Zhang Danwei, Gu Dachuan, Rao Chenfei, Zhang Heng, Su Xiaoting, Chen Sipeng, Ma Hanping, Zhao Yan, Feng Wei, Sun Hansong, Zheng Zhe
National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
BMJ Qual Saf. 2023 Apr;32(4):192-201. doi: 10.1136/bmjqs-2021-014244. Epub 2022 Jun 1.
With increasing surgical workload, it is common for cardiac surgeons to perform coronary artery bypass grafting (CABG) after other procedures in a workday. To investigate whether prior procedures performed by the surgeon impact the outcomes, we compared the outcomes between CABGs performed first versus those performed after prior procedures, separately for on-pump and off-pump CABGs as they differed in technical complexity.
We conducted a retrospective cohort study of patients undergoing isolated CABG in China from January 2013 to December 2018. Patients were categorised as undergoing on-pump and off-pump CABGs. Outcomes of the procedures performed first in primary surgeons' daily schedule (first procedure) were compared with subsequent ones (non-first procedure). The primary outcome was an adverse events composite (AEC) defined as the number of adverse events, including in-hospital mortality, myocardial infarction, stroke, acute kidney injury and reoperation. Secondary outcomes were the individual components of the primary outcome, presented as binary variables. Mixed-effects models were used, adjusting for patient and surgeon-level characteristics and year of surgery.
Among 21 866 patients, 10 109 (16.1% as non-first) underwent on-pump and 11 757 (29.6% as non-first) off-pump CABG. In the on-pump cohort, there was no significant association between procedure order and the outcomes (all p>0.05). In the off-pump cohort, non-first procedures were associated with an increased number of AEC (adjusted rate ratio 1.29, 95% CI 1.13 to 1.47, p<0.001), myocardial infarction (adjusted OR (OR) 1.43, 95% CI 1.13 to 1.81, p=0.003) and stroke (OR 1.73, 95% CI 1.18 to 2.53, p=0.005) compared with first procedures. These increases were only found to be statistically significant when the procedure was performed by surgeons with <20 years' practice or surgeons with a preindex volume <700 cases.
For a technically challenging surgical procedure like off-pump CABG, prior workload adversely affected patient outcomes.
随着手术工作量的增加，心脏外科医生在一个工作日内先进行其他手术再进行冠状动脉旁路移植术（CABG）的情况很常见。为了研究外科医生之前进行的手术是否会影响手术结果，我们分别比较了体外循环CABG和非体外循环CABG中，先进行的CABG与在之前手术之后进行的CABG的结果，因为这两种手术在技术复杂性上有所不同。
我们对2013年1月至2018年12月在中国接受单纯CABG的患者进行了一项回顾性队列研究。患者被分为接受体外循环CABG和非体外循环CABG。将主刀医生日常手术安排中首先进行的手术（首次手术）结果与后续手术（非首次手术）结果进行比较。主要结局是不良事件综合指标（AEC），定义为不良事件的数量，包括住院死亡率、心肌梗死、中风、急性肾损伤和再次手术。次要结局是主要结局的各个组成部分，以二元变量形式呈现。使用混合效应模型，并对患者和医生层面的特征以及手术年份进行了调整。
在21866例患者中，10109例（16.1%为非首次手术）接受了体外循环CABG，11757例（29.6%为非首次手术）接受了非体外循环CABG。在体外循环队列中，手术顺序与结局之间无显著关联（所有p>0.05）。在非体外循环队列中，与首次手术相比，非首次手术的AEC数量增加（调整后的率比为1.29，95%可信区间为1.13至1.47，p<0.001），心肌梗死（调整后的比值比（OR）为1.43，95%可信区间为1.13至1.81，p=0.003）和中风（OR为1.73，95%可信区间为1.18至2.53，p=0.005）。仅在从业年限<20年的外科医生或术前手术量<700例的外科医生进行手术时，这些增加才具有统计学意义。
对于像非体外循环CABG这样技术要求高的手术，之前的工作量会对患者结局产生不利影响。
