Anatomy of a Cardiac Surgical Program Turnaround: Is Risk Aversion the Answer?
Joseph M. Arcidi for the McLaren Cardiac Surgery QI Committee
McLaren Flint Medical Center, Flint, MI
OBJECTIVE: Our established program had become a statistical outlier despite advisory visits by the Michigan Cardiac Surgical Quality Collaborative and the Cleveland Clinic. We since improved our CABG mortality ranking from the bottom 1.8% of the STS database to the top 7.1% over 5 semiannual NQF reporting periods, earning our first 3-Star Composite Quality Rating. We examined whether our improvement reflected risk aversion, a commonly perceived remedy for struggling programs.
METHODS: The STS database records of 1154 consecutive patients having any cardiac surgical procedure (91.0% CABG) between 1/2009-6/2012 were reviewed (yearly mean ±SD = 320 ±48 patients). In late 2010, we prospectively implemented preoperative data checklists, detailed multidisciplinary mortality reviews, and focused on all STS NQF measures.
RESULTS: Operative mortality risk (3.1 ±5.4%, range 0.2%-61.6%) did not decrease during the improvement period (p=0.745) [graph]. Operative mortalities decreased during each reporting period (p=0.018), but the decrease was greater for patients with operative risk ‰¤ 5% (p=0.033) than patients with operative risk > 10% (p=0.608). CABG observed/expected mortality decreased from 1.92 to a nadir of 0.47, and paralleled CABG NQF improvements in prolonged ventilation (16.4%vs6.3%), stroke (2.9%vs0.5%), renal failure (5.1%vs1.5%), and IMA use (88.6%vs97.9%).
CONCLUSIONS: Improvement from the 1-Star to 3-Star rating in our moderate volume program was not associated with risk aversion. While improvement was not feasible without success in higher-risk patients, it was greater in lower-risk patients. A comprehensive focus on quality to avoid mortality in lower-risk patients may enable struggling programs with limited volume to similarly achieve optimal results in higher-risk patients.