Potential Impact of Modifiable Clinical Variables on Length of Stay After First-Time Cardiac Surgery

Ad, Niv; Holmes, Sari D.; Shuman, Deborah J.; Pritchard, Graciela; Massimiano, Paul S.; Rongione, Anthony J.; Speir, Alan M.; Halpin, Linda

doi:10.1016/j.athoracsur.2015.05.055

Cited by 10 publications

(25 citation statements)

References 27 publications

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“…In line with other reports, over time, patients undergoing CABG in Israel were older, sicker, and have more advanced coronary disease . The length of hospital stay after both procedures were longer compared with those reported by the Society of Thoracic Surgeons and the National Cardiovascular Data Registry . Similar to mortality, it is impossible to reliably compare our outcomes with any benchmark without using validated length‐of‐stay prediction models.…”

Section: Discussionsupporting

confidence: 68%

“…The majority of patients in Israel are discharged to home, whereas a significant proportion of patients in the United States are discharged to extended-care facilities. 28,29 Parallel to the dramatic change in the volume and type of coronary revascularization procedure, we observed a 46% decline in IHD-related mortality in Israel during the study period-from 84.6 per 100 000 to 46 per 100 000. This absolute rate, as well as the steepness of decline are among the best in the OECD, and substantially better compared with the United States.…”

Section: Discussionmentioning

confidence: 79%

“…A fundamental difference between Israel and the United States is the discharge destination. The majority of patients in Israel are discharged to home, whereas a significant proportion of patients in the United States are discharged to extended‐care facilities …”

Section: Discussionmentioning

confidence: 99%

“…8,25 The length of hospital stay after both procedures were longer compared with those reported by the Society of Thoracic Surgeons and the National Cardiovascular Data Registry. 28 Similar to mortality, it is impossible to reliably compare our outcomes with any benchmark without using validated length-of-stay prediction models. A fundamental difference between Israel and the United States is the discharge destination.…”

Section: Discussionmentioning

confidence: 99%

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Trends in Coronary Revascularization and Ischemic Heart Disease–Related Mortality in Israel

Blumenfeld

Na’amnih

Shapira‐Daniels

et al. 2017

JAHA

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BackgroundWe investigated national trends in volume and outcomes of percutaneous coronary angioplasty (PCI), coronary artery bypass grafting (CABG), and ischemic heart disease–related mortality in Israel.Methods and ResultsUsing International Classification of Diseases 9th and 10th revision codes, we linked 5 Israeli national databases, including the Israel Center for Disease Control National PCI and CABG Registries, the Ministry of Health Hospitalization Report, the Center of Bureau of Statistics, and the Ministry of Interior Mortality Report, to assess the annual PCI and CABG volume, procedural mortality, comorbidities, and ischemic heart disease‐related mortality between 2002 and 2014. Trends over time were analyzed using linear regression, assuming a Poisson distribution. A total of 298 390 revascularization procedures (PCI: 255 724, CABG: 42 666) were performed during the study period. PCI volume increased by 9% from 2002 to 2008 (387.4/100 000 to 423.2/100 000), steadily decreasing by 10.5% to 378.5/100 000 in 2014 (P=0.70 for the trend). CABG volume decreased by 59% (109.0/100 000 to 45.2/100 000) from 2002 to 2013, leveling at 46.4/100 000 (P<0.0001). PCI/CABG ratio increased from 3.6 in 2002 to 8.5 in 2013, slightly decreasing to 8.2 by 2014 (P<0.0001). In‐hospital procedural mortality remained stable (PCI: 1.2–1.6%, P=0.34, CABG: 3.7–4.4%, P=0.29) despite a significant change in patient clinical profile. During the course of the study, ischemic heart disease‐related mortality decreased by 46% (84.6–46/100 000, P<0.001).ConclusionsWe observed a dramatic change in coronary revascularization procedures type and volume, and a marked decrease in ischemic heart disease‐related mortality in Israel. The reasons for the observed changes remain unclear and need to be further investigated.

