Background: China has witnessed a rapid increase in the volume of coronary artery bypass grafting (CABG) but substantial gaps in the performance for CABG across the nation. The present study aimed to investigate the change in CABG performance after years of quality improvement measures in a national registry in China. Methods: The study included 66 971 patients who underwent isolated CABG in a cohort of 74 tertiary hospitals in China between January 2013 and December 2018. Data were collected from the Chinese Cardiac Surgery Registry. Outcomes were in-hospital mortality and postoperative length of stay. Five process measures for surgical technique and secondary prevention were also analyzed. We described the changes in the overall performance and interhospital heterogeneity across the years. Results: The in-hospital mortality declined from 0.9% in 2013 to 0.6 in 2018, with a risk-adjusted odds ratio of 0.66 (95% CI, 0.46–0.93; P <0.001). The standard mean difference for risk-standardized mortality rate between hospitals in the lowest and highest quartile narrowed from 1.63 in 2013 to 1.35 in 2018. The median (interquartile range) hospital-level rate of using arterial graft increased from 93.9% (86.0%–97.8%) to 94.6% (83.3%–99.2%), but the difference was not statistically significant. Meanwhile, the rate of free from blood transfusion increased from 17.0% (2.6%–32.0%) to 34.1% (8.8%–52.9%). The hospital-level rate of prescribing β-blockers at discharge significantly increased from 82.8% (66.7%–90.3%) to 91.1% (82.1%–97.1%), statin from 75.8% (55.7%–88.9%) to 88.9% (75.0%–96.0%), and aspirin from 90.3% (83.9%–95.2%) to 95.3% (88.9%–98.1%). Conclusions: In the Chinese Cardiac Surgery Registry, there were notable improvements in the treatment process related to CABG and decline of in-hospital mortality with reduced interhospital heterogeneity.
BackgroundWith 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.MethodsWe 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.ResultsAmong 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.ConclusionsFor a technically challenging surgical procedure like off-pump CABG, prior workload adversely affected patient outcomes.
Aims Current guidelines recommend a heart team in the decision making for patients with complex coronary artery disease (CAD). However, the decision-making stability of these teams has not been evaluated and the optimum protocol is unknown. We assessed inter-team agreement for revascularization decision-making and influencing factors to inform the development of a heart team protocol. Methods and results This sequential, explanatory mixed methods study included (1) a cross-sectional quantitative study to assess inter-team agreement on treatment strategy for retrospectively enrolled complex CAD patients and (2) a qualitative study that used semi-structured interviews with heart team members to identify factors influencing decision-making discrepancy. We randomly selected 101 complex CAD patients. Sixteen specialists were randomly assigned to 4 heart teams to make decisions for these patients. The primary outcome kappa of inter-team decision-making agreement was moderate (kappa 0.58). Factors influencing decision-making were generated through inductive thematic analysis and were summarized by 3 themes (specialist quality, team composition, meeting process) and 10 subthemes. Recommendations of heart team implementation were generated based on qualitative and quantitative data at 5 levels: specialist selection, specialist training, team composition, team training, and meeting process. A detailed protocol on the integration of guidelines, previous experience and recommendations was generated to establish and deploy a qualified heart team. Conclusions Agreement between heart teams for revascularization decision-making in complex CAD patients was moderate. Potential factors associated with decision discrepancies were summarized and recommendations were generated. A detailed heart team protocol was designed and should be validated in future.
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