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Results for “Propensity Score”

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At least 415 records · Page 23Linked to original sources

PubMed2004

Left internal mammary artery to the left anterior descending artery: effect on morbidity and mortality and reasons for nonusage.

BACKGROUND: The left internal mammary artery to the left anterior descending artery is recognized as the gold standard for revascularization. Several studies have shown the benefits of the left internal mammary artery. However, a substantial portion of patients undergoing coronary artery bypass grafting does not receive this conduit. We sought to identify reasons for nonusage of the left internal mammary artery to the left anterior descending artery, while evaluating short- and medium-term outcomes. METHODS: Between April 1997 and September 2001 a total of 4406 consecutive patients underwent coronary artery bypass grafting with revascularization to the left anterior descending artery. All data were collected prospectively except reasons for nonusage of the left internal mammary artery. Logistic regression and Cox proportional hazards analyses were used to adjust in-hospital and medium-term outcomes, respectively. Selection bias was controlled by constructing a propensity score. A case note review was carried out to determine reasons for nonusage. RESULTS: A total of 4047 patients (91.8%) received the left internal mammary artery to the left anterior descending artery leaving 359 patients (8.2%) who did not. We found no difference in hospital mortality or morbidity, however, patients receiving the left internal mammary artery had a survival advantage at 4 years. Reasons for not using the left internal mammary artery were damage to the conduit (n = 44), poor flow (n = 43), poor lung function (n = 45), unstable symptoms (n = 24), vascular problems (n = 12), and 19 patients with "other" reasons (previous radiotherapy, chest wall deformity, and obese patients). Case notes had no reason stated for 146 patients and reasons for 26 patients were unobtainable. CONCLUSIONS: Left internal mammary artery usage is not associated with any increase in hospital mortality and morbidity, but these patients have better medium-term survival. Injury on harvesting, poor flow, and poor lung function were the most common reasons for not using this conduit.

Aged↗

PubMed2004

Fenoldopam prophylaxis of postoperative acute renal failure in high-risk cardiac surgery patients.

BACKGROUND: Acute renal failure requiring replacement therapy occurs in 1% to 2% of patients who have undergone cardiac surgery with cardiopulmonary bypass and is associated with a very high mortality rate. The aim of this study was to determine if prophylactic treatment with fenoldopam mesylate of patients at high risk of postoperative acute renal failure reduced the incidence of this event. METHODS: This was a multicenter, prospective, cohort study in which 108 patients at high risk of postoperative acute renal failure and undergoing cardiac surgery with cardiopulmonary bypass were treated with fenoldopam mesylate (0.08 microg x kg(-1) x min(-1)) starting at the induction of anesthesia and throughout at least the next 24 hours. A homogeneous control group of 108 patients was created using a propensity-score analysis. RESULTS: Fenoldopam prophylaxis was significantly associated with a reduction in acute renal failure incidence (from 22% to 11%, p = 0.028), a less pronounced creatinine clearance decrease (p = 0.05), and a lower mortality rate (6.5% versus 15.7%, p = 0.03) by the univariate analysis, but these results were not confirmed by a multivariable analysis. Within the subgroup of patients who suffered a postoperative low output syndrome, fenoldopam prophylaxis was an independent protective factor for postoperative renal failure (odds ratio, 0.14; 95% confidence interval, 0.03 to 0.7; p = 0.017). CONCLUSIONS: Given the limitations of a nonrandomized prospective trial, our results support the hypothesis that fenoldopam may reduce the risk of acute renal failure in patients in whom endogenous and exogenous cathecolamines action may induce a renal vascular constrictive condition.

Acute Kidney Injury↗

PubMed2004

Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensity analysis.

