Coronary Artery Bypass Grafting In Hospital Research Articles

Association Between the Physician Quality Score in the Merit-Based Incentive Payment System and Hospital Performance in Hospital Compare in the First Year of the Program

The scientific validity of the Merit-Based Incentive Payment System (MIPS) quality score as a measure of hospital-level patient outcomes is unknown. To examine whether better physician performance on the MIPS quality score is associated with better hospital outcomes. This cross-sectional study of 38 830 physicians used data from the Centers for Medicare & Medicaid Services (CMS) Physician Compare (2017) merged with CMS Hospital Compare data. Data analysis was conducted from September to November 2020. Linear regression was used to examine the association between physician MIPS quality scores aggregated at the hospital level and hospitalwide measures of (1) postoperative complications, (2) failure to rescue, (3) individual postoperative complications, and (4) readmissions. The study cohort of 38 830 clinicians (5198 [14.6%] women; 12 103 [31.6%] with 11-20 years in practice) included 6580 (17.2%) general surgeons, 8978 (23.4%) orthopedic surgeons, 1617 (4.2%) vascular surgeons, 582 (1.5%) cardiac surgeons, 904 (2.4%) thoracic surgeons, 18 149 (47.4%) anesthesiologists, and 1520 (4.0%) intensivists at 3055 hospitals. The MIPS quality score was not associated with the hospital composite rate of postoperative complications. MIPS quality scores for vascular surgeons in the 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.55-percentage point higher hospital rate of failure to rescue (95% CI, 0.06-1.04 percentage points; P = .03). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.41-percentage point higher hospital coronary artery bypass graft (CABG) mortality rate (95% CI, 0.10-0.71 percentage points; P = .01). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile and 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with 0.65-percentage point (95% CI, 0.013-1.16 percentage points; P = .02) and 0.48-percentage point (95% CI, 0.07-0.90 percentage points; P = .02) higher hospital CABG readmission rates, respectively. In this study, better performance on the physician MIPS quality score was associated with better hospital surgical outcomes for some physician specialties during the first year of MIPS.

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.

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.

Adverse Cerebral Outcomes after Coronary Artery Bypass Surgery-More Than a Decade of Experience in a Single Center.

Nonfatal strokes, transient ischemic attacks (TIAs), and reversible ischemic neurological deficits (RIND) after elective coronary artery bypass grafting (CABG) are devastating clinical problems. The anesthesiologist, surgical and intensive care teams in a community hospital adopted a strategy developed in an effort to minimize these adverse outcome events.The purpose of this study is to determine the incidence of and predictors for perioperative adverse neurologic events. A historical cohort study of 1,108 consecutive CABG patients operated between 2002 and 2014. Outcomes were defined as (1) a new neurologic damage (a new stroke, TIA, or RIND) and (2) a new neurologic damage or 30 days mortality. Adverse cerebral outcomes occurred in 16 patients (1.4 percent). Nine patients had postoperative stroke, six suffered TIAs, and one had postoperative RIND.In multivariate analysis, older age (OR 1.07, 95% CI 1.01-1.14), congestive heart failure (OR 3.57, 95% CI 1.22-10.49) and prior stroke (OR 6.27, 95% CI 1.78-22.03) were significantly associated with increased risk of new neurologic damage. These parameters were also significantly associated with increased risk of the combined outcome (new neurologic damage/mortality). A low incidence rate of adverse cerebral outcomes after CABG in community hospital can be achieved with the use of the suggested surgical intensive care, and anesthetic strategy. Advanced age, congestive heart failure, and prior stroke are associated with adverse outcomes.

Hospital procedure volume does not predict acute kidney injury after coronary artery bypass grafting-a nationwide study.

