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Biomedical subjects

T Bruce Ferguson

Publications and source records attributed to T Bruce Ferguson.

45 records · Page 3Linked to original sources
PubMed2003

Continuous quality improvement in medicine: validation of a potential role for medical specialty societies.

A rigorous evaluation of the effects of continuous quality improvement (CQI) on medical practice has not yet been achieved on a large, multicenter scale. The authors sought to test whether a low-intensity CQI intervention could be used to speed the adoption of two coronary artery bypass grafting process-of-care measures on a national level. The infrastructure of the Society of Thoracic Surgeons' National Cardiac Database was used as a CQI Platform in a prospective randomized trial of CQI conducted between January 2001 and July 2002. Preoperative beta-blockade and internal mammary artery grafting in patients aged >75 years were the care processes used. Three hundred fifty-nine National Cardiac Database sites were randomized into two intervention groups (beta blocker, n=124; internal mammary artery grafting, n=114) and one control group (n=114). Each intervention arm received measure-specific information, including a call to action to a physician leader; educational products; and periodic longitudinal, nationally benchmarked, site-specific feedback. Incorporation of the specific care process into everyday clinical practice at the intervention site was the main outcome measure. The analyses included a site-level analysis of differences between pre- and postintervention measure use and a hierarchical analysis using risk-adjustment for patient characteristics and accounting for clustering due to site. Use of beta blockers increased vs. control (Delta=7% vs. Delta=4%), significant at both the site level (p=0.04) and in the hierarchical analyses (p=0.0006). Internal mammary artery graft use also increased vs. control (Delta=9% vs. Delta=5%; p=0.20 and p=0.11, respectively). However, lower volume IMA sites showed significant improvement over lower volume control sites (Delta=14% vs. Delta=8%; p=0.02 for interaction). A multifaceted, physician-led, low-intensity effort can have an impact on the adoption of care processes into national practice. This Society CQI Platform is a potential model for large-scale quality improvement efforts across all disciplines of medicine.

Benchmarking↗
PubMed2002

Nitric oxide is consumed, rather than conserved, by reaction with oxyhemoglobin under physiological conditions.

Although irreversible reaction of NO with the oxyheme of hemoglobin (producing nitrate and methemoglobin) is extremely rapid, it has been proposed that, under normoxic conditions, NO binds preferentially to the minority deoxyheme to subsequently form S-nitrosohemoglobin (SNOHb). Thus, the primary reaction would be conservation, rather than consumption, of nitrogen oxide. Data supporting this conclusion were generated by using addition of a small volume of a concentrated aqueous solution of NO to a normoxic hemoglobin solution. Under these conditions, however, extremely rapid reactions can occur before mixing. We have thus compared bolus NO addition to NO generated homogeneously throughout solution by using NO donors, a more physiologically relevant condition. With bolus addition, multiple hemoglobin species are formed (as judged by visible spectroscopy) as well as both nitrite and nitrate. With donor, only nitrate and methemoglobin are formed, stoichiometric with the amount of NO liberated from the donor. Studies with increasing hemoglobin concentrations reveal that the nitrite-forming reaction (which may be NO autoxidation under these conditions) competes with reaction with hemoglobin. SNOHb formation is detectable with either bolus or donor; however, the amounts formed are much smaller than the amount of NO added (less than 1%). We conclude that the reaction of NO with hemoglobin under normoxic conditions results in consumption, rather than conservation, of NO.

Hemoglobins↗
PubMed2002

Preoperative beta-blocker use and mortality and morbidity following CABG surgery in North America.