BACKGROUND: The purpose of this study was to compare operative mortality and midterm outcome of patients with ischemic mitral regurgitation (MR) undergoing either coronary artery bypass grafting (CABG) alone or CABG with mitral valve (MV) repair. METHODS: From 1996 to 2001, 51 consecutive patients underwent CABG with MV repair for ischemic MR. All patients in this group were matched to similar patients with ischemic MR undergoing CABG alone during the same 6-year period using propensity analysis (considering 24 covariates, including severity of MR and New York Heart Association [NYHA] class). RESULTS: Propensity score matching yielded 51 closely matched control patients. Preoperative MR severity was 3+ or 4+ in 94% of CABG with MV repair and 96% of CABG-alone patients, and 86% of patients in each group were NYHA class III or IV. Operative mortality was 3.9% +/- 2.8% in both groups. Survival was also similar between CABG with MV repair and CABG alone at 1 year (84% +/- 5% versus 82% +/- 5%) and 3 years (70% +/- 7% versus 71% +/- 7% (p = 0.43). Among survivors, NYHA class improved at follow-up (50 +/- 20 months) from 3.4 +/- 0.7 to 1.7 +/- 1.0 for CABG with MV repair (p < 0.001) and from 3.4 +/- 0.7 to 1.8 +/- 1.0 for CABG alone (p < 0.001). CONCLUSIONS: Operative mortality, midterm survival, and late functional class were similar between two well-matched groups of patients undergoing CABG for ischemic MR, differing only in the addition of MV repair. Whereas MV repair can be added safely to CABG in this group of high-risk patients without increasing mortality, its impact on late survival and functional class may be limited.

Aged↗

PubMed2005

Reoperative coronary artery bypass grafting: analysis of early and late outcomes.

BACKGROUND: The purpose of this study was to evaluate early and late results of reoperative coronary artery bypass grafting compared with those of first coronary artery bypass grafting. METHODS: From November 21, 1994, to December 31, 2001, 4,381 patients underwent isolated coronary revascularization: among these patients, 274 (6.3%) underwent a redo. Applying the propensity score, 239 redo patients (group R) were matched with 239 who underwent the first revascularization (group F). RESULTS: Early mortality was 2.1% (group F) and 4.2% (group R), not significantly different. Group R showed significantly higher creatine kinase myocardial band release, length of intensive care unit stay, and incidence of incomplete myocardial revascularization than group F. In group R, off-pump patients showed higher incidence of incomplete revascularization. Redo was a risk factor for abnormal (>19 IU/L) creatine kinase myocardial band release (odds ratio, 1.7; p = 0.0066) and incomplete myocardial revascularization (odds ratio, 2.4; p = 0.0060). Five-year clinical outcome was significantly worse in group R, except for freedom from redo or percutaneous transluminal coronary angioplasty. Redo was an independent variable for lower freedom from death of any cause, cardiac death, acute myocardial infarction, cardiac events, and any event. Patients with higher creatine kinase myocardial band release or incomplete myocardial revascularization showed lower freedom from cardiac-related events. Incidence of incomplete myocardial revascularization and creatine kinase myocardial band release were significantly higher in group R by both univariate and multivariate analysis. This could explain the worse late outcome of redo patients. CONCLUSIONS: Complete revascularization without damaging the heart, whichever technique is used, is the target of redo surgery, to achieve the same quality of results obtained in the first operation.

Aged↗

PubMed2005

Mitral repair versus replacement for ischemic mitral regurgitation.

BACKGROUND: We compared mitral repair to replacement in patients with chronic ischemic mitral regurgitation (IMR), due to left ventricular dysfunction (LV-IMR) or papillary muscle infarction (PM-IMR). METHODS: Patients with IMR undergoing repair (n = 65) or replacement (n = 137) from 1990 to 2001 were evaluated. There were 87 patients with LV-IMR, and 115 patients with PM-IMR. Patients presenting in cardiogenic shock were excluded. Outcomes were evaluated by Cox survival analysis with propensity score adjustment and bootstrap validation. RESULTS: Survival at 3, 5, and 9 years was, respectively, 0.94, 0.79, and 0.63 in the repair group, and 0.73, 0.67, and 0.59 in the replacement group. The hazard ratio (HR) of death for mitral repair versus replacement was not constant over the period of follow-up. Repair was associated with better early survival in the PM-IMR group, with an adjusted HR of 0.25 (95% confidence interval: 0.09 to 0.71) at 1 year. In the LV-IMR group and in patients with PM-IMR with high acuity and comorbidity, there was no significant survival advantage associated with repair. The beneficial effect of repair was not evident at late follow-up in either group. These findings were independent of the surgeon. Need for reoperation was more common after repair than after replacement (14% versus 3%, p = 0.003). CONCLUSIONS: Patients with PM-IMR benefit from mitral repair with a significantly better early survival. However, the benefit of repair is not evident at longer follow-up. There was a nonsignificant trend toward greater early survival among patients with LV-IMR who underwent repair.

