Phillip P Brown

On-Pump Versus Off-Pump Coronary Artery Bypass Surgery in a Matched Sample of Women A Comparison of Outcomes

Background—Women have consistently higher mortality and morbidity than men after coronary artery bypass grafting (CABG). Whether elimination of cardiopulmonary bypass and performance of coronary artery bypass grafting off-pump (OPCAB) have a beneficial effect specifically in women has not been defined. Methods and Results—From January 1998 through March 2002, 21 902 consecutive female patients at 82 hospitals underwent isolated CABG, as reported in an administrative database. Propensity score computer matching was performed based on 13 variables representing patient characteristics and preoperative risk factors to correct for and minimize selection bias. A total of 7376 (3688 pairs) women undergoing CABG surgery were able to be successfully matched. In a propensity score computer-matched cohort, multivariate logistic regression (odds ratio) revealed that women undergoing on-pump surgery had a 73.3% higher mortality (P=0.002) and a 47.2% higher risk of bleeding complications (P=0.019). Conclusions—In a retrospective analysis of women undergoing CABG, computer-matched to minimize selection bias, off-pump surgery led to decreased mortality and morbidity including bleeding complications.

Outcomes experience with off-pump coronary artery bypass surgery in women.

BACKGROUND It has been well documented that women have higher morbidity and mortality rates than men following coronary artery bypass graft (CABG) surgery. In view of this evidence, we investigated the following question: compared with on-pump CABG surgery, is there benefit to off-pump CABG surgery in women? METHODS Our investigation analyzes patient mortality and 13 procedure complications controlling for 35 variables representing patient characteristics and comorbid conditions, and for procedure characteristics for a population of 16,871 consecutive women undergoing off-pump and on-pump CABG surgery at 78 hospitals for the period January 1998 to June 2001. RESULTS Mean comparisons reveal that the mortality rate for women undergoing off-pump CABG surgery is nearly a percentage point lower than for women undergoing on-pump surgery (3.12 vs 3.90; p = 0.052). The complication rates for all complications analyzed (shock/hemorrhage, neurologic, cardiac, respiratory, renal, acute renal failure, adult respiratory distress syndrome, implant infection, postoperative infection, septicemia, pneumonia, and peripheral vascular) were lower for women off-pump than women on-pump with the exception of mechanical complications. Logistic regression results reveal, after controlling for 35 relevant patient characteristics, comorbid conditions and procedure characteristics, that women undergoing on-pump CABG surgery experience a 42% higher mortality rate (p = 0.0239) than women undergoing off-pump CABG surgery. CONCLUSIONS Evidence suggests that off-pump CABG surgery may be better for women than on-pump CABG surgery because it appears to reduce mortality and respiratory complications, shorten lengths-of-stay, and increases discharges directly home. None of the 12 other complications investigated demonstrated an advantage for women undergoing on-pump surgery relative to those receiving off-pump surgery.

Comparing clinical outcomes in high-volume and low-volume off-pump coronary bypass operation programs

UNLABELLED sites and then analyzed the patient and hospital characteristics that had an impact on clinical outcomes. RESULTS The mortality rates for the high- and low-volume OPCAB facilities both averaged 2.9% (p = NS). Patients at the high-volume OPCAB facilities had significantly lower rates of major complications (shock/hemorrhage, neurologic, renal, and cardiac) than those at the low-volume OPCAB facilities. Of the seven minor complications, rates for six were lower in the high-volume OPCAB facilities, but none of the differences reached statistical significance. High-volume OPCAB sites were significantly more likely to discharge their patients directly home than were low-volume OPCAB sites (80% versus 66%; p = 0.001). CONCLUSIONS The results suggested that surgical team experience and choice of approaches to performing CABG had an impact on patient outcomes.

