title: Enhancing quality control and performance monitoring in thoracic aortic surgery: a 10-year single institutional experience.
abstract: OBJECTIVE
  The aim of the present study was to monitor performance and learning effects for thoracic aortic surgery. In addition, we evaluated the volume-outcome relationship of patients undergoing surgery of the thoracic aorta, comparing the results of two higher-volume surgeons (HVSs) with six lower volume surgeons.
  
  
  METHODS
  A total of 867 thoracic aortic procedures (elective cases n = 753 and Type A acute dissection n = 114) were performed from 2003 to 2013 by eight surgeons (range 28-238 procedures) at our institution. Departmental and individual performance was monitored using control charts, with a predetermined acceptable failure rate of 10%. Perioperative death or one or more of four adverse events constituted failure. Moreover, results of two higher-volume operators (n = 460; 53%) were compared with those of six lower-volume operators (n = 407; 47%).
  
  
  RESULTS
  The incidence rate of in-hospital mortality for elective cases was 2% and for Type A dissection repair 9.6%. Institutional control charts revealed that the surgical process was under control for all the study periods apart from small periods of worse than expected performance which were congruent with new surgeons joining the programme. The predominant surgical failure was reoperation for bleeding. There were differences between surgeons with regard to the learning curves and performance. No significant differences were observed between high- and low-volume surgeons in terms of mortality and morbidity for elective cases. However, high-volume surgeons presented a trend suggesting a higher mortality rate in Type A aortic dissection repair (17.1 vs 6.3%; P = 0.09).
  
  
  CONCLUSIONS
  Thoracic aortic surgery can be performed with similar results by high- and low-volume surgeon. Control charts can facilitate learning effects and performance monitoring. Implementation of continuous departmental and individual performance monitoring is practicable.
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Murzi
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Miceli
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Gioia
authors.initials: G
authors.lastname: Di Stefano
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Alfredo G
authors.initials: AG
authors.lastname: Cerillo
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Enkel
authors.initials: E
authors.lastname: Kallushi
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Pierandrea
authors.initials: P
authors.lastname: Farneti
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Solinas
authors.affiliation: Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy glauber@ftgm.it glauber@ifc.cnr.it.
authors.forename: Mattia
authors.initials: M
authors.lastname: Glauber
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000601:surgery; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D057216:Propensity Score; D011446:Prospective Studies; D019616:Thoracic Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000592:standards* / Q000706:statistics & numerical data*
keywords: Aortic surgery; Performance monitoring; Training