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Now showing items 1 - 16 of 7384

  • Impact of Medicaid Expansion on Cardiac Surgery Volume and Outcomes

    Eric J. Charles   Lily E. Johnston   Morley A. Herbert   J. Hunter Mehaffey   Kenan W. Yount   Donald S. Likosky   Patricia F. Theurer   Clifford E. Fonner   Jeffrey B. Rich   Alan M. Speir   Gorav Ailawadi   Richard L. Prager   Irving L. Kron   for the   Investigators for the Virginia Cardiac Services Quality Initiative and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative  

    Background Thirty-one states approved Medicaid expansion after implementation of the Affordable Care Act. The objective of this study was to evaluate the effect of Medicaid expansion on cardiac surgery volume and outcomes comparing one state that expanded to one that did not. Methods Data from the Virginia (nonexpansion state) Cardiac Services Quality Initiative and the Michigan (expanded Medicaid, April 2014) Society of Thoracic and Cardiovascular Surgeons Quality Collaborative were analyzed to identify uninsured and Medicaid patients undergoing coronary bypass graft or valve operations, or both. Demographics, operative details, predicted risk scores, and morbidity and mortality rates, stratified by state and compared across era (preexpansion: 18 months before vs postexpansion: 18 months after), were analyzed. Results In Virginia, there were no differences in volume between eras, whereas in Michigan, there was a significant increase in Medicaid volume (54.4% [558 of 1,026] vs 84.1% [954 of 1,135], p < 0.001) and a corresponding decrease in uninsured volume. In Virginia Medicaid patients, there were no differences in predicted risk of morbidity or mortality or postoperative major morbidities. In Michigan Medicaid patients, a significant decrease in predicted risk of morbidity or mortality (11.9% [8.1% to 20.0%] vs 11.1% [7.7% to 17.9%], p = 0.02) and morbidities (18.3% [102 of 558] vs 13.2% [126 of 954], p = 0.008) was identified. Postexpansion was associated with a decreased risk-adjusted rate of major morbidity (odds ratio, 0.69; 95% confidence interval, 0.51 to 0.91; p = 0.01) in Michigan Medicaid patients. Conclusions Medicaid expansion was associated with fewer uninsured cardiac surgery patients and improved predicted risk scores and morbidity rates. In addition to improving health care financing, Medicaid expansion may positively affect patient care and outcomes.
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  • Individual Surgeon Performance in Adult Cardiac Surgery

    David M. Shahian   Richard L. Prager   Robert S.D. Higgins   Thomas E. MacGillivray   Joseph F. Sabik   Joseph A. Dearani   Keith S. Naunheim  

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  • Battling the Chimaera: How Much Disclosure of Rare Risks Is Necessary?

    Richard L. Prager   Alejandro Murillo Berlioz   Gregory D. Trachiotis   Joseph B. Zwischenberger   Robert M. Sade  

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  • Introduction to Dr Joseph E. Bavaria’s Presidential Address

    Richard L. Prager  

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  • The Society of Thoracic Surgeons National Database 2017 Annual Report

    Jeffrey P. Jacobs   David M. Shahian   Richard S. D’Agostino   Marshall L. Jacobs   Benjamin D. Kozower   Vinay Badhwar   Vinod H. Thourani   Henning A. Gaissert   Felix G. Fernandez   Richard L. Prager  

    The Society of Thoracic Surgeons (STS) National Database has three major component databases: the STS Adult Cardiac Surgery Database (ACSD), the STS Congenital Heart Surgery Database (CHSD), and the STS General Thoracic Surgery Database (GTSD). Beginning in January 2016, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article summarizes the status of the STS National Database as of October 2017 and summarizes the articles about the STS National Database that appeared in The Annals of Thoracic Surgery 2017 series “Outcomes Analysis, Quality Improvement, and Patient Safety.”
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  • The University of Michigan Cardiac and Thoracic Surgery Program

    Richard L. Prager   Edward L. Bove   Andrew C. Chang   Mark B. Orringer  

    In 1928, the University of Michigan opened its thoracic surgery residency under the leadership of Dr John Alexander. Initially tasked with providing surgical care for patients with thoracic diseases such as tuberculosis, thoracic surgery subspecialties now provide surgical treatment for a spectrum of diseases, ranging from congenital cardiopulmonary abnormalities to thoracic malignancy to acquired heart and great vessel diseases. Both the residency and the medical center have evolved to mirror the changing practice of thoracic surgery.
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  • Longitudinal functional recovery after geriatric cardiac surgery

    Lillian Min   Lauren Mazzurco   Tanya R. Gure   Christine T. Cigolle   Pearl Lee   Cathie Bloem   Chiao-Li Chan   Matthew A. Romano   Brahmajee K. Nallamothu   Kenneth M. Langa   Richard L. Prager   Preeti N. Malani  

