Background In the setting of a statewide quality collaborative approach to the review of cardiac surgical mortalities in intensive care units (ICUs), variations in complication-related outcomes became apparent. Utilizing “failure to rescue” methodology, (FTR; the probability of death after a complication), we compared FTR rates after adult cardiac surgery in low, medium, and high mortality centers from a voluntary, 33-center quality collaborative. Methods We identified 45,904 patients with a Society of Thoracic Surgeons predicted risk of mortality who underwent cardiac surgery between 2006 and 2010. The 33 centers were ranked according to observed-to-expected (O/E) ratios for mortality and were categorized into 3 equal groups. We then compared rates of complications and FTR. Results Overall unadjusted mortality was 2.6%, ranging from 1.5% in the low-mortality group to 3.6% in the high group. The rate of 17 complications ranged from 19.1% in the low group to 22.9% in the high group while FTR rates were 6.6% in the low group, 10.4% in the medium group, and 13.5% in the high group (p<0.001). The FTR rate was significantly better in the low mortality group for the majority of complications (11 of 17) with the most significant findings for cardiac arrest, dialysis, prolonged ventilation, and pneumonia. Conclusion Low mortality hospitals have superior ability to rescue patients from complications after cardiac surgery procedures. Outcomes review incorporating a collaborative multi-hospital approach can provide an ideal opportunity to review processes that anticipate and manage complications in the ICU and help recognize and share “differentiators” in care.
Objective: To compare perioperative and long-term outcomes in patients undergoing hemiarch and aggressive arch replacement for acute type A aortic dissection (ATAAD). Methods: From 1996-2017, we compared outcomes of hemiarch (n=322) versus aggressive arch replacements (zones 2 and 3 arch replacement with implantation of 2-4 arch branches, n=150) in ATAAD. Indications for aggressive arch were arch aneurysm >4 cm or intimal tear in the aortic arch that was not resectable by hemiarch replacement, or dissection of arch branches with malperfusion. Results: Patients in the aggressive arch group were significantly younger (mean age: 57 vs. 61 years old) and had significantly longer hypothermic circulatory arrest, cardiopulmonary bypass, and aortic cross-clamp times. There were no significant differences in perioperative outcomes between hemiarch and aggressive arch groups, including 30-day mortality (5.3% vs. 7.3%, p=0.38) and postoperative stroke rate (7% vs. 7%, p=0.96). Over 15 year Kaplan-Meier survival was similar between hemiarch and aggressive arch groups (log-rank p=0.55, 10-year survival 70% vs. 72%). Given death as a competing factor, incidence rates of reoperation over 15 years (2.1% vs. 2.0% per year, p=1) and 10-year cumulative incidence of reoperation (14% vs. 12%, p=0.89) for arch and distal aorta pathology were similar between the two groups. Conclusion: Both hemiarch and aggressive arch replacement are appropriate approaches for select patients with ATAAD. Aggressive arch replacement should be considered for an arch aneurysm >4 cm or an intimal tear at the arch unable to be resected by hemiarch replacement, or dissection of the arch branches with malperfusion.
STRUCTURED ABSTRACT Objective To project readmission penalties for hospitals performing cardiac surgery and examine how these penalties will affect minority-serving hospitals. Background The Hospital Readmission Reduction Program (HRRP) will potentially expand penalties for higher-than-predicted readmission rates to cardiac procedures in the near future. The impact of these penalties on minority-serving hospitals is unknown. Methods We examined national Medicare beneficiaries undergoing coronary artery bypass grafting (CABG) in 2008–2010 (N=255,250 patients, 1,186 hospitals). Using hierarchical logistic regression, we calculated hospital observed-to-expected readmission ratios. Hospital penalties were projected according to the HRRP formula using only CABG readmissions with a 3% maximum penalty of total Medicare revenue. Hospitals were classified into quintiles according to proportion of black patients treated. Minority-serving hospitals were defined as hospitals in the top quintile while non-minority-serving hospitals those in the bottom quintile. Projected readmission penalties were compared across quintiles. Results Forty-seven percent of hospitals (559 of 1,186) were projected to be assessed a penalty. Twenty-eight percent of hospitals (330 of 1,186) would be penalized <1% of total Medicare revenue while 5% of hospitals (55 of 1,186) would receive the maximum 3% penalty. Minority-serving hospitals were almost twice as likely to be penalized than non-minority-serving hospitals (61% vs. 32%) and were projected almost triple the reductions in reimbursement ($112 million vs. $41 million). Conclusions Minority-serving hospitals would disproportionately bear the burden of readmission penalties if expanded to include cardiac surgery. Given these hospitals’ narrow profit margins, readmission penalties may have a profound impact on these hospitals’ ability to care for disadvantaged patients.
Objective We sought to determine whether the changes in incentive design in Phase 2 of Medicare’s flagship Pay-for-Performance program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals. Background The Premier HQID was initiated in 2003 to reward high-performing hospitals. The program redesigned its incentive structure in 2006 to also reward hospitals that achieved significant improvement. The impact of the change in incentive structure on outcomes in surgical populations is unknown. Methods We examined discharge data for patients who underwent coronary artery bypass (CABG), hip replacement, and knee replacement at Premier hospitals and non-Premier hospitals in Hospital Compare from 2003–2009 in 12 states (n=861,411). We assessed the impact of incentive structural changes in 2006 on serious complications and 30-day mortality. In these analyses, we adjusted for patient characteristics using multiple logistic regression models. To account for improvement in outcomes over time, we used difference-in-difference techniques that compare trends in Premier vs. non-Premier hospitals. We repeated our analyses after stratifying hospitals into quintiles according to risk-adjusted mortality and serious complication rates. Results After restructuring incentives in 2006 in Premier hospitals, there were lower risk-adjusted mortality and complication rates for both cardiac and orthopedic patients. However, after accounting for temporal trends in non-Premier hospitals, there were no significant improvements in mortality for CABG (OR 1.09, 95% CI 0.92 to 1.28) or joint replacement (OR 0.81, 95% CI 0.58 to 1.12). Similarly, there were no significant improvements in serious complications for CABG (OR 1.05, 95% CI 0.97 to 1.14) or joint replacement (OR 1.12, 95% CI 1.01 to 1.23). Analysis of the “worst” quintile hospitals that were targeted in the incentive structural changes also did not reveal a change in mortality (OR 1.01, 95% CI 0.78 to 1.32 for CABG and OR 0.96, 95% CI 0.22 to 4.26 for joint replacement) or serious complication rates (OR 1.08, 95% CI 0.88 to 1.34 for CABG and OR 0.92, 95% CI 0.67 to 1.28). Conclusions Despite recent enhancements to incentive structures, the Premier HQID did not improve surgical outcomes at participating hospitals. Unless significantly redesigned, pay-for-performance may not be a successful strategy to improve outcomes in surgery.
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