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Patient outcomes and clinical decision making in aortic valve replacement.

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Call No.	R853.O87 B57 1997
Author	Birkmeyer, Nancy Joan O'Connor
Title	Patient outcomes and clinical decision making in aortic valve replacement.
Date	1997
Abstract	Aortic valve disease is a frequent and serious disorder. Although aortic valve replacement (AVR) is arguably the only effective treatment, important issues remain unresolved in the care of patients with this disease. Recent studies have focused attention on variation in the use of surgical procedures. In Study 1, we explored variation in population-based rates of valve procedures relative to other cardiac procedures in Northern New England (NNE). Within the 5 NNE hospital referral regions, variation in age and sex-adjusted rates of valve procedures was moderate relative to other cardiac procedures. The observed variation in use of valve procedures may reflect controversies regarding indications and timing of intervention in valve disease. AVR may involve substantial risk depending on patient characteristics. In Study 2, we developed a clinical prediction rule to estimate risks of in-hospital mortality based on 2,542 AVR patients. Independent predictors included: age, priority of surgery, coronary artery disease, congestive heart failure, concomitant procedures, insulin-dependent diabetes, and an interaction between age and sex. This instrument may improve the accuracy of risk estimates for individuals and aid in communicating risks to patients. Many studies have compared provider-specific outcomes for other cardiac procedures. In Study 3, we investigated the relative roles of patient casemix, chance, and procedure volume in producing regional variation in outcomes of AVR. Chance alone could account for all of the observed variation in casemix-adjusted mortality rates by center, but a procedure volume effect may contribute to differences in mortality rates by surgeon. Pending confirmation of these results by other studies, a policy of within center specialization of valve replacement surgery might be considered. The choice between mechanical and tissue valves in patients undergoing AVR involves trade-offs between bleeding risks with mechanical valves and long-term durability problems with tissue valves. In Study 4, we developed a Markov decision-analytic model to estimate quality-adjusted life expectancy in patients undergoing AVR with each valve type. Tissue valves were favored for all patients over the age of 65 years. For younger patients decisions about valve type should account for the patient''''s sex, surgical indication, and especially, preferences for chronic anticoagulation therapy.
Description	1 online resource (xii, 123 leaves) : illustrations, map
Format	application/pdf
Advisor	Tosteson, Anna N. A.
Subject	Outcome assessment (Medical care). ; Aortic valve -- Surgery -- Complications. ; Aortic valve -- Surgery -- New England. ; Cardiovascular instruments Implanted.
College	Dartmouth Medical School -- Center for the Evaluative Clinical Sciences.
Issuing Body	Dartmouth Dissertations are made available through the Dartmouth Digital Library.
Degree	Thesis (Ph.D)--Dartmouth College.
Copyright	In Copyright. This material is protected by copyright and/or related rights. You are free to use this material in any way that is permitted by copyright law that applies to your use. For other uses, you need to obtain permission from the rights-holder(s). http://rightsstatements.org/page/InC/1.0/
DOI	https://doi.org/10.1349/ddlp.2978

Title	birkmeyer1997 1
Full Text	Patient Outcomes and Clinical Decision Making in Aortic Valve Replacement in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Evaluative Clinical Sciences Nancy Joan O'Connor Birkmeyer, M.S. DARTMOUTH COLLEGE Hanover, New Hampshire A Dissertation Submitted to the Faculty by May 23, 1997

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