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Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a
Danwei Zhang1, Dachuan Gu1,2, Chenfei Rao1,2
1National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
Insights
Cardiac surgeons performing off-pump coronary artery bypass grafting (CABG) later in the day face increased adverse events. Prior surgical workload negatively impacts outcomes for this complex procedure, especially for less experienced surgeons.
Area of Science:
- Cardiovascular Surgery
- Surgical Outcomes Research
- Health Services Research
Background:
- Increasing surgical workload is common for cardiac surgeons performing coronary artery bypass grafting (CABG).
- The impact of prior procedures on CABG outcomes is not well understood.
- CABG procedures differ in technical complexity between on-pump and off-pump techniques.
Purpose of the Study:
- To investigate whether the order of coronary artery bypass grafting (CABG) procedures impacts patient outcomes.
- To compare outcomes of first versus non-first procedures for both on-pump and off-pump CABG.
- To identify surgeon-specific factors influencing the association between procedure order and outcomes.
Main Methods:
- Retrospective cohort study of 21,866 isolated CABG patients in China (2013-2018).
- Patients categorized into on-pump and off-pump CABG groups.
- Outcomes compared between first and non-first procedures using mixed-effects models, adjusting for patient and surgeon factors.
Main Results:
- No significant association between procedure order and outcomes in on-pump CABG.
- Off-pump CABG non-first procedures showed increased adverse events composite (1.29), myocardial infarction (ORadj 1.43), and stroke (ORadj 1.73).
- These adverse outcomes were significant for surgeons with <20 years' practice or <700 preindex cases.
Conclusions:
- Prior surgical workload adversely affects patient outcomes for off-pump CABG.
- Off-pump CABG is technically demanding, and surgeon fatigue may play a role.
- Surgical experience and case volume moderate the impact of workload on off-pump CABG outcomes.
Background:
With increasing surgical workload, it is common for cardiac surgeons to perform coronary artery bypass grafting (CABG) after other procedures in a workday. To investigate whether prior procedures performed by the surgeon impact the outcomes, we compared the outcomes between CABGs performed first versus those performed after prior procedures, separately for on-pump and off-pump CABGs as they differed in technical complexity.
Methods:
We conducted a retrospective cohort study of patients undergoing isolated CABG in China from January 2013 to December 2018. Patients were categorised as undergoing on-pump and off-pump CABGs. Outcomes of the procedures performed first in primary surgeons' daily schedule (first procedure) were compared with subsequent ones (non-first procedure). The primary outcome was an adverse events composite (AEC) defined as the number of adverse events, including in-hospital mortality, myocardial infarction, stroke, acute kidney injury and reoperation. Secondary outcomes were the individual components of the primary outcome, presented as binary variables. Mixed-effects models were used, adjusting for patient and surgeon-level characteristics and year of surgery.
Results:
Among 21 866 patients, 10 109 (16.1% as non-first) underwent on-pump and 11 757 (29.6% as non-first) off-pump CABG. In the on-pump cohort, there was no significant association between procedure order and the outcomes (all p>0.05). In the off-pump cohort, non-first procedures were associated with an increased number of AEC (adjusted rate ratio 1.29, 95% CI 1.13 to 1.47, p<0.001), myocardial infarction (adjusted OR (ORadj) 1.43, 95% CI 1.13 to 1.81, p=0.003) and stroke (ORadj 1.73, 95% CI 1.18 to 2.53, p=0.005) compared with first procedures. These increases were only found to be statistically significant when the procedure was performed by surgeons with <20 years' practice or surgeons with a preindex volume <700 cases.
Conclusions:
For a technically challenging surgical procedure like off-pump CABG, prior workload adversely affected patient outcomes.
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