The early efficacy of CABG care delivery in a low procedure-volume community hospital: operative and midterm results

The Leapfrog Group recommended that CABG surgery should be done at high volume hospitals (> 450 per year) without corresponding surgeon-volume criteria. Recent studies have indicated that the effects of hospital volume are substantially confounded by surgeon volume, and that high surgeon volume (>125 per year) may be a more appropriate indicator of CABG quality. We thus compared operative morbidity and mortality outcomes for a low-volume hospital (LVH) (504 CABG, 2001–2003) served by five high-volume surgeons (161–285 per year) with the corresponding Society of Thoracic Surgeons (STS) national data over the same period. The LVH program implemented 'best practice' care including effective practice guidelines, protocols, data acquisition capabilities, case review process, dedicated facilities and support personnel (anesthesiology, intensivists and pharmacists). Operative mortality was similar for LVH and STS (OM: 2.38% vs 2.53%), and the corresponding LVH observed-to-expected mortality (O/E = 0.81) indicated good quality relative to the STS risk model (O/E <1). Also, these results were consistent irrespective risk category: O/E was 0, 0.9 and 1.03 for very-low risk (<1%), low risk (1–3%) and moderate-to-high risk (> 3%) categories, respectively. While postoperative leg wound infections, ventilator hours, renal failure, and atrial fibrillation were increased in the LVH, the length of stay was not. The unadjusted Kaplan–Meier survival for the LVH cohort was 96%, 94%, and 92% at 1, 2, and 3 years, respectively. Our results demonstrated that high-quality CABG care can be achieved at LVH programs when served by high-volume cardiac surgeons. This approach may prove a useful paradigm to ensure high-quality CABG care and early efficacy at low-volume institutions (Table 1 shows predictors of 0-year to 3-year mortality; Cox regression).

Table 1