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Published on: September 15, 2023
Volume-Outcome Relationship of Resternotomy Coronary Artery Bypass Grafting
Nadav Rappoport1, David M Shahian2, Noya Galai3
1Department of Software and Information Systems Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel.
Insights
Surgeon experience, not hospital volume, significantly impacts resternotomy coronary artery bypass grafting (CABG) outcomes. Higher individual surgeon case volume improves mortality and morbidity rates for this complex procedure.
Area of Science:
- Cardiovascular Surgery
- Health Services Research
- Surgical Outcomes
Background:
- Assessing the relationship between surgical case volume and patient outcomes is crucial for quality improvement in cardiac surgery.
- Resternotomy coronary artery bypass grafting (CABG) is a complex procedure with potentially higher risks.
- Understanding factors influencing resternotomy CABG outcomes can guide surgical practice and patient selection.
Purpose of the Study:
- To evaluate the association between surgical case volume and outcomes for resternotomy coronary artery bypass grafting (CABG).
- To determine whether hospital-level or surgeon-level volume is a more significant predictor of resternotomy CABG success.
- To identify optimal case volume thresholds for improving patient safety in resternotomy CABG.
Main Methods:
- Analysis of 1,362,218 first-time CABG and 93,985 resternotomy CABG cases from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2010-2019).
- Comparison of in-hospital mortality and mortality and morbidity (M&M) rates across hospital and surgeon volume categories.
- Application of multivariable generalized linear mixed-effects models to assess volume-outcome relationships, adjusting for patient characteristics and clustering effects.
Main Results:
- Unadjusted mortality and M&M rates for resternotomy CABG declined with increasing hospital and surgeon case volume.
- Optimal outcomes were observed beyond annual volumes of 200-300 cases for hospitals and 100-150 cases for surgeons.
- Higher procedural volume was significantly associated with improved surgeon-level outcomes (mortality AOR 0.39, M&M AOR 0.37 per 100 procedures), but hospital-level associations were not significant.
Conclusions:
- Individual surgeon experience, reflected in procedural volume, is the primary determinant of improved outcomes in resternotomy CABG.
- Institutional or hospital-level volume did not show a statistically significant association with improved resternotomy CABG outcomes after adjustment.
- Focusing on surgeon-specific experience may be more impactful for enhancing the quality of care in resternotomy CABG procedures.
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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