Factors influencing risk-adjusted patient satisfaction after coronary artery bypass grafting.
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Aged↗
Biomedical subjects
Frederick L Grover
Publications and source records attributed to Frederick L Grover.
Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: a randomized controlled trial.
CONTEXT: A rigorous evaluation of continuous quality improvement (CQI) in medical practice has not been carried out on a national scale. OBJECTIVE: To test whether low-intensity CQI interventions can be used to speed the national adoption of 2 coronary artery bypass graft (CABG) surgery process-of-care measures: preoperative beta-blockade therapy and internal mammary artery (IMA) grafting in patients 75 years or older. DESIGN, SETTING, AND PARTICIPANTS: Three hundred fifty-nine academic and nonacademic hospitals (treating 267 917 patients using CABG surgery) participating in the Society of Thoracic Surgeons National Cardiac Database between January 2000 and July 2002 were randomized to a control arm or to 1 of 2 groups that used CQI interventions designed to increase use of the process-of-care measures. INTERVENTION: Each intervention group received measure-specific information, including a call to action to a physician leader; educational products; and periodic longitudinal, nationally benchmarked, site-specific feedback. MAIN OUTCOME MEASURE: Differential incorporation of the targeted care processes into practice at the intervention sites vs the control sites, assessed by measuring preintervention (January-December 2000)/postintervention (January 2001-July 2002) site differences and by using a hierarchical patient-level analysis. RESULTS: From January 2000 to July 2002, use of both process measures increased nationally (beta-blockade, 60.0%-65.6%; IMA grafting, 76.2%-82.8%). Use of beta-blockade increased significantly more at beta-blockade intervention sites (7.3% [SD, 12.8%]) vs control sites (3.6% [SD, 11.5%]) in the preintervention/postintervention (P =.04) and hierarchical analyses (P<.001). Use of IMA grafting also tended to increase at IMA intervention sites (8.7% [SD, 17.5%]) vs control sites (5.4% [SD,15.8%]) (P =.20 and P =.11 for preintervention/postintervention and hierarchical analyses, respectively). Both interventions tended to have more impact at lower-volume CABG sites (for interaction: P =.04 for beta-blockade; P =.02 for IMA grafting). CONCLUSIONS: A multifaceted, physician-led, low-intensity CQI effort can improve the adoption of care processes into national practice within the context of a medical specialty society infrastructure.
Adrenergic beta-Antagonists↗
Variation in mortality risk factors with time after coronary artery bypass graft operation.
BACKGROUND: Differences in mortality risk factor sets during different time periods (eg, short-term versus intermediate-term) after coronary artery bypass grafting have been reported. However, little is known about the time-varying effects of mortality risk factors after the operation. METHODS: We analyzed 11,815 veterans who had coronary artery bypass grafting at any of the 43 Veterans Affairs cardiac surgery centers from October 1997 to September 1999. Time-varying effects of 14 mortality risk factors during the 210 days after coronary artery bypass grafting were evaluated using Cox B-spline regression, which provides an estimate of risk for each variable for each day after operation. RESULTS: Eight variables showed significant time-varying effects after operation. The effect of prior heart operation was very high immediately after operation, but disappeared within 1 week. Three other cardiac variables (prior myocardial infarction, preoperative intraaortic balloon pump, and Canadian Cardiovascular Society anginal class III or IV) also conferred the highest risk on the day of operation and decreased thereafter. In contrast, the four time-varying noncardiac risk variables (age, impaired functional status, chronic obstructive pulmonary disease, and renal dysfunction) showed little or no association with mortality immediately after operation, but had increasing impact during the several months after operation. CONCLUSIONS: A sizable number of mortality risk factors have time-varying effects after coronary artery bypass grafting. Several cardiac risk factors have peak impact immediately after operation but dissipate thereafter. Several noncardiac risk factors confer little risk immediately after operation, but these risks increase during several months. This information may help clinicians focus management strategies for patients during the 7 months after operation.
Age Factors↗
The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models.
BACKGROUND: Although 30 day risk-adjusted operative mortality (ROM) has been used for quality assessment, it is not sufficient to describe the outcomes after coronary artery bypass grafting (CABG) surgery. Risk-adjusted major morbidity may differentially impact quality of care (as complications occur more frequently than death) and enhance a surgical team's ability to assess their quality. This study identified the preoperative risk factors associated with several complications and a composite outcome (the presence of any major morbidity or 30-day operative mortality or both). METHODS: For CABG procedures, the 1997 to 1999 Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database was used to develop ROM and risk-adjusted morbidity (ROMB) models. Risk factors were selected using standard STS univariate screening and multivariate logistic regression approaches. Risk model performance was assessed. Across STS participating sites, the association of observed-to-expected (O/E) ratios for ROM and ROMB was evaluated. RESULTS: The 30-day operative death and major complication rates for STS CABG procedures were 3.05% and 13.40%, respectively (503,478 CABG procedures), including stroke (1.63%), renal failure (3.53%), reoperation (5.17%), prolonged ventilation (5.96%), and sternal infection (0.63%). Risk models were developed (c-indexes for stroke [0.72], renal failure [0.76], reoperation [0.64], prolonged ventilation [0.75], sternal infection [0.66], and the composite endpoint [0.71]). Only a slight correlation was found, however, between ROMB and ROM indicators. CONCLUSIONS: Used in combination, ROMB and ROM may provide the surgical team with additional information to evaluate the quality of their care as well as valuable insights to allow them to focus on areas for improvement.
