Interhospital variability in 180-day infections following cardiac surgery
Syed Sikandar Raza1, Shiwei Zhou2, Noah M Barnett3
1Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich.
Objective:
To evaluate hospital-level variation in infections following cardiac surgery and develop and evaluate a 180-day infection quality metric.
Methods:
This study evaluated Medicare claims that were merged with institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database files among patients undergoing cardiac surgery across 33 Michigan centers. The primary outcome was infection occurring within 180 days of surgery. Adjusted institutional infection rates were estimated using logistic regression with robust variance estimation. Terciles of observed/expected ratios were created to assess interhospital variability in infections and associated morbidity and mortality.
Results:
A total of 5466 operations were evaluated. The average patient age was 71.1 ± 7.8 years, 29.5% of the patients were female, and 4.8% were black. The infection rate was 21.2% overall and higher among females. Infection was associated with lower left ventricular ejection fraction, diabetes, severe chronic lung disease, cerebrovascular disease, and urgent operations (P < .0001 for all). The most common infection was pneumonia (8.5%). Adjusted infection rates varied 39.5% across hospitals (range, 7.2%-46.7%). Patients treated in hospitals in the highest tercile of observed/expected infection ratio had a higher rate of associated discharge to extended care/rehabilitation (27.9% vs 24.7%, P < .0001) but comparable stroke and mortality risk compared to patients treated in hospitals in the lowest tercile.
Conclusions:
One in 5 Medicare beneficiaries develop a 180-day infection following cardiac surgery, with rates varying 39.5% across hospitals. Patients at higher versus lower O:E tercile hospitals were more commonly discharged to extended care/rehabilitation settings, although rates of stroke and mortality were equivalent in the 2 groups. Collaborative learning interventions may be warranted to advance the observed variability in 180-day infections.
Insights
One in five cardiac surgery patients develop infections within 180 days. Hospital infection rates vary significantly, impacting patient discharge but not mortality. Collaborative learning can reduce this variability.
Area of Science:
- Cardiovascular Surgery
- Healthcare Quality Improvement
- Infectious Disease Epidemiology
Background:
- Post-cardiac surgery infections pose a significant risk to patient outcomes.
- Existing quality metrics may not fully capture the nuances of 180-day post-operative infection rates.
- Understanding hospital-level variation is crucial for targeted quality improvement initiatives.
Purpose of the Study:
- To assess variations in 180-day post-cardiac surgery infection rates across different hospitals.
- To develop and validate a quality metric for 180-day post-cardiac surgery infections.
- To identify factors associated with increased infection risk and outcomes.
Main Methods:
- Utilized Medicare claims data linked with the Society of Thoracic Surgeons Adult Cardiac Surgery Database.
- Analyzed data from 5,466 cardiac surgeries across 33 Michigan hospitals.
- Employed logistic regression to estimate adjusted institutional infection rates and assessed variability using observed/expected ratios.
Main Results:
- An overall 180-day infection rate of 21.2% was observed, with significant hospital-level variation (39.5%).
- Infections were more common in females and associated with comorbidities like diabetes and chronic lung disease.
- Patients from higher-risk hospitals had increased discharge to extended care but similar stroke and mortality rates.
Conclusions:
- A substantial proportion of Medicare beneficiaries experience 180-day infections after cardiac surgery, with considerable inter-hospital variability.
- While infection rates differ, associated mortality and stroke risks were comparable across varying hospital risk tiers.
- Interventions focused on collaborative learning are recommended to mitigate the observed variability in 180-day post-cardiac surgery infections.
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