Impact of Advanced Practice Provider Integration into Multispecialty Group Practices on Outcomes Following Major Surgery

Background. While advanced practice providers (APPs) are increasingly integrated into care delivery models, little is known about their impact in surgical settings. Given that many patients undergo surgery in multispecialty group practice settings, we examined the impact of APP integration into such practices on outcomes after major surgery. Methods. We used a 20% sample of national Medicare claims to identify 190 101 patients who underwent 1 of 4 major surgeries (coronary artery bypass graft [CABG], colectomy, major joint replacement, and cystectomy) at multispecialty group practices from 2010 through 2016. The level of APP integration was measured as the ratio of APPs to physicians within each practice. Rates of mortality, major complications, and readmission within 30 days of discharge after the index surgery were compared between patients treated in practices with low, medium, and high levels of APP integration using multivariable regression analysis. Results. Relative to patients treated in practices with low APP integration, those treated in practices with medium or high APP integration had significantly lower rates of mortality (2.4% [low integration] vs 1.9% [medium integration] vs 2.0% [high integration]; P < .01), major complications (34.1% [low] vs 31.2% [medium] vs 30.2% [high]; P < .01), and readmission (11.7% [low] vs 10.6% [medium] vs 10.1% [high]; P < .01). This relationship was consistent for virtually all outcomes when considering each surgery type individually. Conclusions. Integration of APPs into multispecialty group practices was associated with improved postoperative outcomes after major surgery. Future research should identify the mechanisms by which APPs improve outcomes to inform optimal utilization.

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Evolving oncology provider perspectives on care delivery during the COVID-19 pandemic.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e18609 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e18609-e18609

Author(s):

Divya Ahuja Parikh ◽

Meera Vimala Ragavan ◽

Sandy Srinivas ◽

Sarah Garrigues ◽

Eben Lloyd Rosenthal ◽

...

Keyword(s):

Cancer Care ◽

Care Delivery ◽

The United States ◽

Advanced Practice ◽

Curative Surgery ◽

Time Points ◽

Patients With Cancer ◽

Provider Perspectives ◽

Significant Difference ◽

The Impact

e18609 Background: The COVID-19 pandemic prompted rapid changes in cancer care delivery. We sought to examine oncology provider perspectives on clinical decisions and care delivery during the pandemic and to compare provider views early versus late in the pandemic. Methods: We invited oncology providers, including attendings, trainees and advanced practice providers, to complete a cross-sectional online survey using a variety of outreach methods including social media (Twitter), email contacts, word of mouth and provider list-serves. We surveyed providers at two time points during the pandemic when the number of COVID-19 cases was rising in the United States, early (March 2020) and late (January 2021). The survey responses were analyzed using descriptive statistics and Chi-squared tests to evaluate differences in early versus late provider responses. Results: A total of 132 providers completed the survey and most were white (n = 73/132, 55%) and younger than 49 years (n = 88/132, 67%). Respondents were attendings in medical, surgical or radiation oncology (n = 61/132, 46%), advanced practice providers (n = 48/132, 36%) and oncology fellows (n = 16/132, 12%) who predominantly practiced in an academic medical center (n = 120/132, 91%). The majority of providers agreed patients with cancer are at higher risk than other patients to be affected by COVID-19 (n = 121/132, 92%). However, there was a significant difference in the proportion of early versus late providers who thought delays in cancer care were needed. Early in the pandemic, providers were more likely to recommend delays in curative surgery or radiation for early-stage cancer (p < 0.001), delays in adjuvant chemotherapy after curative surgery (p = 0.002), or delays in surveillance imaging for metastatic cancer (p < 0.001). The majority of providers early in the pandemic responded that “reducing risk of a complication from a COVID-19 infection to patients with cancer” was the primary reason for recommending delays in care (n = 52/76, 68%). Late in the pandemic, however, providers were more likely to agree that “any practice change would have a negative impact on patient outcomes” (p = 0.003). At both time points, the majority of providers agreed with the need for other care delivery changes, including screening patients for infectious symptoms (n = 128/132, 98%) and the use of telemedicine (n = 114/132, 86%) during the pandemic. Conclusions: We found significant differences in provider perspectives of delays in cancer care early versus late in the pandemic which reflects the swiftly evolving oncology practice during the COVID-19 pandemic. Future studies are needed to determine the impact of changes in treatment and care delivery on outcomes for patients with cancer.

