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Brescia AA, Groskurth JD, Murphy ET, Hawkins RB, Theurer P, Clark M, He C, Bolling SF, Pruitt AL, Prager RL, Pagani FD, Ailawadi G. Increasing Adoption of Left Atrial Appendage Occlusion in Isolated Coronary Artery Bypass Grafting. Ann Thorac Surg 2024; 118:854-862. [PMID: 38823757 DOI: 10.1016/j.athoracsur.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 05/04/2024] [Accepted: 05/13/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Recent randomized trial data showed fewer strokes with left atrial appendage occlusion (LAAO) after cardiac surgery in patients with atrial fibrillation. This study developed a quality initiative to increase LAAO adoption. METHODS Among 11,099 patients who underwent isolated coronary artery bypass grafting (CABG) between January 2019 and March 2021 at 33 hospitals in Michigan, those patients with atrial fibrillation who underwent first-time, on-pump CABG were eligible (n = 1241). A goal LAAO rate of 75% was selected as a quality improvement target through a statewide collaborative. An interrupted time series analysis evaluated the change in LAAO rate before implementation (January to December 2019) vs after implementation (January 2020 to March 2021). RESULTS Implementation of the quality metric improved the LAAO rate from 61% (357 of 581) before implementation to 79% (520 of 660) after implementation (P < .001). Compared with patients who did not undergo concomitant LAAO, patients who underwent LAAO (71%; 877 of 1241) were older, more frequently male, and had a lower The Society of Thoracic Surgeons Predicted Risk of Mortality score (2.9% ± 3.5% vs 3.7% ± 5.7%; P = .003), whereas other baseline characteristics, including CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex category) scores, were similar. Mean bypass and cross-clamp times were 7 and 6 minutes longer, respectively, in the LAAO group among patients who did not undergo concomitant ablation. Operative mortality, major morbidity, blood product administration, and thromboembolic events were similar between the groups. Interrupted time series analysis showed a significant increase in LAAO rate after implementation (P = .009). CONCLUSIONS LAAO in patients with atrial fibrillation who underwent isolated CABG did not add operative risk vs isolated CABG without LAAO. A statewide quality improvement initiative was successful in increasing the rate of concomitant LAAO and could be further evaluated as a potential quality metric in cardiac surgery.
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Affiliation(s)
| | | | | | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Patricia Theurer
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI
| | - Melissa Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew L Pruitt
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI; St. Joseph Mercy Hospital, Ann Arbor, MI
| | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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2
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Kalata S, Reddy RM, Norton EC, Clark MJ, He C, Leyden T, Adams KN, Popoff AM, Lall SC, Lagisetty KH. Quality improvement mechanisms to improve lymph node staging for lung cancer: Trends from a statewide database. J Thorac Cardiovasc Surg 2024; 167:1469-1478.e3. [PMID: 37625618 DOI: 10.1016/j.jtcvs.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/25/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Our statewide thoracic quality collaborative has implemented multiple quality improvement initiatives to improve lung cancer nodal staging. We subsequently implemented a value-based reimbursement initiative to further incentivize quality improvement. We compare the impact of these programs to steer future quality improvement initiatives. METHODS Since 2016, our collaborative focused on improving lymph node staging for lung cancer by leveraging unblinded, hospital-level metrics and collaborative feedback. In 2021, a value-based reimbursement initiative was implemented with statewide yearly benchmark rates for (1) preoperative mediastinal staging for ≥T2N0 lung cancer, and (2) sampling ≥5 lymph node stations. Participating surgeons would receive additional reimbursement if either benchmark was met. We reviewed patients from January 2015 to March 2023 at the 21 participating hospitals to determine the differential effects on quality improvement. RESULTS We analyzed 6228 patients. In 2015, 212 (39%) patients had ≥5 nodal stations sampled, and 99 (51%) patients had appropriate preoperative mediastinal staging. During 2016 to 2020, this increased to 2253 (62%) patients and 739 (56%) patients, respectively. After 2020, 1602 (77%) patients had ≥5 nodal stations sampled, and 403 (73%) patients had appropriate preoperative mediastinal staging. Interrupted time-series analysis demonstrated significant increases in adequate nodal sampling and mediastinal staging before value-based reimbursement. Afterward, preoperative mediastinal staging rates briefly dropped but significantly increased while nodal sampling did not change. CONCLUSIONS Collaborative quality improvement made significant progress before value-based reimbursement, which reinforces the effectiveness of leveraging unblinded data to a collaborative group of thoracic surgeons. Value-based reimbursement may still play a role within a quality collaborative to maintain infrastructure and incentivize participation.
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Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | | | - Edward C Norton
- Departments of Health Management and Policy and Economics, University of Michigan, Ann Arbor, Mich
| | - Melissa J Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
| | | | - Kumari N Adams
- Department of Thoracic Surgery, St. Joseph Mercy Hospital, Ann Arbor, Mich
| | - Andrew M Popoff
- Department of Thoracic Surgery, Henry Ford Hospital, Detroit, Mich
| | - Shelly C Lall
- Department of Thoracic Surgery, Munson Medical Center, Traverse City, Mich
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Stewart JW, Nieter D, Wu X, DeLucia A, Graebner BN, Paone G, Fitzgerald DC, Dickinson TA, Zhang M, Pagani FD, Likosky DS. Advancing cardiotomy suction practices for coronary surgery via multidisciplinary collaborative learning. JTCVS OPEN 2024; 17:121-144. [PMID: 38420528 PMCID: PMC10897666 DOI: 10.1016/j.xjon.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 03/02/2024]
Abstract
Objective Professional standards recommend stopping cardiotomy suction at the termination of cardiopulmonary bypass before protamine administration based on perceived safety concerns. This study evaluated a multidisciplinary collaborative quality-improvement intervention promoting this agreed-upon cardiotomy suction practice during coronary artery bypass grafting (CABG). Methods A statewide intervention (eg, unblinded surgeon and perfusionist feedback, evidence-based lectures, evaluating barriers to change) involved 32 centers participating in the PERForm (ie, Perfusion Measures and Outcomes) Registry to standardize cardiotomy suction practices at cardiopulmonary bypass termination during CABG. Four non-Michigan registry participating centers were not exposed to collaborative learning. Cardiotomy suction practice was defined as the absence of or stopping cardiotomy suction before protamine administration. The practice changes attributed to the intervention, including Michigan and non-Michigan comparisons, were evaluated with the change of time effect modeled using splines. Multivariable regression was used to evaluate the intervention's associated impact (eg, mortality, reoperation, transfusion). Results Among 10,394 patients undergoing CABG at Michigan centers, 80.7% achieved agreed-upon cardiotomy suction practices. The Michigan centers had nonsignificant changes in agreed-upon cardiotomy suction practices during the preintervention period (P = .24), with significant increased monthly change in practice thereafter, absent adjusted morbidity and mortality increases. The Michigan centers achieved a significantly greater adjusted monthly improvement in agreed-upon practices relative to non-Michigan centers within 7 months after the intervention (adjusted odds ratio for change of trends: 2.53, P < .001). Conclusions This initiative demonstrates the effectiveness of multidisciplinary collaborative quality improvement in advancing agreed-upon cardiotomy suction practices without negatively impacting clinical outcomes.
