Nontertiary Care Setting Research Articles

Diagnostic accuracy study of routine echocardiography for bicuspid aortic valve: a retrospective study and meta-analysis.

Transthoracic echocardiography (TTE) is the standard procedure to distinguish tricuspid aortic valve (TAV) from bicuspid aortic valve (BAV). Published studies assessed the accuracy of TTE for BAV under ideal conditions. Conversely, we aimed at assessing accuracy of TTE for BAV under routine conditions. This retrospective, cross-sectional study of 216 adults included 132 men aged 62±14 years. Of these, 108 had BAV and 108 were age-matched individuals with TAV. All diagnoses were confirmed at surgery. We assessed TTE in two patient groups. First, in the (I) group of all 216 individuals, where we assessed accuracy for BAV according to the original diagnoses as documented by the primary investigators during original TTE examination. Second, we assessed accuracy for BAV according to expert re-evaluation in (II) all 158 TTE with availability of original recordings. Third, we performed a meta-analysis of published results on the accuracy of TTE for BAV according to PRISMA standards. Sensitivity, specificity and accuracy of (I) primary investigators was 46.3%, 97.2, and 71.8% as compared to (II) expert re-evaluation with 59.7%, 93%, and 77.8%, respectively. Sensitivity was significantly higher at re-evaluation (P<0.001). TTE at a non-tertiary care center (P=0.012), presence of aortic aneurysm (P=0.001) and presence of severe aortic valve calcification (P=0.003) predicted an inaccurate diagnosis of BAV. Conversely, meta-analysis of published TTE studies identified a pooled sensitivity of 87.7% and a pooled specificity of 88.3% for BAV. The current study shows that TTE yields almost ideal diagnostic accuracy when ideal investigators examine ideal patients. However, the study also shows that TTE yields suboptimal diagnostic accuracy under routine conditions. TTE in non-tertiary care settings, concomitant aortic aneurysm, and presence of severe aortic valve calcification predict an inaccurate diagnosis of BAV.

Successful Use of Recombinant Activated Coagulation Factor VII in a Patient with Massive Hemoptysis From a Penetrating Thoracic Injury

Acute massive hemoptysis is a rare complication of pulmonary injury and contusion, and it is particularly difficult to manage in the nontertiary care setting. Recombinant activated coagulation factor VII (rFVIIa) is a prothrombotic drug that is increasingly being used to treat coagulopathy in massively exsanguinating trauma patients. We report a case in which recombinant activated coagulation factor VII successfully controlled massive hemoptysis and improved ventilation from a severe pulmonary contusion in a noncoagulopathic patient who suffered a penetrating thoracic injury in a military setting in Afghanistan.

Hand-Assisted Laparoscopic Colectomy Compared with Open Colectomy in a Nontertiary Care Setting

Laparoscopic colectomy allows oncologic resection equivalent to open colectomy while reducing postoperative morbidity, at the cost of longer operating time. Hand-assisted laparoscopy might yield the benefits of laparoscopy while reducing operating time. We compared the intraoperative and postoperative experience of patients undergoing hand-assisted laparoscopic colectomy (HALC) to those who had open colectomy. In this retrospective case review of consecutive patients undergoing HALC for colon tumors from April 2003 to September 2004 compared with patients who had open colectomy, patients with rectal cancer and stage IV disease were excluded, and reported variables were compared by the nonparametric Mann-Whitney U test; all P values are 2-tailed. The number of patients with HALC versus open colectomy was 39 and 55, respectively. The locations of tumors were as follows: right colon, 62% versus 56%; left colon, 2.5% versus 11%; sigmoid colon, 31% versus 33%; and rectosigmoid colon, 5% versus 0. Stage distribution was as follows: stage 0, 23% versus 11%; stage I, 23% versus 23%; stage II, 31% versus 36%; and stage III, 23% versus 31%. Median operating room time was 139 minutes versus 137 minutes (P = 0.94). Four 39 (10%) HALC procedures were converted to open colectomy. Duration of hospitalization was 6 days versus 10 days (P = 0.007). Median number of lymph nodes in resection specimen was 12 versus 9 (P = 0.043). There were 3 cases of serious postoperative infection in the HALC group versus 9 in the open colectomy cohort. Hand-assisted laparoscopic colectomy is technically feasible in the nontertiary care setting, with duration of surgery equivalent to that of open colectomy but significantly shorter duration of hospitalization and equivalent or superior quality resection and pathologic staging.

