trends in hospitalization of patients with peripheral vascular disorders in public hospitals,...
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Trends in Hospitalization of patients with Peripheral Vascular Disorders in Public Hospitals, 2000-08
Class 18Alice Brás, Ana Filipa Mendes, António Carujo, Bernardo Cruz, Mafalda Costa, Mariana Fernandes, Marisa Barros, Marta Dantas,
Pedro Gonçalves, Sara Salvador, Sara Araújo, Susana Merim, Tomás Fontes e Vanessa Nunes
Introdução à Medicina II 25th May 2012
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Clinical case of reduction of the size of blood vessels in both the lower and upper limb, which causes pain in the affected parts of body.
Affects 12-14% of the population in general
Peripheral Vascular Disease
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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There are several risk factors associated with peripheral vascular disease (PVD), including:
SmokingHigh blood pressure (hypertension)High cholesterolDiabetesFamily history of heart or vascular diseaseBeing overweightLack of exercise or physical activityAge over 50
Risk Factors
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Which are the trends in Hospitalizations for Peripheral Vascular Disorders in portuguese
public hospitals between 2000-2008?
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Aims
By making an analytical study of PVD patients’ hospitalizations in Portuguese hospitals, we want to:
1. Study the evolution of the disease between 2000 and 2008, according to different variables:
Number of admissions; Type of admission; Hospital mortality and type of admission; Clinical outcome;
2. Compare the influence in the number of hospitalizations between 2000 and 2008 of some factors:
Gender; Age group; Month; Patient’s residency according to the geographic subregion where the
patient lives.
3. Analyze the success of different types of programmed surgeries according to Hospital mortality.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Methods
Target population: Patients hospitalized with Peripheral Vascular Disorders (PVD) in Portuguese mainland public hospitals between 2000 and 2008 – 116236 hospitalizations.
Source: The administrative database managed by ACSS (Administração Central do Sistema de Saúde – Portuguese Central Authority for Health Services) which contains an index of all hospitalizations in Portuguese public acute care hospitals.
This is a retrospective observational cohort clinical study.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Index of Diseases and Injuries
250.7 Diabetes with peripheral circulatory disorders
440.2 Atherosclerosis; Of native arteries of the extremities
440.3 Atherosclerosis; Of bypass graft of the extremities
440.4 Chronic total occlusion of artery of the extremities
443 Other peripheral vascular disease
444.2 Arterial embolism and thrombosis; Of arteries of the extremities
444.81 Arterial embolism and thrombosis; Of Iliac artery
ICD-9-CM“International Statistical Classification of Diseases and Related Health Problems”
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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ICD-9-CM“International Statistical Classification of Diseases and Related Health Problems”
Index of Procedures
00.55 – Insertion of drug-eluting peripheral vessel stent(s)
38.13 – Endarterectomy, upper limb vessels
38.18 – Endarterectomy, lower limb vessels
39.25 – Aorta-iliac-femoral bypass
39.26 – Other intra-abdominal vascular shunt or bypass
39.29 – Other (peripheral) vascular shunt or bypass
39.90 – Insertion of non-drug-eluting peripheral vessel stent(s)
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Gender
Figure 1 - Percentage of admission of patients diagnosed with PVD, as principal or secondary diagnosis, per gender, in Portuguese public hospitals, from 2000 to 2008.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
The number of hospitalizations of men was higher than that of women.
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Age Group
Figure 2 -Percentage of people within each age groups hospitalized with Peripheral Vascular Disease, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008.
There were more PVD hospitalizations of older people, which lets us guess that there are more cases of this disease in this age group.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References0 - 14 years 15 - 24 years 25 - 64 years > 64 years0
0.5
1
1.5
2
2.5
3
3.5
4
0.00800000000000002 0.01
0.44
3.78
Percentage of people hospitalized in 2000-2008
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Months
Figure 3 - Number of admissions of patients diagnosed with PVD, as principal or secondary diagnosis, per month of admission, in Portuguese public hospitals, from 2000 to 2008.
There were less hospitalizations in hotter months (May, June and September) when comparing to colder months (January, February and March).
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Regions/Patients Residency
Figure 4 – Admission’s rate per a thousand people of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008 according to patient residence: Algarve, Alentejo, Lisboa, Centro and Norte (NUT II)
Lisbon and Alentejo had the highest number of hospitalizations according to their population. Algarve, was the region with the lowest.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Regions/Patients Residency
Figure 5 – Hospital mortality rate per 1000 hospitalizations of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008 according to patient residence: Algarve, Alentejo, Lisboa, Centro and Norte (NUT II).
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
Lisbon, Alentejo and Algarve had the highest number of hospital deaths according to the number of hospitalizations.
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Hospital Mortality Rate
Figure 6 – Percentage of hospital fatalities of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
Between 2000 and 2008 the hospital mortality rate showed no clear trend.
%
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Vascular surgeries and hospital mortality rate
Figure 7 - Hospital mortality associated with treatment procedures on patients who had a programmed admission, diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
The procedure associated with higher hospital mortality in patients who had a programmed admission was endarterectomy, followed by bypass surgery. The procedure associated with a lower mortality was angioplasty.