Aged↗

PubMed2005

Late outcome after stenting or coronary artery bypass surgery for the treatment of multivessel disease: a single-center matched-propensity controlled cohort study.

BACKGROUND: Although several randomized controlled trials examined the relative benefits of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI), the most appropriate treatment remains a matter of debate, at least in some subsets of patients. Therefore, we evaluated the 8-year outcome after multivessel stent implantation (stent group) or coronary artery bypass surgery (CABG group) in a single-center propensity-matched cohort study. METHODS: The stent study population consisted of all 409 consecutive patients who underwent an elective coronary intervention between 1995 and 1999 in whom at least 2 stents were implanted in multiple vessels. They were matched by using the propensity score method with 409 CABG patients of 1,723 CABG patients with multivessel disease who underwent elective CABG in the same period of time. The two populations were very different before matching. After matching, the CABG population resembled a stent population. RESULTS: The cumulative survival rates after stent were 93%, 90%, and 82% at, respectively, 3, 5, and 8 years; and after CABG 97%, 93%, and 87% (p = 0.02). This was caused mainly by patients with left main disease (p = 0.03). Event-free survival was only 70%, 68%, and 64% after stent and 89%, 82%, and 78% after CABG at, respectively, 3, 5, and 8 years (p < 0.0001). After adjusting, stent was an independent predictor of higher mortality. CONCLUSIONS: In this matched cohort study with an 8-year follow-up, survival was better and less repeat revascularizations were needed among patients undergoing elective CABG for the treatment of multivessel disease as compared with the stent group.

Angioplasty, Balloon, Coronary↗

PubMed2005

Is hospital procedure volume a reliable marker of quality for coronary artery bypass surgery? A comparison of risk and propensity adjusted operative and midterm outcomes.

BACKGROUND: Worse operative mortality has been reported for hospitals with low versus high coronary artery bypass grafting surgery volumes. Despite a lack of comparisons beyond the early postoperative period and evidence of surgeon-volume confounding, some have suggested that regionalization of coronary artery bypass grafting in favor of high volume institutions is warranted. METHODS: We retrospectively compared operative mortality and 3-year survival in coronary artery bypass grafting patients (2001 to 2003) at a low-volume hospital (n = 504; 160 per year [median]) versus a high-volume hospital (n = 1,410; 487 per year) served by the same high-volume surgeon team. Covariate risk adjustment was done via multivariate and propensity modeling. RESULTS: The two hospital cohorts exhibited multiple demographic and risk factor differences. Unadjusted low-volume hospital vs high-volume hospital operative mortality was similar overall (2.38% vs 2.98%; p = 0.59) with nearly identical Society of Thoracic Surgeons observed-to-expected ratios (0.83 vs 0.82), irrespective of preoperative risk category. Hospital volume did not predict operative mortality (odds ratio, 95% confidence interval = 0.82; p = 0.602). At follow-up, a total of 28 low-volume hospital deaths (5.6%) and 135 high-volume hospital deaths (9.6%) occurred at similar surgery-to-death intervals (p = 0.7). Unadjusted 0 to 3-year survival was significantly worse for high-volume hospitals (risk ratio = 1.59; 1.06 to 2.39; p = 0.026). Yet procedure volume was not independently associated with worse midterm survival after covariate (risk ratio = 1.28; 0.84 to 1.96; p = 0.247) or propensity score (risk ratio = 1.11; 0.72 to 1.71; p = 0.648) adjustment. CONCLUSIONS: Hospital and surgeon volume effects on coronary artery bypass grafting outcomes are interdependent, and therefore hospital coronary artery bypass grafting volume per se is not a reliable marker of quality. Instead, outcome quality markers should rely on thorough risk-adjustment based on detailed clinical databases, possibly including annual and cumulative surgeon volume.