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Affiliation(s)
- James W Stewart
- Department of Surgery, Yale School of Medicine, New Haven, Conn
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Donald Nieter
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Mich
| | - Alphonse DeLucia
- Department of Cardiac Surgery, Bronson Methodist Hospital, Kalamazoo, Mich
| | | | - Gaetano Paone
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - David C Fitzgerald
- Cardiovascular Perfusion Program, College of Health Professions, Medical University of South Carolina, Charleston, SC
| | | | - Min Zhang
- Department of Biostatistics, University of Michigan, Ann Arbor, Mich
| | - Francis D Pagani
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Mich
| | - Donald S Likosky
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Mich
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Zhou S, Yang G, Hou H, Zhang M, Grady KL, Chenoweth CE, Aaronson KD, Pienta M, Fetters MD, Paul Chandanabhumma P, Stewart JW, Cabrera L, Malani PN, Pagani FD, Likosky DS. Infections following left ventricular assist device implantation and 1-year health-related quality of life. J Heart Lung Transplant 2023; 42:1307-1315. [PMID: 37187319 PMCID: PMC10527882 DOI: 10.1016/j.healun.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Left ventricular assist device (LVAD) implantation leads to substantial and sustained improvement in health-related quality of life (HRQOL) among patients. Infection following device implantation remains an important and frequent complication and adversely affects patient-reported HRQOL. METHODS Patients in The Society of Thoracic Surgeons' Interagency Registry for Mechanically Assisted Circulatory Support receiving a primary LVAD between April 2012 to October 2016 were included. The primary exposure was one-year post-implant infection, characterized by: (1) any infection; (2) total number of infections and (3) type (LVAD-specific, LVAD-related, non-LVAD). The association between infection and the primary composite adverse outcome (defined as EuroQoL Visual Analog Scale< 65, too sick to complete the survey, or death at 1-year) was estimated using inverse probability weighting and Cox regression. RESULTS The study cohort included 11,618 patients from 161 medical centers with 4,768 (41.0%) patients developing an infection, and 2,282 (19.6%) patients having> 1 infection during the follow up period. The adjusted odds ratio for the primary composite adverse outcome was 1.22 (95% CI, 1.19-1.24, p < 0.001) for each additional infection. Each additional infection was associated with a 3.49% greater probability of the primary composite outcome and was associated with worse performance across multiple dimensions of HRQOL as assessed by the EQ-5D for patients who survived to 1 year. CONCLUSIONS For patients undergoing LVAD implantation, each additional infection within the first post-implantation year was associated with an incremental negative effect on survival free of impaired HRQOL.
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Affiliation(s)
- Shiwei Zhou
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, Ann Arbor, MI.
| | - Guangyu Yang
- Institute of Statistics and Big Data, Renmin University of China, People's Republic of China
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Kathleen L Grady
- Division of Cardiac Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Carol E Chenoweth
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, Ann Arbor, MI
| | - Keith D Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, MI
| | - Michael Pienta
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI
| | | | | | - James W Stewart
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT
| | - Lourdes Cabrera
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI
| | - Preeti N Malani
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, Ann Arbor, MI
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Tam DY, Fremes SE. Commentary: Who benefits from public reporting of outcomes in coronary surgery? J Thorac Cardiovasc Surg 2023; 166:816-818. [PMID: 35221027 DOI: 10.1016/j.jtcvs.2022.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Derrick Y Tam
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Do-Nguyen CC, Sturmer DL, Yang G, Hawkins RB, Engoren M, Wolverton J, Heung M, Zhang M, Likosky DS. Oxygen Delivery Thresholds During Cardiopulmonary Bypass and Risk for Acute Kidney Injury. Ann Thorac Surg 2023; 116:607-613. [PMID: 37271444 DOI: 10.1016/j.athoracsur.2023.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) in cardiac surgery patients is multifactorial and associated with low oxygen delivery (DO2) during cardiopulmonary bypass. METHODS Cardiac surgical patients undergoing full cardiopulmonary bypass between May 1, 2016 and December 31, 2021 were included, whereas those on preoperative dialysis, undergoing circulatory arrest procedures, or lacking minute-to-minute physiologic data were excluded. A 5-minute running average of indexed DO2 (DO2i, mL/min/m2) was calculated ([pump flow] × [hemoglobin] × 1.36 [hemoglobin saturation] + 0.003 [arterial oxygen tension]/body surface area). AKI was defined using established Kidney Disease: Improving Global Outcomes criteria. The threshold of nadir DO2i on the effect of AKI was estimated using risk-adjusted Constrained Broken-Stick models. RESULTS Postoperative AKI occurred among 1155 patients (29.4%), with 276 (7.0%) having stage 2 to 3 AKI. The median nadir DO2i was lower for those with (vs without) AKI (197.9 mL/min/m2 [interquartile range {IQR}, 166.3-233.2] vs 217.2 mL/min/m2 [IQR, 184.5-252.2], P < .001) and stage 2 to 3 AKI relative to stage 1 or none (186.9 mL/min/m2 [IQR, 160.1-220.5] vs 213.8 mL/min/m2 [IQR, 180.4-249.4]). In risk-adjusted analyses the estimated threshold for nadir DO2i was 231.2 mL/min/m2 (95% CI, 173.6-288.8) for any AKI and 103.3 (95% CI, 68.4-138.3) for stage 2 to 3 AKI. CONCLUSIONS Decreasing nadir DO2i was associated with an increased risk of AKI. The identified nadir DO2i thresholds suggest management and treatment of nadir DO2i during cardiopulmonary bypass may decrease a patient's postoperative AKI risk.
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Affiliation(s)
- Chi Chi Do-Nguyen
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - David L Sturmer
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Guangyu Yang
- Institute of Statistics and Big Data, Renmin University of China, Beijing, China
| | - Robert B Hawkins
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Milo Engoren
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jeremy Wolverton
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michael Heung
- Division of Nephrology, Department of Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Min Zhang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
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7
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Zhou S, Yang G, Zhang M, Pienta M, Chenoweth CE, Pagani FD, Aaronson KD, Fetters MD, Chandanabhumma PP, Cabrera L, Hou H, Malani PN, Likosky DS. Mortality following durable left ventricular assist device implantation by timing and type of first infection. J Thorac Cardiovasc Surg 2023; 166:570-579.e4. [PMID: 34895722 PMCID: PMC9094062 DOI: 10.1016/j.jtcvs.2021.10.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/24/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Although infections are common after left ventricular assist device implantation, the relationship between timing and type of first infection with regard to mortality is less well understood. METHODS The Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support patients receiving a primary left ventricular assist device from April 2012 to May 2017 were included. The primary exposure was defined 3 ways: any infection, timing of first infection (early: ≤90 days; intermediate: 91-180 days; late: >180 days), and type (ventricular assist device specific, ventricular assist device related, non-ventricular assist device). The association between first infection and all-cause mortality was estimated using Cox regression. RESULTS The cohort included 12,957 patients at 166 centers (destination therapy: 47.4%, bridge-to-transplant: 41.2%). First infections were most often non-ventricular assist device (54.2%). Rates of first infection were highest in the early interval (10.7/100 person-months). Patients with any infection had a significantly higher adjusted hazard of death (hazard ratio, 2.63; 2.46-2.86). First infection in the intermediate interval was associated with the largest increase in adjusted hazard of death (hazard ratio, 3.26; 2.82-3.78), followed by late (hazard ratio, 3.13; 2.77-3.53) and early intervals (hazard ratio, 2.37; 2.16-2.60). Ventricular assist device-related infections were associated with the largest increase in hazard of death (hazard ratio, 3.02; 2.69-3.40), followed by ventricular assist device specific (hazard ratio, 2.92; 2.57-3.32) and non-ventricular assist device (hazard ratio, 2.42; 2.20-2.65). CONCLUSIONS Relative to those without infection, patients with any postimplantation infection had an increased risk of death. Ventricular assist device-related infections and infections occurring in the intermediate interval were associated with the largest increase in risk of death. After left ventricular assist device implantation, infection prevention strategies should target non-ventricular assist device infections in the first 90 days, then shift to surveillance/prevention of driveline infections after 90 days.
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Affiliation(s)
- Shiwei Zhou
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich.
| | - Guangyu Yang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Mich
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Mich
| | - Michael Pienta
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | | | | | - Lourdes Cabrera
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Preeti N Malani
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
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Topcu AC, Magouliotis DE, Milojevic M, Bond CJ, Clark MJ, Theurer PF, Pagani FD, Pruitt AL, Prager RL. Lessons learned from the EACTS-MSTCVS quality fellowship: a call to action for continuous improvement of cardiothoracic surgery outcomes in Europe. Eur J Cardiothorac Surg 2023; 64:ezad293. [PMID: 37653577 DOI: 10.1093/ejcts/ezad293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023] Open
Abstract
The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS), a pioneer in initiating and nurturing quality improvement strategies in statewide cardiothoracic surgery, has been running the Quality Collaborative (MSTCVS-QC) program since 2001. This initiative has significantly grown over the years, facilitating at least 4 in-person meetings annually. It actively engages cardiac and general thoracic surgeons, data managers and researchers from all 32 non-federally funded cardiothoracic surgery sites across Michigan. Broadening its influence on joint learning and clinical outcomes, the MSTCVS-QC formed a strategic partnership with Blue Cross Blue Shield of Michigan, the state's largest private insurer, to further promote its initiatives. The MSTCVS-QC, operating from a dedicated QC centre employs an STS-associated database with additional aspects for data collection and analysis. The QC centre also organizes audits, facilitates collaborative meetings, disseminates surgical outcomes and champions the development and implementation of quality improvement initiatives related to cardiothoracic surgery in Michigan. Recognizing the MSTCVS-QC's successful efforts in advancing quality improvement, the European Association for Cardiothoracic Surgery (EACTS) introduced a fellowship program in 2018, facilitated through the EACTS Francis Fontan Fund (FFF). This program allows early-career academic physicians to spend 4-6 months with the MSTCVS-QC team in Ann Arbor. This article chronicles the evolution and functionality of the MSTCVS-QC, enriched by the experiences of the inaugural 4 EACTS/FFF fellows. Our objective is to emphasize the critical importance of fostering a culture of quality improvement and patient safety in the field of cardiothoracic surgery with open discussion of audited, high-quality data points. This principle, while implemented locally, has implications and value extending far beyond Europe, resonating globally.
