A retrospective multicenter study of operating room extubation and extubation timing after cardiac surgery
Published October of 2024 in the Journal of Thoracic and Cardiovascular Surgery
Etchill EW, Wu X, Alejo D, Fonner CE, Ling C, Worrall N, Lehr E, Pagani F, Haber T, Theurer P, Collins-Brandon J, Hira R, Brevig J, Mallory E, Maynard C, Likosky DS, Whitman GJR; IMPROVE Network. J Thorac Cardiovasc Surg. 2024 Oct 18:S0022-5223(24)00928-0. doi: 10.1016/j.jtcvs.2024.09.057. Online ahead of print. PMID: 39426716
Methods: Patients undergoing on-pump cardiac surgery across 79 hospitals between 2011 and 2020 were included to (1) compare outcomes among OR extubation and early ICU extubation patients and (2) assess time to overall ICU extubation and outcomes.
Results: The overall study cohort comprised 163,982 patients, including 95,982 patients (OR extubation: n ¼ 2529 [2.6%] and early ICU extubation: n ¼ 93,453 [97.4%]) who underwent comparison of OR with early ICU extubation. After overlap weighting, patients with OR extubation had longer OR times (5.6 vs 5.1 hours, P<. 0001) and greater rates of reintubation (5.2% vs 2.9%, P ¼ .003), prolonged ventilation (3% vs 2%, P ¼ .021), reoperation for bleeding (1.5% vs 0.7%, P<.01), pneumonia (1.9% vs 1.1%, P<.006), and greater in-hospital mortality on multivariable regression (odds ratio, 1.34, P<.001). Patients with OR extubation at centers with low OR extubation rates (<10%, n ¼ 60) had greater mortality (odds ratio, 1.6, P ¼ .001). Beyond 22 hours of postoperative ICU ventilation, the risk of morbidity and mortality increased significantly.
Conclusions: Few patients who undergo cardiac surgery are extubated in the OR, which is associated with no clinical benefit and with increased morbidity. Cardiac surgery programs should reconsider OR extubation after cardiopulmonary bypass. In addition, increased intubation time, in particular>22 hours, is associated with an increase in adverse outcomes.
Methods: Patients undergoing on-pump cardiac surgery across 79 hospitals between 2011 and 2020 were included to (1) compare outcomes among OR extubation and early ICU extubation patients and (2) assess time to overall ICU extubation and outcomes.
Results: The overall study cohort comprised 163,982 patients, including 95,982 patients (OR extubation: n ¼ 2529 [2.6%] and early ICU extubation: n ¼ 93,453 [97.4%]) who underwent comparison of OR with early ICU extubation. After overlap weighting, patients with OR extubation had longer OR times (5.6 vs 5.1 hours, P<. 0001) and greater rates of reintubation (5.2% vs 2.9%, P ¼ .003), prolonged ventilation (3% vs 2%, P ¼ .021), reoperation for bleeding (1.5% vs 0.7%, P<.01), pneumonia (1.9% vs 1.1%, P<.006), and greater in-hospital mortality on multivariable regression (odds ratio, 1.34, P<.001). Patients with OR extubation at centers with low OR extubation rates (<10%, n ¼ 60) had greater mortality (odds ratio, 1.6, P ¼ .001). Beyond 22 hours of postoperative ICU ventilation, the risk of morbidity and mortality increased significantly.
Conclusions: Few patients who undergo cardiac surgery are extubated in the OR, which is associated with no clinical benefit and with increased morbidity. Cardiac surgery programs should reconsider OR extubation after cardiopulmonary bypass. In addition, increased intubation time, in particular>22 hours, is associated with an increase in adverse outcomes.