Aged↗

PubMed2005

Coronary endarterectomy: impact on morbidity and mortality when combined with coronary artery bypass surgery.

BACKGROUND: The results of coronary endarterectomy (CE) performed in addition to coronary artery bypass grafting (CABG) have been controversial. We aimed to examine the impact of CE performed in addition to CABG when compared with CABG alone in our unit. METHODS: Patients who had CABG between January 1995 and December 2001 were included. They were divided into two groups, the CABG-only group and CABG and CE group. The following outcomes were compared: perioperative myocardial infarction, postoperative ventricular arrhythmias, cerebrovascular accident, renal impairment, and early mortality. RESULTS: Of 5,782 patients who underwent CABG, 461 patients (8.6%) required CE in addition to CABG. There was a higher mortality and incidence of postoperative renal impairment in the group of patients who had CABG and CE, with no significant difference in other outcomes. However, the patients in the CABG and CE group had a higher incidence of male sex, previous myocardial infarctions, preoperative renal impairment, and poor left ventricular function, with longer cross-clamp and cardiopulmonary bypass times than in the CABG-only patients. Although female sex, renal impairment, nonelective surgery, impaired left ventricular function, and peripheral vascular disease were associated with increased mortality in all the patients, and use of statins and aspirin was associated with a reduction in mortality, CE was not a predictor of mortality. Furthermore, on propensity scores analysis, CE was not associated with increased mortality. CONCLUSIONS: Coronary endarterectomy when combined with CABG seemed to be associated with a higher mortality than isolated CABG in our study groups, but this is related to comorbidities of these patients rather than the CE.

Aged↗

PubMed2005

Radial artery grafts in women: utilization and results.

BACKGROUND: Despite a known survival benefit with the use of the left internal mammary artery, it is used less frequently in women when compared with men. This study evaluated the hypotheses that the radial artery graft is used less frequently in women compared with men, that the radial artery is smaller in women compared with men, and that the use of the radial artery influences operative mortality and long-term survival in women. METHODS: The use of a radial artery graft was evaluated in 2,633 patients who underwent isolated coronary artery bypass. Radial artery size and flow were compared in 207 patients who had intraoperative radial artery diameter and flow measurements. Propensity scoring was utilized to compare short- and long-term outcomes in a matched cohort of 588 women. RESULTS: Of 862 women (33%) who had isolated coronary artery bypass grafting, only 301 (35%) received a radial artery graft versus 44% of men (786 of 1,771, p < 0.001). Radial artery size and flow were significantly less in women. Operative mortality was not different between women with a radial artery graft and women without; however, 5-year survival was significantly better in women with a radial artery graft than in those without. CONCLUSIONS: Women received fewer radial artery grafts than men. Radial artery size and flow were significantly less in women than in men. Use of a radial artery graft did not influence operative mortality among women. However, 5-year survival among women who received a radial artery graft was significantly better than among women who did not.

Aged↗

PubMed2005

Single versus bilateral internal mammary artery for isolated first myocardial revascularization in multivessel disease: long-term clinical results in medically treated diabetic patients.

