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Observational study of the relationship between volume and outcomes using data from the National Audit of Cardiac Rehabilitation.

ABSTRACT: OBJECTIVE:Cardiac rehabilitation (CR) is an evidence-based intervention delivered by a wide range of high-volume and low-volume centres; however, the extent of volume-outcome relationship is yet to be studied. There is a lack of consensus about the effect of volume on outcomes, with evidence of mixed effects in acute and chronic care. The aim of this study is, to investigate the extent of association of outcomes in CR with patient volume. METHODS:Data was validated and extracted from the national audit from 2012 to 2013 for each CR centre. Volume was calculated as the total number of patients entering outpatient CR. Hierarchical multiple regression models were used to test for relationships between volume and outcomes. The outcomes included body mass index, blood pressure, psychosocial well-being, cholesterol, smoking cessation and physical activity. The analyses were adjusted for centre and patient characteristics and confounders. RESULTS:The number of patients included in the volume analysis was 48?476, derived from 178 CR centres. The average age per centre was 66?years with a 70% male distribution of patients enrolled. Regression analysis revealed no volume-outcome relationship, additionally no statistical significance existed. CONCLUSIONS:Unlike cardiac surgery this study, after accounting for staffing, age, gender and comorbidity, shows no effect of volume on outcome following CR delivered by high-volume and low-volume programmes. Based on our data there is no support for centralisation of services. Our findings and methodology can be used as a benchmark for future volume-outcome relationship studies in CR.

SUBMITTER: Doherty P

PROVIDER: S-EPMC4654095 | biostudies-other | 2015

REPOSITORIES: biostudies-other

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Observational study of the relationship between volume and outcomes using data from the National Audit of Cardiac Rehabilitation.

Doherty Patrick P Harrison Alexander S AS Knapton Mike M Dale Veronica V

Open heart 20151030 1

<h4>Objective</h4>Cardiac rehabilitation (CR) is an evidence-based intervention delivered by a wide range of high-volume and low-volume centres; however, the extent of volume-outcome relationship is yet to be studied. There is a lack of consensus about the effect of volume on outcomes, with evidence of mixed effects in acute and chronic care. The aim of this study is, to investigate the extent of association of outcomes in CR with patient volume.<h4>Methods</h4>Data was validated and extracted f ...[more]

PMID: 26629349

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Project description:BackgroundAlthough disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes.MethodsA retrospective cohort study was conducted on a 100% sample of Medicare beneficiaries undergoing inpatient coronary revascularization between July 2016 and December 2018. Community-level distress was defined using the Distressed Community Index quintile at the beneficiary zip code level, with the first and fifth quintiles representing prosperous and distressed communities, respectively. Outpatient claims were used to identify any CR use within 1 year of discharge. Beneficiary and CR facility zip codes were used to describe access to CR facilities. Adjusted logistic regression models evaluated the association between Distressed Community Index quintiles, CR use, and clinical outcomes, including one-year mortality, all-cause hospitalization, and acute myocardial infarction hospitalization.ResultsA total of 414 730 beneficiaries were identified, with 96 929 (23.4%) located in the first and 67 900 (16.4%) in the fifth quintiles, respectively. Any CR use was lower for beneficiaries in distressed compared with prosperous communities (26.0% versus 46.1%, P<0.001), which was significant after multivariable adjustment (odds ratio, 0.41 [95% CI, 0.40-0.42]). A total of 98 458 (23.7%) beneficiaries had a CR facility within their zip code, which increased from 16.3% in prosperous communities to 26.6% in distressed communities. Any CR use was associated with absolute reductions in mortality (-6.8% [95% CI, -7.0% to -6.7%]), all-cause hospitalization (-5.9% [95% CI, -6.3% to -5.6%]), and acute myocardial infarction hospitalization (-1.3% [95% CI, -1.5% to -1.1%]), which were similar across each Distressed Community Index quintiles.ConclusionsAlthough community-level distress was associated with lower CR participation, the clinical benefits were universally received. Addressing barriers to CR in distressed communities should be considered a significant priority to improve survival after coronary revascularization and reduce disparities.

