Impact of Public Reporting of 30-day Mortality on Timing of Death after Coronary Artery Bypass Graft Surgery

Translating Policy to Practice: An Association Between Medicare Access and Children's Health Insurance Program Reauthorization Act Implementation and Palliative Care Consultations and Perioperative Mortality in Critical Care

OBJECTIVES

To evaluate the 30-day postoperative mortality and palliative care consultations in patients that underwent surgical procedures in the United States before and after Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) implementation.

DESIGN

Retrospective, Observational cohort study.

SETTING

Secondary data were collected from the U.S. National Inpatient Sample, the largest hospital database in the country. The time span was from 2011 to 2019.

PATIENTS

Adult patients that electively underwent 1 of 19 major procedures.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was cumulative postoperative mortality in two study cohorts. The secondary outcome was palliative care use. We identified 4,900,451 patients and categorized them into two study cohorts: PreM: 2011-2014 ( n = 2,103,836) and PostM: 2016-2019 ( n = 2,796,615). Regression discontinuity estimates and multivariate analysis were used. Across all procedures, 149,372 patients (7.1%) and 156,610 patients (5%) died within 30 days of their index procedures in the PreM and PostM cohorts, respectively. There was no statistically significant increase in mortality rates around postoperative day (POD) 30 (POD 26-30 vs 31-35) for both cohorts. More patients had inpatient palliative consultations during POD 31-60 compared with POD 1-30 in PreM (8,533 of 2,081,207 patients [0.4%] vs 1,118 of 22,629 patients [4.9%]) and PostM (18,915 of 2,791,712 patients [0.7%] vs 417 of 4,903 patients [8.5%]). Patients were more likely to receive palliative care consultations during POD 31-60 compared with POD 1-30 in both the PreM (odds ratio [OR] 5.31; 95% CI, 2.22-8.68; p < 0.001) and the PostM (OR 7.84; 95% CI, 4.83-9.10; p < 0.001) cohorts.

CONCLUSIONS

We did not observe an increase in postoperative mortality after POD 30 before or after MACRA implementation. However, palliative care use markedly increased after POD 30. These findings should be considered hypothesis-generating because of several confounders.

Operative mortality in adult cardiac surgery: is the currently utilized definition justified?

Background

This study evaluated operative mortalities following adult cardiac surgical operations to determine if this metric remains appropriate for the modern era.

Methods

This was a retrospective review of Society of Thoracic Surgeons (STS) indexed adult cardiac operations that included coronary artery bypass grafting (CABG), aortic valve replacement (AVR), CABG + AVR, mitral valve repair (MVr), CABG + MVr, mitral valve replacement (MVR) and CABG + MVR, performed at a single institution between 2011 and 2017. The primary outcome was the timing and relatedness of operation mortality, as defined by the STS as mortality within 30-day or during the index hospitalization, compared to the index operation. The secondary outcomes evaluated cause of death and the rates of postoperative complications.

Results

A total of 11,190 index cardiac operations were performed during the study period and operative mortality occurred in 246 (2.2%) of patients. The distribution of operative mortalities included 83.7% (n=206) who expired within 30-day while an inpatient, 6.9% (n=17) died within 30-day as an outpatient, 11.2% (n=23) expired after 30-day. The most common causes of operative mortality were cardiac (38.7%, n=92), renal failure (15.6%, n=37), and strokes (13.9%, n=33). Furthermore, 98.4% (n=242) of deaths were attributable to the index operation. Postoperative complications occurred frequently in those with operative mortality, with blood transfusions (80.1%), reoperations (65.0%) and prolonged ventilation (62.2%) being most common.

Conclusions

Most of the operative mortalities seemed to be attributable to the index cardiac operation. We believe that the current definition of mortality remains appropriate in the modern era.

The Association Between Institutional Mortality After Coronary Artery Bypass Grafting at One Year and Mortality Rates at 30 Days

OBJECTIVE

To assess the association between the common quality metric of 30-day mortality and mortality at 60 days, 90 days, and one year after coronary artery bypass grafting.

DESIGN

A retrospective cohort study, with multivariate logistic regression to assess association among mortality outcomes.

SETTING

Hospitals participating in Medicare and reporting data within the Centers for Medicare and Medicaid Services Limited Data Set between April 1, 2016, and March 31, 2017.

PARTICIPANTS

A total of 37,036 patients undergoing surgery at 394 hospitals.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Mortality rates were 1.0%-to-3.1% for the top and bottom quartile of hospitals at 30 days. At one year, the top 25th percentile of hospitals had mortality rates averaging 3.9%; while hospitals below the 75th percentile had mortality rates averaging 7.6%. Twenty-three percent of hospitals in the top quartile at 30 days were no longer in the top quartile at 60 days. At one year, only 48% of hospitals that were in the top quartile at 30 days remained in the top quartile. The correlation between mortality rates at 30 days and the reported points was assessed using Spearman's rho. The R value between mortality at 30 days and mortality at one year was 0.53, which improved to 0.7 and 0.76 at 60 and 90 days.

