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Schwann TA, Engoren M, Gaudino MF, Mentz G, Saadat S, Engelman D, Lobdell KW, Vekstein AM, Habib RH. Practice makes perfect? Institutional coronary artery bypass case volumes and outcomes. Eur J Cardiothorac Surg 2023; 64:ezad324. [PMID: 37812216 DOI: 10.1093/ejcts/ezad324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 08/14/2023] [Accepted: 10/06/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVES Older studies of coronary artery bypass grafting (CABG) institutional case volumes and outcomes reported conflicting results. We explored this association in the rapidly changing contemporary practice of American surgeons using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. METHODS The 2018-2019 isolated primary CABG experience in the STS Adult Cardiac Surgery Database was analysed (241 902 patients; 1014 hospitals; 2718 surgeons). Generalized Estimating Equations were used to estimate coefficients between CABG institutional case volumes and outcomes. The observed-to-expected ratios based on STS risk models were used to assess risk-adjusted operative mortality (OM), mortality/major morbidity (MM) and deep sternal wound infections (DSWI) as a function of institutional case volumes. RESULTS The mean (standard deviation) OM, MM and DSWI rates were 2.1% (2.7), 11.1% (9.2) and 0.6% (0.5), respectively. The mean (standard deviation) institutional case volumes per study period was 239 (192); 23% and 9% of institutions performed <100 and >500 cases/study period, respectively. There was a weak negative correlation between expected mortality (R2 -0.0014), OM (R2 -0.0272), MM (R2 -0.1213) and DSWI (R2 -0.003) and institutional case volumes. CONCLUSIONS CABG outcomes generally improve with increasing institutional case volumes. Given the large number of CABG cases performed nationally, even the documented weak correlation has the potential to appreciably decrease OM, MM and DSWI if cases are performed at higher volume institutions. Studies focusing on additional hospital and surgeon factors are warranted to further define quality improvement opportunities.
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Affiliation(s)
| | | | | | | | - Siavash Saadat
- University of Massachusetts-Baystate, Springfield, MA, USA
| | | | | | - Andrew M Vekstein
- Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Thourani VH, Brennan JM, Edelman JJ, Thibault D, Jawitz OK, Bavaria JE, Higgins RSD, Sabik JF, Prager RL, Dearani JA, MacGillivray TE, Badhwar V, Svensson LG, Reardon MJ, Shahian DM, Jacobs JP, Ailawadi G, Szeto WY, Desai N, Roselli EE, Woo YJ, Vemulapalli S, Carroll JD, Yadav P, Malaisrie SC, Russo M, Nguyen TC, Kaneko T, Tang G, Ruel M, Chikwe J, Lee R, Habib RH, George I, Leon MB, Mack MJ. Association of Volume and Outcomes in 234,556 Patients Undergoing Surgical Aortic Valve Replacement. Ann Thorac Surg 2021; 114:1299-1306. [PMID: 34785247 DOI: 10.1016/j.athoracsur.2021.06.095] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/26/2021] [Accepted: 06/30/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The relationship between institutional volume and operative mortality following SAVR remains unclear. METHODS From 1/2013 to 6/2018, 234,556 patients underwent isolated SAVR (n=144,177) or SAVR+CABG (n=90,379) within the STS ACSD. The association between annualized SAVR volume [Group 1 (1-25 SAVR), Group 2 (26-50 SAVR), Group 3 (51-100 SAVR), and Group 4 (>100 SAVR)] and operative mortality and composite major morbidity/mortality was assessed. Random effects models were used to evaluate whether historic (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes. RESULTS The annualized median number of SAVRs per site was 35 [IQR: 22-59, isolated AVR: 20, AVR+CABG: 13]. Among isolated SAVR cases, the mean operative mortality and composite morbidity/mortality were 1.5% and 9.7%, respectively, at the highest volume sites (Group 4); with significantly higher rates among progressively lower volume groups (p-trend<0.001). After adjustment, lower volume centers experienced increased odds of operative mortality [Group 1 vs. 4 (Ref): AOR (SAVR), 2.24 (1.91-2.64); AOR (SAVR+CABG), 1.96 (1.67-2.30)] and major morbidity/mortality [AOR (SAVR), 1.53 (1.39-1.69); AOR (SAVR+CABG), 1.46 (1.32-1.61)] compared to the highest volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category and prior outcomes explained a greater proportion of hospital operative outcomes than prior volume. CONCLUSIONS Operative outcomes following SAVR±CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive than prior volume of future outcomes. Given excellent outcomes observed at many lower volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.