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Affiliation(s)
- Ahmet Can Topcu
- Department of Cardiovascular Surgery, Kosuyolu Education and Research Hospital, Istanbul, Turkey
| | | | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Chris J Bond
- Department of Cardiac Surgery, Queen Elizabeth University Hospital, Birmingham, UK
| | - Melissa J Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Patricia F Theurer
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
| | - Francis D Pagani
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Andrew L Pruitt
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
- Department of Cardiothoracic Surgery, Saint Joseph Mercy Ann Arbor, Ann Arbor, MI, USA
| | - Richard L Prager
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI, USA
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
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Lussiez A, Eton R, Anderson M, Valbuena V, Campbell D, Englesbe M, Howard R. Heterogeneity in Surgical Quality Improvement in Michigan. Ann Surg 2023; 277:612-618. [PMID: 35129495 DOI: 10.1097/sla.0000000000005282] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate changes in 30-day postoperative outcomes and individual hospital variation in outcomes from 2012 to 2019 in a collaborative quality improvement network. SUMMARY BACKGROUND DATA Collaborative quality improvement efforts have been shown to improve postoperative outcomes overall; however, heterogeneity in improvement between participating hospitals remains unclear. Understanding the distribution of individual hospital-level changes is necessary to inform resource allocation and policy design. METHODS We performed a retrospective cohort study of 51 hospitals in the Michigan Surgical Quality Collaborative (MSQC) from 2012 to 2019. Risk-and reliability-adjusted hospital rates of 30-day mortality, complications, serious complications, emergency department (ED) visits, readmissions, and reoperations were calculated for each year and compared between the last 2 years and the first 2 years of the study period. RESULTS There was a significant decrease in the rates of all 5 adverse outcomes across MSQC hospitals from 2012 to 2019. Of the 51 individual hospitals, 31 (61%) hospitals achieved a decrease in mortality (range -1.3 percentage points to +0.6 percentage points), 40 (78%) achieved a decrease in complications (range -8.5 percentage points to +2.9 percentage points), 26 (51%) achieved a decrease in serious complications (range -3.2 percentage points to +3.0 percentage points), 29 (57%) achieved a decrease in ED visits (range 5.0 percentage points to +2.2 percentage points), 46 (90%) achieved a decrease in readmissions (range -3.1 percentage points to +0.4 percentage points) and 39 (76%) achieved a decrease in reoperations (range 3.3 percentage points to +1.0 percentage points). CONCLUSIONS Despite overall improvement in surgical outcomes across hospitals participating in a quality improvement collaborative, there was substantial variation in improvement between hospitals, highlighting opportunities to better understand hospital-level barriers and facilitators to surgical quality improvement.
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Affiliation(s)
- Alisha Lussiez
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Ryan Eton
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Maia Anderson
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Valeria Valbuena
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI
| | - Darrell Campbell
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Michael Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Michigan Surgical Quality Collaborative, Ann Arbor, MI
| | - Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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10
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Brescia AA, Ailawadi G. Commentary: The reality of The Society of Thoracic Surgeons risk calculators at high volume centers. J Thorac Cardiovasc Surg 2023; 165:607-608. [PMID: 33838913 DOI: 10.1016/j.jtcvs.2021.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 01/18/2023]
Affiliation(s)
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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Likosky DS, Strobel RJ, Wu X, Kramer RS, Hamman BL, Brevig JK, Thompson MP, Ghaferi AA, Zhang M, Lehr EJ. Interhospital failure to rescue after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2023; 165:134-143.e3. [PMID: 33712236 PMCID: PMC8679510 DOI: 10.1016/j.jtcvs.2021.01.064] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 01/06/2021] [Accepted: 01/12/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We evaluated whether interhospital variation in mortality rates for coronary artery bypass grafting was driven by complications and failure to rescue. METHODS An observational study was conducted among 83,747 patients undergoing isolated coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals. Failure to rescue was defined as operative mortality among patients developing complications. Complications included the Society of Thoracic Surgeons 5 major complications (stroke, surgical reexploration, deep sternal wound infection, renal failure, prolonged intubation) and a broader set of 19 overall complications. After creating terciles of hospital performance (based on observed:expected mortality), each tercile was compared on the basis of crude rates of (1) major and overall complications, (2) operative mortality, and (3) failure to rescue (among major and overall complications). The correlation between hospital observed and expected (to address confounding) failure to rescue rates was assessed. RESULTS Median Society of Thoracic Surgeons predicted mortality risk was similar across hospital observed:expected mortality terciles (P = .831). Mortality rates significantly increased across terciles (low tercile: 1.4%, high tercile: 2.8%). Although small in magnitude, rates of major (low tercile: 11.1%, high tercile: 12.2%) and overall (low tercile: 36.6%, high tercile: 35.3%) complications significantly differed across terciles. Nonetheless, failure to rescue rates increased substantially across terciles among patients with major (low tercile: 9.1%, high tercile: 14.3%) and overall (low tercile: 3.3%, high tercile: 6.8%) complications. Hospital observed and expected failure to rescue rates were positively correlated among patients with major (R2 = 0.14) and overall (R2 = 0.51) complications. CONCLUSIONS The reported interhospital variability in successful rescue after coronary artery bypass grafting supports the importance of identifying best practices at high-performing hospitals, including early recognition and management of complications.
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Affiliation(s)
- Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
| | | | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Robert S Kramer
- Division of Cardiothoracic Surgery, Maine Medical Center, Portland, Me
| | - Baron L Hamman
- Cardiovascular & Thoracic Surgery, Texas Health Resources, Arlington, Tex
| | - James K Brevig
- Providence St Joseph Heart Institute, Renton, Wash; Providence Regional Medical Center, Everett, Wash
| | | | - Amir A Ghaferi
- Department of General Surgery, University of Michigan, Ann Arbor, Mich
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Mich
| | - Eric J Lehr
- Department of Cardiac Surgery, Swedish Heart & Vascular Institute, Swedish Medical Center, Seattle, Wash
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12
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Alabbadi S, Rowe G, Gill G, Vouyouka A, Chikwe J, Egorova N. Sex Disparities in Failure to Rescue After Cardiac Surgery in California and New York. Circ Cardiovasc Qual Outcomes 2022; 15:e009050. [PMID: 36458533 DOI: 10.1161/circoutcomes.122.009050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Women have a higher risk of mortality than men after cardiac surgery independent of other risk factors. The reason for this may not be limited to patient-specific variables. Failure to rescue (FTR) patients from death after a postoperative complication is a nationally endorsed quality care metric. We aimed to identify whether sex disparities exist in the quality of care after cardiac surgery using FTR rates. METHODS A retrospective analysis of 30 973 men (70.4%) and 13 033 women (29.6%) aged over 18 years undergoing coronary artery bypass graft or valve surgery in New York (2016-2019) and California (2016-2018) who experienced at least one serious postoperative complication. The primary outcome was the FTR. Multivariable logistic regression was used to identify predictors of death after complication. Propensity matching was used to adjust for baseline differences between sexes and yielded 12 657 pairs. RESULTS Female patients that experienced complications were older (mean age 67.8 versus 66.7, P<0.001), more frail (median frailty score 0.1 versus 0.07, P<0.001), and had more comorbidities (median Charlson score 2.5 versus 2.3, P<0.001) than male patients. The overall FTR rate was 5.7% (2524), men were less likely to die after a complication than women (4.8% versus 8%, P<0.001). Independent predictors of FTR included female sex (relative risk [RR]: 1.46 [CI, 1.30-1.62]), area-level poverty rate >20% (RR, 1.21 [CI, 1.01-1.59]), higher frailty (RR, 2.83 [CI, 1.35-5.93]), undergoing concomitant coronary artery bypass graft and valve surgeries (RR, 1.69 [CI, 1.49-1.9]), and higher number of postoperative complications (RR, 16.28 [CI, 14-18.89]). In the propensity-matched cohorts, the FTR rate remained significantly lower among men than women (6.0% versus 8.0%, P<0.001). CONCLUSIONS Women are less likely to be rescued from death following postoperative complications, independent of socioeconomic and clinical characteristics. Further research is warranted to investigate the clinical practices contributing to this disparity in quality of care following cardiac surgery.
