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Schwann TA, Engoren M, Gaudino MF, Mentz G, Saadat S, Engelman D, Lobdell KW, Vekstein AM, Habib RH. Practice makes perfect? Institutional coronary artery bypass case volumes and outcomes. Eur J Cardiothorac Surg 2023; 64:ezad324. [PMID: 37812216 DOI: 10.1093/ejcts/ezad324] [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: 11/15/2022] [Revised: 08/14/2023] [Accepted: 10/06/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVES Older studies of coronary artery bypass grafting (CABG) institutional case volumes and outcomes reported conflicting results. We explored this association in the rapidly changing contemporary practice of American surgeons using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. METHODS The 2018-2019 isolated primary CABG experience in the STS Adult Cardiac Surgery Database was analysed (241 902 patients; 1014 hospitals; 2718 surgeons). Generalized Estimating Equations were used to estimate coefficients between CABG institutional case volumes and outcomes. The observed-to-expected ratios based on STS risk models were used to assess risk-adjusted operative mortality (OM), mortality/major morbidity (MM) and deep sternal wound infections (DSWI) as a function of institutional case volumes. RESULTS The mean (standard deviation) OM, MM and DSWI rates were 2.1% (2.7), 11.1% (9.2) and 0.6% (0.5), respectively. The mean (standard deviation) institutional case volumes per study period was 239 (192); 23% and 9% of institutions performed <100 and >500 cases/study period, respectively. There was a weak negative correlation between expected mortality (R2 -0.0014), OM (R2 -0.0272), MM (R2 -0.1213) and DSWI (R2 -0.003) and institutional case volumes. CONCLUSIONS CABG outcomes generally improve with increasing institutional case volumes. Given the large number of CABG cases performed nationally, even the documented weak correlation has the potential to appreciably decrease OM, MM and DSWI if cases are performed at higher volume institutions. Studies focusing on additional hospital and surgeon factors are warranted to further define quality improvement opportunities.
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Affiliation(s)
| | | | | | | | - Siavash Saadat
- University of Massachusetts-Baystate, Springfield, MA, USA
| | | | | | - Andrew M Vekstein
- Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Rappoport N, Shahian DM, Galai N, Aviel G, Keaney JF, Shapira OM. Volume-Outcome Relationship of Resternotomy Coronary Artery Bypass Grafting. Ann Thorac Surg 2022:S0003-4975(22)01390-X. [PMID: 36328096 DOI: 10.1016/j.athoracsur.2022.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 08/26/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND We assessed volume-outcome relationships of resternotomy coronary artery bypass grafting (CABG). METHODS We studied 1,362,218 first-time CABG and 93,985 resternotomy CABG patients reported to The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2010 and 2019. Primary outcomes were in-hospital mortality and mortality and morbidity (M&M) rates calculated per hospital and per surgeon. Outcomes were compared across 6 total cardiac surgery volume categories. Multivariable generalized linear mixed-effects models were used considering continuous case volume as the main exposure, adjusting for patient characteristics and within-surgeon and hospital variation. RESULTS We observed a decline in resternotomy CABG unadjusted mortality and M&M from the lowest to the highest case-volume categories (hospital-level mortality, 3.9% ± 0.6% to 3.3% ± 0.1%; M&M, 18.5% ± 1.1% to 15.7% ± 0.4%, P < .001; surgeon-level mortality, 4.1% ± 0.3% to 4.1% ± 1.3%; M&M, 18.5% ± 0.6% to 14.5% ± 2.2%, P < .001). Looking at outcomes vs continuous volume showed that beyond a minimum annual volume (hospital 200-300 cases; surgeon 100-150 cases, approximately), mortality and M&M rates did not further improve. Using individual-level data and adjusting for patient characteristics and clustering within surgeon and hospital, we found higher procedural volume was associated with improved surgeon-level outcomes (mortality adjusted odds ratio, 0.39/100 procedures; 95% CI, 0.24-0.61; M&M adjusted odds ratio, 0.37/100 procedures; 95% CI, 0.28-0.48; P < .001 for both). Hospital-level adjusted volume-outcomes associations were not statistically significant. CONCLUSIONS We observed an inverse relationship between total cardiac case volume and resternotomy CABG outcomes at the surgeon level only, indicating that individual surgeon's experience, rather than institutional volume, is the key determinant.
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Affiliation(s)
- Nadav Rappoport
- Department of Software and Information Systems Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - David M Shahian
- Division of Cardiac Surgery, Department of Surgery and The Center of Quality & Safety, Massachusetts General Hospital, Boston, Massachusetts
| | - Noya Galai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Statistics, University of Haifa, Mount Carmel, Israel
| | - Gal Aviel
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - John F Keaney
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Oz M Shapira
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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Bennetts J, Sinhal A, Walters D, MacIsaac A, Fayers T, Lo S, Almeida A, Muller DWM. 2021 CSANZ and ANZSCTS Position Statement on the Operator and Institutional Requirements for a Transcatheter Aortic Valve Implantation (TAVI) Program in Australia. Heart Lung Circ 2021; 30:1811-1818. [PMID: 34483050 DOI: 10.1016/j.hlc.2021.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 12/28/2022]
Abstract
This document establishes the minimum standard for accreditation of institutions and operators as endorsed by the Cardiac Society of Australia and New Zealand (CSANZ) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS). The original Joint Society Position Statement was ratified in August 2014. This 2021 update replaces the original and serves as a consensus within which the Conjoint Committee for Trancatheter Aortic Valve Implantation (TAVI) Accreditation will function, as recommended by Medical Services Advisory Committee (MSAC) Determination for TAVI. This is not a Guideline Statement but takes into consideration regional, legislative, and health system factors important to establishing requirements for TAVI accreditation in Australia.
