Coronary Artery Bypass Grafting Volume Research Articles

Myocardial Infarction Across COVID-19 Pandemic Phases: Insights From the Veterans Health Affairs System.

Background Cardiovascular procedural treatments were deferred at scale during the COVID-19 pandemic, with unclear impact on patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI). Methods and Results In a retrospective cohort study of all patients diagnosed with NSTEMI in the US Veterans Affairs Healthcare System from January 1, 2019 to October 30, 2022 (n=67 125), procedural treatments and outcomes were compared between the prepandemic period and 6 unique pandemic phases: (1) acute phase, (2) community spread, (3) first peak, (4) post vaccine, (5) second peak, and (6) recovery. Multivariable regression analysis was performed to assess the association between pandemic phases and 30-day mortality. NSTEMI volumes dropped significantly with the pandemic onset (62.7% of prepandemic peak) and did not revert to prepandemic levels in subsequent phases, even after vaccine availability. Percutaneous coronary intervention and coronary artery bypass grafting volumes declined proportionally. Compared with the prepandemic period, patients with NSTEMI experienced higher 30-day mortality during Phases 2 and 3, even after adjustment for COVID-19-positive status, demographics, baseline comorbidities, and receipt of procedural treatment (adjusted odds ratio for Phases 2 and 3 combined, 1.26 [95% CI, 1.13-1.43], P<0.01). Patients receiving Veterans Affairs-paid community care had a higher adjusted risk of 30-day mortality compared with those at Veterans Affairs hospitals across all 6 pandemic phases. Conclusions Higher mortality after NSTEMI occurred during the initial spread and first peak of the pandemic but resolved before the second, higher peak-suggesting effective adaptation of care delivery but a costly delay to implementation. Investigation into the vulnerabilities of the early pandemic spread are vital to informing future resource-constrained practices.

A single-patient-use ECG system for cardiothoracic surgery admissions in the UK: A cost-consequence analysis.

Deep sternal wound infections (DSWI) are severe complications in up to 1.36% of coronary artery bypass grafting (CABG) procedures in the United Kingdom. Each event adds between £4,000 and £11,000 in healthcare costs, owing primarily to prolonged hospitalisations. ECG devices have been shown to convey infection throughout perioperative CABG. On the other hand, single-patient ECG devices (spECG) can effectively reduce the incidence of surgical site infections (SSI), including DSWI, but no assessment of spECG impact in NHS cardiac units has been conducted. To estimate the impact of spECG on NHS cardiac units, we conducted a cost-consequence analysis modeling the CABG care pathway in the United Kingdom using Simul8 software for a probabilistic, individual-patient simulation. The simulation time was 1 year, with each patient followed from admission through 30 days post-discharge. The base case simulation mirrors the cardiac unit of Bart Health NHS Trust, London. A total of 2,183 patients are generated with demographic and clinical attributes from probabilistic distributions informed by hospital-specific inputs from NHS Digital Data. The Brompton Harefield Infection Score (BHIS) is allocated to gauge the risk of SSI. Results are averaged across 50 independent and randomly seeded iterations. Simulation results indicate a base-case savings of £388 per patient, determined by the incidence of infections rather than the number of CABG procedures. In the base-case simulation, the mean cost of care with rECG was £13,096, whereas the mean cost with spECG was £12,708, resulting in a cost saving of £388 (2021 GBP). The simulation yielded an overall 8.6% SSI incidence rECG, whereas the incidence of SSIs with spECG was 6.9%. The model was most sensitive to changes in general ward and ICU costs, and infection incidence was a stronger predictor of potential per-patient savings than annual CABG volume. Single-patient ECG is a sustainable and effective alternative to reusable ECG cables and lead wires in terms of patient safety and resource allocation.

