Preparing for Bundled Payments: Impact of Complications Post–Coronary Artery Bypass Grafting on Costs

Haddad, Devin; Shipe, Maren E.; Absi, Tarek; Danter, Matthew; Vyas, Rushikesh; Levack, Melissa M.; Shah, Ashish S.; Grogan, Eric L.; Balsara, Keki R.

doi:10.1016/j.athoracsur.2020.06.105

Cited by 3 publications

(2 citation statements)

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“…Our analyses identified factors associated with ALI, rather than predictors of ALI. 25 Although adjusted models accounted for known baseline characteristics, postrandomization variables were not included, and residual confounding may exist. Outcomes after events (eg, death after ALI) are not necessarily caused by the proximate events, and observations should be treated as associations.…”

Section: Discussionmentioning

confidence: 99%

“…21 Other analyses have reported that the average hospital lengths of stay after acute myocardial infarction and stroke are 3 and 5 days, respectively, 22,23 and the median length of stay after coronary artery bypass graft surgery is 5 days. 24 Thus, although there is a spectrum of severity of ALI, overall, risks of subsequent mortality and associated health care resource use after ALI appear to be greater than for other cardiovascular conditions.…”

Section: Discussionmentioning

confidence: 99%

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Reduction in Acute Limb Ischemia With Rivaroxaban Versus Placebo in Peripheral Artery Disease After Lower Extremity Revascularization: Insights From VOYAGER PAD

et al. 2021

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Background: Patients with peripheral artery disease (PAD) are at heightened risk of acute limb ischemia (ALI), a thrombotic event associated with amputation, disability, and mortality. Prior lower extremity revascularization (LER) is associated with increased ALI risk in chronic PAD. However, the pattern of risk, clinical correlates, and outcomes after ALI early after LER are not well-studied, and effective therapies to reduce ALI post-LER are lacking. Methods: VOYAGER PAD (NCT02504216) randomized patients with PAD undergoing LER to rivaroxaban 2.5 mg twice daily or placebo on a background of low-dose aspirin. The primary outcome was a composite of ALI, major amputation of vascular cause, myocardial infarction, ischemic stroke, or cardiovascular death. ALI was prospectively ascertained and adjudicated by a blinded committee. The cumulative incidence of ALI was calculated using Kaplan Meier estimates, and Cox proportional-hazards models were used to generate hazard ratios and associated confidence intervals. Analyses were performed as intention-to-treat. Results: Among 6,564 patients followed for a median of 2.3 years, 382 (5.8%) had a total of 508 ALI events. In placebo patients, the 3-year cumulative incidence of ALI was 7.8%. After multivariable modeling, prior LER, baseline ABI <0.50, surgical LER, and longer target lesion length were associated with increased risk of ALI. Incident ALI was associated with subsequent all-cause mortality (HR 2.59, 95% CI 1.98-3.39) and major amputation (HR 24.87, 95% CI 18.68-33.12). Rivaroxaban reduced ALI relative to placebo by 33% (absolute risk reduction 2.6% at 3 years, HR 0.67, 95% CI 0.55-0.82, P=0.0001), with benefit starting early (HR 0.45, 95% CI 0.24-0.85, P=0.0068 at 30 days). Benefit was present for severe ALI (associated with death, amputation, or prolonged hospitalization and ICU stay, HR 0.58, 95% CI 0.40-0.83, P=0.003) and regardless of LER type (surgical vs endovascular revascularization, p-interaction=0.42) or clopidogrel use (p-interaction=0.59). Conclusions: After LER for symptomatic PAD, ALI is frequent, particularly early after LER, and is associated with poor prognosis. Low-dose rivaroxaban plus aspirin reduces ALI after LER, including ALI events associated with the most severe outcomes. The benefit of rivaroxaban for ALI appears early, continues over time, and is consistent regardless of revascularization approach or clopidogrel use.

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Section: Discussionmentioning

confidence: 99%