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Affiliation(s)
- Sundos Alabbadi
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (S.A., A.V., N.E.)
| | - Georgina Rowe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., G.G., J.C.)
| | - George Gill
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., G.G., J.C.)
| | - Ageliki Vouyouka
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (S.A., A.V., N.E.)
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (G.R., G.G., J.C.)
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (S.A., A.V., N.E.)
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13
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Thompson MP, Yaser JM, Forrest A, Keteyian SJ, Sukul D. Evaluating the Feasibility of a Statewide Collaboration to Improve Cardiac Rehabilitation Participation: THE MICHIGAN CARDIAC REHAB NETWORK. J Cardiopulm Rehabil Prev 2022; 42:E75-E81. [PMID: 35831233 PMCID: PMC10069950 DOI: 10.1097/hcr.0000000000000706] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Regional quality improvement collaboratives may provide one solution to improving cardiac rehabilitation (CR) participation through performance benchmarking and provider engagement. The objective of this study was to evaluate the feasibility of the Michigan Cardiac Rehab Network to improve CR participation. METHODS Multipayer claims data from the Michigan Value Collaborative were used to identify hospitals and CR facilities and assemble a multidisciplinary advisory group. Univariate analyses described participating hospital characteristics and hospital-level rates of CR performance across eligible conditions including enrollment within 1 yr, mean days to first CR visit, and mean number of CR visits within 1 yr. Three diverse CR facilities were chosen for virtual site visits to identify areas of success and barriers to improvement. RESULTS A total of 95 hospitals and 84 CR facilities were identified, with 48 hospitals (51%) providing interventional cardiology services and 33 (35%) providing cardiac surgical services. A 17-member multidisciplinary advisory group was assembled representing 13 institutions and diverse roles. Statewide CR enrollment across eligible admissions was 33.4%, with wide variation in CR performance measures across participating hospitals and eligible admissions. Virtual site visits revealed individual successes in improving CR participation but a variety of barriers to participation related to referrals, capacity and staffing constraints, and geographic and financial barriers. CONCLUSIONS This study demonstrated the feasibility of creating a statewide collaboration of hospitals and CR facilities centered around the goal of equitably improving CR enrollment for all eligible patients in Michigan that is supported by a multidisciplinary advisory group and performance benchmarking.
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Affiliation(s)
- Michael P Thompson
- Section of Health Services Research and Quality, Department of Cardiac Surgery (Dr Thompson) and Division of Cardiovascular Medicine, Department of Internal Medicine (Dr Sukul), Michigan Medicine, Ann Arbor; Michigan Value Collaborative, Ann Arbor (Dr Thompson and Ms Yaser); Blue Cross Blue Shield of Michigan Cardiovascular Consortium, Ann Arbor (Ms Forrest and Dr Sukul); and Division of Cardiovascular Medicine, Henry Ford Health System, Detroit, Michigan (Dr Keteyian)
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14
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Yang G, Zhang M, Zhou S, Hou H, Grady KL, Stewart JW, Chenoweth CE, Aaronson KD, Fetters MD, Chandanabhumma PP, Pienta MJ, Malani PN, Hider AM, Cabrera L, Pagani FD, Likosky DS. Incompleteness of health-related quality of life assessments before left ventricular assist device implant: A novel quality metric. J Heart Lung Transplant 2022; 41:1520-1528. [PMID: 35961829 PMCID: PMC10405265 DOI: 10.1016/j.healun.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/16/2022] [Accepted: 07/01/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Improved health-related quality of life (HRQOL) is an important outcome following durable left ventricular assist device (LVAD) implant. However, half of pre-implant HRQOL data are incomplete in The Society of Thoracic Surgeons' Intermacs registry. Pre-implant HRQOL incompleteness may reflect patient status or hospital resources to capture HRQOL data. We hypothesized that pre-implant HRQOL incompleteness predicts 90 day outcomes and serves as a novel quality metric. METHODS Risk factors for pre-implant HRQOL (EQ-5D-5L visual analog scale; 12-item Kansas City Cardiomyopathy Questionnaire "KCCQ") incompleteness were examined by stepwise logistic modeling. Direct standardization method was used to calculate adjusted incompleteness rates using a mixed effects logistic model. Hospitals were dichotomized as low or high based on median adjusted incompleteness rates. Andersen-Gill models were used to associate pre-implant HRQOL adjusted incompleteness rate with adverse events within 90 day post-implant. RESULTS The study cohort included 14,063 patients receiving a primary LVAD (4/2012-8/2017). HRQOL incompleteness at high-rate hospitals was more often due to administrative reasons (risk difference, EQ-5D: 10.1%; KCCQ-12: 11.6%) and less likely due to patient reasons (risk difference, EQ-5D: -8.9%; KCCQ-12: -11.4%). A 10% increase in the adjusted pre-implant EQ-5D incompleteness rate was significantly associated with higher risk of infection-related mortality (HR: 1.09), infection (HR: 1.05), and renal dysfunction (HR: 1.03). A 10% increase in the adjusted pre-implant KCCQ-12 incompleteness rate was significantly associated with higher risk of infection (HR: 1.04). CONCLUSIONS Hospital adjusted pre-implant HRQOL incompleteness was predictive of 90-day post-implant outcomes and may serve as a novel quality metric.
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Affiliation(s)
- Guangyu Yang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Shiwei Zhou
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kathleen L Grady
- Division of Cardiac Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - James W Stewart
- Division of Cardiac Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Carol E Chenoweth
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michael D Fetters
- Department of Family Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - P Paul Chandanabhumma
- Department of Family Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michael J Pienta
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Preeti N Malani
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ahmad M Hider
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lourdes Cabrera
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
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15
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Mejia OAV, Borgomoni GB, Palma Dallan LR, Mioto BM, Duenhas Accorsi TA, Lima EG, de Matos Soeiro A, Lima FG, Manuel de Almeida Brandão C, Alberto Pomerantzeff PM, Oliveira Dallan LA, Ferreira Lisboa LA, Jatene FB. Quality improvement program at Latin America. Int J Surg 2022; 106:106931. [PMID: 36126857 DOI: 10.1016/j.ijsu.2022.106931] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The current challenge of cardiac surgery (CS) is to improve outcomes in adverse scenarios. The aim of this study was to assess the impact of a quality improvement program (QIP) on hospital mortality in the largest CS center in Latin America. METHODS Patients were divided into two groups: before (Jan 2013-Dec 2015, n = 3534) and after establishment of the QIP (Jan 2017-Dec 2019, n = 3544). The QIP consisted of the implementation of 10 central initiatives during 2016. The procedures evaluated were isolated coronary artery bypass grafting surgery (CABG), mitral valve surgery, aortic valve surgery, combined mitral and aortic valve surgery, and CABG associated with heart valve surgery. Propensity Score Matching (PSM) was used to adjust for inequality in patients' preoperative characteristics before and after the implementation of QIP. A multivariate logistic regression model was built to predict hospital mortality and validated using discrimination and calibration metrics. RESULTS The PMS paired two groups using 5 variables, obtaining 858 patients operated before (non-QIP) and 858 patients operated after the implementation of the QIP. When comparing the QIP versus Non-QIP group, there was a shorter length of stay in all phases of hospitalization. In addition, the patients evolved with less anemia (P = 0.001), use of intra-aortic balloon pump (P = 0.003), atrial fibrillation (P = 0.001), acute kidney injury (P < 0.001), cardiogenic shock (P = 0.011), sepsis (P = 0.046), and hospital mortality (P = 0.001). In the multiple model, among the predictors of hospital mortality, the lack of QIP increased the chances of mortality by 2.09 times. CONCLUSION The implementation of a first CS QIP in Latin America was associated with a reduction in length of hospital stay, complications and mortality after the cardiac surgeries analyzed.