CONCLUSIONS

Mortality at 30 days correlated poorly with mortality at one year. Hospitals that were high- or low-performing at 30 days frequently were no longer within the same performance group at one year.

Is a hospital quality policy based on a triad of accreditation, public reporting and inspection evidence-based? A narrative review

BACKGROUND

Since 2009, hospital quality policy in Flanders, Belgium, is built around a quality-of-care triad, which encompasses accreditation, public reporting (PR) and inspection. Policy makers are currently reflecting on the added value of this triad.

METHODS

We performed a narrative review of the literature published between 2009 and 2020 to examine the evidence base of the impact accreditation, PR and inspection, both individually and combined, has on patient processes and outcomes. The following patient outcomes were examined: mortality, length of stay, readmissions, patient satisfaction, adverse outcomes, failure to rescue, adherence to process measures and risk aversion. The impact of accreditation, PR and inspection on these outcomes was evaluated as either positive, neutral (i.e. no impact observed or mixed results reported) or negative.

OBJECTIVES

To assess the current evidence base on the impact of accreditation, PR and inspection on patient processes and outcomes.

RESULTS

We identified 69 studies, of which 40 were on accreditation, 24 on PR, three on inspection and two on accreditation and PR concomitantly. Identified studies reported primarily low-level evidence (level IV, n = 53) and were heterogeneous in terms of implemented programmes and patient populations (often narrow in PR research). Overall, a neutral categorization was determined in 30 articles for accreditation, 23 for PR and four for inspection. Ten of these recounted mixed results. For accreditation, a high number (n = 12) of positive research on adherence to process measures was discovered.

CONCLUSION

The individual impact of accreditation, PR and inspection, the core of Flemish hospital quality, was found to be limited on patient outcomes. Future studies should investigate the combined effect of multiple quality improvement strategies.

Barriers to High Quality End of Life Care in the Surgical Intensive Care Unit

End of life discussions frequently take place in surgical intensive care units, as a significant number of patients die while admitted to the hospital, and surgery is common during the last month of life. Multiple barriers exist to the initiation of these conversations, including: miscommunication between clinicians and surrogates, a paternalistic approach to surgical patients, and perhaps, conflicts of interest as an unwanted consequence of surgical quality reporting. Goal discordant care refers to the care that is provided to a patient that is incapacitated and that is not concordant to his/her wishes. This is a largely unrecognized medical error with devastating consequences, including inappropriate prolongation of life and non-beneficial therapy utilization. Importantly, hospice and palliative care needs to be recognized as quality care in order to deter the incentives that might persuade clinicians from offering these services.

Minimally invasive single-vessel left internal mammary to left anterior descending artery bypass grafting improves outcomes over conventional sternotomy: A single-institution retrospective cohort study

BACKGROUND

Coronary artery bypass grafting (CABG) can be performed through a variety of approaches. Minimally-invasive CABG (MICABG) may reduce perioperative morbidity. Previous results demonstrate improved perioperative outcomes; however, adoption has been limited.

METHODS

The Society of Thoracic Surgeons (STS) database and electronic medical record at a single institution were reviewed for isolated left internal mammary to left anterior descending artery (LIMA-LAD) bypass procedures performed between 2011 and 2018. Patients were grouped on the basis of operative approach, comparing sternotomy to non-sternotomy (minimally-invasive). Patient characteristics, perioperative variables, and short- and long-term outcomes were compared. Primary outcomes included mortality and major adverse cardiac events (MACE). Secondary outcomes were morbidity.

RESULTS

A total of 42 MICABG and 54 conventional LIMA-LAD procedures were performed with 95.2% of MICABG procedures performed by two surgeons. MICABG were more often elective (83.3 vs 38.9%, P < .001). STS risk scores predicted equitable mortality and morbidity for MICABG dependent on operative indication. MICABG was associated with fewer pulmonary complications (0.0 vs 11.1%, P = .033), in-hospital events (11.9 vs 37.0%, P = .005), and shorter intensive care unit (34.1 vs 66.0 hours, P = .022) and total length of stay (3.7 vs 6.5 days, P = .002). There were no observed strokes, myocardial infarctions, or reoperations. MICABG patients demonstrated reduced thirty-day mortality (0.0 vs 10.9%, P = .036) and improved Kaplan-Meier 5-year (95.2 vs 77.9%, P = .016) and MACE-free survival (89.2 vs 63.9%, P = .010).

