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Abstract Background Work-related musculoskeletal problems impact everyday function, working ability, and quality of life. Unaddressed musculoskeletal problems can lead to major injury and loss of function, contributing to participation restrictions, economic loss and the increasing burden of disease worldwide. Medical science laboratory technicians are not immune with reported work-related musculoskeletal problems between 40 and 80%. Similar data is not available for medical science students, who may be the most vulnerable at the beginning of their careers. This study investigated the prevalence, common sites, impact and potential solutions for work-related musculoskeletal problems in medical science students during their university laboratory training. Methods A Standardised Nordic Musculoskeletal Questionnaire was administered to medical science students at a local university in Sydney, Australia, to evaluate the prevalence, site and impact of work-related musculoskeletal problems. Problems were defined as an ache, pain, discomfort or numbness in body regions within 12 months and last 7 days in this period. The questionnaire was administered between April and June 2017. Results The response rate was 38.2% (n = 110/288). Over a third (n = 38/110) reported a laboratory related musculoskeletal problem in the last 12 months and just over a fifth (n = 24/110) within 7 days. The lower back (30% and 17%), neck (24% and 10%) and upper back (21% and 10%) were the most common sites of problems reported within a 12 month and 7 day period respectively. Problems reported in the lower back, neck and upper back prevented daily activities in the majority of cases (between 63 to 83%) with many seeking physician or health professional assistance (between 13 to 83%). Solutions suggested by respondents included better seating designs, rest periods and education about correct working posture. Conclusions Some medical science students during their laboratory training are already experiencing high levels of musculoskeletal problems, even before they enter the workforce. While the response rate was low affecting generalizability, the extent of problems limiting activity and needs to seek assistance of those reporting problems is of concern. Strategies are suggested to address ergonomic and postural training, as part of university curriculums, including the identification of problems for early intervention to facilitate sustainable workforces.

BACKGROUND: Little is known about what treatments patients receive after being diagnosed with stable coronary artery disease or what the comparative outcomes are for routine medical treatment (RMT) versus percutaneous coronary intervention (PCI) with RMT for patients in a setting apart from randomized controlled trials. METHODS AND RESULTS: Patients with stable coronary artery disease undergoing cardiac catheterization in New York State between 2003 and 2008 were followed up to determine the treatment they received. Patients receiving RMT and patients receiving PCI with RMT were propensity matched through the use of 20 factors that could have a bearing on outcomes. The resulting cohort of 933 matched pairs was used to compare mortality/myocardial infarction (MI), mortality, MI, and subsequent revascularization rates. A total of 89% of all patients underwent PCI with RMT. PCI/RMT patients had significantly lower adverse outcome rates at 4 years for mortality/MI (16.5% versus 21.2%; P=0.003), mortality (10.2% versus 14.5%; P=0.02), MI (8.0% versus 11.3%; P=0.007), and subsequent revascularization (24.1% versus 29.1%; P=0.005). Adjusted RMT versus (PCI with RMT) hazard ratios were 1.49 (95% confidence interval, 1.16-1.93) for mortality/MI and 1.46 (95% confidence interval, 1.08-1.97) for mortality. There were no differences for patients <=65 years of age or for patients with single-vessel disease. CONCLUSIONS: Most patients with stable coronary artery disease in New York undergoing catheterization between 2003 and 2008 received PCI. Patients who received PCI experienced lower mortality, mortality/MI, and revascularization rates. The reasons for this finding need to be better understood, including the possible role of low medication adherence rates that have been found in other studies. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We sought to quantify Veterans Health Administration (VA) patients' utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n=6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals. RESULTS: VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal. CONCLUSIONS: For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans. [ABSTRACT FROM AUTHOR]

Background: In recent years, several studies in the medical and health service research literature have advocated the use of hierarchical statistical models (multilevel models or random-effects models) to analyze data that are nested (eg, patients nested within hospitals). However, these models are computer-intensive and complicated to perform. There is virtually nothing in the literature that compares the results of standard logistic regression to those of hierarchical logistic models in predicting future provider performance.Objective: We sought to compare the ability of standard logistic regression relative to hierarchical modeling in predicting risk-adjusted hospital mortality rates for coronary artery bypass graft (CABG) surgery in New York State.Design, Setting and Patients: New York State CABG Registry data from 1994 to 1999 were used to relate statistical predictions from a given year to hospital performance 2 years hence.Main Outcome Measures: Predicted and observed hospital mortality rates 2 years hence were compared using root mean square errors, the mean absolute difference, and the number of hospitals whose predicted mortality rate data was within a 95% confidence interval around the observed mortality rate.Results: In these data, standard logistic regression performed similarly to hierarchical models, both with and without a second level covariate. Differences in the criteria used for comparison were minimal, and when the differences could be statistically tested no significant differences were identified.Conclusions: It is instructive to compare the predictive abilities of alternative statistical models in the process of assessing their relative performance on a specific database and application. [ABSTRACT FROM AUTHOR]