Aged↗
Adult cardiac surgery during the first 50 years of the Southern Thoracic Surgical Association.
This is a review of some of the outstanding adult cardiac surgical papers presented during the first 50 years of the Southern Thoracic Surgical Association to commemorate the 50th Anniversary meeting. Since the founding of the Southern Thoracic Surgical Association in 1954 there have been a total 512 adult cardiac surgery and great vessels papers presented, 138 from 1954 to 1970, 157 from 1971 to 1986, and 217 from 1987 to 2002. Since 1964 most of these papers have been published in The Annals of Thoracic Surgery. Forty-three papers were reviewed, the first having been presented in 1956 and the last in 2002. Not all of the papers could be located but the vast majority were retrievable and reviewed. This paper presents a broad spectrum of adult cardiac surgery beginning with early pump technology, early myocardial revascularization including the Vineberg procedure followed by coronary bypass as we know it today, valvular surgery, including several papers on aortic valve homograft and autograft procedures, ventricular aneurysms, aortic aneurysms and aortic dissections. Evaluations of various valve prostheses, cardiac transplantation, mitral valve reconstruction, quality assurance in cardiac surgery, neurobehavioral outcome after cardiac surgery, endocarditis and off-pump coronary bypass surgery were reviewed. We hope that this article is representative of the broad spectrum of issues that have characterized the specialty of cardiothoracic surgery over the second half of the 20th century and the beginning of the 21st century.
Adult↗
Atherogenic effects of Chlamydia pneumoniae: refuting the innocent bystander hypothesis.
OBJECTIVE: Serologic evidence of Chlamydia pneumoniae infection and atherosclerosis was first demonstrated in patients with ischemic heart disease in 1988. Subsequently, the organism has been detected in several cardiovascular lesions. Outside of observational reports, few studies mechanistically link vascular infection with C. pneumoniae and atherogenesis. To better define its pathophysiologic role, we examined the influence of C. pneumoniae infection of human vascular smooth muscle cells on vascular smooth muscle cell proliferation, cell-cycle protein expression, and inflammatory cytokine release. METHODS: Human aortic vascular smooth muscle cells were inoculated with C. pneumoniae in culture. Proliferation was assessed by mitochondrial activity, direct cell counting, and immunohistochemical staining for proliferating cell nuclear antigen. Electromobility gel shift assays probed for the antiproliferative cell-cycle protein p53. Supernatants were assayed for the mitogens interleukin-6 and interleukin-8 by enzyme-linked immunosorbent assay. RESULTS: After C. pneumoniae inoculation, vascular smooth muscle cell proliferation increased 2-fold by mitochondrial activity and more than 3-fold by cell numbers. C. pneumoniae infection promoted a 3-fold increase in proliferating cell nuclear antigen expression, which was associated with decreased nuclear binding of p53. Compared with control, C. pneumoniae inoculation resulted in a 2.5-fold increase in released interleukin-6 and interleukin-8. In each experiment, the influence of C. pneumoniae was abrogated by concomitant treatment with the macrolide antibiotic azithromycin. CONCLUSIONS: C. pneumoniae induced human vascular smooth muscle cell proliferation and proliferating cell nuclear antigen expression, down-regulated p53, and promoted release of prototypical atherogenic cytokines. These in vitro findings indicate that C. pneumoniae is more than an innocent bystander, rather it is a pathophysiologic participant in atherogenesis warranting elimination.
Arteriosclerosis↗
Thoracic transplantation.
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Heart Transplantation↗
The impact of ethnicity on outcomes following coronary artery bypass graft surgery in the Veterans Health Administration.
