Coronary artery bypass graft surgery--care globalization: the impact of national care on fatal and nonfatal outcome.
OBJECTIVE
In an international, prospective, observational study, we contrasted adverse vascular outcomes among four countries and then assessed practice pattern differences that may have contributed to these outcomes.


METHODS
A total of 5065 patients undergoing coronary artery bypass graft surgery were analyzed at 70 international medical centers, and from this pool, 3180 patients from the 4 highest enrolling countries were selected. Fatal and nonfatal postoperative ischemic complications related to the heart, brain, kidney, and gastrointestinal tract were assessed by blinded investigators.


RESULTS
In-hospital mortality was 1.5% (9/619) in the United Kingdom, 2.0% (9/444) in Canada, 2.7% (34/1283) in the United States, and 3.8% (32/834) in Germany (P = .03). The rates of the composite outcome (morbidity and mortality) were 12% in the United Kingdom, 16% in Canada, 18% in the United States, and 24% in Germany (P < .001). After adjustment for difference in case-mix (using the European System for Cardiac Operative Risk Evaluation) and practice, country was not an independent predictor for mortality. However, there was an independent effect of country on composite outcome. The practices that were associated with adverse outcomes were the intraoperative use of aprotinin, intraoperative transfusion of fresh-frozen plasma or platelets, lack of use of early postoperative aspirin, and use of postoperative heparin.


CONCLUSIONS
Significant between-country differences in perioperative outcome exist and appear to be related to hematologic practices, including administration of antifibrinolytics, fresh-frozen plasma, platelets, heparin, and aspirin. Understanding the mechanisms for these observations and selection of practices associated with improved outcomes may result in significant patient benefit.
Ott
Elisabeth
E
Multicenter Study of Perioperative Ischemia Research Group, San Bruno, Calif, USA. diane@iref.org
Mazer
C David
CD
Tudor
Iulia C
IC
Shore-Lesserson
Linda
L
Snyder-Ramos
Stephanie A
SA
Finegan
Barry A
BA
Möhnle
Patrick
P
Hantler
Charles B
CB
Böttiger
Bernd W
BW
Latimer
Ray D
RD
Browner
Warren S
WS
Levin
Jack
J
Mangano
Dennis T
DT
D000368:Aged; D002170:Canada / Q000453:epidemiology; D001026:Coronary Artery Bypass / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D005858:Germany / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology*; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology; D014481:United States / Q000453:epidemiology