BACKGROUND: We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVG), increases the quality of the results of coronary bypass grafting in medically treated diabetic patients who undergo first myocardial revascularization, when compared with the use of a single left internal mammary artery (LIMA) and SVG. METHODS: From October 1991 to December 2001, 558 diabetic patients with multivessel coronary disease had first isolated myocardial revascularization using LIMA and SVG (group LIMA) in 217 cases and BIMA +/- SVG (group BIMA) in 341. Propensity score analysis identified 400 patients, 200 for each group, with similar preoperative characteristics. Thirty-day outcome and 8-year freedom from death from any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA in a grafted area, target cardiac events, and any event were evaluated. Follow-up ranged from 2.0 to 12.2 years (mean 6.0 +/- 2.0). RESULTS: There was no difference between groups except the cardiac deaths, which were significantly higher in the LIMA group (7 versus 0, p = 0.015). The BIMA group showed better 8-year freedom from death any cause (86.7 +/- 3.2 versus 79.5 +/- 4.1, p = 0.0274), cardiac death (96.3 +/- 1.4 versus 88.4 +/- 4.0, p = 0.0406), acute myocardial infarction (99.5 +/- 0.5 versus 92.0 +/- 3.9, p = 0.0092), and acute myocardial infarction in a grafted area (99.5 +/- 0.5 versus 93.4 +/- 3.7, p = 0.0204). Cox analysis confirmed that the use of LIMA and SVG was an independent predictor for lower freedom from death (hazard ratio [HR] = 1.8, p = 0.0310), cardiac death (HR = 1.9, p = 0.0426), AMI (HR = 9.7, p = 0.0033) and AMI in a grafted area (HR = 8.2, p = 0.0410). CONCLUSIONS: In diabetic patients with multivessel disease who undergo first myocardial revascularization, BIMA +/- SVG provides higher freedom from death, any cause, and cardiac-related death, if compared with LIMA + SVG. It plays a protective role in reducing the incidence of late AMI.

Aged↗

PubMed2005

Is reoperation still a risk factor in coronary artery bypass surgery?

BACKGROUND: Hospital mortality for reoperative coronary artery bypass grafting (CABG) is approaching that of primary CABG. This raises two questions: (1) has experience neutralized the risk of reoperation attributable to its greater difficulty, or (2) has experience neutralized the risk attributable to the higher-risk profile of reoperative patients?. METHODS: From 1990 to 2003, 21,568 CABG procedures were performed, of which 4,518 (21%) were reoperations: 3,919 first, 552 second, 43 third, 3 fourth, and 1 fifth. Reoperative patients had a higher-risk profile than primary patients, with more vascular disease, left ventricular dysfunction, and coronary artery disease (all p < 0.0001). Logistic regression was used to identify factors associated with hospital death and to develop a propensity score for reoperation, which was used to (1) adjust multivariable analyses of death and (2) compare outcomes in matched patients. RESULTS: Hospital mortality was 4.3% (168 of 3,919) for first reoperation, 5.1% (28 of 552) for second, and 6.4% (3 of 47) for third or more, compared with 1.5% (263 of 17,050) for primary operations. Risk of both primary and reoperative CABG decreased with experience (p > 0.0002); however, reoperative risk fell markedly in the mid-1990s. In both the overall and matched-pairs analyses, reoperation was a risk factor before 1997 (p < or = 0.008), but not after (p = 0.2). Reoperation within 1 year of previous CABG increased risk (p < 0.0001). Risk attributable to left ventricular dysfunction decreased with experience (p = 0.05). CONCLUSIONS: Hospital mortality for reoperative CABG has been consistently higher than for primary operation, but this difference has narrowed considerably. Patient characteristics, not reoperation itself, now have greater influence.

Aged↗

PubMed2005

Incomplete revascularization during OPCAB surgery is associated with reduced mid-term event-free survival.

BACKGROUND: The aim of this study was to compare early and mid-term outcome in patients undergoing off-pump coronary artery bypass surgery who have had complete revascularizations and incomplete revascularizations (IRs). METHODS: Patient and operative data were collected prospectively for all patients who had off-pump coronary artery bypass surgery. Patients with multivessel disease were classified as having IR if the number of diseased coronary systems (left anterior descending coronary artery, circumflex and right coronary artery) exceeded the number of distal anastomoses. In-hospital outcomes, survival, and event-free survival were compared between patients with complete revascularization and IR using propensity scores to take account of differences in prognostic factors. RESULTS: There were 1,479 off-pump coronary artery bypass surgery patients between April 1996 and December 2002 (30% of all coronary artery bypass graft patients), and 16.0% (237 patients) had IRs. Patients with IRs tended to be older and were female, had more extensive disease, worse dyspnea, a higher Parsonnet score, poorer ejection fraction, congestive cardiac failure, asthma or chronic obstructive airways disease, and previous cardiac surgery. The adjusted hazard ratio for patient survival with IRs versus complete revascularizations was 1.56 (95% confidence interval, 1.19 to 2.06; p = 0.001). Analyses for multiple time periods confirmed that IRs had a significantly increased risk of death, but also that the risk disappeared after the first 4 to 6 months of follow-up (p < 0.0001). CONCLUSIONS: Compared with off-pump coronary artery bypass surgery patients with complete revascularizations, those with IRs have reduced survival, but only in the first 4 to 6 months after surgery. Patients' preoperative condition, rather than IR itself, may explain these findings because IRs should have mid-term as well as early effects.