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Affiliation(s)
- Vinod H Thourani
- Department of Cardiovascular Surgery and Cardiology, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA.
| | | | - J James Edelman
- Department of Cardiac Surgery, Fiona Stanley Hospital, Perth, Australia
| | | | | | - Joseph E Bavaria
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Robert S D Higgins
- Division of Cardiothoracic Surgery, Johns Hopkins University, Baltimore, MD
| | - Joseph F Sabik
- Division of Cardiac Surgery, Case Western University, Cleveland, OH
| | | | | | | | - Vinay Badhwar
- Division of Cardiothoracic Surgery, West Virginia University, Morgantown, WV
| | - Lars G Svensson
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | | | - David M Shahian
- Division of Surgery, Massachusetts General Hospital, Harvard University, Boston, MA
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, MI
| | - Wilson Y Szeto
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Nimesh Desai
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Eric E Roselli
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Y Joseph Woo
- Department of Cardiac Surgery, Stanford University, Palo Alto, CA
| | | | - John D Carroll
- Division of Cardiology, University of Colorado, Aurora, CO
| | - Pradeep Yadav
- Department of Cardiovascular Surgery and Cardiology, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA
| | | | - Mark Russo
- Division of Cardiac Surgery, RWJ Barnabas Health, New Brunswick, NJ
| | - Tom C Nguyen
- Division of Cardiac Surgery, University of California San Francisco, CA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA
| | - Gilbert Tang
- Department of Cardiac Surgery, Mt Sinai Medical Center, New York, NY
| | - Marc Ruel
- Department of Cardiac Surgery, Ottawa Heart Institute, Canada
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars Sinai Heart Institute, Los Angeles, CA
| | - Richard Lee
- Department of Cardiac Surgery, Augusta University, Augusta, GA
| | | | - Isaac George
- Division of Cardiac Surgery, Columbia University, New York, NY
| | - Martin B Leon
- Division of Cardiology, Columbia University, New York, NY
| | - Michael J Mack
- Department of Cardiac Surgery, Baylor, Scott and White, Plano, Dallas, TX
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Schwann TA, Habib RH, Wallace A, Shahian D, Gaudino M, Kurlansky P, Engoren MC, Tranbaugh RF, Schwann AN, Jacobs JP. Bilateral internal thoracic artery versus radial artery multi-arterial bypass grafting: a report from the STS database†. Eur J Cardiothorac Surg 2019; 56:926-934. [DOI: 10.1093/ejcts/ezz106] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 02/27/2019] [Accepted: 03/06/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Multi-arterial bypass grafting with bilateral internal thoracic (BITA-MABG) or radial (RA-MABG) arteries improves long-term survival, but its increased complexity raises perioperative safety concerns. We compared perioperative outcomes of RA-MABG and BITA-MABG using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD).
METHODS
We analysed the 2004–2015 BITA-MABG and RA-MABG experience in STS-ACSD. Primary end points were operative mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios [AOR (95% confidence interval)] were derived via multivariable logistic regression. Sensitivity analyses were done in patient sub-cohorts and based on institutional BITA-utilization rates (<5%, 5–10%, 10–20%, 20–40% and >40%).
RESULTS
Eighty-five thousand nine hundred five RA-MABG (82.5% men; 61 years) and 61 336 BITA-MABG (85.1% men; 59 years) patients were analysed; 41.6% of BITA-MABG and 27.3% of RA-MABG cases came from institutions with low MABG utilization rates (<10%). Unadjusted OM was equivalent for both techniques (BITA-MABG versus RA-MABG: 1.3% vs 1.2%, P = 0.79), while DSWI was lower for RA-MABG (1.0% vs 0.6%, P < 0.001). RA-MABG was associated with lower adjusted OM [AOR = 0.80 (0.69–0.96)] and DSWI [AOR = 0.39 (0.32–0.46)]. Sensitivity analyses confirmed robustness of these findings. Equivalent outcomes were observed at high BITA-use institutions where BITA cases comprised >20% of all cases for OM and ≥40% for DSWI.
CONCLUSIONS
This analysis of the STS-ACSD showed that RA-MABG is a generally safer form of multi-arterial coronary artery bypass grafting surgery. However, this advantage is mitigated at institutions with substantial BITA experience.
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Affiliation(s)
- Thomas A Schwann
- Department of Surgery, University of Massachusetts-Baystate, Springfield, MA, USA
- Department of Surgery, University of Toledo, Toledo, OH, USA
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, IL, USA
| | - Amelia Wallace
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - David Shahian
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Mario Gaudino
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Paul Kurlansky
- Department of Surgery, Columbia University, New York, NY, USA
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Jeffrey P Jacobs
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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