Determining predictors of delayed recovery and the need for transitional cardiac rehabilitation after cardiac surgery.
ABSTRACT To examine the relationship between demographic and clinical characteristics of cardiac surgery patients with postoperative length of stay (PLOS) greater than 7 days and determine the demographic, social, and clinical predictors of the need for transitional cardiac rehabilitation (TCR) after cardiac surgery.
A retrospective review of characteristics, clinical indices, caregiver availability, and patient status (whether living alone) was completed for 304 patients undergoing cardiac surgery over 24 consecutive months. Univariate analyses and multivariable logistic regression models were used to evaluate risk factor characteristics for PLOS greater than 7 days and to predict discharge disposition to TCR or home.
Older patients, those with preoperative comorbidities, and those without a caregiver at home experience delays in functional recovery and discharge and are more likely to need TCR services.
Our findings support the addition of functional recovery and social support risk items to the preoperative cardiac surgery risk assessment.
- SourceAvailable from: Judith A Malmgren[show abstract] [hide abstract]
ABSTRACT: Preoperative severity of illness in patients undergoing coronary artery bypass grafting (CABG) surgery is a major determinant of clinical postoperative outcomes and surgical length of stay (SLOS). Preoperative patient reported health status and social risk have not been quantified as predictors of SLOS post-CABG. Our hypothesis was that poorer self-reported health and greater social risk, as measured by standardized instruments, are significantly associated with extended SLOS defined as greater than or equal to 7 days. In the pilot phase of the Washington State Clinical Outcomes Assessment Program (COAP) patients in a case series between 1995 and 1996 at all hospitals with a cardiac surgery program were administered preoperative SF-36 and Seattle Angina Questionnaires (SAQ) in addition to the collection of prospective clinical data with Society of Thoracic Surgeons' compatible definitions (n = 1073). Factors found significant from bivariate analysis were incorporated into a logistic regression model to assess relative association with extended SLOS (>/= 7 days). The final model included the following elements in descending order of significance: site, SF-36 health perceptions (HP) scale, social risk factors, age, intraaortic balloon pump, congestive heart failure, comorbidity score more than 2, preoperative days more than 2, emergency operation, prior CABG, and gender. The HP subscore of the SF-36 and the composite social risk factors score were significantly associated with extended SLOS after controlling for other standard clinical variables. "Hospital site" remained the factor with the greatest variance independent of patient severity of illness.The Annals of Thoracic Surgery 02/2004; 77(2):557-62. · 3.45 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Fast-track recovery after coronary artery bypass surgery has influenced patient care positively. Predicting patients who fall off track and require prolonged (> or =7 days) hospitalization remains uncertain. The Parsonnet risk assessment score is effective in predicting length of stay, but is limited by inaccurate subdivision of risk categories. We simplified the Parsonnet risk scale to better identify patients eligible for fast-track recovery. The cases of 604 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) were reviewed retrospectively. A rapid recovery protocol emphasizing reduced CPB time, preoperative intra-aortic balloon pump (IABP) criteria, and atrial fibrillation prophylaxis was applied to all patients. The five original divisions of the Parsonnet risk scale were reduced to three risk categories: Low (0-10; Group A), Intermediate (11-20; Group B), High (> 20; Group C). Comparisons of progressive risk categories were analyzed to identify predictive factors associated with fast-track outcomes. The thirty-day operative mortality for the entire group was 3.6%. Three clinical features were identified that distinguished risk progression-female gender, reoperative CABG, and increased age. Additionally, the presence of diabetes (p < 0.05), congestive heart failure (p < 0.01), and peripheral vascular disease (p < 0.001) distinguished Groups A and B, while acute myocardial infarction (p < 0.05) influenced outcomes in Group C. Group A (48%) mean risk score 5.9+/-3.2 was compared to Group B (34%) 14.8+/-2.6, which was further compared to Group C (18%) 26.4+/-2.8. The mean length of stay for Group A (5.3+/-4.1 days) was notably less than Group B (6.1+/-4.7 days; p < 0.05); however, both groups responded favorably to fast-track techniques. Group C did not respond comparably (9.2+/-9.2 vs 6.1+/-4.7 days; p < 0.001) and experienced prolonged recovery. The simplified Parsonnet risk scale did not identify differences in operative mortality and revealed only pneumonia (p < 0.05) and atrial fibrillation (p < 0.01) to be greater in Group C. As risk increased, significantly less revascularization was performed (Group A 3.6+/-1.2 grafts/patient vs Group B 3.3+/-1.2 [p < 0.01]; Group B 3.3+/-1.2 vs Group C 2.5+/-1.0 [p < 0.001]). A simplified Parsonnet risk scale (three categories) is an effective tool in identifying factors limiting fast-track recovery. Low- and intermediate-risk patients represent the majority (82%) and respond well to fast-track methods. High-risk patients (18%) are limited by a greater percentage of female patients, reoperative CABG, and the very elderly, resulting in fast-track failure. Strategies to improve recovery in high-risk patients may include evolving off-pump techniques.Journal of Cardiac Surgery 01/2000; 15(5):316-22. · 1.35 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: To relate morbidity and mortality risk to preoperative severity of illness in patients undergoing coronary artery bypass grafting. Retrospective analysis of 5051 patients using univariate and logistic regression to identify risk factors associated with perioperative morbidity and mortality. Prospective application of models to a subsequent 2-year validation cohort (n = 4069). Cleveland Clinic Foundation. All adult patients undergoing coronary artery bypass graft surgery between July 1, 1986, and June 30, 1988 (reference group), and July 1, 1988, and June 30, 1990 (validation group). Mortality and morbidity (myocardial infarction and use of intra-aortic balloon pump, mechanical ventilation for 3 or more days, neurological deficit, oliguric or anuric renal failure, or serious infection). Emergency procedure, preoperative serum creatinine levels of greater than 168 mumol/L, severe left ventricular dysfunction, preoperative hematocrit of 0.34, increasing age, chronic pulmonary disease, prior vascular surgery, reoperation, and mitral valve insufficiency were found to be predictive of mortality. In addition to these factors, diabetes mellitus, body weight of 65 kg or less [corrected], aortic stenosis, and cerebrovascular disease were predictive of morbidity. Logistic regression equations were developed, and a simple additive score for clinical use was designed by allocating each of these risk-factor values of 1 to 6 points. Both methods predict mortality. Increased morbidity was demonstrated with increases in score. The logistic or clinical models developed are superior to the currently available methods for comparing mortality outcome and provide previously unavailable information on morbidity based on preoperative status. The clinical scoring system is useful for preoperative estimates of morbidity and mortality risks.JAMA The Journal of the American Medical Association 06/1992; 267(17):2344-8. · 29.98 Impact Factor