Current Clinical Outcomes of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting

BACKGROUND Randomized trials have compared coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). However, results of these trials in select patients may not accurately reflect current clinical practice using drug-eluting stents (DES) and off-pump CABG. We undertook a prospective registry of coronary revascularization by CABG on-pump and off-pump, and PCI with or without DES, to determine clinical outcomes. METHODS All patients undergoing isolated coronary revascularization in 8 community-based hospitals were enrolled. Preprocedural, intraprocedural, and postprocedural data were captured, with outcomes obtained at 18 months by patient and physician contact, and the Social Security Death Index. RESULTS The study enrolled 4336 patients, 71.2% PCI and 28.8% CABG. DESs were used in 2249 PCIs (73.1%), and 596 CABG procedures (47.8%) were off-pump. Incidence of major adverse cardiac events at 18 months was 14.7% for CABG vs 23.3% for PCI (p < 0.001). Cardiac death and myocardial infarction had similar rates. The need for repeat revascularization was significantly less with CABG (6.2% vs 13.6%, p < 0.001). Hazard ratio of CABG to PCI was 0.76 (95% confidence interval, 0.571 to 0.872). CABG outcome was similar on-pump and off-pump, as was repeat revascularization with DES (12.1%) vs BMS (14.9%; p = 0.096). Overall event-free survival was 85.3% in CABG and 76.8% in PCI (p < 0.001). CONCLUSIONS Rates of repeat revascularization were significantly higher for PCI than for CABG, but mortality and myocardial infarction were the same. There were no significant differences in outcomes between DES and BMS or between on-pump and off-pump CABG.

Trends in Coronary Revascularization Procedures Among Medicare Beneficiaries Between 2008 and 2012

Background— This study reports on the trends in the volume and outcomes of coronary revascularization procedures performed on Medicare beneficiaries between 2008 and 2012. Methods and Results— This retrospective study identifies all Medicare beneficiaries undergoing a coronary revascularization procedure: coronary artery bypass graft surgery or percutaneous coronary intervention (PCI) performed in either the nonadmission or inpatient setting. International Classification of Diseases, 9th Revision, Clinical Modification procedure codes (inpatient setting) and Current Procedural Terminology and Ambulatory Payment Classification codes (nonadmission) were used to identify revascularizations. The study population consists of 2 768 007 records. This study finds that the rapid growth in nonadmission PCIs performed on Medicare beneficiaries (60 405–106 495) has been more than offset by the decrease in PCI admissions (363 384–295 434) during the study period. There also were >18 000 fewer coronary artery bypass graft admissions in 2012 than in 2008. This study finds lower observed mortality rates (3.7%–3.2%) among Medicare beneficiaries undergoing any coronary artery bypass graft surgery and higher observed mortality rates (1.7%–1.9%) for Medicare beneficiaries undergoing any PCI encounter. This study also finds a growth in the number of facilities performing revascularization procedures during the study period: 268 (20.2%) more sites were performing nonadmission PCIs; 136 (8.2%) more sites were performing inpatient PCIs; and 19 (1.6%) more sites were performing coronary artery bypass graft surgery. Conclusions— The total number of revascularization procedures performed on Medicare beneficiaries peaked in 2010 and declined by >4% per year in 2011 and 2012. Observed mortality rates among all Medicare beneficiaries undergoing any coronary revascularization remained between 2.1% and 2.2% annually during the study period.

Sex differences in hospital risk-adjusted mortality rates for Medicare beneficiaries undergoing CABG surgery.

