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Class 18

Introdução à Medicina II 25 th May 2012. Trends in Hospitalization of patients with Peripheral Vascular Disorders in Public Hospitals, 2000-08. Class 18 Alice Brás, Ana Filipa Mendes, António Carujo, Bernardo Cruz, Mafalda Costa, Mariana Fernandes, Marisa Barros, Marta Dantas,

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Class 18

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  1. Introdução à Medicina II 25thMay 2012 Trends in Hospitalization of patients with Peripheral Vascular Disorders in Public Hospitals, 2000-08 Class 18 Alice 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

  2. Peripheral Vascular Disease • 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 FMUP

  3. RiskFactors There are several risk factors associated with peripheral vascular disease (PVD), including: • Smoking • High blood pressure (hypertension) • High cholesterol • Diabetes • Family history of heart or vascular disease • Being overweight • Lack of exercise or physical activity • Age over 50 Peripheral Vascular Disease FMUP

  4. Which are the trends in Hospitalizations for Peripheral Vascular Disorders in portuguese public hospitals between 2000-2008? Peripheral Vascular Disease FMUP

  5. Aims • By making an analytical study of PVD patients’ hospitalizations in Portuguese hospitals, we want to: • 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; • 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. • Analyze the success of different types of programmed surgeries according to Hospital mortality. Peripheral Vascular Disease FMUP

  6. 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. Peripheral Vascular Disease FMUP

  7. ICD-9-CM • “International Statistical Classification of Diseases and Related Health Problems” • 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 embolismandthrombosis; Of arteries of the extremities 444.81 Arterial embolismandthrombosis; OfIliac artery Peripheral Vascular Disease FMUP

  8. 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) Peripheral Vascular Disease FMUP

  9. Gender • The number of hospitalizations of men was higher than that of women. 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. Peripheral Vascular Disease FMUP

  10. Age Group • There were more PVD hospitalizations of older people, which lets us guess that there are more cases of this disease in this 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. Peripheral Vascular Disease FMUP

  11. Months • There were less hospitalizations in hotter months (May, June and September) when comparing to colder months (January, February and March). 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. Peripheral Vascular Disease FMUP

  12. Regions/PatientsResidency • Lisbon and Alentejo had the highest number of hospitalizations according to their population. Algarve, was the region with the lowest. 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) Peripheral Vascular Disease FMUP

  13. Regions/PatientsResidency • Lisbon, Alentejo and Algarve had the highest number of hospital deaths according to the number of hospitalizations. 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). Peripheral Vascular Disease FMUP

  14. Hospital Mortality Rate • Between 2000 and 2008 the hospital mortality rate showed no clear trend. % Figure 6 – Percentage of hospital fatalities of patients diagnosed with PVD, as principal or secondary diagnosis, in Portuguese public hospitals, from 2000 to 2008. Peripheral Vascular Disease FMUP

  15. Vascular surgeries and hospital mortality rate • 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. 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. Peripheral Vascular Disease FMUP

  16. Typeofadmission • The rate of programmed admissions has increased in the analyzed period. 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) Peripheral Vascular Disease FMUP

  17. Type of admission of hospitalizations ending in fatality • For hospitalizations ending in fatality, 91.8% had a non-programmed admission. 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. Peripheral Vascular Disease FMUP

  18. Type of admission of hospitalizations ending in fatality • Over time, this association (between death and non scheduled admissions) seems to become clearer. Numberofadmissionsendinginfatality 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 Peripheral Vascular Disease FMUP

  19. Type of admission of hospitalizations not ending in fatality • For hospitalizations in which the patients survived, 70.7% had a non-programmed admission. 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. Peripheral Vascular Disease FMUP

  20. Hospital mortality per type of admission • 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. 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) Peripheral Vascular Disease FMUP

  21. Conclusions 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; Some statistical background was given to the idea that hot temperatures are a relief factor for PVD, although this conclusion needs deeper research; 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. Peripheral Vascular Disease FMUP

  22. 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. Peripheral Vascular Disease FMUP

  23. 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.CardiovascInterventRadiol, 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 VascSurg, 2010. 51(5): p. 1167-1177 e1. • Landry, G.J., et al., Long-term outcome of revised lower-extremity bypass grafts. J VascSurg, 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 VascSurg, 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 VascSurg, 2009. 50(4): p. 776-783 e1. • Matsi, P.J. and H.I. Manninen, Complications of lower-limb percutaneoustransluminal angioplasty: a prospective analysis of 410 procedures on 295 consecutive patients.CardiovascInterventRadiol, 1998. 21(5): p. 361-6. Peripheral Vascular Disease FMUP

  24. Acknowledgments • Prof. DoutorAltamiroda Costa Pereira • Prof. DoutorAlberto Freitas • Prof. DoutorSérgioSampaio • Dr. Fernando Lopes Peripheral Vascular Disease FMUP

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