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Affiliation(s)
- Omar Asdrúbal Vilca Mejia
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Gabrielle Barbosa Borgomoni
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Luís Roberto Palma Dallan
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Bruno Mahler Mioto
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Tarso Augusto Duenhas Accorsi
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Eduardo Gomes Lima
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Alexandre de Matos Soeiro
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Felipe Gallego Lima
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Carlos Manuel de Almeida Brandão
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Pablo Maria Alberto Pomerantzeff
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Luís Alberto Oliveira Dallan
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Luiz Augusto Ferreira Lisboa
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Fábio Biscegli Jatene
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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16
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Kim KD, Funk RJ, Hou H, Airhart A, Nassar K, Pagani FD, Zhang M, Chandanabhumma PP, Aaronson KD, Chenoweth CE, Hider A, Cabrera L, Likosky DS. Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care-Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset. Circ Cardiovasc Qual Outcomes 2022; 15:e008592. [PMID: 36065815 PMCID: PMC9489640 DOI: 10.1161/circoutcomes.121.008592] [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: 09/14/2021] [Accepted: 06/30/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. METHODS Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections. RESULTS The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (β=16032.5, p=0.008). CONCLUSIONS Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.
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Affiliation(s)
- K. Dennie Kim
- Strategy, Ethics, and Entrepreneurship, Darden School of Business, University of Virginia, Charlottesville, VA
| | - Russell J. Funk
- Department of Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | | | - Khalil Nassar
- University Hospital, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - P. Paul Chandanabhumma
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Ahmad Hider
- University of Michigan Medical School, Ann Arbor, MI
| | - Lourdes Cabrera
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI
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17
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Pienta MJ, Wu X, Cascino TM, Brescia AA, Abou El Ela A, Zhang M, McCullough JS, Shore S, Aaronson KD, Thompson MP, Pagani FD, Likosky DS. Advancing Quality Metrics for Durable Left Ventricular Assist Device Implant: Analysis of the Society of Thoracic Surgeons Intermacs Database. Ann Thorac Surg 2022; 113:1544-1551. [PMID: 35176258 PMCID: PMC9035070 DOI: 10.1016/j.athoracsur.2022.01.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing left ventricular assist device (LVAD) implantation are at risk for death and postoperative adverse outcomes. Interhospital variability and concordance of quality metrics were assessed using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs). METHODS A total of 22 173 patients underwent primary, durable LVAD implantation across 160 hospitals from 2012 to 2020, excluding hospitals performing <10 implant procedures. Observed and risk-adjusted operative mortality rates were calculated for each hospital. Outcomes included operative and 90-day mortality, a composite of adverse events (operative mortality, bleeding, stroke, device malfunction, renal dysfunction, respiratory failure), and secondarily failure to rescue. Rates are presented as median (interquartile range [IQR]). Hospital performance was evaluated using observed-to-expected (O/E) ratios for mortality and the composite outcome. RESULTS Interhospital variability existed in observed (median, 7.2% [IQR, 5.1%-9.6%]) mortality. The rates of adverse events varied across hospitals: major bleeding, 15.6% (IQR, 11.4%-22.4%); stroke, 3.1% (IQR, 1.6%-4.7%); device malfunction, 2.4% (IQR, 0.8%-3.7%); respiratory failure, 10.5% (IQR, 4.6%-15.7%); and renal dysfunction, 6.4% (IQR, 3.2%-9.6%). The O/E ratio for operative mortality varied from 0.0 to 6.1, whereas the O/E ratio for the composite outcome varied from 0.28 to 1.99. Hospital operative mortality O/E ratios were more closely correlated with the 90-day mortality O/E ratio (r = 0.74) than with the composite O/E ratio (r = 0.12). CONCLUSIONS This study reported substantial interhospital variability in performance for hospitals implanting durable LVADs. These findings support the need to (1) report hospital-level performance (mortality, composite) and (2) undertake benchmarking activities to reduce unwarranted variability in outcomes.
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Affiliation(s)
- Michael J Pienta
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan.
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Thomas M Cascino
- Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan
| | | | | | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey S McCullough
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Supriya Shore
- Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan
| | | | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan
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18
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Simonato M, Vemulapalli S, Ben-Yehuda O, Wu C, Wood L, Popma J, Feldman T, Krohn C, Hardy KM, Guibone K, Christensen B, Alu MC, Chen S, Ng VG, Chau KH, Shahim B, Vincent F, MacMahon J, James S, Mack M, Leon MB, Thourani VH, Carroll J, Krucoff M. Minimum Core Data Elements for Evaluation of TAVR: A Scientific Statement by PASSION CV, HVC, and TVT Registry. JACC Cardiovasc Interv 2022; 15:685-697. [PMID: 35367168 DOI: 10.1016/j.jcin.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/03/2021] [Accepted: 01/10/2022] [Indexed: 01/07/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is the standard of care for severe, symptomatic aortic stenosis. Real-world TAVR data collection contributes to benefit/risk assessment and safety evidence for the U.S. Food and Drug Administration, quality evaluation for the Centers for Medicare and Medicaid Services and hospitals, as well as clinical research and real-world implementation through appropriate use criteria. The essential minimum core dataset for these purposes has not previously been defined but is necessary to promote efficient, reusable real-world data collection supporting quality, regulatory, and clinical applications. The authors performed a systematic review of the published research for high-impact TAVR studies and U.S. multicenter, multidevice registries. Two expert task forces, one from the Predictable and Sustainable Implementation of National Cardiovascular Registries/Heart Valve Collaboratory and another from The Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry convened separately and then met to reconcile a final list of essential data elements. From 276 unique data elements considered, unanimous consensus agreement was achieved on 132 "core" data elements, with the most common reasons for exclusion from the minimum core dataset being burden or difficulty in accurate assessment (36.9%), duplicative information (33.3%), and low likelihood of affecting outcomes (10.7%). After a systematic review and extensive discussions, a multilateral group of academicians, industry representatives, and regulators established 132 interoperable, reusable essential core data elements essential to supporting more efficient, consistent, and informative TAVR device evidence for regulatory submissions, safety surveillance, best practice, and hospital quality assessments.
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Affiliation(s)
| | | | - Ori Ben-Yehuda
- University of California-San Diego, San Diego, California, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Changfu Wu
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Larry Wood
- Edwards Lifesciences, Irvine, California, USA
| | | | - Ted Feldman
- Edwards Lifesciences, Irvine, California, USA
| | - Carole Krohn
- The Society of Thoracic Surgeons, Chicago, Illinois, USA
| | | | - Kimberly Guibone
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York, USA
| | - Shmuel Chen
- Columbia University Irving School of Medicine, New York, New York, USA
| | - Vivian G Ng
- Columbia University Irving School of Medicine, New York, New York, USA
| | - Katherine H Chau
- Columbia University Irving School of Medicine, New York, New York, USA
| | - Bahira Shahim
- Cardiovascular Research Foundation, New York, New York, USA
| | | | - John MacMahon
- Mitre Medical Corporation, Morgan Hill, California, USA
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala, Sweden
| | - Michael Mack
- Baylor Scott and White Health, Dallas, Texas, USA
| | - Martin B Leon
- Columbia University Irving School of Medicine, New York, New York, USA
| | | | - John Carroll
- University of Colorado School of Medicine, Denver, Colorado, USA
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19
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Simonato M, Vemulapalli S, Ben-Yehuda O, Wu C, Wood L, Popma J, Feldman T, Krohn C, Hardy KM, Guibone K, Christensen B, Alu MC, Chen S, Ng VG, Chau KH, Shahim B, Vincent F, MacMahon J, James S, Mack M, Leon MB, Thourani VH, Carroll J, Krucoff M. Minimum Core Data Elements for Evaluation of TAVR: A Scientific Statement by PASSION CV, HVC, and TVT Registry. Ann Thorac Surg 2022; 113:1730-1742. [PMID: 35367049 DOI: 10.1016/j.athoracsur.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/10/2022] [Indexed: 11/20/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is the standard of care for severe, symptomatic aortic stenosis. Real-world TAVR data collection contributes to benefit/risk assessment and safety evidence for the U.S. Food and Drug Administration, quality evaluation for the Centers for Medicare and Medicaid Services and hospitals, as well as clinical research and real-world implementation through appropriate use criteria. The essential minimum core dataset for these purposes has not previously been defined but is necessary to promote efficient, reusable real-world data collection supporting quality, regulatory, and clinical applications. The authors performed a systematic review of the published research for high-impact TAVR studies and U.S. multicenter, multidevice registries. Two expert task forces, one from the Predictable and Sustainable Implementation of National Cardiovascular Registries/Heart Valve Collaboratory and another from The Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry convened separately and then met to reconcile a final list of essential data elements. From 276 unique data elements considered, unanimous consensus agreement was achieved on 132 "core" data elements, with the most common reasons for exclusion from the minimum core dataset being burden or difficulty in accurate assessment (36.9%), duplicative information (33.3%), and low likelihood of affecting outcomes (10.7%). After a systematic review and extensive discussions, a multilateral group of academicians, industry representatives, and regulators established 132 interoperable, reusable essential core data elements essential to supporting more efficient, consistent, and informative TAVR device evidence for regulatory submissions, safety surveillance, best practice, and hospital quality assessments.