Hand-assisted laparoscopic vs open colectomy in a rural healthcare center

14587 Background: Complete surgical resection is a key component of curative therapy for colon cancer. Accurate pathologic staging requires examination of a sufficient number of lymph nodes in the resection specimen. Open colectomy (OC) is the traditional surgical technique, newer minimally-invasive laparoscopic techniques allow equivalent-quality cancer resection while reducing post-operative morbidity, but require longer operating time. Hand-assisted laparoscopic colectomy (HALC) may yield the benefits of laparoscopic colectomy while reducing operating time. The benefits of laparoscopic surgery reported in tertiary healthcare centers may not be achievable in non-tertiary care centers. We compared the operative experience of patients undergoing HALC to those who had OC at a rural veterans Hospital. Methods: Study design: Retrospective case-control study of consecutive patients undergoing HALC for colon cancer from April 2000 to September 2004 compared to patients who had OC. Patients with rectal and stage IV colon cancer were excluded. Reported variables were compared by the non-parametric Mann-Whitney U-test, all p-values are two-tailed. Results: Data is reported as HALC vs. OC. N= 39 in HALC cohort vs. 55 in OC. Median age: 72.1 vs 70.3 yrs (p 0.46). Location of tumors: right colon 62% vs 56%, left colon 2.5 vs 11%, sigmoid colon 36% vs 33. Stage: 0, 23% vs 11%; I 23% vs 23%; II 31% vs 36%; III 23% vs 31%. Median operating room time was 139 vs 137 minutes (p 0.94). 4 of 39 (10%) HALC procedures were converted to OC. Number of lymph nodes in resection specimen 12 vs 9 (p=0.043). Duration of hospitalization: 6 days vs 10 days (p=0.007). 5% of HALC patients were transfused vs 13% of OC patients. There were 3 cases of serious post-operative infection in the HALC group vs 9 in the OC cohort, 0 cases of wound dehiscence vs 3, 0 perioperative deaths vs 3. Overall, 8% of HALC patients developed severe post-operative surgical complications vs 22% of OC patients (p&lt;0.05). Conclusions: HALC is technically feasible in the non-tertiary care setting, with equivalent duration of surgery to OC, but significantly shorter duration of hospitalization. The quality of surgical resection, pathologic staging and rates of peri-operative morbidity and mortality are similar or slightly better with HALC. No significant financial relationships to disclose.

Depression in veterans with Parkinson's disease: frequency, co‐morbidity, and healthcare utilization

To determine the frequency of depression in Parkinson's disease (PD) in routine clinical care, and to examine its association with co-morbid psychiatric and medical conditions and healthcare utilization. Depression diagnoses and healthcare utilization data for all male veterans with PD age 55 or older seen in fiscal year 2002 (n = 41,162) were analyzed using Department of Veterans Affairs (VA) national databases. Frequencies of co-morbid disorders and healthcare utilization were determined for depressed and non-depressed patients; associations with depression were examined using multivariate logistic regression models. A depression diagnosis was recorded for 18.5% of PD patients, including major depression in 3.9%. Depression decreased in frequency and severity with increasing age. In multivariate logistic regression models, depressed patients had significantly greater psychiatric and medical co-morbidity, including dementia, psychosis, stroke, congestive heart failure, diabetes, and chronic obstructive pulmonary disease than non-depressed patients (all p < 0.01). Depressed PD patients were also significantly more likely to have medical (OR = 1.34, 95% CI = 1.25-1.44) and psychiatric hospitalizations (OR = 2.14, 95% CI = 1.83-2.51), and had more outpatient visits (p < 0.01), than non-depressed PD patients in adjusted models. Depression in PD in non-tertiary care settings may not be as common or as severe as that seen in specialty care, though these findings also may reflect under-recognition or diagnostic imprecision. The occurrence of depression in PD is associated with greater psychiatric and medical co-morbidity, and greater healthcare utilization. These findings suggest that screening for depression in PD is important and should be embedded in a comprehensive psychiatric, neuropsychological, and medical evaluation.

Assessing the Effect of Publication of Clinical Guidelines on the Management of Unstable Angina and Non-ST Elevation Myocardial Infarction in The TIMI III (1990-1993) and the GUARANTEE (1995-1996) Registries