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Affiliation(s)
- Jayme Bennetts
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia; Department of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
| | - Ajay Sinhal
- Department of Cardiology, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, SA, Australia; Department of Medicine, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Darren Walters
- St. Vincent's Northside Medical Centre, Brisbane, Qld, Australia
| | - Andrew MacIsaac
- Department of Cardiology St. Vincent's Hospital Melbourne, Melbourne, Vic, Australia
| | - Trevor Fayers
- St. Vincent's Northside Medical Centre, Brisbane, Qld, Australia; Gold Coast University Hospital, Southport, Gold Coast, Qld, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia
| | - Aubrey Almeida
- Department of Cardiothoracic Surgery, Monash Medical Centre, Monash Health, Melbourne, Vic, Australia
| | - David W M Muller
- Department of Cardiology, St. Vincent's Hospital Sydney, Sydney, NSW, Australia
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Bianco V, Aranda‐Michel E, Sultan I, Gleason TG, Chu D, Navid F, Kilic A. Inconsistent correlation between procedural volume and publicly reported outcomes in adult cardiac operations. J Card Surg 2019; 34:1194-1203. [DOI: 10.1111/jocs.14218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburgh Pennsylvania
| | - Edgar Aranda‐Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburgh Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburgh Pennsylvania
| | - Thomas G. Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburgh Pennsylvania
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburgh Pennsylvania
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburgh Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh and Heart and Vascular InstituteUniversity of Pittsburgh Medical CenterPittsburgh Pennsylvania
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Single- Versus Multicenter Surgeons’ Risk-Adjusted Coronary Artery Bypass Graft Procedural Outcomes. Ann Thorac Surg 2018; 105:1308-1314. [DOI: 10.1016/j.athoracsur.2018.01.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/30/2017] [Accepted: 01/03/2018] [Indexed: 11/23/2022]
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Antevil JL, Mullenix PS, Reoma JL, Massimiano PS, Lough FC, Elster EA. Maintaining Quality in Lower Volume Cardiac Surgery: A Blueprint From a Military Program. Am J Med Qual 2017; 33:426-433. [PMID: 29239197 DOI: 10.1177/1062860617747729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although there is a clear volume-outcome relationship in the field of cardiac surgery, the existence of high-performing programs with relatively low case volumes is well established. This report describes the programmatic and institutional processes in place at a lower volume cardiac surgery center in a US military hospital, which have been executed to optimally leverage available resources in the delivery of exemplary patient care. By implementing a highly collaborative practice, rigorous outcomes review, evidence-based standardized care pathways, consistent attending surgeon oversight for care delivery, careful case selection, and a mechanism for support from highly experienced outside cardiac surgeons, the cardiac surgery program at the authors' institution delivers care on par with its higher volume counterparts. A review of these practices and available supporting evidence may provide a model for other programs seeking success in this setting.
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Affiliation(s)
- Jared L Antevil
- 1 Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Philip S Mullenix
- 1 Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Junewai L Reoma
- 1 Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
| | | | - Frederick C Lough
- 1 Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Eric A Elster
- 1 Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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8
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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9
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper. ACTA ACUST UNITED AC 2015; 68:976-995.e10. [PMID: 26315766 DOI: 10.1016/j.rec.2015.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023]
Abstract
Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.
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Affiliation(s)
- José López-Sendón
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain.
| | - José Ramón González-Juanatey
- Sociedad Española de Cardiología, Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Fausto Pinto
- European Society of Cardiology; Department of Cardiology, University Hospital Santa Maria, Lisbon, Portugal
| | - José Cuenca Castillo
- Sociedad Española de Cirugía Torácica-Cardiovascular; Servicio de Cirugía Cardiaca, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Lina Badimón
- Centro de Investigación Cardiovascular (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Regina Dalmau
- Unidad de Rehabilitación Cardiaca, Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Esteban González Torrecilla
- Unidad de Electrofisiología y Arritmias, Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - José Ramón López-Mínguez
- Unidad de Cardiología intervencionista, Servicio de Cardiología, Hospital Infanta Crsitina, Badajoz, Spain
| | - Alicia M Maceira
- Unidad de Imagen Cardiaca, Servicio de Cardiología, ERESA Medical Center, Valencia, Spain
| | - Domingo Pascual-Figal
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | - Alessandro Sionis
- Unidad de Cuidados Intensivos Cardiológicos, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Luis Zamorano
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Walters DL, Webster M, Pasupati S, Walton A, Muller D, Stewart J, Williams M, MacIsaac A, Scalia G, Wilson M, Gamel AE, Clarke A, Bennetts J, Bannon P. Position Statement for the Operator and Institutional Requirements for a Transcatheter Aortic Valve Implantation (TAVI) Program. Heart Lung Circ 2015; 24:219-23. [DOI: 10.1016/j.hlc.2014.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/18/2014] [Indexed: 12/14/2022]