CONTEXT: beta-Blockade therapy has recently been shown to convey a survival benefit in preoperative noncardiac vascular surgical settings. The effect of preoperative beta-blocker therapy on coronary artery bypass graft surgery (CABG) outcomes has not been assessed. OBJECTIVES: To examine patterns of use of preoperative beta-blockers in patients undergoing isolated CABG and to determine whether use of beta-blockers is associated with lower operative mortality and morbidity. DESIGN, SETTING, AND PATIENTS: Observational study using the Society of Thoracic Surgeons National Adult Cardiac Surgery Database (NCD) to assess beta-blocker use and outcomes among 629 877 patients undergoing isolated CABG between 1996 and 1999 at 497 US and Canadian sites. MAIN OUTCOME MEASURE: Influence of beta-blockers on operative mortality, examined using both direct risk adjustment and a matched-pairs analysis based on propensity for preoperative beta-blocker therapy. RESULTS: From 1996 to 1999, overall use of preoperative beta-blockers increased from 50% to 60% in the NCD (P<.001 for time trend). Major predictors of use included recent myocardial infarction; hypertension; worse angina; younger age; better left ventricular systolic function; and absence of congestive heart failure, chronic lung disease, and diabetes. Patients who received beta-blockers had lower mortality than those who did not (unadjusted 30-day mortality, 2.8% vs 3.4%; odds ratio [OR], 0.80; 95% confidence interval [CI], 0.78-0.82). Preoperative beta-blocker use remained associated with slightly lower mortality after adjusting for patient risk and center effects using both risk adjustment (OR, 0.94; 95% CI, 0.91-0.97) and treatment propensity matching (OR, 0.97; 95% CI, 0.93-1.00). Procedural complications also tended to be lower among treated patients. This treatment advantage was seen among the majority of patient subgroups, including women; elderly persons; and those with chronic lung disease, diabetes, or moderately depressed ventricular function. Among patients with a left ventricular ejection fraction of less than 30%, however, preoperative beta-blocker therapy was associated with a trend toward a higher mortality rate (OR, 1.13; 95% CI, 0.96-1.33; P =.23). CONCLUSIONS: In this large North American observational analysis, preoperative beta-blocker therapy was associated with a small but consistent survival benefit for patients undergoing CABG, except among patients with a left ventricular ejection fraction of less than 30%. This analysis further suggests that preoperative beta-blocker therapy may be a useful process measure for CABG quality improvement assessment.

Adrenergic beta-Antagonists↗
PubMed2002

Right coronary artery arising from the pulmonary trunk in a 63-year-old man.

Unlike anomalous origin of the left coronary artery (CA) from the pulmonary trunk (PT), right CA from the PT, a rare congenital malformation, may present in adulthood. We herein describe a man with anomalous origin of the right CA from the PT who presented with angina and syncope at age 63.

Angina Pectoris↗
PubMed2002

A decade of change--risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990-1999: a report from the STS National Database Committee and the Duke Clinical Research Institute. Society of Thoracic Surgeons.

BACKGROUND: The Society of Thoracic Surgeons National Adult Cardiac Database is the largest voluntary clinical database in medicine. Using this database we examined changes in the risk profile of patients undergoing isolated coronary artery bypass grafting (CABG) and their outcomes during the decade 1990 to 1999. METHODS: Trends in 23 preoperative risk factors were tracked for CABG cases during this decade. Using a multivariate logistic risk model, we also determined the degree to which operative risk and risk-adjusted operative mortality changed during this 10-year interval. RESULTS: Between 1990 and 1999, 1,154,486 patient records were harvested by the Society of Thoracic Surgeons National Adult Cardiac Database for isolated CABG procedures performed at 522 Society of Thoracic Surgeons participant sites in the United States and Canada. Over time, CABG patients were more likely to be older (mean age 63.7 in 1990, 65.1 in 1999), of female gender (25.7% women in 1990, 28.7% in 1999), and have a history of smoking, diabetes mellitus, renal failure, hypertension, stroke, chronic lung disease, New York Heart Association functional class IV, and three-vessel disease (p < 0.0001). Patients' predicted operative risk increased by 30.1%, from 2.6% in 1990 to 3.4% in 1999. Despite higher risk, observed operative mortality decreased by 23.1%, from 3.9% in 1990 to 3.0% in 1999 (p < 0.0001). During the decade, a Medicare-aged subset (n = 629,174) experienced similar increases in risk and declines in mortality. CONCLUSIONS: Patients referred for isolated CABG are significantly older, sicker, and have a higher risk than a decade ago. Despite this, CABG mortality rates have declined substantially. These results highlight the excellent progress in the care of CABG patients achieved during the past decade.

Adult↗
PubMed2002

Hospital variability in length of stay after coronary artery bypass surgery: results from the Society of Thoracic Surgeon's National Cardiac Database.