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Impact of atrial fibrillation on in-hospital outcomes among hospitalizations for cardiac surgery: an analysis of the National Inpatient Sample

Journal of Investigative Medicine ◽

10.1136/jim-2021-001864 ◽

2022 ◽

pp. jim-2021-001864

Author(s):

Kanishk Agnihotri ◽

Paris Charilaou ◽

Dinesh Voruganti ◽

Kulothungan Gunasekaran ◽

Jawahar Mehta ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Valve Replacement ◽

Failure Time ◽

Artery Bypass ◽

Bypass Graft ◽

National Inpatient Sample ◽

Inpatient Mortality ◽

Hospitalization Costs ◽

The Impact

The short-term impact of atrial fibrillation (AF) on cardiac surgery hospitalizations has been previously reported in cohorts of various sizes, but results have been variable. Using the 2005–2014 National Inpatient Sample, we identified all adult hospitalizations for cardiac surgery using the International Classification of Diseases, Ninth Revision, Clinical Modification as any procedure code and AF as any diagnosis code. We estimated the impact of AF on inpatient mortality, length of stay (LOS), and cost of hospitalization using survey-weighted, multivariable logistic, accelerated failure-time log-normal, and log-transformed linear regressions, respectively. Additionally, we exact-matched AF to non-AF hospitalizations on various confounders for the same outcomes. A total of 1,269,414 hospitalizations were noted for cardiac surgery during the study period. Coexistent AF was found in 44.9% of these hospitalizations. Overall mean age was 65.6 years, 40.9% were female, mean LOS was 11.6 days, and inpatient mortality was 4.5%. Stroke rate was lower in AF hospitalizations (1.8% vs 2.1%, p<0.001). Mortality was lower in the AF (3.9%) versus the non-AF (5%) group (exact-matched OR or emOR=0.48, 95% CI 0.29 to 0.80, p<0.001; 987 matched pairs, n=2423), with similar results after procedural stratification: isolated valve replacement/repair (emOR=0.38, p<0.001), isolated coronary artery bypass graft (CABG) (emOR=0.33, p<0.001), and CABG with valve replacement/repair (emOR=0.55, p<0.001). A 12% increase was seen in LOS in the AF subgroup (exact-matched time ratio=1.12, 95% CI 1.10 to 1.14, p<0.001) among hospitalizations which underwent valve replacement/repair with or without CABG. Hospitalizations for cardiac surgery which had coexistent AF were found to have lower inpatient mortality risk and stroke prevalence but higher LOS and hospitalization costs compared with hospitalizations without AF.

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The impact of minimal invasive extracorporeal circulation on postoperative kidney function

Perfusion ◽

10.1177/0267659120954601 ◽

2020 ◽

pp. 026765912095460

Author(s):

Ara Shwan Media ◽

Peter Juhl-Olsen ◽

Nils Erik Magnusson ◽

Ivy Susanne Modrau

Keyword(s):

Acute Kidney Injury ◽

Renal Function ◽

Kidney Function ◽

Extracorporeal Circulation ◽

Artery Bypass ◽

Bypass Graft ◽

Kidney Injury ◽

Minimal Invasive ◽

Mortality And Morbidity ◽

The Impact

Introduction: Acute kidney injury following cardiac surgery is a frequent complication associated with increased mortality and morbidity. Minimal invasive extracorporeal circulation is suggested to preserve postoperative renal function. The aim of this study was to assess the impact of minimal invasive versus conventional extracorporeal circulation on early postoperative kidney function. Methods: Randomized controlled trail including 60 patients undergoing elective stand-alone coronary artery bypass graft surgery and allocated in a 1:1 ratio to either minimal invasive (n = 30) or conventional extracorporeal circulation (n = 30). Postoperative kidney injury was assessed by elevation of plasma neutrophil gelatinase-associated lipocalin (NGAL), a sensitive tubular injury biomarker. In addition, we assessed changes in estimated glomerular filtration rate (eGFR), and the incidence of acute kidney injury according to the Acute Kidney Injury Network (AKIN) classification. Results: We observed no differences between groups regarding increase of plasma NGAL (p = 0.31) or decline of eGFR (p = 0.82). In both groups, 6/30 patients developed acute kidney injury according to the AKIN classification, all regaining preoperative renal function within 30 days. Conclusion: Our findings challenge the superiority of minimal invasive compared to conventional extracorporeal circulation in terms of preservation of renal function following low-risk coronary surgery.

