (CABG) were tracked in the HCA Casemix Database from 1999 through the first quarter of 2002. Comorbid conditions, procedures, complications, and outcome variables were defined through International Classification of Diseases, Ninth Revision coding. Odds ratios (OR) for death and other procedure-related complications were estimated using logistic regression adjusting for age, sex, and 31 other patient clinical and procedural characteristics. RESULTS: Now 65.4% of all coronary revascularization is by PCI with a 6.8% annual rate of increase whereas CABG volume is declining by 1.9% per year. However the majority of these changes occurred between 1999 and 2000 with only small changes in the last 3 years. Coronary artery bypass grafting is still utilized primarily for multivessel disease (3.38 bypasses per patient) whereas PCI is predominately (83%) still limited to single-vessel intervention. Unadjusted mortality rates over the full 13-quarter period were 1.25% for PCI and 2.63% for CABG (p < 0.001), with PCI rates remaining constant and CABG mortality declining. Twenty-three percent of CABG is performed off pump with a lower mortality than conventional on-pump CABG (2.37% versus 2.69%, p < 0.001). Percutaneous coronary intervention patients have lower mortality (OR 0.51), and fewer acute renal failure (OR 0.39), neurologic (OR 0.12), and cardiac (OR 0.16) complications than CABG patients (p < 0.001). CONCLUSIONS: Interventions for coronary artery disease continue to rise primarily due to an increase in PCI. The volume of PCI continues to increase relative to CABG. Although adverse outcomes are higher after CABG, the proportion of multivessel disease treated is greater. The difference in adverse outcomes between CABG and PCI remains small and continues to decline.

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PubMed2004

Methods for the economic and quality of life supplement to the cilostazol for RESTenosis (CREST) trial.

OBJECTIVE: To determine economic and quality of life outcomes for the Cilostazol for RESTenosis (CREST) trial, which is investigating the efficacy of cilostazol vs. placebo in preventing post-stent restenosis. DESIGN: CREST is a prospective, multicenter, randomized, placebo-controlled, double-blind trial. SETTING: 20 clinical sites; the Emory Center for Outcomes Research (ECOR) will serve as the economic and data coordinating center. PATIENTS: 705 patients (>18 years) who have undergone successful, uncomplicated placement of an intracoronary stent in a native coronary artery. INTERVENTION: Cilostazol (100 mg twice daily) or placebo for 6 months. OUTCOME MEASURES COSTS: Primary endpoint, total direct medical costs at 6 months; secondary endpoints, initial hospital costs and follow-up costs. QOL: Health-related quality of life (QOL) will be assessed using the EQ-5D and the Seattle Angina Questionnaire at baseline and at 1, 3, and 6 months. Cost-effectiveness analysis: Preliminary data show that cilostazol is clinically superior to placebo and if the mean cost for the cilostazol arm is higher than that for placebo, cost-effectiveness analysis will be determined for the cost per episode of restenosis prevented, the cost per episode of major clinical and angiographic endpoints averted, and the cost per quality-adjusted life-years gained.

Angioplasty, Balloon, Coronary↗

PubMed2003

Practice and outcomes of percutaneous coronary intervention in the community before drug-eluting stents: a report from the HCA database.

BACKGROUND: Percutaneous coronary intervention (PCI) using balloon angioplasty and/or intracoronary stents has increasingly become the treatment choice for myocardial revascularization. While acute clinical outcomes of the community-based PCI procedures have been examined, much less is known about long-term revascularization rates, disease progression and other adverse outcomes. METHODS AND RESULTS: Information on patient demographics, coronary risk factors, lesion characteristics, procedures and outcomes were derived from an HCA, Inc. database on all patients undergoing a PCI procedure in one of four community cardiac catheterization laboratories. A total of 3,192 consecutive patients were enrolled from July 1, 1999 through September 30, 2000. Analysis was limited to those patients undergoing PCI of native vessels with stents or conventional balloon angioplasty; target lesions in bypass grafts or those treated with atherectomy were excluded. Approximately one-third of enrolled patients were surveyed concerning their utilization of cardiovascular services 1 year following their initial procedure. The 1-year target lesion revascularization (TLR) was 9.9% while target vessel revascularization was 13.5%. Overall, 27.6% of patients underwent repeat revascularization within 1 year; 24.7% underwent at least 1 additional PCI and 5.6% underwent coronary artery bypass graft surgery. A total of 4.5% of patients reported an interval acute myocardial infarction with a major adverse cardiac event rate of 30.3% at 1 year. CONCLUSION: While clinically significant restenosis remains a problem for 10 15% of patients undergoing PCI, progression of coronary artery disease elsewhere appears to be an equally powerful driver in the need for recurrent revascularization. This analysis of contemporary PCI practice prior to drug-eluting stent utilization suggests that while these novel devices will likely reduce the incidence of TLR, many patients with coronary artery disease will still require additional revascularization for disease progression.

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PubMed2003

The influence of diabetes mellitus on the practice and outcomes of percutaneous coronary intervention in the community: a report from the HCA database.