Adolescent↗

PubMed2006

Impact of no-to-moderate mitral regurgitation on late results after isolated coronary artery bypass grafting in patients with ischemic cardiomyopathy.

BACKGROUND: This study analyzes retrospectively a cohort of patients with ischemic cardiomyopathy (ejection fraction < or = 0.30) who underwent isolated coronary artery bypass grafting to evaluate the impact of no-to-moderate mitral regurgitation (MR) on long-term results. METHODS: From January 1988 to December 2002, 6,108 patients had isolated coronary artery bypass grafting. Two hundred thirty-nine (3.9%) had ischemic cardiomyopathy; 60 patients had no, 102 had mild, and 77 had moderate MR. Using propensity score, a group of 70 patients with no or mild MR (group A) was case-matched with a group of 70 patients with moderate MR (group B) to obtain two groups with similar preoperative characteristics. RESULTS: Nine patients (6.4%) died within the first 30 days; all deaths were cardiac-related. There was no difference in the early results between groups. Patients in group B showed lower freedom from death, from cardiac death, from cardiac death and ischemic events, and from death and New York Heart Association class III and IV than patients in group A. Cox analysis confirmed that moderate MR was an independent variable for worse late outcome in this subgroup of patients. Functional and echocardiographic results, after a mean of 62 +/- 28 months in 87.8% of survivors, showed a significant impairment of New York Heart Association class (from 2.2 +/- 0.5 to 2.8 +/- 0.6; p < 0.001) and MR degree (from 2.0 to 2.7 +/- 1.0; p = 0.023) in patients with preoperative moderate MR. CONCLUSIONS: This study confirms that moderate ischemic MR has an important negative impact on survival and quality of life of patients with severely impaired left ventricular function, treated by coronary artery bypass grafting alone.

Aged↗

PubMed2006

Malignant natural history of asymptomatic severe aortic stenosis: benefit of aortic valve replacement.

BACKGROUND: Patients with asymptomatic severe aortic stenosis (AS) are reported to have a benign prognosis and hence the American College of Cardiology/American Heart Association guidelines do not recommend aortic valve replacement (AVR) for patients with isolated asymptomatic severe AS. However, symptoms are subjective and would depend upon patient's life style. We examined the natural and unnatural history of initially asymptomatic patients with severe AS. METHODS: A search of our echocardiographic database between 1993 and 2003 yielded 740 patients with severe AS defined as aortic valve area 0.8 cm2 or less. Thorough chart reviews were conducted to collect clinical and pharmacologic data. Of these, 338 patients were asymptomatic at the initial encounter forming the study cohort. RESULTS: Patient characteristics were the following: age 71 +/- 15 years, males 51%, aortic valve area 0.72 +/- 0.17 cm2, left ventricular ejection fraction 0.59 +/- 0.17. Ninety-nine (29%) patients had AVR during a mean follow-up of 3.5 years. Survival at 1, 2, and 5 years in the nonoperated patients were 67%, 56%, and 38%, respectively, compared with 94%, 93%, and 90% in those who underwent AVR (p < 0.0001). The Cox regression model was used to adjust for the effect of 18 clinical, echocardiographic, and pharmacologic variables on survival. The adjusted hazard ratio for death with AVR was 0.17 (95% confidence interval [CI] 0.10 to 0.29). In the nonoperated group, renal insufficiency (risk ratio [RR] 3.1, 95% CI 1.5 to 6.6), beta blocker use (RR 0.52, 95% CI 0.31 to 0.88), statin use (RR 0.52, 95% CI 0.27 to 0.99), age (per year RR 1.03, 95% CI 1.02 to 1.05), and left ventricular ejection fraction (per % RR 0.99, 95% CI 0.98 to 1.00) were found to be the independent predictors of mortality. The benefit of AVR was further supported by sensitivity and propensity score analyses. CONCLUSIONS: Our observational data indicate that the natural history of asymptomatic AS is not benign and that survival is dramatically improved by AVR. Survival of the asymptomatic unoperated or nonoperable patients may potentially be improved by the use of beta blockers and statins.

