Margaret W Arnold

Johns Hopkins Medicine, Baltimore, Maryland, United States

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Publications (4)14.66 Total impact

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    ABSTRACT: OBJECTIVE: We have previously demonstrated an adverse impact of black race and Hispanic ethnicity on the outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS). The current study was undertaken to examine the influence of race and ethnicity on the cost of CEA and CAS. METHODS: The Nationwide Inpatient Sample (2005-2009) was queried using ICD-9 codes for CEA and CAS in patients with carotid artery stenosis. The primary outcome was total hospital charges. Multivariate analysis was performed using a generalized linear model adjusting for age, sex, race, comorbidities (Charlson index), high-risk status, procedure type, symptomatic status, year, insurance type, and surgeon and hospital operative volumes and characteristics. RESULTS: Hispanic and black patients were more likely to have a symptomatic presentation, and were more likely to undergo either CEA or CAS by low-volume surgeons at low-volume hospitals (P < 0.05, all). They were also less likely to have private insurance or Medicare (P < 0.001). Overall, CEA was less expensive than CAS over the 4-y study period ($29,502 ± $104 versus $46,713 ± $409, P < 0.001). Total hospital charges after CEA were increased in both blacks ($39,562 ± $843) and Hispanics ($45,325 ± $735) compared with whites on univariate analysis ($28,403 ± $101, P < 0.001). After CAS, total hospital charges were similarly increased in both blacks ($51,770 ± $2085) and Hispanics ($63,637 ± $2766) compared with whites on univariate analysis ($45,550 ± $412, P < 0.001). On multivariable analysis, however, only Hispanic ethnicity remained independently associated with increased charges after both CEA (exponentiated coefficient 1.18; 95% CI [1.15-1.20]; P < 0.001) and CAS (exponentiated coefficient 1.17; 95% CI [1.09-1.24]; P < 0.001). CONCLUSION: Hispanic ethnicity was independently associated with increased hospital charges after both CEA and CAS. The increased charges seen in black patients were explained, in part, by decreased surgeon operative volume and increased postoperative complications. Further efforts are warranted to contain costs in minorities undergoing carotid revascularization.
    Journal of Surgical Research 04/2013; DOI:10.1016/j.jss.2013.03.057 · 2.12 Impact Factor
  • Journal of Surgical Research 02/2013; 179(2):200. DOI:10.1016/j.jss.2012.10.332 · 2.12 Impact Factor
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    ABSTRACT: This study sought to evaluate the short-, intermediate-, and longer-term outcomes after endovascular versus open repair of abdominal aortic aneurysms (AAA), including both AAA-related and all-cause mortality. Endovascular stent graft placement for AAA has gained broad acceptance as an alternative to open surgical repair due to a lower perioperative morbidity and mortality. The intermediate- and long-term all-cause and aneurysm-related mortality vary among studies. Thus, we sought to perform a meta-analysis of open versus endovascular repair for treating AAA. Electronic databases were queried for identification of prospective, randomized trials of open surgery versus endovascular stent graft repair of AAA. A total of 10 published papers reporting on 6 studies at different follow-up intervals were identified; they involved 2,899 patients with AAA repair procedures, of whom, 1,470 underwent endovascular stent graft AAA exclusion and 1,429 were treated by open AAA repair. At 30 days, the pooled relative risk of all-cause mortality was lower in the endovascular group (relative risk [RR]: 0.35, 95% confidence interval [CI]: 0.19 to 0.64) than in the open surgery group. At intermediate follow-up, the all-cause mortality had a nonsignificant difference (RR: 0.78, 95% CI: 0.57 to 1.08), the AAA-related mortality was significantly lower (RR: 0.46, 95% CI: 0.28 to 0.74) and reintervention rates were higher (RR: 1.48, 95% CI: 1.06 to 2.08) in the endovascular group than in the open surgery group. At long-term follow-up, there was no significant difference in all-cause mortality (RR: 0.99, 95% CI: 0.85 to 1.15) or AAA-related mortality (RR: 1.58, 95% CI: 0.20 to 12.74), whereas the significant difference in the rate of reinterventions persisted (RR: 2.54, 95% CI: 1.58 to 4.08). In patients randomized to open or endovascular AAA repair, all-cause perioperative mortality, as well as AAA-related mortality at short- and intermediate-term follow-up are lower in patients undergoing endovascular stent graft placement. This was associated with greater reintervention in the endovascular group noted at intermediate follow-up. Long-term survival appears to converge between the 2 groups.
    JACC. Cardiovascular Interventions 10/2012; 5(10):1071-80. DOI:10.1016/j.jcin.2012.06.015 · 7.44 Impact Factor
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    ABSTRACT: We sought to determine the effects of open (O) and closed (C) cell stents on the size and number of embolic particles generated during carotid artery stenting (CAS) and assess the impact on outcome. Embolic debris from carotid filters after CAS was analyzed using photomicroscopy and imaging software. Patient comorbidities, preoperative cerebrovascular symptoms, stent type, and outcomes (perioperative major adverse events) were examined. Carotid filters from 173 consecutive CAS procedures (O, 125 and C, 48) were reviewed. The mean age was 70.9 ± 9.2 years; 58% were men. Mean stenosis was 88.2% ± 8.1%; 36.6% had neurological symptoms preprocedurally. There was no difference in preoperative symptoms between the two groups (O, 38.7% vs C, 31.3%; P = not significant [NS]). However, closed cell stent use was associated with higher degree of stenosis (O, 87.2% ± 8.0% vs C, 90.6% ± 7.8%; P = .01), an older age (O, 70.0 ± 8.6 years vs C, 73.4 ± 10.2 years; P = .03), and peripheral arterial disease (21.1% vs 43.5%; P = .01). A larger mean particle size was observed in patients treated with open cell stents compared to closed cell stents (O, 416.5 ± 335.7 μm vs C, 301.1 ± 251.3 μm; P = .03). There was no significant difference in the total number of particles (O, 13.8 ± 21.5 vs C, 17.6 ± 19.9; P = NS), periprocedural stroke (P = NS), and major adverse events between the two groups (P = NS). Open cell stents are associated with a larger mean particle size compared to closed cell stents. No impact on procedural outcomes based on stent type was observed.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2012; 56(1):89-95. DOI:10.1016/j.jvs.2011.12.077 · 2.98 Impact Factor

Publication Stats

23 Citations
14.66 Total Impact Points

Institutions

  • 2013
    • Johns Hopkins Medicine
      • Department of Surgery
      Baltimore, Maryland, United States
  • 2012
    • Mount Sinai Medical Center
      New York City, New York, United States
    • Icahn School of Medicine at Mount Sinai
      Borough of Manhattan, New York, United States