Resultados de la cirugía coronaria en España. Análisis del conjunto mínimo básico de datos 2001-2020

Introduction and objectivesTo analyze the recent evolution of the risk profile, mortality and burden of healtcare delivery of coronary artery bypass grafting (CABG) in Spain. MethodsEpisodes with any isolated CABG coded procedure were retrieved from Minimum Basic Data Set between 2001 & 2020. The study period was divided in 4: 2001-2005, 2006-2010, 2011-2015 and 2016-2020. Changes in activity volume and factors associated to in-hospital mortality were analyzed using linear trend analysis and multivariate logistic regression models. ResultsWe included 96,073 episodes in which isolated CABG was performed. A reduction in the annual volume of procedures was observed from 6134 in 2001 to 3421 in 2020, and an increase in the coronary intervention/surgery ratio from 2.4 to 8. Between the first and the last period, we detected an increase in the prevalence of almost all comorbidities with an uprising of mean Charlson's index from 2.99 to 3.68 (P<.001). Nevertheless, mortality was reduced from 6.2% to 2.6% (P<.001) and the risk-adjusted mortality rate from 1.84 to 0.51 (P<.001). The CABG volume of healthcare centers was independently associated to a lower mortality independently (P<.001) ConclusionsBetween 2001 and 2020, the volume of CABG in Spain was significantly reduced. Despite a worsening of the risk profile, we detected a decrease in mortality. The volume of procedures has a decisive impact in the performance of CABG.

Public reporting for coronary artery bypass graft surgery: The quest for the optimal scorecard

ObjectiveA number of publicly available rating algorithms are used to assess hospital performance in coronary artery bypass grafting (CABG). However, concerns remain that these algorithms fail to correlate with each other and inadequately capture the case complexity of individual center practices. MethodsComposite star ratings for isolated CABG from the Society of Thoracic Surgeons public reporting database were extracted for 2018-2019. U.S. News & World Report Best Hospitals was used to extract CABG ratings as well as overall cardiology and heart surgery ranking, and the Centers for Medicare & Medicaid Services Hospital Compare was used to extract CABG volume and 30-day mortality. Spearman correlation coefficients were used to assess possible relationships. Expert opinion on risk adjustment and program evaluation was incorporated. ResultsCorrelations between Society of Thoracic Surgeons star rating and U.S. News & World Report overall ranking in cardiology and heart surgery (r = 0.15) and Centers for Medicare & Medicaid Services 30-day mortality (r = −0.27) were poor. Society of Thoracic Surgeons star rating correlated weakly with U.S. News & World Report CABG ratings (r = 0.33) and with Centers for Medicare & Medicaid Services CABG volume (r = 0.32), whereas the latter 2 correlated moderately (r = 0.52) with each other. Of the 75 centers with accredited cardiac surgery training programs, 13 (17%) did not participate in Society of Thoracic Surgeons public reporting. Important gaps were identified in risk assessment, and potential solutions are proposed. ConclusionsCorrelations between current CABG public reporting systems are weak. Further work is needed to refine and standardize CABG rating systems to more adequately capture the scope and complexity of an individual center's clinical practice and to better inform patients.

Abstract 14072: Long-Term Mortality Following 59253 Patients Who Underwent Coronary Artery Bypass Surgery in New South Wales, Australia: A Statewide Population-Linkage Study From 2001-2018

