title: Early efficacy of CABG care delivery in a low procedure-volume community hospital: operative and midterm results.
abstract: BACKGROUND
  The Leapfrog Group recommended that coronary artery bypass grafting (CABG) surgery should be done at high volume hospitals (>450 per year) without corresponding surgeon-volume criteria. The latter confounds procedure-volume effects substantially, and it is suggested that high surgeon-volume (>125 per year) rather than hospital-volume may be a more appropriate indicator of CABG quality.
  
  
  METHODS
  We assessed 3-year isolated CABG morbidity and mortality outcomes at a low-volume hospital (LVH: 504 cases) and compared them to the corresponding Society of Thoracic Surgeons (STS) national data over the same period (2001-2003). All CABGs were performed by 5 high-volume surgeons (161-285 per year). "Best practice" care at LVH -- including effective practice guidelines, protocols, data acquisition capabilities, case review process, dedicated facilities and support personnel -- were closely modeled after a high-volume hospital served by the same surgeon-team.
  
  
  RESULTS
  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 of 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 category (>3%), respectively. Postoperative leg wound infections, ventilator hours, renal dysfunction (no dialysis), and atrial fibrillation were higher for LVH, but hospital stay was not. The unadjusted Kaplan-Meier survival for the LVH cohort was 96%, 94%, and 92% at one, two, and three years, respectively.
  
  
  CONCLUSIONS
  Our results demonstrated that high quality CABG care can be achieved at LVH programs if 1) served by high volume surgeons and 2) patient care procedures similar to those of large programs are implemented. This approach may prove a useful paradigm to ensure high quality CABG care and early efficacy at low volume institutions that wish to comply with the Leapfrog standards.
authors.affiliation: Department of Anesthesiology, Medical College of Ohio, 3000 Arlington Avenue, Toledo, OH 43614, USA. TPapadimos@mac.com
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Papadimos
authors.forename: Robert H
authors.initials: RH
authors.lastname: Habib
authors.forename: Anoar
authors.initials: A
authors.lastname: Zacharias
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Schwann
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Riordan
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Durham
authors.forename: Aamir
authors.initials: A
authors.lastname: Shah
mesh_terms: D000368:Aged; D016507:Cardiology Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D002983:Clinical Competence; D001026:Coronary Artery Bypass / Q000401:mortality / Q000706:statistics & numerical data*; D005260:Female; D006276:Health Facility Size; D006764:Hospitals, Community; D006801:Humans; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D013503:Surgery Department, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D015996:Survival Rate