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Section: Discussionsupporting

confidence: 68%

Section: Discussionmentioning

confidence: 79%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Trends in Coronary Revascularization and Ischemic Heart Disease–Related Mortality in Israel

Blumenfeld

Na’amnih

Shapira‐Daniels

et al. 2017

JAHA

View full text Add to dashboard Cite

show abstract

“…Perhaps resampling could shed some light on this matter.Furthermore, LOS data are generally right-skewed and ordinary least squares regression does not adequately accommodate large LOS values. When used for prediction, least squares regression will produce expected LOS values that follow a bellshaped distribution, in contradiction with the right-skewed observed LOS in Figure 1 of Ad and colleagues [1]. Figure 2 in Ad and colleagues [1] shows that expected LOS values (y-axis) are shorter than the observed LOS (x-axis), fact confirmed by the Pearson correlation of 0.632 (1).…”

mentioning

confidence: 89%

Modeling Hospital Length of Stay Data: Pitfalls and Opportunities

Andrei¹

2016

The Annals of Thoracic Surgery

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Hospital length of stay (LOS) represents an important resource utilization aspect in adult cardiac surgery. Ad and colleagues' [1] recent paper identifies significant modifiable clinical variables that are predictive of LOS. A multivariate linear regression predictive model is used to produce expected LOS values and observed-to-expected summary ratios are created for short (<6 days) and extended LOS (>14 days). This ratio is equal to 1.4 in the first group and 0.84 in the second group.Predictive models should avoid overfitting and be well calibrated [2,3]. Overfitting occurs when the model captures important data features and some of the sample's random noise. To objectively evaluate the predictive performance of a model, first model building should occur on a training dataset and its validation on an external dataset [2]. Judging the performance of a model on the training dataset (called the model's apparent performance) is known to produce overly optimistic model performance.There are ways to reduce or avoid overfitting, such as splitting the data into training and testing subsets. Other methods involve resampling, in which this process is repeated dozens or hundreds of times and the results are aggregated. Specific resampling techniques are k-fold cross-validation, generalized cross-validation, or bootstrapping. Upon model selection, calibration is the process of adjusting the model coefficients to ensure that observed and model-based expected values are in good agreement.A question remains whether the observed-to-expected LOS ratios in [1] being different from one reflect a true, underlying clinical reality (that one could also replicate on an external dataset), or the multivariable model's apparent performance. Perhaps resampling could shed some light on this matter.Furthermore, LOS data are generally right-skewed and ordinary least squares regression does not adequately accommodate large LOS values. When used for prediction, least squares regression will produce expected LOS values that follow a bellshaped distribution, in contradiction with the right-skewed observed LOS in Figure 1 of Ad and colleagues [1]. Figure 2 in Ad and colleagues [1] shows that expected LOS values (y-axis) are shorter than the observed LOS (x-axis), fact confirmed by the Pearson correlation of 0.632 (1). Alternative approaches to modeling LOS data involve normality-improving data transformations or Poisson regression.We appreciate Dr Andrei's comments [1] on our study [2] in which we sought to assess the reliability of the Society of Thoracic Surgeons (STS) risk prediction for extended and shorter LOS and examine whether modifiable clinical variables are associated with length of stay (LOS) in first-time cardiac surgery patients. We examined the data from more than 3,000 cardiac surgery patients at our center and found that the STS risk model was reliably predictive of short and extended LOS. In addition, our analyses found that potentially modifiable clinical variables, such as low preoperative hematocrit and blood transfusion, wer...

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Association of Elevated Pre‐operative Hemoglobin A1c and Post‐operative Complications in Non‐diabetic Patients: A Systematic Review

et al. 2017

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Potential Impact of Modifiable Clinical Variables on Length of Stay After First-Time Cardiac Surgery

Cited by 10 publications

References 27 publications

Trends in Coronary Revascularization and Ischemic Heart Disease–Related Mortality in Israel

Trends in Coronary Revascularization and Ischemic Heart Disease–Related Mortality in Israel

Modeling Hospital Length of Stay Data: Pitfalls and Opportunities

Association of Elevated Pre‐operative Hemoglobin A1c and Post‐operative Complications in Non‐diabetic Patients: A Systematic Review

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