CONCLUSIONS

Minimally-invasive LIMA-LAD CABG demonstrates improved early postoperative morbidity and a long-term mortality benefit. In select patients, minimally-invasive approaches to single-vessel grafting may be beneficial when performed by experienced surgeons in the elective setting.

End-of-Life Care in Cardiothoracic Surgery

Patients undergoing cardiothoracic surgery face a small but significant mortality risk. Despite this, end-of-life care specific to this population has received little attention. This article examines current literature on end-of-life care in cardiothoracic surgery and in critical care. Recommendations for management at the end of life are made based on the available evidence.

Using a National Representative Sample to Evaluate the Integrity of the 30-Day Surgical Mortality Metric

The 30-day surgical mortality metric is endorsed by the National Quality Forum for value-based purchasing purposes. However, its integrity has been questioned, as there is documented evidence of hospital manipulation of this measure, by way of inappropriate palliative care designation and changes in patient selection. To determine if there is evidence of potential manipulation, we retrospectively analyzed 1,725,291 surgical admissions from 158 United States hospitals participating in the National Inpatient Sample from 2010 to 2011. As a way of evaluating unnecessary life-prolonging measures, we determined that a significant increase in mortality rate after post-operative day 30 (day 31-35) would indicate manipulation. We compared the post-operative mortality rates for each hospital between Post-Operative Day 26-30 and Post-Operative Day 31-35 using Wilcoxon signed-rank tests. After application of the Bonferroni correction, the results showed that none of the hospitals had a statistically significant increase in mortality after post-operative day 30. This analysis fails to impugn the integrity of this measure, as we did not identify any evidence of potential manipulation of the 30-day surgical mortality metric.

A retrospective evaluation of the risk of bias in perioperative temperature metrics

The prevention and treatment of hypothermia is an important part of routine anesthesia care. Avoidance of perioperative hypothermia was introduced as a quality metric in 2010. We sought to assess the integrity of the perioperative hypothermia metric in routine care at a single large center. Perioperative temperatures from all anesthetics of at least 60 min duration between January 2012 and 2017 were eligible for inclusion in analysis. Temperatures were displayed graphically, assessed for normality, and analyzed using paired comparisons. Automatically-recorded temperatures were obtained from several monitoring sites. Provider-entered temperatures were non-normally distributed, exhibiting peaks at temperatures at multiples of 0.5 °C. Automatically-acquired temperatures, on the other hand, were more normally distributed, demonstrating smoother curves without peaks at multiples of 0.5 °C. Automatically-acquired median temperature was highest, 36.8 °C (SD = 0.8 °C), followed by the three manually acquired temperatures (nurse-documented postoperative temperature, 36.5 °C [SD = 0.6 °C]; intraoperative manual temperature, 36.5 °C [SD = 0.6 °C]; provider-documented postoperative temperature, 36.1 °C [SD = 0.6 °C]). Provider-entered temperatures exhibit values that are unlikely to represent a normal probability distribution around a central physiologic value. Manually-entered perioperative temperatures appear to cluster around salient anchoring values, either deliberately, or as an unintended result driven by cognitive bias. Automatically-acquired temperatures may be superior for quality metric purposes.

Assessing coding practices for gastrointestinal surgery over time in the United States

BACKGROUND

Variations in hospital billing practices may reflect differences in patient risk or may represent the "upcoding" of patients in response to payer incentives/policies. The current study sought to assess whether coding practices for gastrointestinal surgery have changed over time and to evaluate the association between upcoding and in-hospital costs.

METHODS

A total of 1,344,152 patients aged >18 years undergoing a gastrointestinal operation between 2001 and 2011 were identified using the National Inpatient Sample. Coding practices were compared by hospital and patient characteristics. Multivariable analysis was performed to evaluate the association between coding practices and in-hospital costs.

RESULTS

The mean and median number of codes per admission were 8.8 (standard deviation = 4.58) and 9 (interquartile range: 5-11), respectively. Over time, the proportion of admissions being upcoded (>9 codes/admission) increased from 14.1% to 32.9% (∆ = +133.3%, P < .001). This trend was observed for each gastrointestinal operation and was greatest for hepatectomy (∆ = +73.3%). Although admissions that were upcoded were more likely to be for patients with greater comorbidity and Medicare enrollees, an increase in the proportion of patients upcoded was also observed regardless of the primary payer, among patients presenting without comorbidity, and among patients undergoing an elective operation (all P < .001). On adjusted analysis, admissions that were upcoded were independently associated with a $13,754 (95% confidence interval: $13,638-$13,870) greater in-hospital cost.

CONCLUSION

The number of "upcoded" patients was observed to increase with time. Greater education, regulation, and scrutiny are required of coding practices.