Purpose: To describe changes in long-term mortality following coronary artery bypass graft (CABG) in New South Wales (NSW), Australia, from 2001-2018. Methods: Patients who underwent CABG were identified from the NSW Admission-Patient-Data-Collection registry linked to the NSW death registry and were stratified into six, 3-year groups. Changes in comorbidities and procedural techniques over time were determined. Primary outcome was death (end of follow-up: 31-December-2018). Secondary outcome was time to first percutaneous coronary intervention (PCI) post-CABG, with death as the competing event. Outcomes analyses using Cox regression were adjusted for baseline and procedural differences and geographical clustering. Results: A total 59253 patients underwent CABG during the study period. From 2001-03 to 2016-18, procedural numbers fell (11875 vs 7606); however patient complexity increased (Charlson comorbidity index [CCI]&gt;0: 40% vs 55%) as did male patients (77% vs 83%). During a median (interquartile range) follow-up of 7.7yrs (3.8-12.1yrs), 16,484 (27.8%) patients died. Factors associated with increased long-term mortality included older age (&gt;75 vs ≤60: hazard ratio [HR]=6.69, 95% confidence interval [CI]=6.33-7.08), female sex (HR=1.06, 95%CI=1.02-1.11), acute myocardial infarction (HR=1.86, 95%CI=1.80-1.92), atrial fibrillation (HR=1.38, 95%CI=1.29-1.47), valvular heart disease (HR=1.84, 95%CI=1.56-2.18), and CCI (per-1-score increase: HR=1.31, 95%CI=1.26-1.35). Multivariable survival analysis showed that, compared to 2001-03, the risk of death reduced from 2004-06 to 2016-18: HR=0.96, 95%CI=0.93-1.00 to HR=0.61, 95%CI=0.54-0.70, respectively. Multivariable time-to-PCI analysis with death as the competing event showed no significant difference over the years. Conclusion: Between 2001 and 2018, though CABG volume has decreased, proportionally more males and higher comorbid patients had CABG in recent years. Female sex and other major comorbidities were expectedly related to an increased association with mortality. Overall, mortality has fallen significantly over time, with no significant trend of PCI undertaken over time in these post CABG patients.

Trends in Characteristics and Outcomes of Hospitalized Young Patients Undergoing Coronary Artery Bypass Grafting in the United States, 2004 to 2018.

BackgroundData are limited about young adults' characteristics and outcomes undergoing coronary artery bypass grafting (CABG).Methods and ResultsWe used the National Inpatient Sample database to identify adults aged 18 to 45 years who underwent CABG between 2004 and 2018. The data were weighted to generate national estimates of the entire US hospitalized population. We identified 110 463 CABG cases, equivalent to 62.2 per 1 000 000 person‐years; 27.1% were women, and 70.2% were White adults. Overall, annual CABG volume per 1 000 000 significantly decreased from 87.3 in 2004 to 45.7 in 2018. The prevalence of obesity, diabetes mellitus, hypertension, drug abuse, and chronic medical conditions increased over time. Overall, inpatient mortality was 1.76%; ST‐segment–elevation myocardial infarction, non–ST‐segment–elevation myocardial infarction, heart failure, peripheral vascular disease, renal failure, and valvular surgery were associated with higher inpatient mortality. Women had higher inpatient mortality than men (2.29% versus 1.57%), and Black patients had higher deaths than White patients (2.86% versus 1.58%). Inpatient mortality remained stable overall, according to sex, race, or clinical indication of CABG. However, the mean length of stay (8.4 days in 2004 to 9.5 days in 2018) and inflation‐adjusted cost of care ($40 522.8 in 2004 to $52 434.2 in 2018) significantly increased during the study period.ConclusionsDespite the increased burden of cardiometabolic risk factors, the inpatient mortality in young adults undergoing CABG remained stable during the last 15 years. However, CABG volumes have decreased, but length of stay and inflation‐adjusted costs have increased over time.

Patient and hospital factors associated with 30-day readmissions after coronary artery bypass graft (CABG) surgery: a systematic review and meta-analysis