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Affiliation(s)
| | | | - Ori Ben-Yehuda
- University of California-San Diego, San Diego, California; Cardiovascular Research Foundation, New York, New York
| | - Changfu Wu
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Larry Wood
- Edwards Lifesciences, Irvine, California
| | | | | | - Carole Krohn
- The Society of Thoracic Surgeons, Chicago, Illinois
| | | | | | | | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York
| | - Shmuel Chen
- Columbia University Irving School of Medicine, New York, New York
| | - Vivian G Ng
- Columbia University Irving School of Medicine, New York, New York
| | - Katherine H Chau
- Columbia University Irving School of Medicine, New York, New York
| | - Bahira Shahim
- Cardiovascular Research Foundation, New York, New York
| | | | | | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Martin B Leon
- Columbia University Irving School of Medicine, New York, New York
| | | | - John Carroll
- University of Colorado School of Medicine, Denver, Colorado
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20
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Pienta MJ, Theurer P, He C, Zehr K, Drake D, Murphy E, Bolling SF, Romano MA, Prager R, Thompson MP, Ailawadi G, Martin D, George K, Batra S, Liakonis C, Dabir R, Shannon F, Robinson P, Delucia A, Kaakeh B, Zehr K, Mandal K, Simonetti V, Nemeh H, Alnajjar R, Holmes R, Batra S, Gandhi D, Minanov K, Talbott J, Martin J, Downey R, Collar A, Lall S, Pridjian A, Fanning J, Baghelai K, Pruitt A, Schwartz C, Kim K, Blakeman B. Racial Disparities in Mitral Valve Surgery: A Statewide Analysis. J Thorac Cardiovasc Surg 2022; 165:1815-1823.e8. [PMID: 35414409 DOI: 10.1016/j.jtcvs.2021.11.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 11/01/2021] [Accepted: 11/04/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Racial disparities in health care have come to the forefront. We hypothesized that Black race was associated with worse preoperative risk, lower repair rates, and worse outcomes among patients who underwent mitral valve surgery. METHODS All patients who underwent mitral valve repair or replacement with or without coronary artery bypass grafting from 2011 to 2020 in a statewide collaborative database were stratified into 3 racial groups, White, Black, and other. Preoperative characteristics, procedure type, and outcomes were evaluated. RESULTS A total of 9074 mitral valve operations were performed at 33 centers (Black 1009 [11.1%], White 7862 [86.6%]). Preoperative combined Society of Thoracic Surgeons morbidity and mortality was higher for Black patients (Black 32%, White 22%, other 23%, [P < .001]) because of a greater proportion of diabetes, hypertension, and chronic lung disease. White patients were more likely to undergo mitral repair (White 66%, Black 53.3%, other 57%; P < .001). Operative mortality was similar across racial groups (White 3.7%, Black 4.6%, other 4.5%; P = .36). After adjusting for preoperative factors, mitral etiology, and hospitals, race was not associated with mitral valve repair, complications, or mortality, but Black patients had higher odds of extended care facility utilization and readmission. CONCLUSIONS Contrary to our hypothesis, there was no difference in the odds of repair or operative mortality across races after accounting for risk and etiology. However, Black patients were more likely to be readmitted after discharge. These findings support a greater focus on reducing disparities in mitral valve surgery.
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21
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Ariyo P, Abernathy JH, Hensley NB. Role of Value-Added Care by Cardiothoracic Anesthesiology and Impact on Outcomes After Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2022; 26:173-178. [PMID: 35130773 DOI: 10.1177/10892532211048953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The medical community is increasingly aware of the need for high-quality and high-value patient care. Anesthesiologists in particular have long demonstrated leadership in the field of quality and safety. Cardiothoracic anesthesiologists can improve the quality of care delivered to cardiac patients both with anesthesia-specific practices and in a team-based approach with other perioperative care providers. Collecting large volumes of multicentered data to study, measure, and improve anesthesia care is one of the many commitments of cardiothoracic anesthesiologists to this cause. This article reviews this and other aspects of the work of cardiothoracic anesthesiologists to improve value-added care to cardiac patients.
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Affiliation(s)
- Promise Ariyo
- 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Nadia B Hensley
- 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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Sun LY, Chu A, Tam DY, Wang X, Fang J, Austin PC, Feindel CM, Oakes GH, Alexopoulos V, Tusevljak N, Ouzounian M, Lee DS. Derivation and validation of predictive indices for 30-day mortality after coronary and valvular surgery in Ontario, Canada. CMAJ 2021; 193:E1757-E1765. [PMID: 34810162 PMCID: PMC8608458 DOI: 10.1503/cmaj.202901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 01/21/2023] Open
Abstract
Background: Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG + AVR. Methods: We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020). Results: The derivation cohorts included 13 435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG, 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts. Interpretation: Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions.
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Affiliation(s)
- Louise Y Sun
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Anna Chu
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Derrick Y Tam
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Xuesong Wang
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Jiming Fang
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Peter C Austin
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Christopher M Feindel
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Garth H Oakes
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Vicki Alexopoulos
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Natasa Tusevljak
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Maral Ouzounian
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont
| | - Douglas S Lee
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute, Ottawa, Ont.; ICES Central (Sun, Chu, Tam, Wang, Fang, Austin, Tusevljak, Lee), Toronto, Ont.; School of Epidemiology and Public Health (Sun), University of Ottawa, Ottawa, Ont.; Sunnybrook Health Sciences Centre (Tam); University Health Network and Peter Munk Cardiac Centre (Feindel, Ouzounian, Lee); Departments of Cardiac Surgery (Tam, Feindel, Ouzounian), Physical Therapy (Chu), Surgery (Feindel), Cardiology (Lee), University of Toronto, Toronto, Ont.; Institute for Health Policy, Management and Evaluation (Austin), University of Toronto, Toronto, Ont.; CorHealth Ontario (Oakes, Alexopoulos), Toronto, Ont.