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11
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Tommaso CL, Fullerton DA, Feldman T, Dean LS, Hijazi ZM, Horlick E, Weiner BH, Zahn E, Cigarroa JE, Ruiz CE, Bavaria J, Mack MJ, Cameron DE, Bolman RM, Craig Miller D, Moon MR, Mukherjee D, Trento A, Aldea GS, Bacha EA. SCAI/AATS/ACC/STS operator and institutional requirements for transcatheter valve repair and replacement. Part II. Mitral valve. Catheter Cardiovasc Interv 2014; 84:567-80. [PMID: 24828236 DOI: 10.1002/ccd.25540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 05/06/2014] [Indexed: 01/22/2023]
Affiliation(s)
- Carl L Tommaso
- Cardiac Cath Lab, North Shore Cardiologists, North Shore University Health System, 9669 North Kenton, Skokie, Illinois
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12
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SCAI/AATS/ACC/STS Operator and Institutional Requirements for Transcatheter Valve Repair and Replacement. Part II. Mitral Valve. J Am Coll Cardiol 2014; 64:1515-26. [DOI: 10.1016/j.jacc.2014.05.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 05/06/2014] [Indexed: 01/22/2023]
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13
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SCAI/AATS/ACC/STS operator and institutional requirements for transcatheter valve repair and replacement. Part II. Mitral valve. J Thorac Cardiovasc Surg 2014; 148:387-400. [PMID: 24996693 DOI: 10.1016/j.jtcvs.2014.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 05/06/2014] [Indexed: 01/22/2023]
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14
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Tommaso CL, Fullerton DA, Feldman T, Dean LS, Hijazi ZM, Horlick E, Weiner BH, Zahn E, Cigarroa JE, Ruiz CE, Bavaria J, Mack MJ, Cameron DE, Bolman RM, Miller DC, Moon MR, Mukherjee D, Trento A, Aldea GS, Bacha EA. SCAI/AATS/ACC/STS operator and institutional requirements for transcatheter valve repair and replacement: Part II. Mitral valve. Ann Thorac Surg 2014; 98:765-77. [PMID: 24835557 DOI: 10.1016/j.athoracsur.2014.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 01/22/2023]
Affiliation(s)
- Carl L Tommaso
- Cardiac Cath Lab, North Shore Cardiologists, North Shore University Health System, Skokie, Illinois.
| | - David A Fullerton
- Cardiothoracic Surgery, University of Colorado Denver, Aurora, Colorado
| | - Ted Feldman
- Cardiac Catheterization Laboratory, Evanston Hospital, Evanston, Illinois; Cardiology Division, Evanston Hospital, Evanston, Illinois
| | - Larry S Dean
- University of Washington School of Medicine, Seattle, Washington; UW Medicine Regional Heart Center, Seattle, Washington
| | - Ziyad M Hijazi
- Rush Center for Congenital & Structural Heart Disease, Chicago, Illinois; Pediatric Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Eric Horlick
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Bonnie H Weiner
- Saint Vincent Hospital at Worcester Medical Center/Fallon Clinic, Worcester, Massachusetts; Boston Biomedical Associates, Northborough, Massachusetts
| | - Evan Zahn
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Joaquin E Cigarroa
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Carlos E Ruiz
- Lenox Hill Heart and Vascular Institute of New York, New York, New York
| | - Joseph Bavaria
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Mack
- Cardiovascular Council Dallas, Heart Hospital Baylor Plano, Plano, Texas
| | - Duke E Cameron
- The Dana and Albert "Cubby" Broccoli Center for Aortic Diseases, The Johns Hopkins Hospital, Baltimore, Maryland
| | - R Morton Bolman
- Division of Cardiac Surgery, Harvard Medical School, Boston, Massachusetts
| | - D Craig Miller
- Cardiovascular Surgical Physiology Research Laboratories, Stanford University Medical Center, Stanford, California; Cardiovascular Surgery, Falk CV Research Center, Stanford, California
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
| | | | - Alfredo Trento
- Division of Cardiothoracic Surgery, Cedar Sinai Medical Center, Los Angeles, California
| | - Gabriel S Aldea
- Regional Heart Center, University of Washington Medical Center, Seattle, Washington
| | - Emile A Bacha
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center, New York, New York; Pediatric Cardiac Surgery, Morgan Stanley Children's Hospital of New York, New York, New York
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Tommaso CL, Bolman RM, Feldman T, Bavaria J, Acker MA, Aldea G, Cameron DE, Dean LS, Fullerton D, Hijazi ZM, Horlick E, Miller DC, Moon MR, Ringel R, Ruiz CE, Trento A, Weiner BH, Zahn EM. Multisociety (AATS, ACCF, SCAI, and STS) expert consensus statement: operator and institutional requirements for transcatheter valve repair and replacement, part 1: transcatheter aortic valve replacement. J Thorac Cardiovasc Surg 2012; 143:1254-63. [PMID: 22595626 DOI: 10.1016/j.jtcvs.2012.03.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Carl L Tommaso
- Division of Cardiology, NorthShore University HealthSystem, Skokie Hospital, Skokie, IL 60076, USA.
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Tommaso CL, Bolman RM, Feldman T, Bavaria J, Acker MA, Aldea G, Cameron DE, Dean LS, Fullerton D, Hijazi ZM, Horlick E, Miller DC, Moon MR, Ringel R, Ruiz CE, Trento A, Weiner BH, Zahn EM. Multisociety (AATS, ACCF, SCAI, and STS) expert consensus statement: operator and institutional requirements for transcatheter valve repair and replacement, part 1: transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2012; 80:1-17. [PMID: 22383383 DOI: 10.1002/ccd.24394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 02/27/2012] [Indexed: 01/22/2023]
Affiliation(s)
- Carl L Tommaso
- Division of Cardiology, NorthShore University HealthSystem, Skokie Hospital, Skokie, Illinois 60076, USA.