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Type of admission
Table 1 - Type of admission of patients diagnosed with PVD, as principal or secondary diagnosis, per year of discharge, in Portuguese public hospitals, from 2000 to 2008. (p<0.001)
Type of admission
Scheduled Not scheduled Recovery programs of waiting lists
Year of discharge
2000 25,0% 75,0% 0,0%2001 25,2% 74,8% 0,0%2002 26,9% 73,1% 0,0%2003 26,1% 73,8% 0,2%2004 27,2% 72,6% 0,1%2005 25,9% 73,6% 0,5%2006 27,5% 71,1% 1,4%2007 26,5% 72,9% 0,6%2008 26,2% 72,4% 1,4%
Total 26,3% 73,2% 0,5%
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
The rate of programmed admissions has increased in the analyzed period.
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Type of admission of hospitalizations ending in fatality
Figure 8 - Type of admission of hospitalizations ending in fatality of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008.
For hospitalizations ending in fatality, 91.8% had a non-programmed admission.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Type of admission of hospitalizations ending in fatality
Figure 9 - Evolution of fatalities according to type of admission of patients diagnosed with PVD as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
Over time, this association (between death and non scheduled admissions) seems to become clearer.
Num
ber o
f adm
issi
ons
endi
ng in
fata
lity
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Type of admission of hospitalizations not ending in fatality
Figure 10 - Type of admission of hospitalizations ending in survival of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008.
For hospitalizations in which the patients survived, 70.7% had a non-programmed admission.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Hospital mortality per type of admission
Table 2 – Hospital mortality and type of admission of patients diagnosed with PVD as principal or secondary diagnosis , in Portuguese public hospitals, from 2000 to 2008. (p<0.001)
Hospital mortality
Alive Dead
Type of admission
Scheduled 96,5% 3,5%
Not scheduled 85,3% 14,7%
Recovery programs of waiting lists
93,5% 6,5%
Total 88,3% 11,7%
There was a higher percentage of survival with scheduled admissions (96.5%) than with not-scheduled (85.3%). There was 11.7% of hospital mortality.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Conclusions
1. There is an association between non-programmed admission and the outcome death. So, we may say that patient follow-up is a critical component of health care quality;
2. Some statistical background was given to the idea that hot temperatures are a relief factor for PVD, although this conclusion needs deeper research;
3. Endarterectomy is associated with higher mortality than bypass surgery, and that both these procedures are associated with higher mortality than angioplasty, although we cannot point out a cause for these associations.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Limitations
The admnistrative records are not all done with the same criteria in the different hospital centres;
Not all hospital centres record secondary diagnosis of their patients ;
We are dealing with admissions and not with PVD patients;
We are not able to detect readmissions of the same PVD patient in the period of analysis. So, the hospital mortality rate we calculated may not reflect the PVD overall mortality;
Analysis is limited by the seasonal irregularities.
Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
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Introduction
Problem
Aims
Methods
Statistical Analysis and Discussion
Conclusions and Limitatios
References
Bergan, J.J., et al., Unexpected, late cardiovascular effects of surgery for peripheral artery disease. Veterans Affairs Cooperative Study 199. Arch Surg, 1992. 127(9): p. 1119-23; discussion 1123-4.
Bosiers, M., et al., Endovascular therapy as the primary approach for limb salvage in patients with critical limb ischemia: experience with 443 infrapopliteal procedures. Vascular, 2006. 14(2): p. 63-9.
Houston, J.G., et al., Long-term results after placement of aortic bifurcation self-expanding stents: 10 year mortality, stent restenosis, and distal disease progression. Cardiovasc Intervent Radiol, 2007. 30(1): p. 42-7.
Inoue, Y., et al., Cuffed anastomosis for above-knee femoropopliteal bypass with a stretch expanded polytetrafluoroethylene graft. Surg Today, 2008. 38(8): p. 679-84.
Pulli, R., et al., Midterm results from a multicenter registry on the treatment of infrainguinal critical limb ischemia using a heparin-bonded ePTFE graft. J Vasc Surg, 2010. 51(5): p. 1167-1177 e1.
Landry, G.J., et al., Long-term outcome of revised lower-extremity bypass grafts. J Vasc Surg, 2002. 35(1): p. 56-62; discussion 62-3.
Chung, J., et al., Wound healing and functional outcomes after infrainguinal bypass with reversed saphenous vein for critical limb ischemia. J Vasc Surg, 2006. 43(6): p. 1183-90.
Feinglass, J., et al., Perioperative outcomes and amputation-free survival after lower extremity bypass surgery in California hospitals, 1996-1999, with follow-up through 2004. J Vasc Surg, 2009. 50(4): p. 776-783 e1.
Matsi, P.J. and H.I. Manninen, Complications of lower-limb percutaneous transluminal angioplasty: a prospective analysis of 410 procedures on 295 consecutive patients. Cardiovasc Intervent Radiol, 1998. 21(5): p. 361-6.
References
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Acknowledgments
Prof. Doutor Altamiro da Costa Pereira
Prof. Doutor Alberto Freitas
Prof. Doutor Sérgio Sampaio
Dr. Fernando Lopes