The clinical guidelines for unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI) published in 1994 by the Agency for Health Care Policy Research (AHCPR) were intended to help improve treatment. No large study, however, has evaluated the effect of the guidelines on clinical practice We compared the treatment of 3,318 patients admitted with UA/NSTEMI in the preguideline Thrombolysis in Myocardial Infarction (TIMI) III Registry (1990-1993) and 2,948 patients enrolled in the postguideline Global Unstable Angina Registry and Treatment Evaluation (GUARANTEE) Registry (1995-1996). More patients in GUARANTEE received guideline-recommended medication than did those in TIMI III, specifically beta-blockers (50.9% vs. 40.7%, P < 0.001), heparin (63.3% versus 57.5%, P < 0.001), and the combination of aspirin, heparin, and beta-blockers on admission plus aspirin at discharge (26.9% vs. 18.8%, P < 0.001). These changes were similar in all subgroups, but the greatest improvement in medication use was seen in patients admitted to a tertiary care hospital and in those with a final diagnosis of NSTEMI, i.e., with positive cardiac markers. Conversely, fewer patients in GUARANTEE who fulfilled AHCPR criteria for catheterization underwent the procedure (62.3% in GUARANTEE tertiary centers vs. 44.6% in GUARANTEE nontertiary centers vs. 66.0% in TIMI, P < 0.001). After publication of clinical guidelines for UA/NSTEMI, more patients received appropriate pharmacologic treatment, but a significant number of patients remained under-treated. Efforts to improve compliance with guideline recommendations via education and critical pathways are warranted, especially in nontertiary care settings.

Assessing the Effect of Publication of Clinical Guidelines on the Management of Unstable Angina and Non-ST Elevation Myocardial Infarction in The TIMI III (1990???1993) and the GUARANTEE (1995???1996) Registries

Background: The clinical guidelines for unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI) published in 1994 by the Agency for Health Care Policy Research (AHCPR) were intended to help improve treatment. No large study, however, has evaluated the effect of the guidelines on clinical practice Methods: We compared the treatment of 3,318 patients admitted with UA/NSTEMI in the preguideline Thrombolysis in Myocardial Infarction (TIMI) III Registry (1990-1993) and 2,948 patients enrolled in the postguideline Global Unstable Angina Registry and Treatment Evaluation (GUARANTEE) Registry (1995-1996). Results: More patients in GUARANTEE received guidelinerecommended medication than did those in TIMI III, specifically beta-blockers (50.9% vs. 40.7%,P< 0.001), heparin (63.3% versus 57.5%,P< 0.001), and the combination of aspirin, heparin, and beta-blockers on admission plus aspirin at discharge (26.9% vs. 18.8%,P< 0.001). These changes were similar in all subgroups, but the greatest improvement in medication use was seen in patients admitted to a tertiary care hospital and in those with a final diagnosis of NSTEMI, i.e., with positive cardiac markers. Conversely, fewer patients in GUARANTEE who fulfilled AHCPR criteria for catheterization underwent the procedure (62.3% in GUARANTEE tertiary centers vs. 44.6% in GUARANTEE nontertiary centers vs. 66.0% in TIMI,P< 0.001). Conclusion: After publication of clinical guidelines for UA/NSTEMI, more patients received appropriate pharmacologic treatment, but a significant number of patients remained under-treated. Efforts to improve compliance with guideline recommendations via education and critical pathways are warranted, especially in nontertiary care settings.

Prolonged pregnancy and the biophysical profile: A birthing center perspective

A triage system for antepartum surveillance of postdates pregnancy is studied in a busy, indigent care service with limited resources for in-hospital delivery. One hundred seventy-eight pregnancies (13.2% of the total population) were thought to be at least 42 weeks' gestation by clinical criteria, and 128 of these underwent at least one complete biophysical profile within seven days of delivery. We find no statistically significant difference in the incidence of meconium staining, fetal distress in labor, or low Apgar scores when either the high or low scoring groups are compared, or when compared with the 50 patients who delivered without a biophysical evaluation. Specific components of the testing schema, however, namely oligohydramnios and spontaneous decelerations on the nonstress test, are highly associated with adverse perinatal events. Of the total population thought to be postmature clinically, only 60 infants (33.9%) were actually beyond 42 weeks' gestation by Dubowitz scoring. We conclude that a modified biophysical assessment as described is easily performed in a nontertiary care setting where a cnm-md team approach is applied and may help to differentiate patients who require expeditious termination of pregnancy in-hospital from those who can be managed expectantly in the birthing center.

Context in Organizational Groups: The Case of Hospital Clusters

Although previous research has shown that the structure of groups or clusters of hospitals depends upon environmental characteristics of local service areas, little work has been done to demonstrate the importance of specifying the appropriate environmental framework for hospital clusters of varying composition. Clusters composed of only community general hospitals are affected primarily by the characteristics of the local community or service area, whereas clusters composed of both community hospitals and tertiary care hospitals (such as teaching hospitals or Veterans' Administration Hospitals) must respond to both local contingencies and extra-local constraints, such as the regional demands for specialized care and the teaching andlor research activities of other tertiary care hospitals. Thus, the presence of a tertiary care facility within a hospital cluster may alter significantly the context of the cluster. Using longitudinal data on national samples of tertiary and nontertiary care settings, I tested several hypotheses concerning the structure and environmental responsiveness of community hospital clusters in these different contexts.