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Tommaso CL, Bolman RM, Feldman T, Bavaria J, Acker MA, Aldea G, Cameron DE, Dean LS, Fullerton D, Hijazi ZM, Horlick E, Miller DC, Moon MR, Ringel R, Ruiz CE, Trento A, Weiner BH, Zahn EM. Multisociety (AATS, ACCF, SCAI, and STS) Expert Consensus Statement: Operator and Institutional Requirements for Transcatheter Valve Repair and Replacement, Part 1: Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2012; 93:2093-110. [DOI: 10.1016/j.athoracsur.2012.02.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 02/24/2012] [Accepted: 02/24/2012] [Indexed: 01/22/2023]
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Tommaso CL, Bolman RM, Feldman T, Bavaria J, Acker MA, Aldea G, Cameron DE, Dean LS, Fullerton D, Hijazi ZM, Horlick E, Miller DC, Moon MR, Ringel R, Ruiz CE, Trento A, Weiner BH, Zahn EM. Multisociety (AATS, ACCF, SCAI, and STS) Expert Consensus Statement: Operator and Institutional Requirements for Transcatheter Valve Repair and Replacement, Part 1: Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2012; 59:2028-42. [DOI: 10.1016/j.jacc.2012.02.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Schüpfer G, Gfrörer R, Schleppers A. [Anaesthetists learn--do institutions also learn? Importance of institutional learning and corporate culture in clinics]. Anaesthesist 2008; 56:983-91. [PMID: 17898964 DOI: 10.1007/s00101-007-1265-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In only a few contexts is the need for substantial learning more pronounced than in health care. For a health care provider, the ability to learn is essential in a changing environment. Although individual humans are programmed to learn naturally, organisations are not. Learning that is limited to individual professions and traditional approaches to continuing medical education is not sufficient to bring about substantial changes in the learning capacity of an institution. Also, organisational learning is an important issue for anaesthesia departments. Future success of an organisation often depends on new capabilities and competencies. Organisational learning is the capacity or processes within an organisation to maintain or improve performance based on experience. Learning is seen as a system-level phenomenon as it stays in the organisation regardless of the players involved. Experience from other industries shows that learning strategies tend to focus on single loop learning, with relatively little double loop learning and virtually no meta-learning or non-learning. The emphasis on team delivery of health care reinforces the need for team learning. Learning organisations make learning an intrinsic part of their organisations and are a place where people continually learn how to learn together. Organisational learning practice can help to improve existing skills and competencies and to change outdated assumptions, procedures and structures. So far, learning theory has been ignored in medicine, due to a wide variety of complex political, economic, social, organisational culture and medical factors that prevent innovation and resist change. The organisational culture is central to every stage of the learning process. Learning organisations move beyond simple employee training into organisational problem solving, innovation and learning. Therefore, teamwork and leadership are necessary. Successful organisations change the competencies of individuals, the systems, the organisation, the strategy and the culture.
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Affiliation(s)
- G Schüpfer
- Institut für Anästhesie, chirurgische Intensivmedizin und Schmerztherapie, Kantonsspital Luzern, 6000, Luzern 16, Schweiz.
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Geissler HJ, Beyersdorf F. [Minimum provider volumes in heart surgery]. Chirurg 2007; 78:994-8. [PMID: 17928976 DOI: 10.1007/s00104-007-1413-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The introduction of minimum provider volumes for certain medical procedures has been the subject of scientific investigation and political controversy for quite a while. The core of the discussion focuses on the hypothesis that minimum provider volumes could significantly improve operative results and cost efficiency. In Germany the Fifth Volume of Social Law (Sozialgesetzbuch V) set the legal stage for the implementation of minimum provider volumes. This article is a brief review on the experience with minimum provider volumes in cardiac surgery. The main focus is on coronary artery bypass surgery, as this happens to be the most frequently investigated procedure.
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Affiliation(s)
- H J Geissler
- Abteilung für Herz- und Gefässchirurgie, Universitätsklinikum, Hugstetterstrasse 55, Freiburg, Germany.
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Nallamothu BK, Eagle KA, Ferraris VA, Sade RM. Should Coronary Artery Bypass Grafting Be Regionalized? Ann Thorac Surg 2005; 80:1572-81. [PMID: 16242420 DOI: 10.1016/j.athoracsur.2005.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2005] [Revised: 04/04/2005] [Accepted: 04/04/2005] [Indexed: 11/27/2022]
Affiliation(s)
- Brahmajee K Nallamothu
- Health Services Research & Development Center of Excellence, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
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22
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Vassiliades TA, Block PC, Cohn LH, Adams DH, Borer JS, Feldman T, Holmes DR, Laskey WK, Lytle BW, Mack MJ, Williams DO. The Clinical Development of Percutaneous Heart Valve Technology. Ann Thorac Surg 2005; 79:1812-8. [PMID: 15854994 DOI: 10.1016/j.athoracsur.2005.02.062] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Vassiliades TA, Block PC, Cohn LH, Adams DH, Borer JS, Feldman T, Holmes DR, Laskey WK, Lytle BW, Mack MJ, Williams DO. The Clinical Development of Percutaneous Heart Valve Technology. J Am Coll Cardiol 2005; 45:1554-60. [PMID: 15862441 DOI: 10.1016/j.jacc.2004.12.024] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Vassiliades TA, Block PC, Cohn LH, Adams DH, Borer JS, Feldman T, Holmes DR, Laskey WK, Lytle BW, Mack MJ, Williams DO. The clinical development of percutaneous heart valve technology. J Thorac Cardiovasc Surg 2005; 129:970-6. [PMID: 15867768 DOI: 10.1016/j.jtcvs.2005.02.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Vassiliades TA, Block PC, Cohn LH, Adams DH, Borer JS, Feldman T, Holmes DR, Laskey WK, Lytle BW, Mack MJ, Williams DO. The clinical development of percutaneous heart valve technology: A position statement of the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society of Cardiovascular Angiography and Intervention (SCAI). Catheter Cardiovasc Interv 2005; 65:73-9. [PMID: 15791621 DOI: 10.1002/ccd.20281] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Thomas A Vassiliades
- Division of Cardiothoracic Surgery. Emory University School of Medicine, 1365 Clifton Road NE, Atlanta, GA 30322, USA.