BackgroundAcute kidney injury (AKI) is common after coronary artery bypass grafting (CABG) and is associated with poor outcome. Increased hospital procedure volume has been associated with better outcomes. However, the impact of hospital CABG volume on AKI needing dialysis (AKI-D) is less clear. We designed this study to examine (i) the impact of number of annual CABG procedures per hospital (CABG-vol) on AKI-D and inpatient mortality and (ii) if it modifies the relationship between AKI-D and mortality.MethodsUsing the Nationwide Inpatient Sample database from 2000 to 2010, we identified admissions with CABG and those with AKI-D using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multivariable logistic regressions were used to assess the impact of CABG-vol on AKI-D and mortality. We used restricted cubic splines to account for the nonlinear relationship between CABG-vol and mortality. We also evaluated the a priori interaction term between CABG-vol and AKI-D in the model for mortality.ResultsOf 4 002 730 hospitalizations for CABG, 0.7% (24 126) had AKI-D. On adjusted analysis, CABG-vol did not correlate with odds of developing AKI-D [odds ratio (OR) 0.99; 95% confidence interval (CI) 0.99–1.00] but was associated with mortality, though the association was nonlinear. AKI-D was a significant predictor of mortality with OR 7.58 (95% CI 6.81–8.44). The interaction of CABG-vol and AKI-D was not significant (P = 0.8).ConclusionsLower annual CABG hospital procedure volume is significantly associated with higher mortality but not with a higher incidence of AKI-D. AKI-D is associated with higher mortality in those undergoing CABG. However, there is no differential effect of hospital volume on odds of mortality due to AKI-D.

Mitral valve repair for ischemic moderate mitral regurgitation in patients undergoing coronary artery bypass grafting.

Objectives:To investigate whether mitral valve repair (MVR) at the time of coronary artery bypass grafting (CABG) in patients with ischemic moderate mitral regurgitation (MR) and coronary artery disease could improve short- and mid-term postoperative outcomes.Methods:Between March 2013 and December 2015, 90 patients with moderate ischemic MR underwent first-time CABG in Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey. Out of 90 patients, 44 (48.9%) underwent combined CABG+MVR. The remaining 46 (51.1%) underwent CABG alone. Ventricular functions and effort capacities of patients in both groups were evaluated echocardiographically and clinically in the preoperative period, and in the first postoperative year.Results:Postoperative regurgitant volume changes according to preoperative values were -24.76±19 ml/beat in the combined CABG+MVR group, and -8.70±7.2 ml/beat in the CABG alone group (p=0.001). The change of vena contracta width was -3.40±0.2 mm in the combined CABG+MVR group whereas in the CABG alone -1.45±0.7 mm (p=0.019). The changes of left ventricular end-systolic volume index were -30.77±25.9 ml/m2 in the combined CABG+MVR group and -15.6±9.4 ml/m2 in the CABG alone group (p=0.096). Ejection fraction changes in the combined CABG+MVR group was +1.51±5.3% and in the CABG alone group was +1.15±4.3%. No statistically significant difference was found between both groups (p=0.604). Preoperative New York Heart Association class values in the combined CABG+MVR group was 2.18±0.45, and in the CABG alone group was 2.13±0.54.Conclusions:Moderate MR in patients undergoing CABG affects the outcome adversely and it does not reliably improve after CABG alone. Therefore, patients with ischemic moderate MR should undergo simultaneous MVR at the time of CABG.

Association of Hospital Prices for Coronary Artery Bypass Grafting With Hospital Quality and Reimbursement

Although prices for medical services are known to vary markedly between hospitals, it remains unknown whether variation in hospital prices is explained by differences in hospital quality or reimbursement from major insurers. We obtained "out-of-pocket" price estimates for coronary artery bypass grafting (CABG) from a random sample of US hospitals for a hypothetical patient without medical insurance. We compared hospital CABG price to (1) "fair price" estimate from Healthcare Bluebook data using each hospital's zip code and (2) Society of Thoracic Surgeons composite CABG quality score and risk-adjusted mortality rate. Of 101 study hospitals, 53 (52.5%) were able to provide a complete price estimate for CABG. The mean price for CABG was $151,271 and ranged from $44,824 to $448,038. Except for geographic census region, which was weakly associated with price, hospital CABG price was not associated with other structural characteristics or CABG volume (p >0.10 for all). Likewise, there was no association between a hospital's price for CABG with average reimbursement from major insurers within the same zip code (ρ = 0.07, p value = 0.6), Society of Thoracic Surgeoncomposite quality score (ρ = 0.08, p value = 0.71), or risk-adjusted CABG mortality (ρ = -0.03 p value = 0.89). In conclusion, the price of CABG varied more than 10-fold across US hospitals. There was no correlation between price information obtained from hospitals and the average reimbursement from major insurers in the same market. We also found no evidence to suggest that hospitals that charge higher prices provide better quality of care.