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Mortality and Revascularization among Myocardial Infarction Patients with Schizophrenia: A Population-Based Cohort Study

The Canadian Journal of Psychiatry ◽

10.1177/0706743720904845 ◽

2020 ◽

Vol 65 (7) ◽

pp. 454-462 ◽

Cited By ~ 2

Author(s):

Tanya S. Hauck ◽

Ning Liu ◽

Harindra C. Wijeysundera ◽

Paul Kurdyak

Keyword(s):

Myocardial Infarction ◽

Coronary Revascularization ◽

Artery Bypass ◽

Bypass Graft ◽

Coronary Intervention ◽

Population Based ◽

Geographic Region ◽

Time Varying ◽

The Impact ◽

The Relationship

Background: Cardiovascular disease is a major source of mortality in schizophrenia, and access to care after acute myocardial infarction (AMI) is poor for these patients. Aims: To understand the relationship between schizophrenia and access to coronary revascularization and the impact of revascularization on mortality among individuals with schizophrenia and AMI. Method: This study used a retrospective cohort of AMI in Ontario between 2008 and 2015. The exposure was a diagnosis of schizophrenia, and patients were followed 1 year after AMI discharge. The primary outcome was all-cause mortality within 1 year. Secondary outcomes were cardiac catheterization and revascularization (percutaneous coronary intervention or coronary artery bypass graft). Cox proportional hazard regression models were used to study the relationship between schizophrenia and mortality, and the time-varying effect of revascularization. Results: A total of 108,610 cases of incident AMI were identified, among whom 1,145 (1.1%) had schizophrenia. Schizophrenia patients had increased mortality, with a hazard ratio (HR) of 1.55 (95% CI, 1.37 to 1.77) when adjusted for age, sex, income, rurality, geographic region, and comorbidity. After adjusting for time-varying revascularization, the HR reduced to 1.38 (95% CI, 1.20 to 1.58). The impact of revascularization on mortality was similar among those with and without schizophrenia (HR: 0.42; 95% CI, 0.41 to 0.44 vs. HR: 0.40; 95% CI, 0.26 to 0.61). Conclusions: In this sample of AMI, mortality in schizophrenia is increased, and treatment with revascularization reduces the HR of schizophrenia. The higher mortality rate yet similar survival benefit of revascularization among individuals with schizophrenia relative to those without suggests that increasing access to revascularization may reduce the elevated mortality observed in individuals with schizophrenia.

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P2857Implantable cardioverter defibrillator and pacemaker lead extraction: is it safe to do it again?

European Heart Journal ◽

10.1093/eurheartj/ehz748.1166 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

A Cubberley ◽

P Sharedalal ◽

N Shah ◽

G Essilfie ◽

G Burkman ◽

...

Keyword(s):

Coronary Artery ◽

Electronic Device ◽

Artery Bypass ◽

Bypass Graft ◽

Systolic Heart Failure ◽

Adverse Outcomes ◽

Lead Extraction ◽

Major Complications ◽

Significant Difference ◽

First Time

Abstract Background/Introduction There are growing numbers of transvenous implantable devices for patients requiring permanent pacemakers (PPM) as well as Implantable Cardioverter Defibrillators (ICD). As such, there has been a concomitant increased need for lead extraction. Lead extraction is associated with increased morbidity and mortality (Hamid, 2010). Comparative outcomes of repeat lead extraction are not extensively studied. Purpose We compared demographics as well as major and minor adverse outcomes in patients undergoing first time vs. repeat lead extraction procedures. Methods In our single center study, 1278 extractions took place between January 2004 and December of 2018. Of these 1177 patients underwent PPM or ICD lead extraction for the first time; 101 patients underwent repeat extractions. Baseline characteristics including gender, history of coronary artery bypass graft (CABG) surgery, hypertension (HTN), systolic heart failure (HF) defined as ejection fraction <40%, hyperlipidemia (HLD), diabetes mellitus (DM), and coronary artery disease (CAD) were evaluated using chi-squared analysis. Adverse events, as defined by the 2017 HRS Expert Consensus Statement on Cardiovascular Implantable Electronic Device Lead Management and Extraction, were identified as major complications (death, cardiac arrest, cardiac perforation, coronary venous dissection, pericardial tamponade, or urgent cardiac surgery), and minor complications (coronary sinus dissection, pneumothorax, pocket bleeding requiring drainage, worsening tricuspid valve function, vegetation embolization, venous thrombosis, requirement of blood transfusion or lead migration). Results Comparing first time extractions vs repeat extractions, there was no significant difference in proportion of patients of female gender (32.4% vs. 28.3%, p=0.412), patients with prior CABG (23.0 vs. 23.4%, p=0.227), HTN (66.0% vs. 62.2%, p=0.462), HF (52.3% vs. 62.0%), HLD (39.6% vs 39.7%, p=0.682), DM (35.3% vs. 30.8%, p=0.387), or CAD (55.9% vs 56.0%, p=0.978). There was no significant difference in major complications (1.4% vs. 1.0%, p=0.749) and minor complications (3.5% vs 4.1%, p=0.741). Conclusion Patients undergoing repeat lead extractions showed very similar baseline demographics compared to first time lead extractions. Repeat extractions did not have increased rates of major or minor complications.

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