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Shahian DM, Blackstone EH, Edwards FH, Grover FL, Grunkemeier GL, Naftel DC, Nashef SAM, Nugent WC, Peterson ED. Cardiac Surgery Risk Models: A Position Article. Ann Thorac Surg 2004; 78:1868-77. [PMID: 15511504 DOI: 10.1016/j.athoracsur.2004.05.054] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Differences in medical outcomes may result from disease severity, treatment effectiveness, or chance. Because most outcome studies are observational rather than randomized, risk adjustment is necessary to account for case mix. This has usually been accomplished through the use of standard logistic regression models, although Bayesian models, hierarchical linear models, and machine-learning techniques such as neural networks have also been used. Many factors are essential to insuring the accuracy and usefulness of such models, including selection of an appropriate clinical database, inclusion of critical core variables, precise definitions for predictor variables and endpoints, proper model development, validation, and audit. Risk models may be used to assess the impact of specific predictors on outcome, to aid in patient counseling and treatment selection, to profile provider quality, and to serve as the basis of continuous quality improvement activities.
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Affiliation(s)
- A Thomas Pezzella
- Cardiothoracic Surgery, Good Samaritan Hospital, Mt. Vernon, IL, USA
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Cochrane DD, Kestle JRW. The influence of surgical operative experience on the duration of first ventriculoperitoneal shunt function and infection. Pediatr Neurosurg 2003; 38:295-301. [PMID: 12759508 DOI: 10.1159/000070413] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The relationship of surgeon experience, measured by operative volume, to the outcomes of ventricular shunt treatment of hydrocephalus in children is not clear. This paper explores this relationship based on first ventriculoperitoneal shunts (VPS) implanted in English-speaking Canada during the period from April 1989 to March 2001. Three thousand seven hundred and ninety-four first VPS insertions, performed by 254 surgeons, were reviewed. Surgical experience was represented by the number of shunt operations performed during the study period by each surgeon prior to the date of the operation. The 6-month shunt failure risk for less experienced surgeons was 38%, compared to 31% for more experienced surgeons. This difference decreased to 4% at 60 months and 3% at 120 months (p = 0.001). The infection rate for initial shunt insertions was 7% for patients treated by more experienced surgeons and 9.4% for those treated by less experienced surgeons (p = 0.006). A relationship between surgeon experience and shunt outcome that appears to be based on the operative experience that a surgeon brings to a procedure is in keeping with clinical experience. This observation has implications for public policy, service planning and surgical mentorship during the earlier years of a surgeon's career.
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Affiliation(s)
- D D Cochrane
- Department of Surgery, University of British Columbia and Children's and Women's Health Center of British Columbia, Vancouver, Canada.
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Abstract
BACKGROUND Debate continues regarding the effectiveness of thymectomy in the treatment of nonthymomatous autoimmune myasthenia gravis primarily because there have been no controlled prospective studies. The debate is compounded by the lack of recognition that all thymectomies are not equal in extent or effectiveness and by the fact that all the studies are retrospective without common definitions of myasthenia gravis manifestations or response to therapy. In addition, the analysis of data is often inappropriate. REVIEW SUMMARY Evidence is presented demonstrating that the extent of the various thymic resectional techniques is very variable and often incomplete and that the more complete the thymic resection the better the results. The indications for thymectomy, the selection of the technique of the resection, the reoperations issue, the perioperative management of the myasthenia gravis patient, morbidity and mortality, and appropriate methods of outcome research are also reviewed. CONCLUSION In view of the impressive results associated with a complete thymic resection in the treatment of myasthenia gravis, patients should not be denied this operation because of lack of prospective proof to-date, and when a thymectomy is performed a total resection is indicated.
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Affiliation(s)
- Alfred Jaretzki
- College of Physicians and Surgeons, Columbia University, Department of Surgery, Columbia Presbyterian Medical Center, New York, NY, USA.
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Abstract
Numerous reports have documented a volume-outcome relationship for complex medical and surgical care, although many such studies are compromised by the use of discharge abstract data, inadequate risk adjustment, and problematic statistical methodology. Because of the volume-outcome association, and because valid outcome measurements are unavailable for many procedures, volume-based referral strategies have been advocated as an alternative approach to health-care quality improvement. This is most appropriate for procedures with the greatest outcome variability between low-volume and high-volume providers, such as esophagectomy and pancreatectomy, and for particularly high-risk subgroups of patients. Whenever possible, risk-adjusted outcome data should supplement or supplant volume standards, and continuous quality improvement programs should seek to emulate the processes of high-volume, high-quality providers. The Leapfrog Group has established a minimum volume requirement of 500 procedures for coronary artery bypass grafting. In view of the questionable basis for this recommendation, we suggest that it be reevaluated.
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Affiliation(s)
- David M Shahian
- Department of Thoracic and Cardiovascular Surgery, Lahey Clinic, Burlington, Massachusetts 01805, USA.