    Abstract Background Impaired functional and cognitive status is an important outcome for older adults undergoing major cardiac surgery. We conducted this pilot study to gauge feasibility of assessing these outcomes longitudinally, from preoperatively up to two time points postoperatively to assess for recovery. Methods We interviewed patients aged ≥65 y preoperatively and repeated functional and cognitive assessments at 4–6 wk and 4–6 mo postoperatively. Simple unadjusted linear regression was used to test whether baseline measures changed at each follow-up time point. Then we used a longitudinal model to predict postoperative recovery overall, adjusting for comorbidity. Results A total of 62 patients (age 74.7 ± 5.9) underwent scheduled cardiac surgery. Preoperative activities of daily living (ADL) impairment was associated with poorer functional recovery at 4–6 wk postoperatively with each baseline ADL impairment conferring recovery of 0.5 fewer ADLs ( P  < 0.05). By 4–6 mo, we could no longer detect a difference in recovery. Preoperative cognition and physical activity were not associated with postoperative changes in these domains. Conclusions A preoperative and postoperative evaluation of function and cognition was integrated into the surgical care of older patients. Preoperative impairments in ADLs may be a means to identify patients who might benefit from careful postoperative planning, especially in terms of assistance with self-care during the first 4–6 wk after cardiac surgery.
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  • An Individual Surgeon Composite Metric: Are We Ready?

    Richard L. Prager  

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  • Determinants of Variation in Pneumonia Rates After Coronary Artery Bypass Grafting

    Alexander A. Brescia   J. Scott Rankin   Derek D. Cyr   Jeffrey P. Jacobs   Richard L. Prager   Min Zhang   Roland A. Matsouaka   Steven D. Harrington   Rachel S. Dokholyan   Steven F. Bolling   Astrid Fishstrom   Sara K. Pasquali   David M. Shahian   Donald S. Likosky   for the   Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative  

    Background Although conventional wisdom suggests that differences in patient risk profiles drive variability in postoperative pneumonia rates after coronary artery bypass grafting (CABG), this teaching has yet to be empirically tested. We determined to what extent patient risk factors account for hospital variation in pneumonia rates. Methods We studied 324,085 patients undergoing CABG between July 1, 2011, and December 31, 2013, across 998 hospitals using The Society of Thoracic Surgeons Adult Cardiac Database. We developed 5 models to estimate our incremental ability to explain hospital variation in pneumonia rates. Model 1 contained patient demographic characteristics and admission status, while Model 2 added patient risk factors. Model 3 added measures of pulmonary function, Model 4 added measures of cardiac anatomy and function and medications, and Model 5 further added measures of intraoperative and postoperative care. Results Although 9,175 patients (2.83%) experienced pneumonia, the median estimated distribution of pneumonia rates across hospitals was 2.5% (25th to 75th percentile: 1.5% to 4.0%). Wide variability in pneumonia rates was evident, with some hospitals having rates more than 6 times higher than others (10th to 90th percentile: 1.0% to 6.1%). Among all five models, Model 2 accounted for the most variability at 4.24%. In total, 2.05% of hospital variation in pneumonia rates was explained collectively by traditional patient factors, leaving 97.95% of variation unexplained. Conclusions Our findings suggest that patient risk profiles only account for a fraction of hospital variation in pneumonia rates; enhanced understanding of other contributory factors (eg, processes of care) is required to lessen the likelihood of such nosocomial infections.
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  • Association Between Medicaid Expansion and Cardiovascular Interventions in Michigan

    Donald S. Likosky   Devraj Sukul   Milan Seth   Chang He   Hitinder S. Gurm   Richard L. Prager  

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  • Nadir Hematocrit on Bypass and Rates of Acute Kidney Injury: Does Sex Matter?

    Michelle C. Ellis   Theron A. Paugh   Timothy A. Dickinson   John Fuller   Jeffrey Chores   Gaetano Paone   Michael Heung   Karsten Fliegner   Andrew L. Pruitt   Himanshu J. Patel   Min Zhang   Richard L. Prager   Donald S. Likosky   for the   PERForm Registry and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative  