The influence of preoperative quitting time on postoperative hypoxemia of coronary artery bypass grafting patients

Objective To evaluate the influence of preoperative quitting time on coronary artery bypass grafting (CABG) patients with postoperative hypoxemia incidence. Methods 151 patients with coronary bypass surgery and preoperative history of smoking who preparation of CABG in hospital were recruited from September 2011 to September 2013. According to the preoperative smoking cessation time patients were divided into five groups : 0 days, 1-30 days, 31-60 days, 61-90 days, more than 90 days. Single factor regression and Logistic analysis were used to analyse the influence of preoperative quitting time on CABG patients with postoperative hypoxemia incidence. Results Age, weight, smoking habit, quitting time, hypertension, diabetes mellitus were risk factors of hypoxemia after coronary artery bypass grafting. Logistic regression analysis showed that age, body weight, smoking habit, smoking time were independent risk factors of hypoxemia after coronary artery bypass grafting. The incidences of hypoxemia of the five groups 0 days, 1-30 days, 31-60 days, 61-90 days and more than 90 days were 55.56% (15/27), 59.26% (16/27),27.58% (8/29),22.73% (5/22),15.63% (5/32). The incidence of hypoxemia had significant difference (χ2=19.212, P < 0.05). Conclusions Age, weight, smoking habit, quitting time were independent risk factors of hypoxemia after CABG. With the quitting time increase, hypoxemia after CABG overall downward trend. Difference quitting time before the operation ,the hypoxemia occurred difference rate influence, On the preoperative smoking CABG patients were smoking cessation intervention timely helps to reduce the occurrence of postoperative hypoxemia. Key words: Angioplasty, balloon, coronary; Hypoxemia; Smoking

Predicting coronary artery bypass graft surgery in acute coronary syndromes.

To identify features predictive of hospital coronary artery bypass graft (CABG) surgery in patients with acute coronary syndromes (ACSs). Data from 17,434 patients enrolled in an observational study were analysed. Patients in private hospitals were more likely to undergo CABG than those in public hospitals (10.3% vs. 6.9%, P<0.01); CABG was more frequent in the USA than in Europe (11.9 % vs 3.5%, P<0.01). Clinical features independently predictive of CABG on multivariable analysis included no previous CABG, male sex, history of angina, hypertension, hyperlipidaemia, or diabetes, no history of atrial fibrillation or congestive heart failure, ST depression in multiple territories, and absence of ST elevation. These factors were assigned a score to quantify the likelihood of CABG (c-statistic 0.69). This score was predictive regardless of ACS subgroup (c-statistic 0.65-0.71) and remained predictive across institutions regardless of the frequency with which CABG was performed. The score was of greatest clinical utility among hospitals performing CABG in >10% of their ACS patients. Identifying ACS patients likely to undergo CABG using clinical features alone remains difficult. In hospitals with higher rates of surgical revascularisation, a subgroup of patients with an approximate 30% likelihood of CABG can be identified. Therapy in these patients can be tailored to minimise bleeding risk without compromising outcomes.

O uso de inibidores da enzima conversora de angiotensina e sua relação com eventos no pós-operatório de cirurgia de revascularização miocárdica

Angiotensin-converting enzyme (ACE) inhibitors reduce the chance of death, myocardial infarction (MI) and cerebrovascular accident (CVA) in patients with coronary disease. However there is no consensus as to its indication in patients undergoing coronary artery bypass grafting (CABG). To assess the relationship between preoperative use of ACE inhibitors and clinical outcomes after CABG. Retrospective cohort study. We included data from 3,139 consecutive patients undergoing isolated CABG in Brazilian tertiary care hospital between January 1996 and December 2009. Follow-up was until discharge or death. Clinical outcomes after surgery were analyzed between users and nonusers of ACE inhibitors preoperatively. Fifty-two percent (n=1,635) of patients received ACE inhibitors preoperatively. The use of ACE inhibitors was an independent predictor of need for inotropic support (OR 1.24, 95% CI 1.01 to 1.47, P = 0.01), acute renal failure (OR 1.23, 95% CI 1.01 to 1.73, P = 0.04) and progression to atrial fibrillation (OR 1.32, 95% CI 1.02 to 1.7, P = 0.03) postoperatively. The mortality rate among patients receiving or not preoperative ACE inhibitors was similar (10.3% vs. 9.4%, P = 0.436), as well as the incidence of myocardial infarction and stroke (15.6% vs. 15.0%, P = 0.694 and 3.4% vs. 3.5%, P = 0.963, respectively). The use of preoperative ACE inhibitors was associated with increased need for inotropic support and higher incidence of acute renal failure and postoperative atrial fibrillation, not associated with increased rates of myocardial infarction, stroke or death.