Interhospital variability in failure to rescue rates following aortic valve surgery
Published September of 2023 online with JTSCVS Open
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Bauer TM, Pienta M, Wu X, Lehr EJ, Whitman GJR, Kramer RS, Brevig J, Pagani FD, Likosky DS. JTCVS Open. 2023 Sep 1;16:123-138. doi: 10.1016/j.xjon.2023.08.010. eCollection 2023 Dec. PMID: 38204724
Objective: This study evaluated interhospital variability and determinants of failure-to-rescue for patients undergoing surgical aortic valve replacement. Methods: An observational study was conducted among 28,842 patients undergoing aortic valve replacement with or without coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals participating in the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Postoperative complications were defined as major (stroke, renal failure, reoperation, prolonged ventilation, sternal infection) and overall (major plus 14 other morbidities). Hospital terciles of observed to expected (O/E) mortality were compared on crude rates of major and overall complications, operative mortality, and failure to rescue (among major and overall complications). The correlation between hospital observed and expected failure-to-rescue rates was assessed. Results: Median Society of Thoracic Surgeons Adult Cardiac Surgery Database predicted mortality risk was similar across hospital O:E mortality terciles (P ¼ .10). As expected, mortality rates significantly increased across terciles (low O/E tercile: 1.6%, high O/E tercile: 4.7%; P<.001). Failure-to-rescue rates increased substantially across hospital mortality terciles among patients with major (low tercile, 8.8% and high tercile, 20.8%) and overall (low tercile, 3.0% and high tercile, 8.9%) complications. Hospital-level expected failure to rescue had a higher correlation with observed complications for overall complications (R2 ¼ 0.71) compared with Society of Thoracic Surgeons major complications (R2 ¼ 0.24). Conclusions: Considerable interhospital variation exists in failure-to-rescue rates following aortic valve replacement. Hospitals in the low O/E mortality tercile experience failure to rescue nearly one-third less than those in the high O/E mortality tercile. Efforts to advance quality will benefit from identifying and disseminating optimal rescue strategies in this patient population. |
Geographic variability in potentially discretionary red blood cell transfusions after coronary artery bypass graft surgery
Published December of 2014 in the Journal of Thoracic and Cardiovascular Surgery
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OBJECTIVE: A number of established regional quality improvement collaboratives have partnered to assess and improve care across their regions under the umbrella of the Cardiac Surgery Quality Improvement (IMPROVE) Network. The first effort of the IMPROVE Network has been to assess regional differences in potentially discretionary transfusions (<3 units red blood cells [RBCs]).
METHODS: We examined 11,200 patients undergoing isolated nonemergent coronary artery bypass graft surgery across 56 medical centers in 4IMPROVE Network regions between January 2008 and June 2012. Each center submitted the most recent 200 patients who received 0, 1, or 2 units of RBC transfusion during the index admission. Patient and disease characteristics, intraoperative practices, and percentage of patients receiving RBC transfusions were collected. Region-specific transfusion rates were calculated after adjusting for pre- and intraoperative factors among region-specific centers. RESULTS: There were small but significant differences in patient case mix across regions. RBC transfusions of 1 or 2 units occurred among 25.2% of coronary artery bypass graft procedures (2826 out of 11,200). Significant variation in the number of RBC units used existed across regions (no units, 74.8% [min-max, 70.0%-84.1%], 1 unit, 9.7% [min-max, 5.1%-11.8%], 2 units, 15.5% [min-max, 9.1%-18.2%]; P < .001). Variation in overall transfusion rates remained after adjustment (9.1%-31.7%; P < .001). CONCLUSIONS: Delivery of small volumes of RBC transfusions was common, yet varied across geographic regions. These data suggest that differences in regional practice environments, including transfusion triggers and anemia management, may contribute to variability in RBC transfusion rates. |
Interhospital Failure to Rescue After Coronary Artery Bypass Grafting
Published January of 2021 in the Journal of Thoracic and Cardiovascular Surgery
Published January of 2021 in the Journal of Thoracic and Cardiovascular Surgery
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Likosky DS; Strobel RJ; Wu X; Kramer RS; Hamman BL; Brevig JK; Thompson MP; Ghaferi AA; Zhang M; Lehr EJ and the National Cardiac Surgery Quality IMPROVE Network. Interhospital Failure to Rescue After Coronary Artery Bypass Grafting. J Thorac Cardiovasc Surg. 2021 Jan 29;S0022-5223(21)00163-X. doi: 10.1016/j.jtcvs.2021.01.064. Online ahead of print. PMID: 33712236.
