Joseph F. O'Donnell

Coronary artery bypass surgery: the relationship between inhospital mortality rate and surgical volume after controlling for clinical risk factors.

This study uses a new database containing clinical risk factors for cardiac surgery to investigate the relationship between surgical volume (hospital and surgeon) and inhospital mortality rate for all patients receiving coronary artery bypass surgery in New York State in 1989. Also, hospitals with significantly higher and lower mortality rates than expected on the basis of patient preoperative risk factors are identified. The results demonstrate that both annual surgeon volume and annual hospital volume are significantly (inversely) related to mortality rate. The 36% of all coronary bypass operations performed in hospitals with annual bypass volumes of 700 or more by surgeons with annual bypass volumes of 180 or more had a risk-adjusted mortality rate of 2.67% in comparison to a risk-adjusted mortality rate of 4.29% for other bypass operations. Furthermore, low surgical volumes were a major contributor to the outlier status of four of the five hospitals with significantly higher mortality rates than expected.

Interracial Access to Selected Cardiac Procedures for Patients Hospitalized with Coronary Artery Disease in New York State

This study examines black/white differences in the utilization of three cardiac procedures (coronary angiography, coronary artery bypass graft, and coronary angioplasty) for patients hospitalized with coronary artery disease in New York State in the first 6 months of 1987. In contrast with previous studies, disease stages are used to control for severity of illness in addition to various severity proxies. Another methodological difference is that patient episodes (a fixed period of time after an initial hospital admission) are used as the unit of analysis rather than discharges to accurately account for patients whose initial visit is to a hospital not certified to perform the procedure. After controlling for severity using logistic regression analysis, whites were found to undergo significantly more of each of the procedures than blacks (odds ratios of 1.25,2.06, and 1.69 for angiography, bypass graft, and angioplasty, respectively). These significant differences existed for most levels of the various control variables.

Gender differences in mortality rates for coronary artery bypass surgery

This study utilized a state-wide data base containing clinical risk factors for cardiac surgery to investigate differences in in-hospital mortality rates for men and women undergoing coronary artery bypass surgery. The crude mortality rates for coronary artery bypass surgery for men and women were 3.08% and 5.43% respectively, in New York State in 1989. When logistic regression analysis was used to control for preoperative risk, gender remained a significant predictor of mortality. Risk-adjusted (indirectly standardized) mortality rates were 3.33% and 4.45% for men and women, respectively. The risk-adjusted odds ratio of women to men experiencing in-hospital death was 1.52 (95% confidence interval 1.25 to 1.90).

Coronary Artery Surgery in New York State-Reply

In Reply.— We would like to say that what is original about our study is that it allows for comparisons among hospitals after having adjusted for differences in severity of illness. This could not have been done previously because no case-specific severity measures were available for each hospital. On the point of rationing care, we find nothing in comparative studies of hospital performance that inherently leads to, or even suggests, rationing. Between the first 6 months of 1989 and the first 6 months of 1990, the number of cardiac operations in New York State actually increased by 10%. Also, the average severity of illness of those patients receiving operations increased. The purpose of releasing hospital-specific information is to document the variability that exists in hospital performance and to allow potential cardiac surgery patients to make more informed choices among the providers of that care. We feel it is unfortunate that

An evaluation of the quality assurance system for skilled nursing facilities in New York state.

A new quality assurance system for nursing homes was implemented by the New York State Department of Health in 1981 in response to widespread dissatisfaction with the previous survey and Inspection of Care programs. The new program combined the Inspection of Care, which is a patient centered review, and the survey, which is a structurally oriented facility review. In this study, the old and new quality assurance systems are compared with respect to (1) the amount of surveillance staff resources spent on on-site and off-site activities, (2) the types and quantity of deficiency citations issued, and (3) the correction of deficiencies. The results indicate that the new system devotes more resources to on-site activities and identifies more patient care deficiencies, hut also has led to the identification of more repeat deficiencies.