John D. Birkmeyer

A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group.

OBJECTIVEnTo determine whether an organized intervention including data feedback, training in continuous quality improvement techniques, and site visits to other medical centers could improve the hospital mortality rates associated with coronary artery bypass graft (CABG) surgery.nnnDESIGNnRegional intervention study. Patient demographic and historical data, body surface area, cardiac catheterization results, priority of surgery, comorbidity, and status at hospital discharge were collected on CABG patients in Northern New England between July 1, 1987, and July 31, 1993.nnnSETTINGnThis study included all 23 cardiothoracic surgeons practicing in Maine, New Hampshire, and Vermont during the study period.nnnPATIENTSnData were collected on 15,095 consecutive patients undergoing isolated CABG procedures in Maine, New Hampshire and Vermont during the study period.nnnINTERVENTIONSnA three-component intervention aimed at reducing CABG mortality was fielded in 1990 and 1991. The interventions included feedback of outcome data, training in continuous quality improvement techniques, and site visits to other medical centers.nnnMAIN OUTCOME MEASUREnA comparison of the observed and expected hospital mortality rates during the postintervention period.nnnRESULTSnDuring the postintervention period, we observed the outcomes for 6488 consecutive cases of CABG surgery. There were 74 fewer deaths than would have been expected. This 24% reduction in the hospital mortality rate was statistically significant (P = .001). This reduction in mortality rate was relatively consistent across patient subgroups and was temporally associated with the interventions.nnnCONCLUSIONnWe conclude that a multi-institutional, regional model for the continuous improvement of surgical care is feasible and effective. This model may have applications in other settings.

The cost‐effectiveness of preoperative autologous blood donation for total hip and knee replacement

Although the frequency of preoperative autologous blood donation is increasing dramatically, the economic implications of its use remain largely unexplored. Decision analysis was used to calculate the cost‐ effectiveness of autologous blood donation for hip and knee replacement. Cost‐effectiveness, expressed as cost per quality‐adjusted year of life saved, was based on observed red cell use in 629 patients undergoing surgery at two tertiary‐care centers. Autologous blood donation for bilateral and revision joint replacement cost

Effect of Coronary Artery Diameter in Patients Undergoing Coronary Bypass Surgery

40,000 per quality‐adjusted year of life saved at Center 1 and

THE EFFECT OF HOSPITAL VOLUME ON MORTALITY AND RESOURCE USE AFTER RADICAL PROSTATECTOMY

241,000 at Center 2. Autologous blood donation for primary unilateral hip replacement cost

Effect of preoperative aspirin use on mortality in coronary artery bypass grafting patients

373,000 per quality‐adjusted year of life saved at Center 1 and

A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs

740,000 at Center 2. Autologous blood donation was least cost‐ effective for primary unilateral knee replacement (

Volume and process of care in high-risk cancer surgery The views expressed herein do not necessarily represent the views of Center for Medicare and Medicaid Services or the US Government.

1,147,000/quality‐ adjusted year of life saved at Center 1 and

Economic impact of inappropriate blood transfusions in coronary artery bypass graft surgery.

1,467,000/year at Center 2). Differences between autologous blood collections and transfusion requirements explained variations among procedures in the cost‐ effectiveness of autologous blood donation. Higher transfusion rates in autologous blood donors than in nondonors accounted for the poorer cost‐ effectiveness of autologous blood donation at Center 2 than at Center 1. Autologous blood donation is not as cost‐effective as most accepted medical practices. Its cost‐effectiveness can be improved substantially by the avoidance of overcollection and overtransfusion of autologous blood.

Acute normovolemic hemodilution is a cost-effective alternative to preoperative autologous blood donation by patients undergoing radical retropubic prostatectomy

BACKGROUNDnCoronary artery diameter is known to be inversely associated with perioperative mortality related to coronary artery bypass grafting (CABG). This association is believed to be responsible for increased risk among women and smaller people. However, the associations between sex, body size, and coronary size have not been carefully examined because direct information about coronary size is rarely available. Also, whether sex has an independent effect on vessel size is largely unknown.nnnMETHODS AND RESULTSnHeight, weight, sex, age, status at hospital discharge, and luminal diameter of the midleft anterior descending coronary artery (mid-LAD) were recorded prospectively in 1325 patients undergoing CABG. Small vessel size was associated with substantially increased risk of in-hospital mortality (15.8% for 1.0-mm vessels, 4.6% for 1.5- to 2.0-mm vessels, and 1.5% for 2.5- to 3.5-mm vessels, P[trend] < .001). Vessel size was strongly related to both sex and measures of body size. In multiple linear regression analysis, vessel size was positively correlated with body surface area (P[trend] < .01), body mass index (P[trend] = .004), height (P[trend] = .001), and weight (P[trend] = .001). After controlling for differences in age and body size, sex remained an important predictor of coronary size. Within each quartile of each body-size measure, mid-LAD diameter in men was greater than that in women (mean difference [range], 0.14 to 0.23 mm).nnnCONCLUSIONSnSmall mid-LAD diameter is associated with substantially increased risk of in-hospital mortality with CABG. Although body size is correlated with mid-LAD diameter, women have smaller coronary arteries than men after controlling for differences in body size. These findings further support the hypothesis that smaller coronary arteries explain higher perioperative mortality with CABG in women and smaller people.

Efficacy and cost effectiveness of autologous blood predeposit in patients undergoing radical prostatectomy procedures

PURPOSEnThe value of radical prostatectomy for patients with prostate cancer depends on low morbidity and mortality. We assessed whether patient outcome is associated with how many of these procedures are performed at hospitals yearly.nnnMATERIALS AND METHODSnUsing the Nationwide Inpatient Sample, which is a stratified probability sample of American hospitals, we identified 66,693 men who underwent radical prostatectomy between 1989 and 1995. Cases were categorized into volume groups according to hospital annual rate of radical prostatectomies performed, including low-fewer than 25, medium-25 to 54 and high-greater than 54. We performed multivariate logistic regression to control for patient characteristics when assessing the associations of hospital volume, in-hospital mortality and resource use.nnnRESULTSnOverall adjusted in-hospital mortality after radical prostatectomy was relatively low (0.25%). However, patients at low volume centers were 78% more likely to have in-hospital mortality than those at high volume centers (adjusted odds ratio 1.78, 95% confidence interval 1.7 to 2.6). Overall length of stay decreased at all hospitals between 1989 and 1995. However, average length of stay was longer and total hospital charges were higher at low than at high volume centers (7.3 versus 6.1 days, p<0.0001, and