title: Quality, not volume, determines outcome of coronary artery bypass surgery in a university-based community hospital network.
abstract: OBJECTIVE
  The present study examined the relationship between hospital and surgeon coronary artery bypass grafting procedural volume, mortality, morbidity, and National Quality Forum care processes in a university-based community hospital quality improvement program.
  
  
  METHODS
  The study population consisted of 2218 consecutive patients undergoing isolated coronary artery bypass grafting from 2007 to 2009 in a university-based quality improvement program that emphasizes involvement of all surgeons in the academic quality endeavor. The endpoints included operative mortality, major morbidity, and National Quality Forum-endorsed process measures as defined by the Society of Thoracic Surgeons. The procedural volume was analyzed as a categorical and continuous variable using general estimating equations, which accounted for clustering effects and which were adjusted for Society of Thoracic Surgeons risk scores and the propensity for operation in a low- versus high-volume program.
  
  
  RESULTS
  The annual program volume ranged from 67 to 292 (median, 136; interquartile range, 88-224) and surgeon volume from 1 to 124 (median, 58; interquartile range, 30-89). The mortality rate among the hospitals was 0.47% to 2.23% (0.8% overall), and the observed/expected mortality ranged from 0 to 1.20 (0.41 overall). When comparing low-volume (<200 cases/year) and high-volume centers, no difference was found in the mortality (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.46-2.54, P = .85), morbidity (OR, 1.34; 95% CI, 0.73-2.43), or any of the medication process measures. No difference was found in mortality (OR, 1.59; 95% CI, 0.81-3.13; P = .18), morbidity (OR, 1.20; 95% CI, 0.86-1.66; P = .28), or medication failure (OR, 0.57, 95% CI, 0.3-1.10; P = .10) between the high- and low-volume surgeons (<87). After adjustment for both the Society of Thoracic Surgeons risk score and the propensity score, no association was found for either hospital or surgeon volume with mortality or morbidity. However, a lack of compliance with National Quality Forum measures was highly predictive of morbidity (OR, 1.51; 95% CI, 1.18-1.93; P = .001), regardless of volume, even after adjustment for predicted risk.
  
  
  CONCLUSIONS
  In the setting of a university-based community hospital quality improvement program, excellent surgical results can consistently be obtained even in relatively low-volume programs. The surgical outcomes were not associated with program or surgeon volume, but were directly correlated with the focus on quality as manifested by compliance with evidence-based quality standards. Meaningful university affiliation might represent a new quality paradigm for cardiac surgery in the community hospital setting.
authors: Florida Heart Research Institute, Miami, Miami FL 33140, USA. doctorwu18@aol.com
authors: Paul A
authors: PA
authors: Kurlansky
authors: Michael
authors: M
authors: Argenziano
authors: Robert
authors: R
authors: Dunton
authors: Robert
authors: R
authors: Lancey
authors: Edward
authors: E
authors: Nast
authors: Allan
authors: A
authors: Stewart
authors: Timothy
authors: T
authors: Williams
authors: Alex
authors: A
authors: Zapolanski
authors: Helena
authors: H
authors: Chang
authors: Judy
authors: J
authors: Tingley
authors: Craig R
authors: CR
authors: Smith
mesh_terms: D000368:Aged; D019058:Community Networks / Q000592:standards*; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality / Q000592:standards*; D005260:Female; D017052:Hospital Mortality; D006764:Hospitals, Community / Q000592:standards*; D006785:Hospitals, University / Q000592:standards*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009519:New York City; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care / Q000592:standards*; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D015397:Program Evaluation; D058996:Quality Improvement / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000592:standards*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome