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Published on: March 27, 2018
Reduction in coronary artery bypass grafting surgery mortality and morbidity during a 3-year multicenter quality
Neil Worrall1, James Brevig2, Ruyun Jin3
1Providence Sacred Heart Medical Center and Children's Hospital, Spokane, Wash; Providence St Joseph Heart Institute, Renton, Wash.
Insights
A quality improvement initiative significantly reduced operative mortality for coronary artery bypass grafting by 50%. This surgeon-led effort involved data sharing and standardized processes, improving patient outcomes across 14 hospitals.
Area of Science:
- Cardiovascular Surgery
- Quality Improvement Science
- Health Services Research
Background:
- Operative mortality is a critical quality metric for isolated coronary artery bypass grafting (CABG).
- A large, geographically dispersed healthcare system aimed to enhance CABG quality across its surgical programs.
Purpose of the Study:
- To implement and evaluate a multicenter quality improvement initiative focused on reducing risk-adjusted operative mortality for isolated CABG.
- To assess the impact of the initiative on mortality and morbidity rates.
Main Methods:
- A multifaceted, surgeon-led quality improvement intervention was implemented across 14 surgical programs.
- Data on observed and expected mortality/morbidity were collected from January 2014 to June 2017, using Society of Thoracic Surgeons risk models.
- Key interventions included regular data sharing, standardized processes, quality improvement meetings, and care standardization through checklists.
Main Results:
- The observed/expected mortality ratio decreased significantly from 1.19 (baseline) to 0.59 (outcome period), representing a 50% reduction (P = .004).
- No significant changes were observed in expected mortality or case volume.
- Observed/expected mortality/morbidity ratios also decreased, with near elimination of mortality without antecedent morbidity.
Conclusions:
- A multifaceted quality improvement initiative achieved a significant and clinically meaningful 50% reduction in isolated CABG operative mortality.
- Surgeon leadership, transparent data sharing, standardized processes, and a focus on care delivery were crucial for success.
- The initiative also led to decreased morbidity, underscoring the effectiveness of a systematic approach to improving surgical quality.
Objective:
Risk-adjusted operative mortality is a key quality measure for isolated coronary artery bypass grafting. Through a multicenter quality improvement initiative, we sought to improve this measure at 14 surgical programs within a large and geographically dispersed health care system.
Methods:
Observed mortality and combined mortality/morbidity rates for isolated coronary artery bypass grafting were collected from January 2014 to June 2017. Expected mortality and mortality/morbidity rates were determined using the Society of Thoracic Surgeons risk models. The observed/expected ratios during the baseline (2014) and final 12-month outcome period were compared. The quality improvement intervention was multifaceted and surgeon led, and consisted of (1) regular sharing of unblinded data, (2) standardized quality improvement processes, (3) regular system-wide quality improvement meetings, (4) annual observed/expected mortality targets, (5) identification of underperforming institutions and creation of nonpunitive quality improvement action plans, and (6) implementation of checklists to drive perioperative care standardization.
Results:
The observed/expected ratio of mortality was 1.19 during the baseline period and decreased to 0.59 for the outcome period (P = .004) without a change in expected mortality or case volume. The observed/expected ratio decreased for mortality/morbidity, and mortality without antecedent morbidity was almost eliminated.
Conclusions:
A significant and clinically meaningful 50% reduction in the observed/expected ratio for isolated coronary artery bypass grafting mortality was observed during a multifaceted quality improvement initiative across a large multicenter health care system. Morbidity also decreased. Keys to success included surgeon leadership and engagement, frequent unblinded data sharing, development of standardized quality improvement processes, improvement and standardization of care delivery, setting of quality improvement targets, and a shared vision for improved patient outcomes.
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