Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009; 361:1368–75
Payers and regulators are currently assessing ways to reduce the variability in hospital mortality associated with inpatient surgery. These include incentive plans to increase compliance with evidence-based practices and withholding of payment for preventable complications. In addition, the variation in response to patients with major complications may also contribute to variable rates of death.
Data from 84,730 patients, who had undergone inpatient general and vascular surgery from 2005 to 2007, were collected from the American College of Surgeons National Surgical Quality Improvement Program. Hospitals were ranked according to their risk-adjusted overall rate of death and the incidence of overall and major complications. The rate of death among patients with major complications was also assessed.
Rates of death varied widely across hospitals, from 3.5% (low-mortality hospitals) to 6.9% (high-mortality hospitals, odds ratio, 2.04). Patients at very-high-mortality hospitals were more likely to be nonwhite and smokers. Rates of overall complications (24.6 and 26.9%, respectively) and major complications (18.2 and 16.2%, respectively) were similar despite differences in hospital rate of mortality. Rates of individual complications did not vary significantly across hospital mortality groups (e.g. , urinary tract infections, deep venous thromboembosis, or postoperative bleeding). In contrast, mortality in patients with major complications was almost twice as high in hospitals with high overall mortality compared with those with very low overall mortality (21.4 vs. 12.5%, P < 0.001).
Mortality and morbidity were examined in a large group of surgical patients (84,730) treated at numerous hospitals. Although complication rates were similar among hospitals, death rates varied. These data suggest that failure to timely treat complications may contribute to variability in perioperative mortality.
Suggested by: Joseph F. Antognini, M.D.
Apixaban or enoxaparin for thromboprophylaxis after knee replacement. N Engl J Med 2009; 361:594–604
Although use of heparins, vitamin K antagonists, and mechanical methods to prevent venous thromboembolism after major joint surgery has become the standard practice, subclinical venous thrombosis still develops in 15–40% of patients postsurgery and in 2–4% patients within 3 months of surgery. Furthermore, these agents can be inconvenient. Low-molecular-weight heparins such as enoxaparin predominantly inhibit factor Xa and to some extent thrombin. Apixaban, a specific factor Xa inhibitor, may provide effective thromboprophylaxis with a low risk of bleeding and improved ease of use.
Patients in this double-blinded study undergoing total knee replacement were randomized to receive 2.5 mg of apixaban orally twice daily or 30 mg of enoxaparin subcutaneously every 12 h. Both medications were started 12 to 24 h after surgery and continued for 10 to 14 days. Bilateral venography was then performed. Patients were followed up for 60 days after anticoagulation therapy was stopped.
A total of 3,195 patients underwent randomization (apixaban, n = 1,599; enoxaparin, 1,596) and 908 patients were not eligible for efficacy analysis. The majority of patients (61%) were women. The rate of the primary composite endpoint (asymptomatic and symptomatic deep-vein thrombosis, nonfatal pulmonary embolism, and death from any cause during treatment) was 9.0% with apixaban when compared with 8.8% with enoxaparin (RR, 1.02). Deep-vein thrombosis occurred in 8% of patients in the apixaban and enoxaparin groups. At the 60-day follow-up, symptomatic venous thromboembolism was present in 0.3 and 0.5% of apixaban and enoxaparin patients, respectively. The incidence of major bleeding and clinically relevant nonmajor bleeding was 2.9 and 4.3% with apixaban and enoxaparin, respectively (P = 0.03).
Rates of deep-vein thrombosis, pulmonary embolism, or death from any cause were not different in patients who received enoxaparin or apixaban after knee replacement. Apixaban was associated with lower rates of clinically relevant bleeding and it had a similar adverse-event profile.
Suggested by: Lance Lichtor, M.D.
Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med 2009; 361:980–9
Postoperative cardiac events (e.g. , myocardial infarction and death from cardiovascular causes) are common among patients with atherosclerotic vascular disease who undergo noncardiac vascular surgery. Cardiac events occur in 24% of patients in high-risk cohorts. Coronary plaque, thrombus formation, and subsequent vessel occlusion and the inflammatory surgical stress response may contribute to these events.
The Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography III (DECREASE III) trial was conducted in adult patients scheduled for noncardiac vascular surgery. Patients who had not been previously treated with a statin were randomly assigned to receive a β-blocker and either 80 mg of extended-release fluvastatin or placebo once daily before undergoing vascular surgery and continued for at least 30 days after surgery. Lipids, interleukin-6, and C-reactive protein levels were measured at the time of randomization and before surgery. The primary endpoint was the occurrence of myocardial ischemia, defined as transient electrocardiographic abnormalities, release of troponin T, or both, within 30 days after surgery. The secondary endpoint was the composite of death from cardiovascular causes and myocardial infarction.
A total of 250 patients were assigned to fluvastatin and 247 to placebo, a median of 37 days before vascular surgery. The majority of patients underwent abdominal aortic surgery (47.5%) or lower-limb arterial surgery (38.6%). Levels of total cholesterol, low-density lipoprotein cholesterol, interleukin-6, and C-reactive protein were significantly decreased in the fluvastatin group (P = 0.001) but were unchanged in the placebo group. Postoperative myocardial ischemia occurred in 10.8% of patients in the fluvastatin group and in 19% of patients in the placebo group (hazard ratio, 0.55; P = 0.01). Death from cardiovascular causes or myocardial infarction occurred in 12 patients (4.8%) in the fluvastatin group and in 25 patients (10.1%) in the placebo group (hazard ratio, 0.47; P = 0.03).
Perioperative fluvastatin therapy was associated with an improvement in postoperative cardiac outcome. This study supports the use of routine perioperative statins in high-risk patients undergoing vascular surgery.
Suggested by: Lance Lichtor, M.D.