BackgroundReadmission after coronary artery bypass graft (CABG) surgery is associated with adverse outcomes and significant healthcare costs, and 30-day readmission rate is considered as a key indicator of the quality of care. This study aims to: quantify rates of readmission within 30 days of CABG surgery; explore the causes of readmissions; and investigate how patient- and hospital-level factors influence readmission.MethodsWe conducted systematic searches (until June 2020) of PubMed and Embase databases to retrieve observational studies that investigated readmission after CABG. Random effect meta-analysis was used to estimate rates and predictors of 30-day post-CABG readmission.ResultsIn total, 53 studies meeting inclusion criteria were identified, including 8,937,457 CABG patients. The pooled 30-day readmission rate was 12.9% (95% CI: 11.3–14.4%). The most frequently reported underlying causes of 30-day readmissions were infection and sepsis (range: 6.9–28.6%), cardiac arrythmia (4.5–26.7%), congestive heart failure (5.8–15.7%), respiratory complications (1–20%) and pleural effusion (0.4–22.5%). Individual factors including age (OR per 10-year increase 1.12 [95% CI: 1.04–1.20]), female sex (OR 1.29 [1.25–1.34]), non-White race (OR 1.15 [1.10–1.21]), not having private insurance (OR 1.39 [1.27–1.51]) and various comorbidities were strongly associated with 30-day readmission rates, whereas associations with hospital factors including hospital CABG volume, surgeon CABG volume, hospital size, hospital quality and teaching status were inconsistent.ConclusionsNearly 1 in 8 CABG patients are readmitted within 30 days and the majority of these are readmitted for noncardiac causes. Readmission rates are strongly influenced by patients’ demographic and clinical characteristics, but not by broadly defined hospital characteristics.

Retrospective cohort analysis of Spanish national trends of coronary artery bypass grafting and percutaneous coronary intervention from 1998 to 2017

IntroductionSpain is one of the countries with the lowest rates of revascularisation and highest ratio of percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG).ObjectivesTo investigate the changes and...

STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.

Impact of Global Budget Payments on Cardiovascular Care in Maryland: An Interrupted Time Series Analysis.

Background Global budget payments (GBP) are considered effective in containing health care expenditures; however, information on their impact on quality of cardiovascular care is limited. We aimed to evaluate the effects of GBP on utilization, outcomes, and costs for 3 major cardiovascular conditions. Methods We analyzed claims data of hospital admissions in Maryland from fiscal year 2013 to 2018. Using segmented regression, we evaluated temporal trends in hospitalizations, length of stay, percutaneous coronary intervention and coronary artery bypass grafting volumes, case mix-adjusted 30-day readmission rates, risk-standardized mortality rates, and hospitalization charges in patients with principal diagnosis of heart failure, acute ischemic stroke, and acute myocardial infarction (AMI) in relation to GBP implementation. Trends in global cardiovascular procedure charges/volumes were also studied. Results Hospitalization rates for congestive heart failure and AMI remained unaffected by GBP, while the gradient of ischemic stroke admissions decreased (Ptrend <0.0001). Length of stay slightly increased for patients with congestive heart failure (Ptrend=0.03). Inpatient coronary artery bypass grafting surgeries decreased (Ptrend <0.0001). We observed a significant decrease in casemix-adjusted 30-day readmission rate in the AMI cohort beyond the prepolicy trend (Ptrend=0.0069). There were no significant changes in mortality for any of the 3 conditions. Hospitalization charges increased for ischemic stroke (Ptrend <0.0001), remained constant for congestive heart failure (Ptrend=0.1), and decreased for AMI (Ptrend=0.0005). We observed a significant increase in electrocardiography rate charges (Ptrend <0.0001), coincidentally with a reduction in volumes (Ptrend=0.0003). Conclusions Introducing GBP in Maryland had no perceivable adverse effects on inpatient outcomes and quality indicators for 3 major cardiovascular conditions. Savings were observed in the AMI cohort, possibly due to reduced unnecessary readmissions, efficiency improvements, or shifts to outpatient care. Reduced cardiovascular procedure volumes were counterbalanced by a proportional rise in charges. State-level adoption of GBP with pay-for-performance incentives may be effective for cost containment without adversely impacting quality of cardiovascular care.

Coronary artery bypass graft surgery in Brazil from 2008 to 2017.