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Carey JS, Robertson JM, Misbach GA, Fisher AL. Relationship of Hospital Volume to Outcome in Cardiac Surgery Programs in California. Am Surg 2003. [DOI: 10.1177/000313480306900114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There are more than 120 cardiac surgery programs in California. More than half perform less than 200 coronary artery bypass graft (CABG) procedures per year. This study queried the state of California discharge abstract database to analyze the relationship between annual procedural volume and outcomes of all 119 nonfederal hospitals performing cardiac surgery during 1997 through 1999. Unadjusted in-hospital mortality for CABG surgery was 3.91 per cent (923 of 23,619) in hospitals performing fewer than 200 procedures per year and 2.09 per cent (496 of 23,704) in hospitals performing ≥500 procedures annually ( P = 0.001 by Chi-square). Similar findings were noted for CABG + valve and/or aneurysm and for valve procedures. Risk-adjusted CABG data obtained from 78 of 119 hospitals found that a significant difference persisted between a volume of <200 and ≥200 procedures per year ( P = 0.03 by t test). There was wider variation in outcome among lower-volume hospitals. However, many low-volume providers had excellent results. It is concluded that although volume is clearly related to outcome patient-related factors and process variables may be more important. Performance improvement programs should be developed to improve communication between providers with differing outcomes.
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Affiliation(s)
- Joseph S. Carey
- From the California Society of Thoracic Surgeons, Torrance and the Office of Statewide Health Planning and Development, Sacramento, California
| | - John M. Robertson
- From the California Society of Thoracic Surgeons, Torrance and the Office of Statewide Health Planning and Development, Sacramento, California
| | - Gregory A. Misbach
- From the California Society of Thoracic Surgeons, Torrance and the Office of Statewide Health Planning and Development, Sacramento, California
| | - Audrey L. Fisher
- From the California Society of Thoracic Surgeons, Torrance and the Office of Statewide Health Planning and Development, Sacramento, California
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Slim K, Flamein R, Chipponi J. [Relation between activity volume and surgeon's results: myth or reality?]. ANNALES DE CHIRURGIE 2002; 127:502-11. [PMID: 12404844 DOI: 10.1016/s0003-3944(02)00817-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The relationship between volume and surgical outcome seems logical, but needs to be demonstrated in the real world. A qualitative systematic review has been conducted to verify this hypothesis. Five systematic reviews and hundred original papers have been retrieved and analysed. Most of the studies were retrospective and used administrative data instead of medical charts. Moreover few studies involved a good case mix adjustment when comparing surgical units or individual surgeons. These methodological flaws do not allow any evidence based conclusions. Even though a positive relationship is suggested for surgical units, the relationship between volume and outcome was however less obvious for an individual surgeon. There is some evidence that the relationship varied greatly according to the specialty or the procedure evaluated. A new approach based on predictive scores comparing expected versus observed outcomes is mandatory and seems to be the best way to assess objectively the relationship between surgical volume and outcomes.
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Affiliation(s)
- K Slim
- Service de chirurgie générale et digestive, Hôtel-Dieu, boulevard Léon-Malfreyt, 63058 Clermont-Ferrand, France.
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Nallamothu BK, Saint S, Ramsey SD, Hofer TP, Vijan S, Eagle KA. The role of hospital volume in coronary artery bypass grafting: is more always better? J Am Coll Cardiol 2001; 38:1923-30. [PMID: 11738295 DOI: 10.1016/s0735-1097(01)01647-3] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The goal of this study was to determine whether outcomes of nonemergent coronary artery bypass grafting (CABG) differed between low- and high-volume hospitals in patients at different levels of surgical risk. BACKGROUND Regionalizing all CABG surgeries from low- to high-volume hospitals could improve surgical outcomes but reduce patient access and choice. "Targeted" regionalization could be a reasonable alternative, however, if subgroups of patients that would clearly benefit from care at high-volume hospitals could be identified. METHODS We assessed outcomes of CABG at 56 U.S. hospitals using 1997 administrative and clinical data from Solucient EXPLORE, a national outcomes benchmarking database. Predicted in-hospital mortality rates for subjects were calculated using a logistic regression model, and subjects were classified into five groups based on surgical risk: minimal (< 0.5%), low (0.5% to 2%), moderate (2% to 5%), high (5% to 20%), and severe (> or =20%). We assessed differences in in-hospital mortality, hospital costs and length of stay between low- and high-volume facilities (defined as > or =200 annual cases) in each of the five risk groups. RESULTS A total of 2,029 subjects who underwent CABG at 25 low-volume hospitals and 11,615 subjects who underwent CABG at 31 high-volume hospitals were identified. Significant differences in in-hospital mortality were seen between low- and high-volume facilities in subjects at moderate (5.3% vs. 2.2%; p = 0.007) and high risk (22.6% vs. 11.9%; p = 0.0026) but not in those at minimal, low or severe risk. Hospital costs and lengths of stay were similar across each of the five risk groups. Based on these results, targeted regionalization of subjects at moderate risk or higher to high-volume hospitals would have resulted in an estimated 370 transfers and avoided 16 deaths; in contrast, full regionalization would have led to 2,029 transfers and avoided 20 deaths. CONCLUSIONS Targeted regionalization might be a feasible strategy for balancing the clinical benefits of regionalization with patients' desires for choice and access.
