Section of Cardiac Surgery, Department of Surgery, (M.M., A.G.), Yale School of Medicine, New Haven, CT.
Center for Outcomes Research & Evaluation, Yale New Haven Health System, New Haven, CT (M.M., K.N., H.B., A.J., S.L., Y.W., J.G., S.L., N.B., Z.L, S.M.B., H.M.K., L.G.S.).
Circ Cardiovasc Qual Outcomes. 2021 Feb;14(2):e006644. doi: 10.1161/CIRCOUTCOMES.120.006644. Epub 2021 Feb 4.
Coronary artery bypass graft (CABG) surgery is a focus of bundled and alternate payment models that capture outcomes up to 90 days postsurgery. While clinical registry risk models perform well, measures encompassing mortality beyond 30 days do not currently exist. We aimed to develop a risk-adjusted hospital-level 90-day all-cause mortality measure intended for assessing hospital performance in payment models of CABG surgery using administrative data.
Building upon Centers for Medicare and Medicaid Services hospital-level 30-day all-cause CABG mortality measure specifications, we extended the mortality timeframe to 90 days after surgery and developed a new hierarchical logistic regression model to calculate hospital risk-standardized 90-day all-cause mortality rates for patients hospitalized for isolated CABG. The model was derived from Medicare claims data for a 3-year cohort between July 2014 to June 2017. The data set was randomly split into 50:50 development and validation samples. The model performance was evaluated with C statistics, overfitting indices, and calibration plot. The empirical validity of the measure result at the hospital level was evaluated against the Society of Thoracic Surgeons composite star rating.
Among 137 819 CABG procedures performed in 1183 hospitals, the unadjusted mortality rate within 30 and 90 days were 3.1% and 4.7%, respectively. The final model included 27 variables. Hospital-level 90-day risk-standardized mortality rates ranged between 2.04% and 11.26%, with a median of 4.67%. C statistics in the development and validation samples were 0.766 and 0.772, respectively. We identified a strong positive correlation between 30- and 90-day risk-standardized mortality rates, with a regression slope of 1.09. Risk-standardized mortality rates also showed a stepwise trend of lower 90-day mortality with higher Society of Thoracic Surgeons composite star ratings.
We present a measure of hospital-level 90-day risk-standardized mortality rates following isolated CABG. This measure complements Centers for Medicare and Medicaid Services' existing 30-day CABG mortality measure by providing greater insight into the postacute recovery period. It offers a balancing measure to ensure efforts to reduce costs associated with CABG recovery and rehabilitation do not result in unintended consequences.
冠状动脉旁路移植术（CABG）是捆绑式和替代支付模式的重点，这些模式可以捕捉到术后 90 天内的结果。虽然临床登记风险模型表现良好，但目前不存在涵盖 30 天后死亡率的措施。我们旨在利用行政数据，为评估 CABG 手术支付模式下的医院绩效，开发一种风险调整的医院水平 90 天全因死亡率衡量标准。
在医疗保险和医疗补助服务中心（Centers for Medicare and Medicaid Services）医院水平 30 天全因 CABG 死亡率衡量标准的基础上，我们将死亡率时间范围延长至术后 90 天，并开发了一种新的分层逻辑回归模型，用于计算因孤立性 CABG 住院患者的医院风险标准化 90 天全因死亡率。该模型是从 2014 年 7 月至 2017 年 6 月的 3 年队列的医疗保险索赔数据中得出的。数据集被随机分为 50:50 的开发和验证样本。使用 C 统计量、过度拟合指数和校准图评估模型性能。还通过与胸外科医生协会综合星级评定的比较，评估了医院水平测量结果的经验有效性。
在 1183 家医院进行的 137819 例 CABG 手术中，30 天和 90 天内未调整的死亡率分别为 3.1%和 4.7%。最终模型包括 27 个变量。医院水平的 90 天风险标准化死亡率在 2.04%至 11.26%之间，中位数为 4.67%。开发和验证样本中的 C 统计量分别为 0.766 和 0.772。我们发现 30 天和 90 天风险标准化死亡率之间存在很强的正相关，回归斜率为 1.09。风险标准化死亡率也显示出随着胸外科医生协会综合星级评定的提高，90 天死亡率呈逐步下降的趋势。
我们提出了一种衡量孤立性 CABG 后医院水平 90 天风险标准化死亡率的方法。该衡量标准通过提供对急性后期恢复期的更深入了解，补充了医疗保险和医疗补助服务中心现有的 30 天 CABG 死亡率衡量标准。它提供了一种平衡的衡量标准，以确保降低与 CABG 恢复和康复相关的成本的努力不会产生意想不到的后果。