Brazil is an upper middle-income country in South America with the world's sixth largest population. Despite great advances in health-care services and cardiac surgical care in both its public and private health systems, little is known on the volume, outcomes, and trends of coronary artery bypass grafting (CABG) in Brazil's public health system. The aim of this study was to evaluate the outcome of CABG on the public health system from January 2008 to December 2017 through the database DATASUS. This study is based on publicly available material obtained from DATASUS, the Brazilian Ministry of Health's data processing system, on numbers of surgical procedures, death rates, length of stay, and costs. Only isolated CABG procedures were included in our study. We used the TabNet software from the DATASUS website to generate reports. The χ2 test was used to compare death rates. A p < .05 was considered statistically significant. We identified 226,697 CABG procedures performed from January 2008 to December 2017. The overall in-hospital mortality over the 10-year period was 5.7%. We observed statistically significant differences in death rates between the five Brazilian macro-regions. Death rates by state ranged from 2.6% to 13.1%. The national average mortality rate remained stable over the course of time. Over 10 years, a high volume of CABG was performed in the Brazilian Public Health System, with significant differences in mortality, number of procedures, and distribution of surgeries by region. Future databases involving all centers that perform CABG and carry out risk-adjusted analysis will help improve Brazilian resultsand enable policymakers to adopt appropriate health-care policies for greater transparency and accountability.

Hospital Case Volume, Health Care Providers, and Mortality in Patients Undergoing Coronary Artery Bypass Grafting: a Nationwide Cohort Study in South Korea.

Surgical quality is evaluated by measuring the annual hospital case volume; a higher case volume is associated with better survival after various surgeries. We aimed to investigate if the annual hospital case volume and the health care providers were associated with a 90-day mortality after coronary artery bypass grafting (CABG). For this population-based cohort study, we used data from a National Health Insurance Service database in South Korea. We included all adult patients diagnosed with ischemic heart disease who underwent isolated CABG between January 2012 and December 2017. Data on the annual surgical volume for CABG in each hospital where the patients received CABG and the total number of health care providers (including physicians [trainees and specialists] from all department of the hospitals, nurses, and pharmacists) were collected. The final analysis included 15,790 adult patients; of these, 1,039 (6.6%) died within 90 days. The annual CABG volume was divided into 4 groups (Q1: ≤33, Q2: 34-86, Q3: 87-223, and Q4: ≥224). Multivariable Cox regression analysis revealed that the 90-day mortality rates in the Q4, Q3, Q2 groups were 75%, 32%, and 31% lower than that in the Q1 group, respectively. Additionally, an increase in the ratio of the total number of specialist physicians to 100 hospital beds was associated with a 4% decrease in the 90-day mortality after CABG. Both, a higher annual hospital case volume and overall specialist physician volume were associated with better 90-day mortality rates after isolated CABG.

Center-level CABG and valve operative outcomes and volume-outcome relationships in New York State.

We analyzed center-level outcome correlations between valve surgery and coronary artery bypass graft (CABG) in New York (NY) State and how volume-outcome effect differ between case types. We used the 2014-2016 NY cardiac surgery outcomes report. Center-level observed to-expected (observed-to-expected ratio [O/E]) ratio for operative mortality provided risk-adjusted operative outcomes for isolated CABG and valve operations. Correlation coefficient characterized the concordance in center-level outcomes in CABG and valve. Discordant outcomes were defined as having O/E ratio greater than 2 in one operation type with O/E ratio≤1 in another. Linearized slope of volume-outcome effect in case types offered insights into centers with discordant performances between procedures. Among 37 NY centers, annual center volumes were 220 ± 120 cases for CABG and 190 ± 178 cases for valve operations. Modest center-level correlation between CABG and valve O/E ratio was shown (R2 = 0.31). Two centers had discordant performance between valve and CABG (O/E ≤ 1 for CABG while O/E > 2 for valve procedures). No centers had CABG O/E ratio greater than 2 while valve O/E ratio ≤1. Linearized slope describing volume-outcome effects showed stronger effect in valve operations compared to CABG: O/E ratio declined 0.1 units per 100 CABG volume increase, while O/E ratio declined 0.33 units per 100 valve volume increase. In NY hospitals, favorable valve outcomes may indicate good CABG outcomes but good CABG outcomes may not ensure valve outcomes. Outcome variation in valve operation could be related to stronger volume-outcome effect in valve operations relative to CABG. Valve operations may benefit from regionalization.