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23
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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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24
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Milojevic M, Bond C, He C, Shannon FL, Clark M, Theurer PF, Prager RL. Failure to rescue: variation in mortality after cardiac surgery. Interact Cardiovasc Thorac Surg 2021; 33:848-856. [PMID: 34259841 DOI: 10.1093/icvts/ivab188] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/28/2021] [Accepted: 06/03/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Measures to prevent surgical complications are critical components of optimal patient care, and adequate management when complications occur is equally crucial in efforts to reduce mortality. This study aims to elucidate clinical realities underlying in-hospital variations in failure to rescue (FTR) after cardiac surgery. METHODS Using a statewide database for a quality improvement program, we identified 62 450 patients who had undergone adult cardiac surgery between 2011 and 2018 in 1 of the 33 Michigan hospitals performing adult cardiac surgery. The hospitals were first divided into tertiles according to their observed to expected (O/E) ratios of 30-day mortality: low-mortality tertile (O/E 0.46-0.78), intermediate-mortality tertile (O/E 0.79-0.90) and high-mortality tertile (O/E 0.98-2.00). We then examined the incidence of 15 significant complications and the rates of death following complications among the 3 groups. RESULTS A total of 1418 operative deaths occurred in the entire cohort, a crude mortality rate of 2.3% and varied from 1.3% to 5.9% at the hospital level. The death rates also diverged significantly according to mortality score tertiles, from 1.6% in the low-mortality group to 3.2% in the high-mortality group (P < 0.001). Hospitals ranked in a high- or intermediate-mortality tertile had similar rates of overall complications (21.3% and 20.7%, P = 0.17), while low-mortality hospitals had significantly fewer complications (16.3%) than the other 2 tertiles (P < 0.001). FTR increased in a stepwise manner from low- to high-mortality hospitals (8.3% vs 10.0% vs 12.7%, P < 0.001, respectively). Differences in FTR were related to survival after cardiac arrest, multi-system organ failure, prolonged ventilation, reoperation for bleeding and severe acute kidney disease that requires dialysis. CONCLUSIONS This study demonstrates that timely recognition and appropriate treatment of complications are as important as preventing complications to further reduce operative mortality in cardiac surgery. FTR tools may provide vital information for quality improvement initiatives.
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Affiliation(s)
- Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Chris Bond
- Department of Cardiac Surgery, Queen Elizabeth University Hospital, Birmingham, UK
| | - Chang He
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA.,Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative, Ann Arbor, MI, USA
| | - Francis L Shannon
- Division of Cardiovascular Surgery, Beaumont Health, Royal Oak, MI, USA
| | - Melissa Clark
- Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative, Ann Arbor, MI, USA
| | - Patricia F Theurer
- Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative, Ann Arbor, MI, USA
| | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA.,Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative, Ann Arbor, MI, USA
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25
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Likosky DS, Yang G, Zhang M, Malani PN, Fetters MD, Strobel RJ, Chenoweth CE, Hou H, Pagani FD. Interhospital variability in health care-associated infections and payments after durable ventricular assist device implant among Medicare beneficiaries. J Thorac Cardiovasc Surg 2021; 164:1561-1568. [PMID: 34099272 PMCID: PMC10150658 DOI: 10.1016/j.jtcvs.2021.04.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/23/2021] [Accepted: 04/16/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study was to investigate variations across hospitals in infection rates and associated costs, the latter reflected in 90-day Medicare payments. Despite high rates and expenditures of health care--associated infections associated with durable ventricular assist device implantation, few studies have examined interhospital variation and associated costs. METHODS Clinical data on 8688 patients who received primary durable ventricular assist devices from July 2008 to July 2017 from the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) hospitals (n = 120) were merged with postimplantation 90-day Medicare claims. Terciles of hospital-specific, risk-adjusted infection rates per 100 patient-months were estimated using Intermacs and associated with Medicare payments (among 5440 Medicare beneficiaries). Primary outcomes included infections within 90 days of implantation and Medicare payments. RESULTS There were 3982 infections identified among 27.8% (2417/8688) of patients developing an infection. The median (25th, 75th percentile) adjusted incidence of infections (per 100 patient-months) across hospitals was 14.3 (9.3, 19.5) and varied according to hospital (range, 0.0-35.6). Total Medicare payments from implantation to 90 days were 9.0% (absolute difference: $13,652) greater in high versus low infection tercile hospitals (P < .0001). The period between implantation to discharge accounted for 73.1% of the difference in payments during the implantation to 90-day period across terciles. CONCLUSIONS Health care--associated infection rates post durable ventricular assist device implantation varied according to hospital and were associated with increased 90-day Medicare expenditures. Interventions targeting preventing infections could improve the value of durable ventricular assist device support from the societal and hospital perspectives.
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Affiliation(s)
- Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Mich.
| | - Guangyu Yang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Mich
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Mich
| | - Preeti N Malani
- Division of Infectious Diseases, Department of Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Mich
| | - Michael D Fetters
- Department of Family Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Mich
| | | | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Mich
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Mich
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The influence of tobacco load versus smoking status on outcomes following lobectomy for lung cancer in a statewide quality collaborative. J Thorac Cardiovasc Surg 2020; 162:1375-1385.e1. [PMID: 33558118 DOI: 10.1016/j.jtcvs.2020.10.162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Collaborative quality consortia can facilitate implementation of quality measures arising from clinical databases. Our statewide general thoracic surgery (GTS) collaborative investigated the influences of cigarette smoking status on mortality and major morbidity following lobectomy for lung cancer. METHODS Society of Thoracic Surgeons General Thoracic Surgery Database records were identified from 14 institutions participating in a statewide thoracic surgical quality collaborative between 2012 and 2017. We excluded patients with nonelective procedures, stage 0 tumors, American Society of Anesthesiologists class VI disease, and missing clinical characteristics. Outcomes analysis included the combined mortality and major postoperative morbidity rates and the influence of patient characteristics, including smoking status, on composite rate and on postoperative complications. RESULTS The study cohort included 2267 patient records for analysis. Overall combined mortality and major morbidity rate was 10.2% (n = 231). Postoperative 30-day mortality was 1.5%, and major morbidity 9.6%. Significant predictors of the combined outcome included male sex (P = .004), body mass index (P < .001), Zubrod score (P = .02), smoking pack-years (P = .03), and thoracotomy (P < .001). Higher American Society of Anesthesiologists disease class and advanced tumor stage were marginally associated with worse combined outcome (P = .06). Smoking status; that is, current, past (no smoking within 30 days), or never smoked, was not associated with worse combined outcome (P = .56) and had no significant influence on major complications. CONCLUSIONS Smoking status was not associated with worse outcomes; however, smoking dose (pack-years) was associated with worse combined mortality and major morbidity. A statewide quality collaborative provides constructive feedback for participating institutions and surgeons, promoting quality improvement in perioperative patient care strategies and improved outcomes.
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Yao R, Liu X, He Y, Mei C, Shen Y, Zhan Q, Huang L, Li B, Li N. Low platelet count is a risk factor of postoperative pneumonia in patients with type A acute aortic dissection. J Thorac Dis 2020; 12:2333-2342. [PMID: 32642138 PMCID: PMC7330411 DOI: 10.21037/jtd.2020.03.84] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Previous studies have already established that low platelet count is related to adverse outcomes in patients with type A acute aortic dissection (AAAD). However, there are yet limited studies investigating the association of platelet count and the risk of postoperative pneumonia in AAAD patients. Methods This retrospective cohort study was conducted in Xiangya Hospital of Central South University from January 2014 to May 2019. Clinical and laboratory data were collected. The correlation between platelet count and postoperative pneumonia was analyzed using multivariate logistic regression and the area under the receiver operating characteristic curve (AUC) was used to assess the predictive power of platelet count on pneumonia. Results A total of 268 patients with AAAD were enrolled. The overall incidence of pneumonia was 36.94% (n=99). Multivariate logistic regression revealed that platelet count was negatively associated with the risk of postoperative pneumonia (OR 0.93; 95% CI: 0.88–0.98) after adjusting for the confounders. Compared to the lowest platelet count tertile (T1), medium platelet count (T2) and highest platelet count (T3) had a lower risk of postoperative pneumonia after adjusting for the confounders (OR 0.80, 95% CI: 0.40–1.60; OR 0.30, 95% CI: 0.13–0.66; respectively). A similar trend was observed when the platelet count was handled as categorical variables (tertiles). The area under the ROC curve was 0.635 (95% CI: 0.565–0.707), with a sensitivity of 76.77%, a specificity of 50.89% and an accuracy of 60.45%. Conclusions Our findings indicate that low platelet count is an independent risk factor of postoperative pneumonia in patients with AAAD and has a specific predictive power on the risk of postoperative pneumonia.