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Affiliation(s)
- B K Nallamothu
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan 48109-0366, USA
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Mussi A, Lucchi M, Murri L, Ricciardi R, Luchini L, Angeletti CA. Extended thymectomy in myasthenia gravis: a team-work of neurologist, thoracic surgeon and anaesthesist may improve the outcome. Eur J Cardiothorac Surg 2001; 19:570-5. [PMID: 11343933 DOI: 10.1016/s1010-7940(01)00634-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE We reviewed our overall experience on 163 patients, affected by myasthenia gravis, who underwent thymectomy between 1976 and 1998. A comparison between the oldest series of 72 patients (January 1976-December 1992), referred by various neurologists and operated on through different approaches, and the last 91 patients (January 1993-December 1998), taking part in a strict diagnostic-therapeutical programme, was made. METHODS Anagraphic data, duration of symptoms, the surgical approach, necessity of respiratory assistance, the hospital stay, histopathological findings, preoperative and postoperative Osserman classification, as well as medications, were globally analyzed and then compared in the two groups. RESULTS Significant differences in the length of hospitalization (8.7 days vs. 4.2 days; P=0.00001) and in the prolonged intubation rate (18 vs. 0; P<0.000001) were observed in the most recent series. Patients in the pre-operative Osserman stage I and operated on in the second period had a higher complete remission rate at the univariate analysis (P<0.001 and P<0.0001, respectively). At the multivariate analysis the only parameter which affected the outcome was to be operated on in the second period (P<0.01). CONCLUSIONS Our experience confirms the role of the extended thymectomy in the treatment of myasthenia gravis. Whenever an extended thymectomy was performed through a complete sternotomy it was a quick procedure, with short hospitalization and acceptable cosmetic results. A careful pharmacological control of the myasthenic symptoms and the presence of team-work among neurologist, thoracic surgeon and anaesthesist in the peri-operative setting reduce the incidence of complications and might increase the efficacy of the thymectomy.
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Affiliation(s)
- A Mussi
- Cardiac and Thoracic Department, Division of Thoracic Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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Affiliation(s)
- B J Harlan
- Sutter Memorial Hospital, Sacramento, Calif., USA.
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Abstract
Clinical science research incorporates the fields of clinical investigation and health services research. With a focus on the use of either human specimens or subjects, clinical investigation research projects translate knowledge gained from basic science research based on animal models for disease. The goal of clinical investigation is to develop new prevention, intervention, and therapeutic approaches to improve patient clinical outcomes. In contrast, health services research focuses on the improvement of the efficacy, cost-effectiveness, and outcomes of care. Health services research projects examine options to improve the health care delivery system, organization, financing, and reimbursement mechanisms in place today. The purpose of this article is to review common terminology and methodologic approaches that are used in clinical science research. The process of designing a research project is reviewed. Beginning with the development of a research question and hypothesis, the steps for successful completion of the project are discussed. Different study design approaches are presented with their respective strengths and weaknesses. The challenges associated with conducting a clinical research study are discussed, including the development of an appropriate sampling strategy, the designing of data collection, instruments, and the assurance of study data integrity. Possible threats to study validity and generalizability are assessed.One the major advantages of clinical research is that it offers an opportunity to study clinical questions in the clinical setting without the expenses of a basic research laboratory and basic science technology. Thus important clinical questions related to patient care, new technology assessment, clinical practice management, health care administration, or health policy may be addressed.
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Affiliation(s)
- F L Grover
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Health Sciences Center, Denver Department of Veterans Affairs Medical Center, Denver, Colorado 80220, USA
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Early GL, Roberts SR. Excellence and low case volume: an example of the inapplicability of volume-based credentialing. Ann Thorac Surg 2000; 69:146-50. [PMID: 10654504 DOI: 10.1016/s0003-4975(99)01260-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Health care reform, public disclosure of hospital and surgeon-specific results, plus changes in reimbursement patterns have raised the specter of volume-based credentialing. METHODS Using The Society of Thoracic Surgeons Cardiac Database, we examined the data for all coronary artery bypass graft-only patients (n = 615) operated on by us from July 1991 to June 1997. RESULTS The observed mortality was 0.33% and the observed-to-expected ratio was 0.12 (p<0.005). Morbidity was low as well. CONCLUSIONS Excellent results can be obtained for patients undergoing coronary artery bypass grafting in the presence of both low surgeon and low hospital case volume.
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Affiliation(s)
- G L Early
- Heartland Regional Medical Center, St. Joseph, Missouri, USA
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Grover FL. The Society of Thoracic Surgeons National Database: current status and future directions. Ann Thorac Surg 1999; 68:367-73; discussion 374-6. [PMID: 10475399 DOI: 10.1016/s0003-4975(99)00599-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The Society of Thoracic Surgeons National Database, established seven years ago by thoracic surgeons for self improvement and quality assurance, now has 1,181,464 patients registered, including 897,914 coronary artery bypass operations. Risk-adjusted 30 day mortality for coronary bypass procedures, unadjusted mortality for other cardiothoracic procedures, unadjusted morbidity and length of stay as well as several processes of care are measured. There has been a progressive decrease in operative mortality and length of stay over the past seven years. Deaths, complications, and lengths of stay are stratified according to estimated risk of death. Definitions have been refined in conjunction with the American College of Cardiology. The database is being increasingly utilized for state analyses and is in demand by other organizations and third party carriers. Logistic regression analysis is now utilized for development of the risk models. The database has been useful for health care policy decisions and can be useful for our Professional Affairs Committee in their dealings with government. Other uses include measuring access to care and cost. Data quality improvement measures have been put in place, as well as data manager education. The General Thoracic and Congenital data acquisition packages are being modified and improved, and a goal is to begin collecting longitudinal data to demonstrate the long term efficacy of thoracic procedures. The data elements have been decreased from 500 to 200+ core variables for simplification. With the changing healthcare environment and emphasis on cost cutting, collecting valid data by a national specialty group enhances the monitoring of quality of care, thus protecting our patients from overzealous cutbacks. Data is essential to document the efficacy, quality and cost-effectiveness of the procedures we perform and is a necessary tool for each of us to have to assure the quality and continued success of our practices.