Project description:BackgroundSubchondral bone injuries, or bone bruises, are commonly observed on magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) injury. The current relationship between bone bruise volume and postsurgical outcomes remains poorly understood.PurposeTo examine the influence of bone bruise volume on self-reported and objective functional outcomes at the time of return to play and 2 years following ACL reconstruction.Study designCohort study; Level of evidence, 3.MethodsClinical, surgical, and demographic data were obtained for a sample of convenience utilizing a single-surgeon ACL database (n = 1396). For 60 participants, femoral and tibial bone bruise volumes were estimated from preoperative MRI. Data obtained at the time of return to play included International Knee Documentation Committee (IKDC-2000) score, ACL-Return to Sport after Injury (ACL-RSI) score, and performance on an objective functional performance battery. Two-year follow-up data included graft reinjury rate, level of return to sport/activity, and self-reported knee function using the Single Assessment Numeric Evaluation (SANE). The forward stepwise linear regression was used to determine the relationship between bone bruise volume and patient function.ResultsThe distribution of bone bruise injuries was as follows: lateral femoral condyle (76.7%), lateral tibial plateau (88.3%), medial femoral condyle (21.7%), and medial tibial plateau (26.7%). Mean total bone bruise volume of all compartments was 7065.7 ± 6226.6 mm3. At the 2-year follow up, there were no significant associations between total bone bruise volume and time of return to play (P = .832), IKDC-2000 score (P = .200), ACL-RSI score (P = .370), or SANE score (P = .179).ConclusionThe lateral tibial plateau was the most frequent site to sustain bone bruise injury. Preoperative bone bruise volume was not associated with delayed time to return to sport or self-reported outcomes at time of return to play or at 2 years postoperatively.RegistrationNCT03704376 (ClinicalTrials.gov identifier).

Project description:AimsOperability of type A acute aortic dissections (TAAAD) is currently based on non-standardized decision-making process, and it lacks a disease-specific risk evaluation model that can predict mortality. We investigated patient, intraoperative data, surgeon, and centre-related variables for patients who underwent TAAAD in the UK.Methods and resultsWe identified 4203 patients undergoing TAAAD surgery in the UK (2009-18), who were enrolled into the UK National Adult Cardiac Surgical Audit dataset. The primary outcome was operative mortality. A multivariable logistic regression analysis was performed with fast backward elimination of variables and the bootstrap-based optimism-correction was adopted to assess model performance. Variation related to hospital or surgeon effects were quantified by a generalized mixed linear model and risk-adjusted funnel plots by displaying the individual standardized mortality ratio against expected deaths. Final variables retained in the model were: age [odds ratio (OR) 1.02, 95% confidence interval (CI) 1.02-1.03; P < 0.001]; malperfusion (OR 1.79, 95% CI 1.51-2.12; P < 0.001); left ventricular ejection fraction (moderate: OR 1.40, 95% CI 1.14-1.71; P = 0.001; poor: OR 2.83, 95% CI 1.90-4.21; P < 0.001); previous cardiac surgery (OR 2.29, 95% CI 1.71-3.07; P < 0.001); preoperative mechanical ventilation (OR 2.76, 95% CI 2.00-3.80; P < 0.001); preoperative resuscitation (OR 3.36, 95% CI 1.14-9.87; P = 0.028); and concomitant coronary artery bypass grafting (OR 2.29, 95% CI 1.86-2.83; P < 0.001). We found a significant inverse relationship between surgeons but not centre annual volume with outcomes.ConclusionsPatient characteristics, intraoperative factors, cardiac centre, and high-volume surgeons are strong determinants of outcomes following TAAAD surgery. These findings may help refining clinical decision-making, supporting patient counselling and be used by policy makers for quality assurance and service provision improvement.

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Observational study of the relationship between volume and outcomes using data from the National Audit of Cardiac Rehabilitation.

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Observational study of the relationship between volume and outcomes using data from the National Audit of Cardiac Rehabilitation.

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