Effect of Hospital and Surgeon Procedure Volumes on the Incidence of Intraoperative Conversion During Off-Pump Coronary Artery Bypass Grafting

Intraoperative conversion to cardiopulmonary bypass with its subsequent high mortality is a major concern associated with off-pump coronary artery bypass grafting (OPCAB). The impact of procedure volume on the incidence of intraoperative conversion, however, is poorly defined. This study therefore evaluated the effect of procedure volume on the incidence of conversion in OPCAB using nationwide data. We analyzed 31,361 patients who underwent primary, nonemergent, isolated OPCAB during 2013-2016 reported in the Japan Cardiovascular Surgery Database. Hospitals (n = 548) and surgeons (n = 1315) were divided into tertile categories (low-, medium-, and high volumes) based on the total number of isolated coronary artery bypass grafting (CABG). Hierarchical logistic regression analysis, including 22 preoperative factors and hospital and surgeon CABG volumes, was used to assess the relation between procedure volume and the risk of conversion due to bleeding/hemodynamic instability. There were 797 (2.5%) intraoperative conversions due to bleeding/hemodynamic instability. Risk-adjusted odds ratios for conversion were significantly lower in some combined hospital/surgeon CABG volume categories than in the reference category. Hospital/surgeon volumes and their odds ratio (95% confidence interval) were as follows: low/low 1.00 (reference); medium/low 0.62 (0.39-0.96); high/low 0.47 (0.27-0.81); high/high 0.58 (0.38-0.89). There was a lower risk of conversion in medium- and high-volume than low-volume hospitals, especially among low-volume surgeons. Procedure volume is associated with the incidence of conversion during OPCAB. Among low-volume surgeons, hospital CABG volume significantly reduces conversion in a volume-dependent manner. These findings will be useful for safety training of OPCAB surgeons.

Temporal Trends in Percutaneous CoronaryIntervention and Coronary Artery Bypass Grafting: Insights From the Washington Cardiac Care Outcomes Assessment Program.

BackgroundPatient selection and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have changed over the past decade. However, there is limited information on outcomes for both revascularization strategies in the same population. The study evaluated temporal changes in risk profile, procedural characteristics, and clinical outcomes for PCI‐ and CABG‐treated patients.Methods and ResultsWe analyzed all PCI and isolated CABG between 2005 and 2017 in nonfederal hospitals in Washington State. Descriptive analysis was performed to evaluate temporal changes in risk profile and, risk‐adjusted in‐hospital mortality. Over the study period, 178 474 PCI and 36 592 CABG procedures were performed. PCI and CABG volume decreased by 2.9% and 22.6%, respectively. Compared with 2005–2009, patients receiving either form of revascularization between 2014 and 2017 had a higher prevalence of comorbidities including diabetes mellitus and hypertension and dialysis. Presentation with ST‐segment–elevation myocardial infarction (17% versus 20%) and cardiogenic shock (2.4% versus 3.4%) increased for patients with PCI compared with CABG. Conversely, clinical acuity decreased for patients receiving CABG over the study period. From 2005 to 2017, mean National Cardiovascular Data Registry CathPCI mortality score increased for patients treated with PCI (20.1 versus 22.4, P<0.0001) and decreased for patients treated with CABG (18.8 versus 17.8, P<0.0001). Adjusted observed/expected in‐hospital mortality ratio increased for PCI (0.98 versus 1.19, P<0.0001) but decreased for CABG (1.21 versus 0.74, P<0.0001) over the study period.ConclusionsClinical acuity increased for patients treated with PCI rather than CABG. This resulted in an increase in adjusted observed/expected mortality ratio for patients undergoing PCI and a decrease for CABG. These shifts may reflect an increased use of PCI instead of CABG for patients considered to be at high surgical risk.