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Affiliation(s)
- F L Grover
- Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center, Denver VA Medical Center, USA.
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Silvestri GA, Handy J, Lackland D, Corley E, Reed CE. Specialists achieve better outcomes than generalists for lung cancer surgery. Chest 1998; 114:675-80. [PMID: 9743149 DOI: 10.1378/chest.114.3.675] [Citation(s) in RCA: 151] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE A push toward care provided by generalists as opposed to specialists has occurred in the health-care marketplace despite a lack of provider specific outcome data. The objective of this study was to determine whether the outcome of patients undergoing lung cancer surgery is different between general surgeons (GSs) and thoracic surgeons (TSs). DESIGN Examination of data from a state-wide severity-adjusted administrative hospital discharge database. SETTING/PARTICIPANTS Patients undergoing lung cancer resection in all nonfederal acute care hospitals within South Carolina. MAIN OUTCOME MEASURES Mortality by specialty adjusted for case mix. RESULTS From 1991 to 1995, 1,720 resections for lung cancer were performed in South Carolina. One hundred thirty-seven cases were excluded because surgeons did not meet the predefined criteria for board certification, leaving 1,583 resections for analysis. One-half of lobectomies and nearly 60% of pneumonectomies were performed by GSs. Patients were similar in age, sex, gender, race, and the proportion in each severity of illness subclass. Mortality was significantly higher in patients who underwent lobectomy by GSs vs TSs (5.3% vs 3.0%; p<0.05) and in patients with extreme comorbidities (43.6% vs 25.4%; p=0.03) or age >65 years (7.4% vs 3.5%; p<0.05). Seventy percent of TSs performed > 10 cases in the series, whereas 75% of GSs performed <10 (p=0.05). Logistic regression analysis failed to identify any significant variable that might explain the mortality differences between TSs and GSs. CONCLUSION Mortality is lower for lung cancer resection when the surgery is performed by a TS.
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Affiliation(s)
- G A Silvestri
- Department of Medicine, The Center for Health Care Research, Medical University of South Carolina, Charleston, USA
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Abstract
There is a prevailing consensus that the quality of health services can be improved by concentrating care in the hands of those providers who carry out larger volumes of activity. The substantial research literature indicates a positive volume-quality relationship. However, these conclusions are largely based on observational studies using administrative databases which are poorly adjusted for case mix. Better control for confounding shows that volume-quality effects in several cases may be an artefact. The research is also difficult to interpret because of the limited measurement of outcomes, poor analysis of the relative contributions of the clinician and the hospital levels, and the lack of clarity about the direction of cause and effect. Most research is insufficiently reliable to inform policy on the use of volume for credentialling or for the re-configuration of services.
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Grover FL, Shroyer AL, Hammermeister KE. Calculating risk and outcome: the Veterans Affairs database. Ann Thorac Surg 1996; 62:S6-11; discussion S31-2. [PMID: 8893627 DOI: 10.1016/0003-4975(96)00821-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The methodology used by the Department of Veterans Affairs for data collection and analysis to derive observed/expected mortality ratios in cardiac surgical patients is reviewed. The Department of Veterans Affairs' use of univariate and multivariate analysis to develop risk ratios for individual risk factors is described. Its experience with tracking observed/expected mortality and morbidity associated with cardiac surgery and length of hospital stays is reviewed. Results of the Department of Veterans Affairs study of the relationship between hospital surgical volume and observed/expected ratios are reported. Feasible goals for the improvement of the predictive capability of database models and the limitations affecting model accuracy are discussed.
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Affiliation(s)
- F L Grover
- Surgical and Medical Services, Denver Department of Veterans Affairs Medical Center, Colorado, USA
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Abstract
Various approaches to the calculation of medical risk are reviewed, including univariate analysis, additive methods, use of Bayes' theorem by The Society of Thoracic Surgeons, logistic regression, and neural networks. Strengths and weaknesses of the various approaches are evaluated. The use and importance of observed/expected ratios, the C statistic, and receiver operating curves are discussed. Specific requirements for the building of useful risk-calculation models are discussed, including the importance of the model set/test set method and the role of both numbers of patients and time frames in model building.
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Affiliation(s)
- R E Clark
- Department of Surgery, Medical College of Pennsylvania, Pittsburgh 15212, USA
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Abstract
We are currently at a crossroads in our specialty and in the American healthcare delivery system. The manner in which we approach the next 5 to 10 years will deeply affect the future of our specialty. Thoracic surgery has had many accomplishments during my 35-year career that have improved the healthcare for the American public and others. As cardiothoracic surgeons, we have a legacy to be proud of, and the future promises to be every bit as exciting. In spite of these tremendous advances and the potential for future scientific achievements, there has been considerable uncertainty and pessimism because of the changing structure of healthcare in the United States. This has largely been stimulated by increasing health-care expenditures leading to the development of health maintenance organizations in the hopes of curtailing expenses by competition and capitation. In addition to cost containment, managed care is likely to have an impact on the future workforce of cardiothoracic surgeons. Much of our future will be determined by how well we adapt to the changing environment and take charge of our destiny. The demand for performance information for managed care plans will be much greater than it has been in the past. It is, therefore, imperative that we collect data to reflect the quality and value of our work to ensure that significant quality is not being sacrificed for cost containment. We cardiothoracic surgeons must develop our own information management strategies so that we can be in control of our future. If we do this, I am confident that the future of cardiothoracic surgery will be a bright one indeed.
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Affiliation(s)
- F L Grover
- University of Colorado Health Sciences Center, Denver 80262, USA
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