BACKGROUND: There is growing interest in comparing resource, as well as patient outcome metrics among coronary artery bypass graft surgery (CABG) providers, yet few tools exist for adjusting these provider comparisons for patient case-mix. In this study, we aimed to define the magnitude of hospital variability in postoperative length of stay (PLOS) in contemporary practice and to determine the degree to which this variability was accounted for by differences in patient case-mix. We also sought to determine the relationship between hospitals' risk-adjusted PLOS and mortality outcomes. METHODS: We analyzed 496,797 isolated CABG procedures performed between January 1997 to January 2001 at 587 US hospitals participating in the Society of Thoracic Surgeon's National Cardiac Database. Logistic and linear regression were used to identify independent preoperative factors affecting a patient's likelihood for early discharge (PLOS < or = 5 day), prolonged stay (> 14 days), and overall PLOS. Hierarchical models were used to determine the degree to which hospital factors influenced PLOS beyond patient factors. RESULTS: Overall, 53% of CABG patients were discharged within 5 days of CABG, whereas 5% required prolonged (> 14 days) stays. More than 25 preoperative patient factors were independently associated with a patients' likelihood for early discharge and prolonged stay (model C index 0.70 and 0.75, respectively). After adjusting for patient factors, however, there remained wide unexplained variability among hospitals in PLOS and limited correlation between these PLOS metrics and hospitals' risk-adjusted mortality results (Spearman correlation coefficient -0.15 and 0.35). CONCLUSIONS: Our study provides a method for institutions to receive meaningful risk-adjusted bypass PLOS information. Given the marked variability among hospitals in CABG PLOS, institutions should consider benchmarking metrics of efficiency, as well as patient outcomes.

Aged↗
PubMed2002

Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery.

OBJECTIVE: To assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) when applied in a North American cardiac surgical population. METHODS: The simple additive EuroSCORE model was applied to predict operative mortality (in-hospital or 30-day) in 401684 patients undergoing coronary or valve surgery in 1998 and 1999 as well as in 188913 patients undergoing surgery in 1995 in the Society of Thoracic Surgeons (STS) database. RESULTS: The proportion of isolated coronary artery bypass grafting (CABG) was greater in STS patients (84%) than in Europe (65%). STS patients were also older (mean age 65.3 versus 62.5), and had more diabetes (30 versus 17%) and prior cardiac surgery (11 versus 7%). Other comorbidity was also significantly more prevalent in STS patients. EuroSCORE predicted overall mortality was virtually identical to the observed mortality (1998/1999: predicted 3.994%, observed 3.992%; 1995: observed and predicted 4.156%). Predicted mortality also closely matched observed mortality across the risk groups. Discrimination was good to very good for the population overall and for isolated CABG in both time periods, with the area under the receiver operating characteristic curve between 0.75 and 0.78. CONCLUSION: Despite substantial demographic differences between Europe and North America, EuroSCORE performs very well in the STS database, and can be recommended as a simple, additive risk stratification system on both sides of the Atlantic.

Cardiac Surgical Procedures↗
PubMed2002

Internal thoracic artery grafting in the elderly patient undergoing coronary artery bypass grafting: room for process improvement?

OBJECTIVE: The acute and long-term benefits of internal thoracic artery grafting are clear in younger patients undergoing coronary artery bypass grafting. The elderly, however, face higher surgical risks and have shorter life expectancy, and thus the use of internal thoracic artery grafting in this age group has been debated. This study examined the use, complication risks, and operative (30-day) mortality associated with internal thoracic artery grafting in patients 75 years of age and older. METHODS: Between 1996 and 1999, 522,656 patients in the Society of Thoracic Surgeons National Cardiac Database underwent primary, nonemergency-salvage coronary artery bypass grafting; of these, 99,942 were 75 years of age or older. The influence of internal thoracic artery use on operative mortality and 5 major complications in this elderly group was examined by means of (1) risk adjustment (adjusting for 28 baseline risk factors and site) and (2) a treatment propensity score analysis that compares patients with similar baseline likelihood for receiving an internal thoracic artery graft. RESULTS: In the National Cardiac Database 77.4% of patients aged 75 to 84 years received an internal thoracic artery graft compared with 93.5% for those aged 55 years or less. In this elderly group use of the internal thoracic artery was strongly associated with decreased operative mortality (unadjusted mortality, 6.20% vs. 4.05%; P <.0001) that persisted after controlling for baseline risk and provider effects (adjusted odds ratio, 0.85; 95% confidence intervals, 0.79-0.91). This mortality benefit was seen among those with low-to-high baseline propensity for receiving an internal thoracic artery graft. CONCLUSIONS: Use of the internal thoracic artery in elderly patients undergoing coronary artery bypass grafting provides an acute survival benefit. This benefit is similar to that seen in younger patients and persists after adjusting for both patient and provider selection factors. The internal thoracic artery appears to be underused in elderly patients undergoing bypass grafting and is a potential area for quality improvement.

Age Factors↗