    Background Reports have associated nadir hematocrit (Hct) on cardiopulmonary bypass with the occurrence of renal dysfunction. Recent literature has suggested that women, although more often exposed to lower nadir Hct, have a lower risk of postoperative renal dysfunction. We assessed whether this relationship held across a large multicenter registry. Methods We undertook a prospective, observational study of 15,221 nondialysis-dependent patients (10,376 male, 68.2%; 4,845 female, 31.8%) undergoing cardiac surgery between 2010 and 2014 across 26 institutions in Michigan. We calculated crude and adjusted OR between nadir Hct during cardiopulmonary bypass and stage 2 or 3 acute kidney injury (AKI), and tested the interaction of sex and nadir Hct. The predicted probability of AKI was plotted separately for men and women. Results Nadir Hct less than 21% occurred among 16.6% of patients, although less commonly among men (9.5%) than women (31.9%; p < 0.001). Acute kidney injury occurred among 2.7% of patients, with small absolute differences between men and women (2.6% versus 3.0%, p  = 0.20). There was a significant interaction between sex and nadir Hct ( p  = 0.009). The effect of nadir Hct on AKI was stronger among male patients (adjusted odds ratio per 1 unit decrease in nadir Hct 1.10, 95% confidence interval: 1.05 to 1.13) than female patients (adjusted odds ratio 1.01, 95% CI: 0.96, 1.06). Conclusions Lower nadir Hct was associated with an increased risk of AKI, and the effect appears to be stronger among men than women. Understanding of the mechanism underlying this association remains uncertain, although these results suggest the need to limit exposure to lower nadir Hct, especially for male patients.
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  • Invited Commentary

    Richard L. Prager  

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  • The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2016 Update on Research

    Vinay Badhwar   J. Scott Rankin   Jeffrey P. Jacobs   David M. Shahian   Robert H. Habib   Richard S. D’Agostino   Vinod H. Thourani   Rakesh M. Suri   Richard L. Prager   Fred H. Edwards  

    The Society of Thoracic Surgeons Adult Cardiac Database (ACSD) is an international voluntary effort that is the foundation of our specialty’s efforts in clinical performance assessment and quality improvement. Containing nearly 6,000,000 patient records, the ACSD is a robust resource for clinical research. Seven major original publications and four review articles were generated from the ACSD in 2015. The risk-adjusted outcome analyses and quality measures reported in these studies have made substantial contributions to inform daily clinical practice. This report summarizes the ACSD-based research efforts published in 2015.
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  • Invited Commentary

    Richard L. Prager  

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  • Red Blood Cell Transfusions Impact Pneumonia Rates After Coronary Artery Bypass Grafting

    Donald S. Likosky   Gaetano Paone   Min Zhang   Mary A.M. Rogers   Steven D. Harrington   Patricia F. Theurer   Alphonse DeLucia   Astrid Fishstrom   Anton Camaj   Richard L. Prager   for the   Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative  

    Background Pneumonia, a known complication of coronary artery bypass grafting (CABG), significantly increases a patient’s risk of morbidity and mortality. Although not well characterized, red blood cell (RBC) transfusions may increase a patient’s risk of pneumonia. We describe the relationship between RBC transfusion and postoperative pneumonia after CABG. Methods A total of 16,182 consecutive patients underwent isolated CABG between 2011 and 2013 at 1 of 33 hospitals in the state of Michigan. We used multivariable logistic regression to estimate the relative odds of pneumonia associated with the use or number of RBC units (0, 1, 2, 3, 4, 5, and ≥ 6). We adjusted for predicted risk of mortality, preoperative hematocrit values, history of pneumonia, cardiopulmonary bypass duration, and medical center. We confirmed the strength and direction of these relationships among selected clinical subgroups in a secondary analysis. Results Five hundred seventy-six (3.6%) patients had pneumonia and 6,451 (39.9%) received RBC transfusions. There was a significant association between any RBC transfusion and pneumonia (adjusted odds ratio [OR adj ], 3.4; p < 0.001). There was a dose response between number of units and odds of pneumonia, with a ptrend less than 0.001. Patients receiving only 2 units of RBCs had a 2-fold (OR adj , 2.1; p < 0.001) increased odds of developing pneumonia. These findings were consistent across clinical subgroups. Conclusions We found a significant volume-dependent association between an increasing number of RBCs and the odds of pneumonia, which persisted after risk adjustment. Clinical teams should explore opportunities for preventing a patient’s risk of RBC transfusions, including reducing hemodilution or adopting a lower transfusion threshold in a stable patient.
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  • Cardiac Surgeons and the Quality Movement: the Michigan Experience

    Richard L. Prager   Frederick R. Armenti   Joseph S. Bassett   Gail F. Bell   Daniel Drake   Eric C. Hanson   John C. Heiser   Scott H. Johnson   F.B. Plasman   Francis L. Shannon   David Share   Patty Theurer   Jaelene Williams  

    The Michigan Society of Thoracic and Cardiovascular Surgeons created a voluntary quality collaborative with all the cardiac surgeons in the state and all hospitals doing adult cardiac surgery. Utilizing this collaborative over the last 3 years and creating a unique relationship with a payor, an approach to processes and outcomes has produced improvements in the quality of care for cardiac patients in the state of Michigan.
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