Patient Experience After Cardiac Surgery: Identifying Areas for Improvement

Perioperative Optimization of the Cardiac Surgical Patient

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

Patient Satisfaction Scores After Cardiac Surgery: Should They Be Risk-Adjusted?

The Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) is a survey tool that quantifies patient satisfaction after hospitalization. We sought to interrogate our HCAHPS results in order to identify any association between preoperative health, type of operation, and postoperative outcomes, with patient satisfaction after cardiac surgery. Of 12,572 patients who underwent cardiac surgery between December 2012 and December 2019, 2587 patients (20.6%) completed the HCAHPS survey. Patient satisfaction was quantified using HCAHPS responses, focused on 'top-box' rating in nursing care, physician care, hospital environment, and overall hospital rating, as primary endpoints. Multivariable logistic regression was used to identify those variables associated with top-box scores. Elevated patient risk, as measured by the Society of Thoracic Surgeons (STS) risk score in 2112 patients, was predictive of lower rates of top-box responses in nursing care (OR 0.963, P = 0.003), physician care (OR 0.96, P = 0.002), and overall hospital rating (OR 0.97, P = 0.007). Major postoperative complications were associated with lower patient satisfaction for nursing care (OR 0.67, P = 0.038), physician care (OR 0.59, P = 0.012), and overall hospital rating (OR 0.64, P = 0.035); length of stay ≥ 6 days was associated with increased patient satisfaction for nursing care (OR 1.45, P < 0.001). Increased preoperative risk and postoperative complications are associated with lower rates of top-box patient satisfaction scores after cardiac surgery. When assessing patient satisfaction after cardiac surgery, we suggest that a preoperative risk profile be considered.

Length of Stay in Older Patients Undergoing Transcatheter Aortic Valve Replacement: Value of a Geriatric Approach

BACKGROUND

For patients with transcatheter aortic valve replacement (TAVR), increased length of stay (LOS) is associated with increased long-term mortality. The main objective of our study was to analyze the association between geriatrics factors and the hospital LOS for older patients undergoing TAVR for severe aortic stenosis.

METHODS

This retrospective single-center study included all patients aged ≥75 who underwent TAVR between January 2018 and January 2019. Hospital LOS and postoperative complications were analyzed regarding the geriatric factors recorded during a systematic preoperative, comprehensive geriatric assessment (CGA). The individualized-care plans established after the preoperative CGA were also analyzed.

RESULTS

median LOS of the 196 patients included was 6 days (interquartile range: 4-8), and 29% of patients had prolonged LOS. In a multivariable analysis, the preoperative factors associated with a prolonged hospital LOS were EuroSCORE I (p value = 0.02), prior major neurocognitive disorders (p value = 0.01), femoral access (p value <0.001), all complications (p value <0.001), and discharge in a rehabilitation center (p value <0.001). One-fourth (27%) of the patients had at least 1 geriatric complication. After CGA, 69 patients did not need any geriatric recommendation, whereas for the 127 other patients, an individualized-care plan was established but only 46 (36%) of them were followed up.

CONCLUSION

Our results favor the preoperative screening for major neurocognitive disorders in order to reduce LOS. Furthermore, the proposed individual-care plans after CGA were poorly followed. Practitioners may perceive the preoperative CGA as a screening tool, but its primary objective is to develop an individualized-care plan as a prehabilitation plan in order to optimize the physical, functional, and social issues.

Implementing a High Value Care Discharge Protocol in Patients Undergoing CABG Reduces Readmission

BACKGROUND

Readmission after coronary artery bypass grafting (CABG) is associated with adverse outcomes and increased cost. We evaluated the impact of a high value care discharge protocol on readmission, length of stay (LOS) and discharge destination in patients undergoing isolated CABG.

METHODS

In 2016, a comprehensive, patient-centered discharge protocol was implemented. A nurse practitioner was the fulcrum of this program, which focused on improving health literacy, disease management and rigorous follow-up. All patients undergoing isolated CABG between 2012-2019 were retrospectively analyzed with regard to 30-day readmission, LOS, and discharge disposition. Differences were analyzed by Mann-Whitney, chi-squared and t-tests. Analyses were repeated using propensity matching.

RESULTS

A total of 910 consecutive patients undergoing isolated CABG were included in the analyses - 353 pre-protocol and 557 post-protocol. Pre-protocol patients had a readmission rate of 14.4% (n=51), compared to 6.8% (n=38) in the post-protocol patients (p<0.001). Median postoperative LOS prior to implementation was 6 days (interquartile range 5-8) compared to 5 days (interquartile range 4-6) post-implementation (p<0.001). Post-implementation, a higher proportion of patients were discharged to home compared to a skilled nursing facility (82.7% [n=461] vs 73.9% [n=261], p=0.002). Following propensity matching, 298 well-balanced patients were included for analysis and these significant reductions in LOS, readmission and discharge destination persisted.

CONCLUSIONS

Implementation of a new discharge protocol was significantly associated with reduced readmission and LOS, along with higher rates of discharge to home in isolated CABG patients. Importantly, the results were sustainable and did not require additional resources, delivering high value care.

Association of Preoperative Geriatric Assessment With Length of Stay After Combined Cardiac Surgery

BACKGROUND

For older patients undergoing cardiac surgery, geriatric factors are known to increase postoperative complications and prolong length of stay (LOS). Comprehensive geriatric assessment (CGA) is an evidence-based method for geriatric evaluation to develop an individualized-care plan to optimize physical, functional, and social issues. This study analyzed the association between preoperative CGA and hospital LOS after combined cardiac surgery.

METHODS

This retrospective monocentric study included all patients aged 75 years and greater who underwent combined cardiac surgery between 2014 and 2017. Hospital LOS, intensive care unit LOS, and postoperative complications were compared between patients with or without preoperative CGA before and after propensity-score matching.

RESULTS

Mean age of the 407 patients was 79.6 years; 114 underwent a preoperative CGA (28%). For 305 patients (74.9%), coronary artery bypass was associated with aortic valve replacement. After propensity-score matching, a significant difference was found between the 2 groups (preoperative CGA versus none) for in-hospital LOS (12 versus 13 days; P = .04) and intensive care unit LOS (3 versus 4 days; P = .01). In multivariable analysis, a significant association remained between hospital LOS and CGA (P = .02), renal function (P = .02), mitral replacement (P = .001), and complications (P = .001).

CONCLUSIONS

Our results favor the use of systematic preoperative CGA. These encouraging results need to be validated by prospective studies that assess the impact of individualized-care plan established after CGA on postoperative outcomes. With an aging population, efforts are required to determine how to implement preoperative individualized-care plans to improve postoperative outcomes for vulnerable patients undergoing cardiac surgery.

Does Care Transition Matter? Exploring the Newly Published HCAHPS Measure

In recent years, health care systems have undergone a consumer revolution—putting patients at the center. The study aim was to explore the association between care transition—the new measure proposed by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)—and hospital patients’ overall rating based on their experience, along with hospitals’ internal characteristics and operational attributes. Using HCAHPS and American Hospital Association published databases, the authors examined the association between hospital characteristics and measures of patient experience, focusing on the care transition measure, in 2350 US hospitals. Positive significant association was found between care transition and overall rating ( P < .0001). An interaction regression model revealed that each of the following moderators—teaching affiliation, location, and membership in a health system—significantly (all P < .05) strengthens the association between care transition and overall rating in a positive direction. These findings may help improve hospital rating, value-based payments, and patient-centered outcomes.