This study employed a retrospective cohort analysis using New York State's Statewide Planning and Research Cooperative System (SPARCS) to improve the Patient Safety Indicator (PSI) definition of postoperative hemorrhage/hematoma (POHH) and to identify patient risk factors associated with POHH. Study participants were nonobstetric, inpatient surgical admissions in SPARCS and readmissions within 30 days with a principal diagnosis of POHH. The main outcome measures were mortality rate, length of stay, and readmissions. The mortality rates of events identified by a secondary diagnosis only and by the PSI were not significantly different. The number of POHH events increased by 9.3% when readmissions were captured. The PSI definition of POHH may need modification to capture events with no secondary procedure. The PSI misses events identified on readmission, but the consequences of these events are not as severe as those currently captured. A variety of patient and hospital characteristics are predictive of a higher risk of POHH. [ABSTRACT FROM AUTHOR]

CONTEXT: In the last decade, a few states or regions in the United States have initiated efforts to publicly disseminate coronary artery bypass graft (CABG) surgery outcomes and/or formally initiate quality improvement programs for CABG surgery. OBJECTIVE: To compare CABG mortality rates and changes in CABG mortality rates in regions with quality improvement/public dissemination efforts with the remainder of the country. DESIGN, SETTING, AND PATIENTS: Medicare data from 1994 to 1999 were used to develop a logistic regression model that predicts patient mortality for CABG surgery on the basis of preoperative patient risk factors and region of the country. MAIN OUTCOME MEASURES: In-hospital, 30-day, and in-hospital/30-day mortality adjusted for preoperative patient risk factors. RESULTS: Four of the 5 regions with quality improvement/public dissemination programs had significantly lower unadjusted in-hospital/30-day, in-hospital, and 30-day mortality than the remainder of the country. The odds ratio for risk-adjusted mortality for the 6-year period in all study regions combined was significantly lower (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.73-0.85) than in the remainder of the United States. The odds ratio was also significantly lower for each year and for the 6-year time period in New York (OR, 0.66; 95% CI, 0.57-0.77) and Pennsylvania (OR, 0.79; 95% CI, 0.73-0.86). The change in risk-adjusted mortality between 1994 and 1999 remained essentially constant for all regions except New Jersey, the only region to initiate their program during the study period, which exhibited a significant reduction in risk-adjusted mortality. CONCLUSIONS: Public dissemination of outcomes data/formal region-wide quality improvement initiatives appear to be associated with lower risk-adjusted mortality rates for CABG surgery. [ABSTRACT FROM AUTHOR]

Context: Hip fracture is a common clinical problem that leads to considerable mortality and disability. A need exists for a practical means to monitor and improve outcomes, including function, for patients with hip fracture.Objectives: To identify and compare the importance of significant prefracture predictors of functional status and mortality at 6 months for patients hospitalized with hip fracture and to compare risk-adjusted outcomes for hospitals providing initial care.Design: Prospective study with data obtained from medical records and through structured interviews with patients and proxies.Setting and Participants: A total of 571 adults aged 50 years or older with hip fracture who were admitted to 4 New York, NY, metropolitan hospitals between August 1997 and August 1998.Main Outcome Measures: In-hospital and 6-month mortality; locomotion at 6 months; and adverse outcomes at 6 months, defined as death or needing assistance to ambulate, compared by hospital, adjusting for patient risk factors.Results: The in-hospital mortality rate was 1.6%. At 6 months, the mortality rate was 13.5%, and another 12.8% needed total assistance to ambulate. Laboratory values were strong predictors of mortality but were not significantly associated with locomotion. Age and prefracture residence at a nursing home were significant predictors of locomotion (P =.02 for both) but were not significantly associated with mortality. Adjustment for baseline characteristics either substantially augmented or diminished interhospital differences in outcomes. Two hospitals had 1 outcome (functional status or mortality) that was significantly worse than the overall mean while the other outcome was nonsignificantly better than average.Conclusions: Mortality and functional status ideally should be considered both together and individually to distinguish effects limited to one or the other outcome. Hospital performance for these 2 measures may differ substantially after adjustment, probably because different processes of care are important to each outcome. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the associations between 2 types of continuing care retirement communities' (CCRC) residents regarding physical function and perceived quality of life. METHODS: Cross-sectional study (n=406). Eligibility criteria include age 65 years or older, residents of independent living units, and intact cognition (MMSE>or=24). All-inclusive CCRCs provide unlimited access to home health services and nursing home care as needed in return for the entry and monthly fee. Fee-for-service CCRCs offer home health and nursing home services at a full fee-for-service rate. Outcomes were functional status (ADLs and IADLs) and perceived quality of life. Multivariate regressions were used to examine the associations between residents of different types of CCRCs on selected outcomes while adjusting for covariates. RESULTS: The all-inclusive CCRC sample was more likely to be married (53.8% versus 33.4%; P < .001), with more years of education (17.9 versus 14.4; P < .0001), and had few physician visits in the previous year in comparison to the FFS CCRC sample. Multivariate results indicate that the FFS group had worse ADL (beta=0.95; P=.0003), IADL (beta=0.57; P=.02) function than the all-inclusive group. There was no significant difference in perceived quality of life scores between the 2 groups. CONCLUSIONS: Residents of both CCRCs reported equally good quality of life scores. Residents of the all-inclusive CCRC seem to have had better ADL and IADL function than the FFS CCRC residents. Prepaid home health services and nursing home care in the all-inclusive CCRC may facilitate ADL and IADL functional independence. [ABSTRACT FROM AUTHOR]

Objective: To compare outcomes in women undergoing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery., Design: This retrospective, propensity-score matched cohort study from the New York State cardiac registry (2012-2018) included all women with multivessel coronary artery disease undergoing PCI with everolimus-eluting stents (EES) and CABG surgery. The primary outcome was all-cause mortality. The key secondary outcome was major adverse cardiac events, defined as the composite of all-cause mortality, myocardial infarction, and stroke., Results: PCI with EES was associated with a higher 6-year risk of mortality (25.75% vs 23.57%; adjusted hazard ratio [AHR], 1.29; 95% confidence interval [CI], 1.14-1.45). PCI also was associated with a higher rate of the composite outcome of death, myocardial infarction, and stroke (36.58% vs 32.89%; AHR, 1.28; 95% CI, 1.17-1.41), as well as myocardial infarction (14.94% vs 9.12%; AHR, 1.84; 95% CI, 1.56-2.17), but not stroke (7.07% vs 7.62%; AHR, 0.83; 95% CI, 0.67-1.03). Repeat revascularization rates also were higher for women undergoing PCI (21.53% vs 11.57%; AHR, 1.88; 95% CI, 1.63-2.17). There was no difference in mortality between the 2 interventions when PCI patients received complete revascularization or had noncomplex lesions and for women without diabetes., Conclusions: For women with multivessel coronary artery disease, CABG surgery is associated with lower 6-year mortality, myocardial infarction, and repeat revascularization rates compared to PCI with EES., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors., Objectives: The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance., Methods: Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model., Results: Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers., Conclusions: Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity., Competing Interests: Funding Support and Author Disclosures This work was supported by National Institutes of Health/National Heart, Lung, and Blood Institute (R01 HL150044), National Institutes of Health/National Institute of Mental Health (T32 MH019733), and Agency for Healthcare Research and Quality (T32 HS000055). The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the National Institutes of Health, Agency of Healthcare Research and Quality, or New York State Department of Health. Examples of analysis performed within this paper are only examples. They should not be used in real-world analytic products. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Risk models and risk scores derived from those models require periodic updating to account for changes in procedural performance, patient mix, and new risk factors added to existing systems. No risk model or risk score exists for predicting in-hospital/30-day mortality for percutaneous coronary interventions (PCIs) using contemporary data. This study develops an updated risk model and simplified risk score for in-hospital/30-day mortality following PCI. To accomplish this, New York's Percutaneous Coronary Intervention Reporting System was used to develop a logistic regression model and a simplified risk score model for predicting in-hospital/30-day mortality and to validate both models based on New York data from the previous year. A total of 54,770 PCI patients from 2019 were used to develop the models. Twelve different risk factors and 27 risk factor categories were used in the models. Both models displayed excellent discrimination for the development and validation samples (range from 0.894 to 0.896) and acceptable calibration, but the full logistic model had superior calibration, particularly among higher-risk patients. In conclusion, both the PCI risk model and its simplified risk score model provide excellent discrimination and although the full risk model requires the use of a hand-held device for estimating individual patient risk, it provides somewhat better calibration, especially among higher-risk patients., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Congenital heart defects are the most common and resource-intensive birth defects. As children with congenital heart defects increasingly survive beyond early childhood, it is imperative to understand longitudinal disease burden., Objectives: The purpose of this study was to examine chronic outpatient prescription medication use and expenditures for New York State pediatric Medicaid enrollees, comparing