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Affiliation(s)
- Run Yao
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha 410007, China
| | - Xianglin Liu
- Department of Anesthesiology, Changsha Maternal and Child Health Hospital, Changsha 410007
| | - Yi He
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha 410007, China
| | - Cheng Mei
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha 410007, China
| | - Yamei Shen
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha 410007, China
| | - Qinru Zhan
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha 410007, China
| | - Lingjin Huang
- Department of Cardiac Surgery, Xiangya Hospital, Central South University, Changsha 410007, China
| | - Bijuan Li
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha 410007, China
| | - Ning Li
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha 410007, China
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Tam DY, Rushani D, Fremes SE. Commentary: When less is not more—volume-outcome relationships in aortic valve replacement. J Thorac Cardiovasc Surg 2020; 163:2053-2055. [DOI: 10.1016/j.jtcvs.2020.07.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 01/12/2023]
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Gaies M, Pasquali SK, Banerjee M, Dimick JB, Birkmeyer JD, Zhang W, Alten JA, Chanani N, Cooper DS, Costello JM, Gaynor JW, Ghanayem N, Jacobs JP, Mayer JE, Ohye RG, Scheurer MA, Schwartz SM, Tabbutt S, Charpie JR. Improvement in Pediatric Cardiac Surgical Outcomes Through Interhospital Collaboration. J Am Coll Cardiol 2020; 74:2786-2795. [PMID: 31779793 DOI: 10.1016/j.jacc.2019.09.046] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients undergoing complex pediatric cardiac surgery remain at considerable risk of mortality and morbidity, and variation in outcomes exists across hospitals. The Pediatric Cardiac Critical Care Consortium (PC4) was formed to improve the quality of care for these patients through transparent data sharing and collaborative learning between participants. OBJECTIVES The purpose of this study was to determine whether outcomes improved over time within PC4. METHODS The study analyzed 19,600 hospitalizations (18 hospitals) in the PC4 clinical registry that included cardiovascular surgery from August 2014 to June 2018. The primary exposure was 2 years of PC4 participation; this provided adequate time for hospitals to accrue data and engage in collaborative learning. Aggregate case mix-adjusted outcomes were compared between the first 2 years of participation (baseline) and all months post-exposure. We also evaluated outcomes from the same era in a cohort of similar, non-PC4 hospitals. RESULTS During the baseline period, there was no evidence of improvement. We observed significant improvement in the post-exposure period versus baseline for post-operative intensive care unit mortality (2.1% vs. 2.7%; 22% relative reduction [RR]; p = 0.001), in-hospital mortality (2.5% vs. 3.3%; 24% RR; p = 0.001), major complications (10.1% vs. 11.5%; 12% RR; p < 0.001), intensive care unit length of stay (7.3 days vs. 7.7 days; 5% RR; p < 0.001), and duration of ventilation (61.3 h vs. 70.6 h; 13% RR; p = 0.01). Non-PC4 hospitals showed no significant improvement in mortality, complications, or hospital length of stay. CONCLUSIONS This analysis demonstrates improving cardiac surgical outcomes at children's hospitals participating in PC4. This change appears unrelated to secular improvement trends, and likely reflects PC4's commitment to transparency and collaboration.
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Affiliation(s)
- Michael Gaies
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Wenying Zhang
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey A Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nikhil Chanani
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - J William Gaynor
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nancy Ghanayem
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - John E Mayer
- Department of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mark A Scheurer
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Steven M Schwartz
- Departments of Pediatrics and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Tabbutt
- Department of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, California
| | - John R Charpie
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
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Chandanabhumma PP, Fetters MD, Pagani FD, Malani PN, Hollingsworth JM, Funk RJ, Aaronson KD, Zhang M, Kormos RL, Chenoweth CE, Shore S, Watt TMF, Cabrera L, Likosky DS. Understanding and Addressing Variation in Health Care-Associated Infections After Durable Ventricular Assist Device Therapy: Protocol for a Mixed Methods Study. JMIR Res Protoc 2020; 9:e14701. [PMID: 31909721 PMCID: PMC6996720 DOI: 10.2196/14701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/26/2019] [Accepted: 10/29/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Durable ventricular assist device (VAD) therapy is reserved for patients with advanced heart failure who have a poor estimated 1-year survival. However, despite highly protocolized management processes, patients are at a unique risk for developing a health care-associated infection (HAI). Few studies have examined optimal strategies for HAI prevention after durable VAD implantation, despite variability in rates across centers and their impact on short- and long-term outcomes. OBJECTIVE The objective of this study is to develop recommendations for preventing the most significant HAIs after durable VAD implantation. The study has 3 specific aims: (1) identify determinants of center-level variability in HAI rates, (2) develop comprehensive understanding of barriers and facilitators for achieving low center-level HAI rates, and (3) develop and disseminate a best practices toolkit for preventing HAIs that accommodates various center contexts. METHODS This is a sequential mixed methods study starting with a cross-sectional assessment of current practices. To address aim 1, we will conduct (1) a systematic review of HAI prevention studies and (2) in-depth quantitative analyses using administrative claims, in-depth clinical data, and organizational surveys of VAD centers. For aim 2, we will apply a mixed methods patient tracer assessment framework to conduct semistructured interviews, field observations, and document analysis informed by findings from aim 1 at 5 high-performing (ie, low HAIs) and 5 low-performing (ie, high HAI) centers, which will be examined using a mixed methods case series analysis. For aim 3, we will build upon the findings from the previous aims to develop and field test an HAI preventive toolkit, acquire stakeholder input at an annual cardiac surgical conference, disseminate the final version to VAD centers nationwide, and conduct follow-up surveys to assess the toolkit's adoption. RESULTS The project was funded by the Agency for Healthcare Research and Quality in 2018 and enrollment for the overall project is ongoing. Data analysis is currently under way and the first results are expected to be submitted for publication in 2019. CONCLUSIONS This mixed methods study seeks to quantitatively assess the determinants of HAIs across clinical centers and qualitatively identify the context-specific facilitators and barriers for attaining low HAI rates. The mixed data findings will be used to develop and disseminate a stakeholder-acceptable toolkit of evidence-based HAI prevention recommendations that will accommodate the specific contexts and needs of VAD centers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/14701.
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Affiliation(s)
- P Paul Chandanabhumma
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Michael D Fetters
- Mixed Methods Program, Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Preeti N Malani
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | | | - Russell J Funk
- Department of Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis, MN, United States
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Robert L Kormos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Supriya Shore
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Lourdes Cabrera
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, United States
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Milojevic M, Bond C, Theurer PF, Jones RN, Dabir R, Likosky DS, Leyden T, Clark M, Prager RL. The Role of Regional Collaboratives in Quality Improvement: Time to Organize, and How? Semin Thorac Cardiovasc Surg 2020; 32:8-13. [DOI: 10.1053/j.semtcvs.2019.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/26/2019] [Indexed: 11/11/2022]
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32
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de By TMMH, Muslem R, Caliskan K, Bortolussi G, Philipsen T, Friberg Ö, Bogers AJJC, Pagano D. Consolidated quality improvements following benchmarking with cardiothoracic surgery registries—a systematic review. Eur J Cardiothorac Surg 2019; 57:817-825. [DOI: 10.1093/ejcts/ezz330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 12/16/2022] Open
Abstract
Abstract
The influence of registries in medicine is large. However, there has been no systematic assessment conducted to quantify the impact of benchmarking with registries focused on cardiothoracic surgery. Numerous publications conclude that registry participation leads to improvement of outcomes for patients. A large number of registries provide evidence sub-structured by statistics that show decreases in morbidity and mortality in the participants’ clinical units. Many authors praise the benchmarking method making use of databases of registries as having a positive effect on outcome of care. However, studies proving the direct causal relation between the use of cardiothoracic surgery-oriented registries and improvement of clinical in-hospital outcomes are extremely scarce. We aimed to analyse the causal relation between the use of cardiothoracic surgery-oriented registries and improvement of clinical outcomes. In a systematic literature review, publications demonstrating the use of registry data to obtain consolidated quality improvements were selected. After analysis of 2990 scientific publications, 6 studies filled the inclusion criteria. The selected studies acknowledged that benchmarking of data against registries was used for a focused and methodologically organized improvement in cardiothoracic departments. In conjunction with the impact of the applied methods on healthcare, their results demonstrate quantifiable enhanced local outcomes over time.
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Affiliation(s)
- Theo M M H de By
- European Association for Cardio-Thoracic Surgery, Windsor, UK
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Rahatullah Muslem
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Giacomo Bortolussi
- Department of Cardiac Thoracic Vascular Sciences and Public Health, Padua University Hospital, Padua, Italy
| | - Tine Philipsen
- Department of Cardiac Surgery, Universitair Ziekenhuis Gent, Gent, Belgium
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Domenico Pagano
- Department of Cardiothoracic Surgery, University of Birmingham, University Hospital Birmingham, Birmingham, UK
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