Adrenergic beta-Antagonists↗

PubMed2005

SAFE Homes: is it worth the cost? An evaluation of a group home permanency planning program for children who first enter out-of-home care.

OBJECTIVE: To evaluate the SAFE Homes (SH) program, a short-term group care program for children between 3 and 12 years of age who enter care for the first time. The program aims to improve case outcomes by consolidating resources to facilitate assessment and treatment planning. METHODS: The 1-year outcomes of 342 children who received SAFE Home services and 342 matched foster care (FC) control children were compared. The 684 subjects used in this report were selected from a larger pool of 909 subjects using propensity score matching to control for hidden bias in treatment group assignment. We hypothesized that SAFE Homes would result in greater continuity of care for children (e.g., fewer placements, more placements with siblings and in towns of origin), identification of more relatives for substitute care when needed, reduced use of high-cost restrictive care settings (e.g., residential, inpatient), and reduced rates of re-abuse through earlier detection and provision of services to meet child and family treatment needs. RESULTS: Prior to the initiation of the SAFE Homes program, 75% of the children who entered care in the State experienced three or more placements in the first year. The outcomes of both the SH and FC cases were significantly improved over pre-SAFE Home State statistics. The FC group, however, had comparable or better outcomes on most variables examined. In addition, the total cost for out-of-home care for the children in FC was significantly less, despite the fact that the two groups spent similar amounts of time in care (average time in care: 7 months). This finding held when the total placement cost was calculated using the State reimbursement rate of 206.00 US dollars per day for SAFE Home care (SH: 20,851 US dollars +/- 24,231 US dollars; FC: 8,441 US dollars +/- 21,126 US dollars, p < .001), and a conservative SAFE Home program fee of 85.00 US dollars per day that only considered the child care and custodial staffing costs uniquely associated with the program (SH: 13,314 US dollars +/- 21,718 US dollars; FC: 8,441 US dollars +/-21,126 US dollars, p < .001). CONCLUSION: Improvements in outcomes related to continuity of care can be attained through staff training. The SAFE Home model of care is not cost-effective for first-time placements.

Child↗

PubMed2025

Real-World Experience of Midodrine in Hospital Setting in Pulmonary Arterial Hypertension.

BACKGROUND: Pulmonary arterial hypertension (PAH), a progressive disease, is characterized by increased pulmonary vascular resistance (PVR) and leads to right ventricular failure and premature death. PAH therapies aim to reduce PVR; however, these treatments as vasodilators may also result in reduced systemic vascular resistance and mean arterial pressure (MAP), leading to clinical or symptomatic hypotension. Low MAP can limit the administration of optimal dosage of PAH drugs. Midodrine, an oral alpha-1 adrenergic agonist, as a promising intervention, can potentially increase mean MAP and improve tolerance to PAH therapies. RESEARCH QUESTION: Does the use of midodrine improve MAP and allow for simultaneous uptitration of PAH therapy while hospitalized? STUDY DESIGN AND METHODS: A retrospective analysis of 433 patients treated at Houston Methodist Lung Center was undertaken between January 2005 and September 2022. Of these, 57 patients were prescribed midodrine during their hospital stay. We matched 57 patients 1:1 with propensity score matching between patients with PAH not given midodrine (control patients) based on age, sex, World Health Organization functional class, B-type natriuretic peptide, and 6-minute walk distance. RESULTS: Among hospitalized patients with PAH, those receiving midodrine were more likely to undergo uptitration of their PAH medications compared with those not receiving midodrine (n = 30 vs n = 17, respectively; P < .05). Patients on midodrine during hospitalization received higher doses of epoprostenol (P < .001), treprostinil (P < .05), and selexipag (P < .05). Additionally, no adverse effects attributable to midodrine were reported. INTERPRETATION: This study, to our knowledge the first large-scale analysis of PAH data, investigated the use of midodrine in hospitalized patients with PAH. In this single-center study, we share real-world experience of using midodrine to mitigate systemic hypotension, thereby facilitating the uptitration of PAH-targeted therapies.