children who undergo cardiac surgery (cardiac enrollees) and the general pediatric population., Methods: This was a retrospective cohort study of all Medicaid enrollees age <18 years using the New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources database (2006-2019). Primary outcomes were total chronic medications per person-year, enrollees per 100 person-years using ≥1 and ≥3 medications, and medication expenditures per person-year. We described and compared outcomes between cardiac enrollees and the general pediatric population. Among cardiac enrollees, multivariable regression examined associations between outcomes and clinical characteristics., Results: We included 5,459 unique children (32,131 person-years) who underwent cardiac surgery and 4.5 million children (22 million person-years) who did not. More than 4 in 10 children who underwent cardiac surgery used ≥1 chronic medication compared with approximately 1 in 10 children who did not have cardiac surgery. Medication expenditures were 10 times higher per person-year for cardiac compared with noncardiac enrollees. Among cardiac enrollees, disease severity was associated with chronic medication use; use was highest among infants; however, nearly one-half of adolescents used ≥1 chronic medication., Conclusions: Children who undergo cardiac surgery experience high medication burden that persists throughout childhood. Understanding chronic medication use can inform clinicians (both pediatricians and subspecialists) and policymakers, and ultimately the value of care for this medically complex population., Competing Interests: Funding Support and Author Disclosures This study is funded by the National Heart, Lung, and Blood Institute (NIH/NHLBI R01 HL150044, to principal investigator Dr Anderson). The views and opinions expressed in this paper are those of the authors and do not necessarily reflect the official policy or position of the National Institutes of Health, the Agency of Healthcare Research and Quality, or the New York State Department of Health. Examples of analysis performed within this article are only examples. They should not be utilized in real-world analytic products. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: There is very little information about the use of ad hoc percutaneous coronary intervention (PCI) in stable patients with multivessel (MV) disease or unprotected left main (LM) disease patients for whom a heart team approach is recommended., Objective: To identify the extent of ad hoc PCI utilization for patients with multivessel disease or left main disease, and to explore the inter-hospital variation in ad hoc PCI utilization for those patients., Methods: New York State's cardiac registries were used to examine the use and variation in use of ad hoc PCI for MV/LM disease as a percentage of all MV/LM PCIs and revascularizations (PCIs plus coronary artery bypass graft procedures) during 2018 to 2019 in New York., Results: After exclusions, 6,425 of the 8,196 stable PCI patients with MV/LM disease (78.4%) underwent ad hoc PCI, ranging from 58.7% for patients with unprotected LM disease to 85.4% for patients with 2-vessel proximal left anterior descending (PLAD) disease. Ad hoc PCIs comprised 35.1% of all revascularizations, ranging from 11.5% for patients with unprotected LM disease to 63.9% for patients with 2-vessel PLAD disease. The risk-adjusted utilization of ad hoc PCI as a percentage of all revascularizations varied widely among hospitals (eg, from 15% in the first quartile to 46% in the last quartile for 3-vessel disease)., Conclusions: Ad hoc PCIs occur frequently even among patients with MV/LM disease. This is particularly true among patients with 2-vessel PLAD disease. The frequency of ad hoc PCIs is lower but still high among patients with diabetes and low ejection fraction and higher in hospitals without surgery on-site (SOS). Given the magnitude of hospital- and physician-level variation in the use of ad hoc PCIs for such patients, consideration should be given to a systems approach to achieving heart team consultation and shared decision making that is consistent for SOS and non-SOS hospitals., Competing Interests: Funding Support and Author Disclosures This study was partially funded by the New York State Department of Health. The findings do not necessarily represent the opinions of the Department. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The Area Deprivation Index (ADI), popularized by the Neighborhood Atlas, is a multifaceted proxy measure for assessing socioeconomic disadvantage that captures social risk factors that are not available in typical clinical registries and that are related to adverse health outcomes. In applying the ADI to New York State, we found that the downstate regions (New York City and its suburbs) were as deprived as or more deprived than the other regions for thirteen of the seventeen ADI variables (all but the ones measured in dollars), but the Neighborhood Atlas-computed overall ADI deprivation was much less in the downstate areas. Numerous census block groups with high home values (indicating low deprivation) accompanied by high deprivation in the other ADI variables had overall ADI scores as computed by the Neighborhood Atlas in the same or contiguous deciles as the home values. We concluded that Neighborhood Atlas-computed ADI scores for New York block groups are mainly representative of median home value. This can be especially problematic when considering quality assessment, funding, and resource allocation in regions with large variations in cost of living, and it may result in underresourcing for disadvantaged communities with high housing prices. We conclude that the Neighborhood Atlas ADI would be more accurate for comparing block groups if variables were standardized before computing the overall index.