‘The Impact of SIGN guidelines on Carotid Endarterectomy in South-East Scotland’

‘The Impact of SIGN guidelines on Carotid Endarterectomy in South-East Scotland’

Review of the ICD Registry's Third Year, Expansion to include Lead Data and Pediatric ICD Procedures, and Role for Measuring Performance

ntroduction he National ICD Registry became the sole repository of CD implantation data for Medicare beneficiaries on April , 2006, and as of June 2009 had collected data from ,432 hospitals in the United States totaling over 380,000 mplants. The registry was developed through a partnership f the Heart Rhythm Society (HRS [www.HRSonline.org]) nd the American College of Cardiology Foundation ACCF [www.acc.org]) utilizing the expertise of the ational Cardiovascular Data Registry (NCDR [www. ccncdr.com]) and has made substantial progress toward everal predefined goals:

The Ethics of Transparency: Publication of Cardiothoracic Surgical Outcomes in the Lay Press

he Congenital Heart Institute of Florida, Division of Thoracic and Cardiovascular Surgery, All Children’s Hospital and Children’s ospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates of Florida, Saint Petersburg and ampa, Florida; Section of Thoracic Surgery at University of Alabama at Birmingham, Division of CardioThoracic Surgery, epartment of Surgery, Birmingham, Alabama; Division of Cardiothoracic Surgery, Department of Surgery, Institute of Human alues in Health Care, Medical University of South Carolina, Charleston, South Carolina

Investigation of depression and anxiety state after coronary artery bypass grafting and analysis of influential factors correlated

Objective To investigate the incidence of depression and anxiety post-operation of coronary artery bypass grafting(CABG)and analysis the correlated factor.Methods 91 patients underwent scheduled CABG in the first hospital of Peking University from July 2005 to June 2006.The patients were interviewed to assess depression and anxiety symptoms using self-rating depression scale(SDS)and self-rating anxiety scale(SAS)before operation and before discharge.The patients were divided into depression and anxiety group and no depression and anxiety group according to with or without depression and anxiety.Demography characteristic,medical,surgical risk factors were assessed during suery.Results 89 patients completed evaluation.41 patients (46.1%)had depression and/or anxiety symptoms after CABG.Hyperlipemia(OR 3.958,95%CI 1.016～7.689),heart blood vesse]event(OR4.285,95%CI 1.051～6.175),depression and anxiety(OR 3.095,95%CI 0.783～2.426),cerebral infarction(OR 13.775,95%CI 2.805～8.207)before operation ale risk factors for depression and anxiety post surgery.Conclusion The incidence rate of depression and anxiety post CABG is hish and should be paid more attention.Hyperlipemia,heart blood vessel event,depression and anxiety,cerebral infarction before operation ale possible risk factors for depression and anxiety post smgery. Key words: Coronary artery bypass grafting; Depression; Anxiety

