Florida Heart Research Institute, Miami, Miami FL 33140, USA.
J Thorac Cardiovasc Surg. 2012 Feb;143(2):287-93. doi: 10.1016/j.jtcvs.2011.10.043. Epub 2011 Nov 20.
The present study examined the relationship between hospital and surgeon coronary artery bypass grafting procedural volume, mortality, morbidity, and National Quality Forum care processes in a university-based community hospital quality improvement program.
The study population consisted of 2218 consecutive patients undergoing isolated coronary artery bypass grafting from 2007 to 2009 in a university-based quality improvement program that emphasizes involvement of all surgeons in the academic quality endeavor. The endpoints included operative mortality, major morbidity, and National Quality Forum-endorsed process measures as defined by the Society of Thoracic Surgeons. The procedural volume was analyzed as a categorical and continuous variable using general estimating equations, which accounted for clustering effects and which were adjusted for Society of Thoracic Surgeons risk scores and the propensity for operation in a low- versus high-volume program.
The annual program volume ranged from 67 to 292 (median, 136; interquartile range, 88-224) and surgeon volume from 1 to 124 (median, 58; interquartile range, 30-89). The mortality rate among the hospitals was 0.47% to 2.23% (0.8% overall), and the observed/expected mortality ranged from 0 to 1.20 (0.41 overall). When comparing low-volume (<200 cases/year) and high-volume centers, no difference was found in the mortality (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.46-2.54, P = .85), morbidity (OR, 1.34; 95% CI, 0.73-2.43), or any of the medication process measures. No difference was found in mortality (OR, 1.59; 95% CI, 0.81-3.13; P = .18), morbidity (OR, 1.20; 95% CI, 0.86-1.66; P = .28), or medication failure (OR, 0.57, 95% CI, 0.3-1.10; P = .10) between the high- and low-volume surgeons (<87). After adjustment for both the Society of Thoracic Surgeons risk score and the propensity score, no association was found for either hospital or surgeon volume with mortality or morbidity. However, a lack of compliance with National Quality Forum measures was highly predictive of morbidity (OR, 1.51; 95% CI, 1.18-1.93; P = .001), regardless of volume, even after adjustment for predicted risk.
In the setting of a university-based community hospital quality improvement program, excellent surgical results can consistently be obtained even in relatively low-volume programs. The surgical outcomes were not associated with program or surgeon volume, but were directly correlated with the focus on quality as manifested by compliance with evidence-based quality standards. Meaningful university affiliation might represent a new quality paradigm for cardiac surgery in the community hospital setting.
本研究旨在探讨在大学社区医院质量改进计划中，医院和外科医生冠状动脉旁路移植术的程序量、死亡率、发病率和国家质量论坛护理流程之间的关系。
研究人群包括 2007 年至 2009 年在大学社区医院质量改进计划中接受单独冠状动脉旁路移植术的 2218 例连续患者，该计划强调所有外科医生都参与学术质量工作。终点包括手术死亡率、主要发病率和国家质量论坛认可的过程措施，如胸外科医生协会定义的。使用一般估计方程分析程序量作为分类和连续变量，该方程考虑了聚类效应，并根据胸外科医生协会风险评分和在低容量与高容量计划中进行手术的倾向进行了调整。
年度计划量范围为 67 至 292（中位数为 136；四分位间距为 88-224），外科医生量为 1 至 124（中位数为 58；四分位间距为 30-89）。医院的死亡率为 0.47%至 2.23%（总体为 0.8%），观察到/预期死亡率为 0 至 1.20（总体为 0.41）。当比较低容量（<200 例/年）和高容量中心时，死亡率（优势比[OR]，1.08；95%置信区间[CI]，0.46-2.54，P =.85）、发病率（OR，1.34；95%CI，0.73-2.43）或任何药物过程措施均无差异。死亡率（OR，1.59；95%CI，0.81-3.13；P =.18）、发病率（OR，1.20；95%CI，0.86-1.66；P =.28）或药物失败（OR，0.57，95%CI，0.3-1.10；P =.10）在高容量和低容量外科医生之间（<87）无差异。在同时调整胸外科医生协会风险评分和倾向评分后，医院或外科医生的容量与死亡率或发病率均无关联。然而，即使在调整了预测风险后，不符合国家质量论坛措施与发病率高度相关（OR，1.51；95%CI，1.18-1.93；P =.001），而与容量无关。
在大学社区医院质量改进计划的背景下，即使在相对低容量的计划中，也可以持续获得出色的手术结果。手术结果与计划或外科医生的数量无关，但与对质量的关注直接相关，这表现为符合基于证据的质量标准。有意义的大学附属关系可能代表社区医院心脏外科的一种新的质量模式。