Objective: We evaluated whether interhospital variation in mortality rates for coronary artery bypass grafting was driven by complications and failure to rescue. Methods: An observational study was conducted among 83,747 patients undergoing isolated coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals. Failure to rescue was defined as operative mortality among patients developing complications. Complications included the Society of Thoracic Surgeons 5 major complications (stroke, surgical reexploration, deep sternal wound infection, renal failure, prolonged intubation) and a broader set of 19 overall complications. After creating terciles of hospital performance (based on observed:expected mortality), each tercile was compared on the basis of crude rates of (1) major and overall complications, (2) operative mortality, and (3) failure to rescue (among major and overall complications). The correlation between hospital observed and expected (to address confounding) failure to rescue rates was assessed. Results: Median Society of Thoracic Surgeons predicted mortality risk was similar across hospital observed:expected mortality terciles (P = .831). Mortality rates significantly increased across terciles (low tercile: 1.4%, high tercile: 2.8%). Although small in magnitude, rates of major (low tercile: 11.1%, high tercile: 12.2%) and overall (low tercile: 36.6%, high tercile: 35.3%) complications significantly differed across terciles. Nonetheless, failure to rescue rates increased substantially across terciles among patients with major (low tercile: 9.1%, high tercile: 14.3%) and overall (low tercile: 3.3%, high tercile: 6.8%) complications. Hospital observed and expected failure to rescue rates were positively correlated among patients with major (R2 = 0.14) and overall (R2 = 0.51) complications. Conclusions: The reported interhospital variability in successful rescue after coronary artery bypass grafting supports the importance of identifying best practices at high-performing hospitals, including early recognition and management of complications. |
A Comparison of statistical methods for hospital performance assessment.
Published May of 2021 in the Journal of Hospital Administration
Published May of 2021 in the Journal of Hospital Administration
Abstract: During hospital quality improvement activities, statistical approaches are critical to help assess hospital performance for benchmarking. Current statistical approaches are used primarily for research and reimbursement purposes. In this multi-institutional study, these established statistical methods were evaluated for quality improvement applications. Leveraging a dataset of 42,199 patients who underwent coronary artery bypass grafting surgery from 2014 to 2016 across 90 hospitals, six statistical approaches were applied. The non-shrinkage methods were: (1) indirect standardization without hospital effect; (2) indirect standardization with hospital fixed effect; (3) direct standardization with hospital fixed effect. The shrinkage methods were: (4) indirect standardization with hospital random effect; (5) direct standardization with hospital random effect; (6) Bayesian method. Hospital performance related to operative mortality and major morbidity or mortality was compared across methods based on variation in adjusted rates, rankings, and performance outliers. Method performance was evaluated across procedure volume terciles: small (< 96 cases/year), medium (96-171), and large (> 171). Shrinkage methods reduced inter-hospital variation (min-max) for mortality (observed: 0%-10%; adjusted: 1.5%-2.4%) and major morbidity or mortality (observed: 2.6%-35%; adjusted: 6.9%-17.5%). Shrinkage methods shrunk hospital rates toward the group mean. Direct standardization with hospital random effect, compared to fixed effect, resulted in 16.7%-38.9% of hospitals changing quintile mortality ranking. Indirect standardization with hospital random effect resulted in no performance outliers among small and medium hospitals for mortality, while logistic and fixed effect methods identified one small and three medium outlier hospitals. The choice of statistical method greatly impacts hospital ranking and performance outlier’ status. These findings should be considered when benchmarking hospital performance for hospital quality improvement activities.