Publicly Reporting Implantable Cardioverter Defibrillator Outcomes

The past decade has seen a dramatic increase in efforts by both payors and governmental agencies to measure and publicly report patient outcomes to ensure that patients receive appropriate, high-quality care. As a result, terms such as outcomes, quality, report cards, and benchmarking have entered the lexicon of clinical medicine, and both physicians and hospitals are increasingly being held accountable for the outcomes of their patients. This movement shows no sign of slowing down. In May 2008, the Centers for Medicare and Medicaid Services proposed increasing the total number of inpatient hospital measures from 40 to 73,1 and numerous physician measures are in various phases of development. In the current environment, it is likely that implantable cardioverter defibrillators (ICDs), which reduce the risk of sudden cardiac death,2 will soon emerge as a high-priority target for the development of performance measures, given that the procedure is expensive, performed on severely ill patients, and associated with significant risk of complications. Article see p 240 Accordingly, the findings published by Al-Khatib et al3 in this issue of Circulation: Arrhythmia and Electrophysiology warrant consideration in the context of current efforts to publicly report patient outcomes using Medicare claims data. In this excellent article, the authors used data from Centers for Medicare and Medicaid Services standard analytic files to determine the 90-day postprocedure complication rates and 1-year mortality rates of 8581 Medicare beneficiaries who had an ICD implanted by one of 1959 implanting physicians. The authors note that the complication rate declined from 18.8% in 2002 to 14.2% in 2005 and further identified specific factors associated with an increased risk of complication such as chronic lung disease, dementia, and renal disease. Of interest, physician experience as measured by procedure volume was not significantly associated with the risk of complication, although an earlier …

Comparison of Clinical and Administrative Data Sources for Hospital Coronary Artery Bypass Graft Surgery Report Cards

Regardless of statistical methodology, public performance report cards must use the highest-quality validated data, preferably from a prospectively maintained clinical database. Using logistic regression and hierarchical models, we compared hospital cardiac surgery profiling results based on clinical data with those derived from contemporaneous administrative data. Fiscal year 2003 isolated coronary artery bypass grafting surgery results based on an audited and validated Massachusetts clinical registry were compared with those derived from a contemporaneous state administrative database, the latter using the inclusion/exclusion criteria and risk model of the Agency for Healthcare Research and Quality. There was a 27.4% disparity in isolated coronary artery bypass grafting surgery volume (4440 clinical, 5657 administrative), a 0.83% difference in observed in-hospital mortality (2.05% versus 2.88%), corresponding differences in risk-adjusted mortality calculated by various statistical methodologies, and 1 hospital classified as an outlier only with the administrative data-based approach. The discrepancies in volumes and risk-adjusted mortality were most notable for higher-volume programs that presumably perform a higher proportion of combined procedures that were misclassified as isolated coronary artery bypass grafting surgery in the administrative cohort. Subsequent analyses of a patient cohort common to both databases revealed the smoothing effect of hierarchical models, a 9% relative difference in mortality (2.21% versus 2.03%) resulting from nonstandardized mortality end points, and 1 hospital classified as an outlier using logistic regression but not using hierarchical regression. Cardiac surgery report cards using administrative data are problematic compared with those derived from audited and validated clinical data, primarily because of case misclassification and nonstandardized end points.

Certificate of Need Regulation and Cardiac Catheterization Appropriateness After Acute Myocardial Infarction

Certificate of need (CON) regulation was introduced to control healthcare costs and improve quality of care in part by limiting the number of facilities providing complex medical care. Our objective was to examine whether rates of appropriate cardiac catheterization after admission for acute myocardial infarction varied between states with and without CON regulation of cardiac catheterization. We performed a retrospective analysis of chart-abstracted data for 137,279 Medicare patients admitted for acute myocardial infarction between 1994 and 1996 at 4179 US acute-care hospitals. Using 3-level hierarchical generalized linear modeling adjusted for patient sociodemographic and clinical characteristics and physician and hospital characteristics, we compared catheterization rates within 60 days of admission for states (and the District of Columbia) with (n=32) and without (n=19) CON regulation in the full cohort and stratified by catheterization appropriateness. Appropriateness was categorized as strongly, equivocally, or weakly indicated. We found CON regulation was associated with a borderline-significant lower rate of catheterization overall (45.8% versus 46.5%; adjusted risk ratio [RR] 0.91, 95% confidence interval 0.82 to 1.00, P=0.06). After stratification by appropriateness, CON regulation was not associated with a significantly lower rate of catheterization among 63,823 patients with strong indications (49.9% versus 50.3%; adjusted RR 0.94, 95% confidence interval 0.86 to 1.02, P=0.17). However, CON regulation was associated with significantly lower rates of catheterization among 65,077 patients with equivocal indication (45.0% versus 46.0%; adjusted RR 0.88, 95% confidence interval 0.78 to 1.00, P=0.05) and among 8379 patients with weak indications (19.8% versus 21.8%; adjusted RR 0.84, 95% confidence interval 0.71 to 0.98, P=0.04). Associations were weakened substantially after adjustment for hospital coronary artery bypass graft surgery or cardiac catheterization capability. CON regulation was associated with modestly lower rates of equivocally and weakly indicated cardiac catheterization after admission for acute myocardial infarction, but no significant differences existed in rates of strongly indicated catheterization.