BACKGROUND: Diabetics remain a high-risk group for those undergoing percutaneous coronary intervention (PCI) using balloon angioplasty and/or intracoronary stents for myocardial revascularization. The objective of this study is to compare clinical characteristics, demographics, procedure indications, lesion characteristics, and acute and long-term outcomes between diabetic patients and non-diabetic patients in a community based PCI registry. METHODS AND RESULTS: Information on patient demographics, coronary risk factors, lesion characteristics, procedures, and outcomes were derived from an HCA, Inc. database on all patients undergoing a PCI procedure in one of four community cardiac catheterization laboratories (CCL). A total of 3,139 patients who underwent PCI procedures from July 1, 1999 through September 30, 2000 were enrolled in this study. Approximately one-third of these patients completed a follow-up survey one year after their initial encounter. Analysis was limited to those patients undergoing PCI of native vessels with stents or conventional balloon angioplasty; patients with target lesions in bypass grafts or those treated with atherectomy were excluded. Approximately 23.5% of the patients enrolled in the study were diabetic. This study found no significant difference in any acute outcome between diabetic and non-diabetic patients in the hospital episode associated with the index PCI procedure. However, data from the 1-year follow-up survey indicates diabetic patients tended to have more target lesion revascularization (TLR) (13.6% versus 8.9%; p = 0.07) and more target vessel revascularization (TVR) (17.6% versus 12.7%; p = 0.058) than non-diabetic patients. In addition, adjusted odds ratios indicate that diabetic patients were 1.6 times more likely to have a second PCI procedure in another vessel (p = 0.013), 2.4 times more likely to undergo bypass surgery (p = 0.003), 1.9 times more likely to undergo an additional revascularization procedure (p < 0.001) and 1.8 times more likely to experience any major adverse cardiac events (p < 0.001) than non-diabetic patients during the follow-up period. CONCLUSIONS: This study indicates that selected diabetic patients can be treated for myocardial revascularization using PCI procedures with acceptable acute outcomes. However, diabetic patients undergoing PCIs have significantly more disease progression and are more likely to experience the need for recurrent revascularization.

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PubMed2002

Outcomes experience with off-pump coronary artery bypass surgery in women.

BACKGROUND: It has been well documented that women have higher morbidity and mortality rates than men following coronary artery bypass graft (CABG) surgery. In view of this evidence, we investigated the following question: compared with on-pump CABG surgery, is there benefit to off-pump CABG surgery in women? METHODS: Our investigation analyzes patient mortality and 13 procedure complications controlling for 35 variables representing patient characteristics and comorbid conditions, and for procedure characteristics for a population of 16,871 consecutive women undergoing off-pump and on-pump CABG surgery at 78 hospitals for the period January 1998 to June 2001. RESULTS: Mean comparisons reveal that the mortality rate for women undergoing off-pump CABG surgery is nearly a percentage point lower than for women undergoing on-pump surgery (3.12 vs 3.90; p = 0.052). The complication rates for all complications analyzed (shock/hemorrhage, neurologic, cardiac, respiratory, renal, acute renal failure, adult respiratory distress syndrome, implant infection, postoperative infection, septicemia, pneumonia, and peripheral vascular) were lower for women off-pump than women on-pump with the exception of mechanical complications. Logistic regression results reveal, after controlling for 35 relevant patient characteristics, comorbid conditions and procedure characteristics, that women undergoing on-pump CABG surgery experience a 42% higher mortality rate (p = 0.0239) than women undergoing off-pump CABG surgery. CONCLUSIONS: Evidence suggests that off-pump CABG surgery may be better for women than on-pump CABG surgery because it appears to reduce mortality and respiratory complications, shorten lengths-of-stay, and increases discharges directly home. None of the 12 other complications investigated demonstrated an advantage for women undergoing on-pump surgery relative to those receiving off-pump surgery.

Aged↗

PubMedDate not supplied

Patient adherence improves glycemic control.

PURPOSE: The purpose of this study was to assess the influence of appointment keeping and medication adherence on HbA1c. METHODS: A retrospective evaluation was performed in 1560 patients with type 2 diabetes who presented for a new visit to the Grady Diabetes Clinic between 1991 and 2001 and returned for a follow-up visit and HbA1c after 1 year of care. Appointment keeping was assessed by the number of scheduled intervening visits that were kept, and medication adherence was assessed by the percentage of visits in which self-reported diabetes medication use was as recommended at the preceding visit. RESULTS: The patients had an average age of 55 years, body mass index (BMI) of 32 kg/m2, diabetes duration of 4.6 years, and baseline HbA1c of 9.1%. Ninety percent were African American, and 63% were female. Those who kept more intervening appointments had lower HbA1c levels after 12 months of care (7.6% with 6-7 intervening visits vs 9.7% with 0 intervening visits). Better medication adherence was also associated with lower HbA1c levels after 12 months of care (7.8% with 76%-100% adherence). After adjusting for age, gender, race, BMI, diabetes duration, and diabetes therapy in multivariate linear regression analysis, the benefits of appointment keeping and medication adherence remained significant and contributed independently; the HbA1c was 0.12% lower for every additional intervening appointment that was kept (P = .0001) and 0.34% lower for each quartile of better medication adherence (P = .0009). CONCLUSION: Keeping more appointments and taking diabetes medications as directed were associated with substantial improvements in HbA1c. Efforts to enhance glycemic outcomes should include emphasis on these simple but critically important aspects of patient adherence.

Black or African American↗