B-type natriuretic peptide (BNP)↗

PubMed2004

Impact of prescription coverage on hospital and physician costs: a case study of medicare beneficiaries with chronic obstructive pulmonary disease.

BACKGROUND: It is widely believed that appropriate use of prescription medicines can reduce avoidable hospitalizations and more expensive nonpharmacologic therapies, but identifying such cost offsets in operational programs is elusive. Any possible impact would be most apparent in patients with medication-sensitive disease conditions, such as chronic obstructive pulmonary disease (COPD). OBJECTIVE: The goals of this study were to develop an observational study design appropriate for estimating potential cost savings in the US Medicare budget as a result of extending drug coverage to persons with particular chronic diseases and to apply these study methods, in an exploratory analysis, to a sample of Medicare beneficiaries with COPD. METHODS: Spending for drugs, hospitalizations, and physician services was compared for COPD patients with and without prescription coverage using data from the 1999 and 2000 US Medicare Current Beneficiary Survey. To control for channeling bias, multivariate matching on observable variables was combined with tests for missing variable bias. The matching algorithm used propensity score weighting to ensure comparability between the 2 groups on all observed characteristics at baseline. RESULTS: Our sample comprised 462 beneficiaries with prevalent COPD in the year 2000: 384 (83.1%) had prescription coverage the entire year and 78 (16.9%) had no coverage. After adjustment, drug coverage was associated with 61% higher spending on medications and 29% lower spending on physician services (both, P < 0.05). Hospital costs appeared slightly lower for those with drug benefits, but the difference was not statistically significant. No statistically significant effects were found for services specific to COPD. However, effect sizes were large even for nonsignificant findings. CONCLUSIONS: Although this analysis did not establish a strong causal link between drug benefits and lower costs, 11 of our 12 comparisons had signs consistent with the cost-offset hypothesis.

Aged↗

PubMed2004

Association of revascularisation with low mortality in non-ST elevation acute coronary syndrome, a report from GUSTO IV-ACS.

BACKGROUND: Immediate, as well as early, revascularisation is of benefit in patients with acute coronary syndromes (ACS) presenting with ST elevation. However, trials comparing invasive versus medical treatment in patients with an acute coronary syndrome without ST elevation do not consistently show improvement in survival after revascularisation. Accordingly, additional data are warranted. METHODS: The effect of revascularisation within 30 days on one-year survival in the GUSTO IV ACS trial was investigated. A total of 7800 patients were included with an acute coronary syndrome without ST elevation, documented by either elevated cardiac troponin or transient or persistent ST-segment depression. In this trial, comparing abciximab versus placebo as initial medical therapy, coronary angiography within 60 h after randomisation was discouraged. In 30-day survivors, those who underwent revascularisation were compared with 30-day survivors without revascularisation. Adjustments were made for patient characteristics, and for a propensity score that was adjusted for covariates associated with the likelihood of early revascularisation. FINDINGS: Of the 7496 patients who survived at least 30 days, 2265 (30%) underwent coronary revascularisation within 30 days: 789 patients CABG, 1450 PCI and 26 both CABG and PCI. Procedure-related mortality was low at 1.8%. Patients with revascularisation had a lower one-year mortality compared to medically treated patients (2.3% vs. 5.6%, p < 0.001). After multivariable analyses, patients with revascularisation had a relative risk of subsequent mortality within 1 year of 0.53 (95% CI 0.37-0.77) compared to patients without revascularisation. CONCLUSIONS: Revascularisation within 30 days is associated with an improved prognosis in ACS without ST-segment elevation. The relative high mortality in medically treated patients may be related in part to patient selection, but warrants further studies to improve outcome of these patients.

Abciximab↗