OBJECTIVES: We evaluated the effect of African American (AA) and Hispanic American (HA) ethnicity on mortality and complications following coronary artery bypass graft (CABG) surgery in the Veterans Health Administration (VHA). BACKGROUND: Few studies have examined the impact of ethnicity on outcomes following cardiovascular procedures. METHODS: This study included all 29,333 Caucasian, 2,570 AA, and 1,525 HA patients who underwent CABG surgery at any one of the 43 VHA cardiac surgery centers from January 1995 through March 2001. We evaluated the relationship between ethnicity (AA vs. Caucasian and HA vs. Caucasian) and 30-day mortality, 6-month mortality, and 30-day complications, adjusting for a wide array of demographic, cardiac, and noncardiac variables. RESULTS: After adjustment for baseline characteristics, AA and Caucasian patients had similar 30-day (AA/Caucasian odds ratio [OR] 1.07; 95% confidence interval [CI] 0.84 to 1.35; p = 0.59) and 6-month mortality risk (AA/Caucasian OR 1.10; 95% CI 0.91 to 1.34; p = 0.31). However, among patients with low surgical risk, AA ethnicity was associated with higher mortality (OR 1.52, CI 1.10 to 2.11, p = 0.01), and AA patients were more likely to experience complications following surgery (OR 1.28; 95% CI 1.14 to 1.45; p < 0.01). In contrast, HA patients had lower 30-day (HA/Caucasian OR 0.70; 95% CI 0.49 to 0.98; p = 0.04) and 6-month mortality risk (HA/Caucasian OR 0.66; 95% CI 0.50 to 0.88; p < 0.01) than Caucasian patients. CONCLUSIONS: Ethnicity does not appear to be a strong risk factor for adverse outcomes following CABG surgery in the VHA. Future studies are needed to determine why AA patients have more complications, but ethnicity should not affect the decision to offer the operation.
Black or African American↗
Quality improvement in cardiac care.
Quality improvement in cardiac care has made considerable progress over the past 30 years. During that period, there has been the development of multi-institutional databases to monitor outcomes following cardiothoracic surgery. These databases initially began using only volume and unadjusted operative (30-day) mortality as outcome criteria. There has been a progressive increase in their sophistication, with the building of risk models based on preoperative variables, which accurately predict the risk of adverse outcomes. Other outcomes have been added including risk-adjusted mortality and morbidity; efficiency outcomes such as length of stay, quality of life, functional health status, neuropsychological outcomes; and long-term outcomes.
Cardiac Surgical Procedures↗
A decade of change--risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990-1999: a report from the STS National Database Committee and the Duke Clinical Research Institute. Society of Thoracic Surgeons.
BACKGROUND: The Society of Thoracic Surgeons National Adult Cardiac Database is the largest voluntary clinical database in medicine. Using this database we examined changes in the risk profile of patients undergoing isolated coronary artery bypass grafting (CABG) and their outcomes during the decade 1990 to 1999. METHODS: Trends in 23 preoperative risk factors were tracked for CABG cases during this decade. Using a multivariate logistic risk model, we also determined the degree to which operative risk and risk-adjusted operative mortality changed during this 10-year interval. RESULTS: Between 1990 and 1999, 1,154,486 patient records were harvested by the Society of Thoracic Surgeons National Adult Cardiac Database for isolated CABG procedures performed at 522 Society of Thoracic Surgeons participant sites in the United States and Canada. Over time, CABG patients were more likely to be older (mean age 63.7 in 1990, 65.1 in 1999), of female gender (25.7% women in 1990, 28.7% in 1999), and have a history of smoking, diabetes mellitus, renal failure, hypertension, stroke, chronic lung disease, New York Heart Association functional class IV, and three-vessel disease (p < 0.0001). Patients' predicted operative risk increased by 30.1%, from 2.6% in 1990 to 3.4% in 1999. Despite higher risk, observed operative mortality decreased by 23.1%, from 3.9% in 1990 to 3.0% in 1999 (p < 0.0001). During the decade, a Medicare-aged subset (n = 629,174) experienced similar increases in risk and declines in mortality. CONCLUSIONS: Patients referred for isolated CABG are significantly older, sicker, and have a higher risk than a decade ago. Despite this, CABG mortality rates have declined substantially. These results highlight the excellent progress in the care of CABG patients achieved during the past decade.
Adult↗
Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery.
OBJECTIVE: To assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) when applied in a North American cardiac surgical population. METHODS: The simple additive EuroSCORE model was applied to predict operative mortality (in-hospital or 30-day) in 401684 patients undergoing coronary or valve surgery in 1998 and 1999 as well as in 188913 patients undergoing surgery in 1995 in the Society of Thoracic Surgeons (STS) database. RESULTS: The proportion of isolated coronary artery bypass grafting (CABG) was greater in STS patients (84%) than in Europe (65%). STS patients were also older (mean age 65.3 versus 62.5), and had more diabetes (30 versus 17%) and prior cardiac surgery (11 versus 7%). Other comorbidity was also significantly more prevalent in STS patients. EuroSCORE predicted overall mortality was virtually identical to the observed mortality (1998/1999: predicted 3.994%, observed 3.992%; 1995: observed and predicted 4.156%). Predicted mortality also closely matched observed mortality across the risk groups. Discrimination was good to very good for the population overall and for isolated CABG in both time periods, with the area under the receiver operating characteristic curve between 0.75 and 0.78. CONCLUSION: Despite substantial demographic differences between Europe and North America, EuroSCORE performs very well in the STS database, and can be recommended as a simple, additive risk stratification system on both sides of the Atlantic.
Cardiac Surgical Procedures↗
Standard versus fiberoptic pulmonary artery catheterization for cardiac surgery in the Department of Veterans Affairs: a prospective, observational, multicenter analysis.
BACKGROUND: Controversy exists regarding the utility of continuous monitoring of mixed venous oxygen saturation (STvo2) during cardiac surgery. During a multicenter, prospective, observational study in the Department of Veterans Affairs (Cooperative Study #5), frequency of use of standard pulmonary artery catheterization (PAC) and STvo2-PAC was recorded. Here the authors relate these data to clinical outcomes. METHODS: Logistic and Cox regression models evaluating the association of PAC type with mortality, one or more postoperative complications, cardiac complications, time to extubation, and intensive care unit length of stay were constructed. The number of thermodilution cardiac outputs and arterial blood gas analyses performed in the first 24 h postoperatively were compared. RESULTS: Data from 3,265 patients undergoing myocardial revascularization (81.7%) or valve replacement-repair (18.3%) were considered. STvo2-PAC was used in 49% and PAC in 51% of patients. In the 14 hospitals, STvo2-PAC was used in all patients in four, in some patients in four, and never in six. No association of STvo2-PAC use with outcome were observed aside from unexplained hospital level effects. A small but statistically significant reduction in the number of arterial blood gas analyses (8 +/- 3 vs. 10 +/- 4, P < 0.0001, STvo2-PAC vs. PAC, respectively) and thermodilution cardiac outputs (14 +/- 8 vs. 15 +/- 9, P < 0.0001, STvo2-PAC vs. PAC, respectively) was observed with use of STvo2-PAC. CONCLUSIONS: Despite higher cost, STvo2-PAC was commonly used in this cohort. Our analysis failed to detect associations with improved outcomes aside from a small reduction in resource utilization. The precise role of STvo2-PAC remains uncertain.
Adult↗
Effect of definition of mortality on hospital profiles.
BACKGROUND: Hospitals are ranked based on risk-adjusted measures of postoperative mortality, but definitions differ about which deaths following surgery should be included. OBJECTIVE: To determine whether varying the case definition of deaths following surgery that are included in coronary artery bypass surgery quality assessment affects the identification of outlier hospitals. RESEARCH DESIGN: The study used a prospective cohort design. SUBJECTS: A total of 15,288 patients undergoing coronary artery bypass surgery without other cardiac procedures from October 1993 to March 1996 at all (N = 43) Veterans Affairs hospitals that conduct cardiac surgery. MEASURES: The first measure included any death occurring within 30 days after surgery, regardless of cause, in or out of the hospital (30-day mortality). The second measure included 30-day mortality plus any death occurring 30 days to 6 months after surgery that was judged to be a direct result of a perioperative complication of the surgery (all procedure-related mortality). RESULTS: Hospital performance as assessed by the two different definitions of death varied substantially. The rankings of hospitals differed for 86% (37/43) of hospitals. Twenty-one percent (9/43) changed their quartile of rank, and five hospitals changed their outlier status. The correlation of observed-to-expected ratios was high (r = 0.96), but there was disagreement of outlier status (kappa = 0.71). CONCLUSIONS: Judgments regarding the quality of a hospital's performance of coronary artery bypass surgery vary depending on the definition of postoperative mortality that is used. Further research is needed to assess what definition is most appropriate to identify quality of care problems.
Benchmarking↗
Health-related quality of life predicts mortality in older but not younger patients following cardiac surgery.
The investigators assessed preoperative health-related quality of life as a predictor of 6-month mortality after cardiac surgery in older (65 years of age and older) vs. younger patients. Multivariable regression, stratified by age groups, was used to compare the association between preoperative Physical Component Summary and Mental Component Summary scores from the Short Form-36 health status survey and mortality. In multivariable analyses of older patients, lower preoperative Physical Component Summary (odds ratio, 1.54; 95% confidence interval, 1.19-2.00; p=0.01) and Mental Component Summary (odds ratio, 1.26; 95% confidence interval, 1.06-1.49; p=0.03) scores were independently associated with mortality. In contrast, neither Physical Component Summary (p=0.82) nor Mental Component Summary (p=0.79) scores were associated with mortality in the younger subgroup. This study demonstrated that preoperative health status is an independent predictor of mortality following cardiac surgery in older but not younger patients. Preoperative patient self-report of health status may be particularly useful in refining risk stratification and informing decision-making before and following cardiac surgery in older patients.
Adult↗