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Almodovar, Melvin C.

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Almodovar

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Melvin C.

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Almodovar, Melvin C.
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    Development of a Charge Adjustment Model for Cardiac Catheterization
    (Springer US, 2014) Brennan, Andrew; Gauvreau, Kimberlee; Connor, Jean; O’Connell, Cheryl; David, Sthuthi; Almodovar, Melvin C.; DiNardo, James; Banka, Puja; Mayer, John; Marshall, Audrey; Bergersen, Lisa
    A methodology that would allow for comparison of charges across institutions has not been developed for catheterization in congenital heart disease. A single institution catheterization database with prospectively collected case characteristics was linked to hospital charges related and limited to an episode of care in the catheterization laboratory for fiscal years 2008–2010. Catheterization charge categories (CCC) were developed to group types of catheterization procedures using a combination of empiric data and expert consensus. A multivariable model with outcome charges was created using CCC and additional patient and procedural characteristics. In 3 fiscal years, 3,839 cases were available for analysis. Forty catheterization procedure types were categorized into 7 CCC yielding a grouper variable with an R2 explanatory value of 72.6 %. In the final CCC, the largest proportion of cases was in CCC 2 (34 %), which included diagnostic cases without intervention. Biopsy cases were isolated in CCC 1 (12 %), and percutaneous pulmonary valve placement alone made up CCC 7 (2 %). The final model included CCC, number of interventions, and cardiac diagnosis (R2 = 74.2 %). Additionally, current financial metrics such as APR-DRG severity of illness and case mix index demonstrated a lack of correlation with CCC. We have developed a catheterization procedure type financial grouper that accounts for the diverse case population encountered in catheterization for congenital heart disease. CCC and our multivariable model could be used to understand financial characteristics of a population at a single point in time, longitudinally, and to compare populations.
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    Phosphodiesterase Inhibitor‐Based Vasodilation Improves Oxygen Delivery and Clinical Outcomes Following Stage 1 Palliation
    (John Wiley and Sons Inc., 2016) Mills, Kimberly; Kaza, Aditya; Walsh, Brian K.; Bond, Hilary C.; Ford, Mackenzie; Wypij, David; Thiagarajan, Ravi; Almodovar, Melvin C.; Quinonez, Luis; Baird, Christopher; Emani, Sitaram; Pigula, Frank A.; DiNardo, James; Kheir, John
    Background: Systemic vasodilation using α‐receptor blockade has been shown to decrease the incidence of postoperative cardiac arrest following stage 1 palliation (S1P), primarily when utilizing the modified Blalock‐Taussig shunt. We studied the effects of a protocol in which milrinone was primarily used to lower systemic vascular resistance (SVR) following S1P using the right ventricular to pulmonary artery shunt, measuring its effects on oxygen delivery (DO 2) profiles and clinical outcomes. We also correlated Fick‐based assessments of DO 2 with commonly used surrogate measures. Methods and Results: Neonates undergoing S1P were treated according to best clinical judgment prior to (n=32) and following (n=24) implementation of a protocol that guided operative, anesthetic, and postoperative management, particularly as it related to SVR. A majority of the subjects (n=51) received a modified right ventricular to pulmonary artery shunt. In a subset of these patients (n=21), oxygen consumption (VO 2) was measured and used to calculate SVR, DO 2, and oxygen debt. Neonates treated with the protocol had significantly lower SVR (P=0.02), serum lactate (P<0.001), and Sa‐vO 2 difference (P<0.001) and a lower incidence of CPR requiring extracorporeal membrane oxygenation (E‐CPR, P=0.02) within the first 72 postoperative hours. DO 2 was closely associated with SVR (r2=0.78) but correlated poorly with arterial (SaO2) and venous (SvO2) oxyhemoglobin concentrations, the Sa‐vO 2 difference, and blood pressure. Conclusions: A vasodilator protocol utilizing milrinone following S1P effectively decreased SVR, improved serum lactate, and decreased postoperative cardiac arrest. DO 2 correlated more closely with SVR than with Sa‐vO 2 difference, highlighting the importance of measuring VO 2 in this population. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02184169.