Outcome of Percutaneous Coronary Intervention in Relation to the Institutional Volume of Coronary Artery Bypass Surgery.

Background: Percutaneous coronary intervention (PCI) is performed in a wide range of institutions. We sought to assess the relationship between coronary artery bypass grafting (CABG) volume relative to PCI volume and clinical outcome using nationally representative PCI and CABG registries in Japan. Methods: This was a collaborative, registry-based cohort study enrolling patients undergoing percutaneous coronary intervention in 2013–2014 using Japanese nationwide registry (J-PCI) with follow up until discharge. The absolute volume of CABG for each hospital was calculated using additional data from Japan CardioVascular Surgery Database (JCVSD). Patients undergoing their first PCI registered in the registry (N = 220,934), at 943 facilities were studied. Main outcomes were in-hospital mortality, and incidence of composite of in-hospital death and postprocedural complications. Results: Among the 220,934 patients, 162,411 were men, with a mean age of 69.7 (SD 11.6) years. Patients underwent PCI at hospitals with varying CABG volume: The overall in-hospital mortality and composite event rate for PCI patients was 0.9% and 2.4%, respectively. CABG volume was associated with the in-hospital mortality of PCI at facilities performing less than 200 PCIs per year, but not at facilities performing 200 or more. Similarly, in-hospital mortality or complication was associated with PCI volume <200 only if no CABG is done at the facility. The result remained largely consistent in subgroup of patients presenting with acute coronary syndrome or even after excluding these institutions with extremely low number of PCI (<50 cases/year) or CABG (<15 cases / year). Conclusions: In a nationwide registry-based analysis, the surgical volume was associated with patients’ clinical outcome after PCI, when limited number of PCIs were performed at the facility.

Are cost advantages from a modern Indian hospital transferable to the United States?

BackgroundMultiple modern Indian hospitals operate at very low cost while meeting US-equivalent quality accreditation standards. Though US hospitals face intensifying pressure to lower their cost, including proposals to extend Medicare payment rates to all admissions, the transferability of Indian hospitals’ cost advantages to US peers remains unclear.MethodsUsing time-driven activity-based costing methods, we estimate the average cost of personnel and space for an elective coronary artery bypass graft (CABG) surgery at two American hospitals and one Indian hospital (NH). All three hospitals are Joint Commission accredited and have reputations for use of modern performance management methods. Our case study applies several analytic steps to distinguish transferable from non-transferable sources of NH’s cost savings.ResultsAfter removing non-transferable sources of efficiency, NH’s residual cost advantage primarily rests on shifting tasks to less-credentialed and/or less-experienced personnel who are supervised by highly-skilled personnel when perceived risk of complications is low. NH’s high annual CABG volume facilitates such supervised work “downshifting.” The study is subject to limitations inherent in case studies, does not account for the younger age of NH’s patients, or capture savings attributable to NH’s negligible frequency of re-admission or post-acute care facility placement.ConclusionsMost transferable bases for a modern Indian hospital’s cost advantage would require more flexible American states’ hospital and health professional licensing regulations, greater family participation in inpatient care, and stronger support by hospital executives and clinicians for substantially lowering the cost of care via regionalization of complex surgeries and weekend use of costly operating rooms.

Coronary artery bypass grafting in Spain. Influence of procedural volume on outcomes.

To analyze the association between volume and outcomes in coronary artery bypass grafting (CABG) in the Spanish National Health System. We analyzed CABG episodes from 2013 to 2015. The selected outcome variables were in-hospital mortality in the index episode, 30-day cardiac-related readmissions, and mortality during readmission. Risk-adjusted rates of in-hospital mortality (RAMR) and 30-day readmissions (RARR) were calculated using multilevel logistic regression. High- and low-volume hospitals for CABG were identified by a nonconditioned analysis (k-means) and by compliance with the volume recommendation of clinical practice guidelines. A total of 17 335 CABG index episodes were included, with a crude in-hospital mortality rate of 5.0%. Episodes attended in low-volume centers for CABG (< 155 CABG per year) showed 17% higher RAMR (5.81%±2.07% vs 4.96%±1.76%; P <.001) and a negative linear correlation between volume and RARR (r=-0.318; P=.029), as well as a higher percentage of complications during the episode. The same association between volume and more favorable outcomes was found in isolated CABG. The mean CABG volume is low in Spanish National Health System hospitals. Higher volume was associated with better outcomes in CABG, both total and isolated. The findings of this study indicate the need for a higher concentration of CABG programs, as well as the publication of risk-adjusted outcomes of coronary intervention.

