title: Sources of Variation in Hospital-Level Infection Rates After Coronary Artery Bypass Grafting: An Analysis of The Society of Thoracic Surgeons Adult Heart Surgery Database.
abstract: BACKGROUND
  Patients undergoing coronary artery bypass grafting (CABG) are at risk for a variety of infections. Investigators have focused on predictors of these adverse sequelae, but less attention has been focused on characterizing hospital-level variability in these outcomes.
  
  
  METHODS
  Between July 2011 and December 2013, The Society of Thoracic Surgeons Adult Cardiac Surgery Database shows 365,686 patients underwent isolated CABG in 1,084 hospitals. Hospital-acquired infections (HAIs) were defined as pneumonia, sepsis/septicemia, deep sternal wound infection/mediastinitis, vein harvest/cannulation site infection, or thoracotomy infection. Hospitals were ranked by their HAI rate as low (≤ 10th percentile), medium (10th to 90th percentile), and high (>90th percentile). Differences in perioperative factors and composite morbidity and mortality end points across these groups were determined using the Wilcoxon rank sum and χ(2) tests.
  
  
  RESULTS
  HAIs occurred among 3.97% of patients overall, but rates varied across hospital groups (low: <0.84%, medium: 0.84% to 8.41%, high: >8.41%). Pneumonia (2.98%) was the most common HAI, followed by sepsis/septicemia (0.84%). Patients at high-rate hospitals more often smoked, had diabetes, chronic lung disease, New York Heart Association Functional Classification III to IV, and received blood products (p < 0.001); however, they less often were prescribed the appropriate antibiotics (p < 0.001). Major morbidity and mortality occurred among 12.3% of patients, although this varied by hospital group (low: 8.6%, medium: 12.3%, high: 17.9%; p < 0.001).
  
  
  CONCLUSIONS
  Substantial hospital-level variation exists in postoperative HAIs among patients undergoing CABG, driven predominantly by pneumonia. Given the relatively small absolute differences in comorbidities across hospital groups, our findings suggest factors other than case mix may explain the observed variation in HAI rates.
authors: Section of Health Services Research and Quality, Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan. Electronic address: likosky@umich.edu.
authors: Donald S
authors: DS
authors: Likosky
authors: Duke Clinical Research Institute, Duke University, Durham, North Carolina.
authors: Amelia S
authors: AS
authors: Wallace
authors: Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
authors: Richard L
authors: RL
authors: Prager
authors: Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors: Jeffrey P
authors: JP
authors: Jacobs
authors: Department of Biostatistics, University of Michigan, Ann Arbor, Michigan.
authors: Min
authors: M
authors: Zhang
authors: Department of Cardiac Surgery, Heart and Vascular Institute, Henry Ford Macomb Hospitals, Clinton Township, Michigan.
authors: Steven D
authors: SD
authors: Harrington
authors: Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina.
authors: Paramita
authors: P
authors: Saha-Chaudhuri
authors: Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
authors: Patricia F
authors: PF
authors: Theurer
authors: Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
authors: Astrid
authors: A
authors: Fishstrom
authors: Duke Clinical Research Institute, Duke University, Durham, North Carolina.
authors: Rachel S
authors: RS
authors: Dokholyan
authors: Department of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors: David M
authors: DM
authors: Shahian
authors: Vanderbilt University, Nashville, Tennessee.
authors: J Scott
authors: JS
authors: Rankin
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D012042:Registries; D012307:Risk Factors; D012955:Societies, Medical; D013530:Surgical Wound Infection / Q000453:epidemiology*; D015996:Survival Rate / Q000639:trends; D013903:Thoracic Surgery; D014481:United States / Q000453:epidemiology