Evaluation of quality in adult cardiac surgery: let us speak the same language

Comparing Outcomes in Patients Undergoing Coronary Artery Bypass Grafting With and Without Using the Internal Mammary Artery in a Tertiary Care Hospital

Purpose

The left internal mammary artery in coronary artery bypass grafting (CABG) is considered to be an important intraoperative quality indicator with excellent long-term results. The purpose of this study is to compare the early outcomes of CABG with and without the left internal mammary artery (LIMA) in the South Asian population and to look for the utilization of LIMA as per the recommendations of the Society of Thoracic Surgeons in a developing country.

Materials and methods

A retrospective review was carried out for all patients who underwent CABG from 2010 to 2015. Patients were divided into two groups on the basis of whether LIMA was used (Group I) or not used (Group II) as a conduit. Both groups were further subdivided into elective and urgent. Preoperative, intraoperative, and postoperative variables were recorded and compared.

Results

After exclusion, a total of 2619 patients underwent isolated CABG surgery during the required duration. The LIMA was used in 94% of the patients (n=2472) while 147 patients underwent CABG without LIMA. The use of LIMA was associated with significantly lower mortality (2% LIMA vs 8.8% no LIMA), as well as a decrease in major comorbidity, stroke, and prolonged ventilation. In the subgroup analysis, LIMA usage in elective and urgent cases was associated with significantly lower mortality (elective 1.6% LIMA vs 7.4% No LIMA) (urgent 4.8% LIMA vs 15.7 % no LIMA)) and major morbidity.

Conclusion

The outcomes of CABG procedures without LIMA were not encouraging. Our results support compliance with standard adult cardiac surgery quality-of-care guidelines.

Measuring the quality of perioperative care in cardiac surgery

Quality of care is of increasing importance in health and surgical care. In order to maintain and improve quality, we must be able to measure it and identify variation. In this narrative review, we aim to identify measures used in the assessment of quality of care in cardiac surgery and to evaluate their utility. The electronic databases Pubmed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and CINAHL were searched for original published studies using the terms 'cardiac surgery' and 'quality or outcome or process or structure' as either keywords in the title or text or MeSH terms. Secondary searches and identification of references from original articles were carried out. We found a total of 54 original articles evaluating measurements of quality. While structure, process, and outcome indicators remain the mainstay of quality measurement, new and innovative methods of risk assessment have improved reliability and discrimination. Continuous assessment provides a promising method of both maintaining and improving quality of care. Future studies should focus on long-term and patient-centred outcomes, such as quality-of-life measures.

Cardiac operative risk evaluation: The EuroSCORE II, does it make a real difference?

BACKGROUND

The EuroSCORE, worldwide used as a model for prediction of mortality after cardiac surgery, has recently been renewed. Since October 2011, the EuroSCORE II calculator is available at the EuroSCORE website and recommended for clinical use. The intention of this paper is to compare the use of the initial EuroSCORE and EuroSCORE II as a risk evaluation tool.

METHODS

100 consecutive patients who underwent combined mitral valve and coronary bypass surgery (MVR + CABG) and 100 consecutive patients undergoing combined aortic valve surgery and coronary bypass surgery (AVR + CABG) at the Radboud University Nijmegen Medical Center before 10 October 2011 were included. For both groups the initial EuroSCORE and the EuroSCORE II model were used for risk calculation and based on the calculated risks, cumulative sum charts (CUSUM) were constructed to evaluate the impact on performance monitoring.

RESULTS

For the MVR + CABG group the calculated risk using the initial logistic EuroSCORE was 9.95 ± 8.47 (1.51-45.37) versus 5.08 ± 4.03 (0.67-19.76) for the EuroSCORE II. For the AVR + CABG group 9.50 ± 8.6 (1.51-69.5) versus 4.77 ± 6.6 (0.96-64.24), respectively. For both groups the calculated risk by the EuroSCORE II was statistically lower compared with the initial EuroSCORE (p < 0.001). This lower expected risk has influence on performance monitoring, using risk-adjusted CUSUM analysis.

CONCLUSION

The EuroSCORE II, based on a recently updated database, reduces the overestimation of the calculated risk by the initial EuroSCORE. This difference is statistically significant and the EuroSCORE II may also reflect better current surgical performance.

Evaluation of quality in adult cardiac surgery: let us speak the same language

Over the last years, measurements of quality of care have become more and more a public product, used by providers, purchasers and consumers, and patients. This information serves as an important guide for improvement, as well as a decision support tool for everybody taking part in medical treatment. This evolution can be compared with advertising and as in commercials it is important to use the right information. In this report we focus on the quality of adult cardiac surgery. Honest information is of course essential, but in this article attention is asked for the variables used to evaluate the quality of cardiac surgery. (Neth Heart J 2010;18:365-9.).