Cirugía de revascularización aortocoronaria en España. Influencia del volumen de procedimientos en los resultados

Introduction and objectivesTo analyze the association between volume and outcomes in coronary artery bypass grafting (CABG) in the Spanish National Health System. MethodsWe analyzed CABG episodes from 2013 to 2015. The selected outcome variables were in-hospital mortality in the index episode, 30-day cardiac-related readmissions, and mortality during readmission. Risk-adjusted rates of in-hospital mortality (RAMER) and 30-day readmissions (RARER) were calculated using multilevel logistic regression. High- and low-volume hospitals for CABG were identified by a nonconditioned analysis (k-means) and by compliance with the volume recommendation of clinical practice guidelines. ResultsA total of 17 335 CABG index episodes were included, with a crude in-hospital mortality rate of 5.0%. Episodes attended in low-volume centers for CABG (< 155 CABG per year) showed 17% higher RAMR (5.81%±2.07 vs 4.96±1.76; P <.001) and a negative linear correlation between volume and RARR (r=−0.318; P=.029), as well as a higher percentage of complications during the episode. The same association between volume and more favorable outcomes was found in isolated CABG. ConclusionsThe mean CABG volume is low in Spanish National Health System hospitals. Higher volume was associated with better outcomes in CABG, both total and isolated. The findings of this study indicate the need for a higher concentration of CABG programs, as well as the publication of risk-adjusted outcomes of coronary intervention.Full English text available from: www.revespcardiol.org/en

Association between surgical volume and clinical outcomes following coronary artery bypass grafting in contemporary practice.

Studies assessing the association between surgical volume and coronary artery bypass grafting (CABG) outcomes yielded conflicting results. Given the substantial recent decrease in CABG volume, we sough to examine the volume-outcomes effect in contemporary practice. The National Readmission Database was queried to identify patients undergoing CABG between January 1, 2015 and December 31, 2016. Risk-adjusted in-hospital morbidity, mortality, length-of-stay, cost, and 30-day readmission were compared between low-, intermediate-, and high-volume centers. A total of 411 159 CABG hospitalizations at 1558 hospitals were included. Hospitals were classified into three tertiles (high > 250, intermediate 100-250, and low-volume < 100). Hospitals in the highest tertile (n = 568) performed 73.9% of all CABG operations, while those in the intermediate (n = 452), and low (n = 538) volume tertiles performed only 21.7% and 4.4% of all CABGs, respectively. The median number of CABGs performed at high-, intermediate-, and low-volume hospitals was 45 316 335, respectively. After risk adjustment, undergoing CABG at low- or intermediate- volume hospital (vs high-volume hospitals) was associated with higher in-hospital death (odd ratio [OR] = 1.31, 95% confidence interval [CI], 1.19-1.44, and OR = 1.11, 95% CI, 1.05-1.17, respectively, P < .001). Similarly, adjusted odds of stroke, acute kidney injury, and blood transfusion were higher at low- and intermediate-volume centers compared with high-volume centers. Undergoing CABG at a low-volume center was associated with 50% higher adjusted cost and 77% higher adjusted 30-day readmissions. In contemporary practice, in which one-third of CABG-capable hospitals perform < 100 CABG operations annually, a strong relationship is observed between surgical volume and adjusted in-hospital morbidity, mortality, cost, and 30-day readmission.