U.S. Trends In CABG Hospital Volume: The Effect Of Adding Cardiac Surgery Programs

Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality--with low-volume hospitals having the highest mortality. Medicare data (1992-2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume--a side effect that might increase mortality.

Use of a Matching Algorithm to Evaluate Hospital Coronary Artery Bypass Grafting Performance as an Alternative to Conventional Risk Adjustment

Although public reporting of hospital and physician performance is a cornerstone of the effort to improve health care quality, the optimal approach to risk adjustment is unknown. We sought to assess hospital quality using a matching algorithm based on a generalized distance metric and to compare this approach to the more traditional regression-based approach. DESIGN/ DATA SOURCE: This was a retrospective study using the New York State (NYS) Coronary Artery Bypass Surgery Reporting System (CSRS), focusing on all patients undergoing isolated CABG surgery in NYS who were discharged in 1999 (18,116 patients). Patients from specific hospital were matched to a control group using the Mahalanobis distance. The hospitals' expected mortality rate was calculated in 2 ways: (1) as the mortality rate of the control group or (2) as the mortality rate predicted by the NYS CABG model. Hospitals whose observed mortality rate was significantly different from their expected mortality rate (OE difference) were defined as quality outliers. The 2 risk-adjustment methodologies disagreed on the outlier status of 4 of the 33 hospitals. Kappa analysis demonstrated substantial agreement between these 2 methods for identifying quality outliers: kappa = 0.61. There was excellent agreement between the point estimates of the OE difference obtained using these 2 risk adjustment methodologies. Basing outcome assessment on either matching or regression modeling yielded similar findings on hospital ranking but only moderate level of agreement on hospital quality. The use of matching may enhance the transparency and acceptance of outcome report cards by hospitals and physicians.

Contemporary Impact of State Certificate-of-Need Regulations for Cardiac Surgery

Prior research using administrative data associated certificate-of-need (CON) regulation for open heart surgery with higher hospital coronary artery bypass grafting (CABG) volume and lower CABG operative mortality rates in elderly patients. It is unclear whether these findings apply in a general population and after controlling for detailed clinical characteristics and region. Using the Society of Thoracic Surgeons' (STS) National Cardiac Surgery Database, we examined isolated CABG surgery volume, operative mortality, and the composite end point of operative mortality or major morbidity for the years 2000 to 2003. The presence of CON regulations for open heart surgery was ascertained from the National Directory of the American Health Policy Association and by contacting CON administrators. Results were analyzed nationally, by state, and by region (West, Northeast, Midwest, South) and were adjusted for clinical factors and both population density and region with mixed-effects hierarchical logistic regression models. During 2000 to 2003, there were 314,710 isolated CABG surgeries performed at 294 STS hospitals in CON states (n=27, including Washington, DC) and 280 512 procedures at 343 STS hospitals in non-CON states (n=24). Patient clinical characteristics were similar among CON and non-CON hospitals. States with CON regulations tended to have higher population densities and had significantly higher median hospital annual CABG volumes in each of the years 2000 to 2003 (P<0.005). This difference remained significant after adjustment for region and population density. Operative mortality was 2.52% for CON versus 2.62% for non-CON states (P=0.32). There was a significant association between CON law and operative mortality in the South. After adjustment for patient risk factors and region, there was a marginally significant reduction of mortality risk in states with CON regulation (adjusted OR 0.92, 95% CI 0.86 to 1.00). However, this difference was not statistically significant when a revised model accounted for random state effects. Similar volume and outcomes results were seen when the analysis was repeated with data from the national Medicare database. CON states have significantly higher hospital CABG surgery volumes but similar mortality compared with non-CON states. CON regulation alone is not a sufficient mechanism to ensure quality of care for CABG surgery.