BACKGROUND The primary purpose of this study was to rank US hospitals performing coronary artery bypass graft (CABG) surgery on Medicare beneficiaries into 4 performance tiers and determine if there were overall and sex-specific differences in the risk-adjusted mortality rates across performance tiers. METHODS A retrospective analysis was done using a Medicare Provider Analysis and Review (MEDPAR) file of all Medicare beneficiaries who underwent CABG surgery without valve repair or replacement during fiscal years 2003 and 2004. Logistic regression models controlling for demographic characteristics, comorbidities, and cardiac risk factors were used to predict the probability of in-hospital mortality. Hospitals performing at least 52 CABG surgeries during a fiscal year (at least 17 female patients) were ranked into 4 tiers. Rankings were based on the number of lives saved, calculated as the expected number of risk-adjusted deaths minus the actual number of deaths in the hospital during each fiscal year. RESULTS Average risk-adjusted mortality rate was stable and declining over the 2 years: 3.68% in 2003 and 3.61% in 2004. In 2004, the average risk-adjusted mortality rate ranged from 1.39% in tier 1 hospitals to 6.40% in tier 4 hospitals. The sex-specific mortality rate was consistently higher for women in all tiers, with the differential smallest (0.68%) in tier 1 hospitals and greatest (2.67%) in tier 4 hospitals. CONCLUSION The sex differential increases from top- to bottom-tier hospitals, suggesting female beneficiaries could benefit from having CABG performed at tier 1 hospitals.

IS MULTI-VESSEL PRIMARY PCI ADVISABLE? DIFFERENCES IN CLINICAL OUTCOMES AMONG MEDICARE BENEFICIARIES UNDERGOING SINGLE VERSUS MULTI-VESSEL PCI DURING A PRIMARY ST-SEGMENT ELEVATED MYOCARDIAL INFARCTION HOSPITALIZATION IN FISCAL YEAR 2007

METHODS Data: Medicare Provider Analysis and Review (MedPAR) File: An administrative database containing demographic information, up to 9 diagnostic and 6 procedure (ICD-9-CM) codes, length-of-stay, charge information, and the discharge status of all admissions to U.S. short-stay hospitals billed to Medicare program. Study Type: Retrospective Study Period: October 1, 2006 to September 30, 2007; Fiscal Year 2007 Overall, MVl PCI was performed 13.6% of Primary PCI in MB admitted with a primary diagnosis of STEMI. Compared to the SV cohort, the MV cohort was: • More likely to be male and develop cardiogenic shock. • Less likely to receive a BMS • More likely to receive a DES • Less likely to undergo only POBA

Cardiovascular centers of excellence program: a system approach for improving the care and outcomes of cardiovascular patients at HCA hospitals.

BACKGROUND A voluntary continuous quality improvement (CQI) effort, the cardiovascular Centers of Excellence (COE) program was implemented by HCA, Inc., to improve cardiovascular care in its hospital system. METHODS The cardiovascular COE program targeted 165 hospitals that provide cardiovascular services in at least one major service area. Awards (unrestricted grants) provided hospitals with an incentive to participate. RESULTS One hundred fifty-eight hospitals (95.8%) completed the entire 2005 cardiovascular COE program; five were identified as cardiovascular COE. The program developed three key CQI activities: (1) an ongoing Web-based survey to inventory, track, and verify evidence-based practices across all aspects of patient care, including clinical practices, leadership, communications, patient safety, and patient education; (2) quarterly benchmark reports tracking risk-adjusted outcomes and evidence-based practices; and (3) regularly scheduled educational programs presented by an interdisciplinary team in which lessons learned from an institutions successful, evidence-based, best-practice implementation were discussed. DISCUSSION The COE program successfully encouraged facilities to proacrively investigate their evidence-based clinical standards and outcomes.

MEDICARE REIMBURSEMENT ASSOCIATED WITH AN AMI HOSPITALIZATION AND 90-DAYS POST-DISCHARGE

Background: Proposed episode payment model (bundle) for acute myocardial infarction (AMI) necessitates understanding resource consumption. This study identifies resource consumption of Medicare beneficiaries (MBs), index hospitalization and 90 day post discharge, who sustained an AMI in FY 2014.

THE INCREMENTAL HOSPITAL COST OF TREATING MAJOR COMPLICATIONS AMONG MEDICARE BENEFICIARIES UNDERGOING CORONARY ARTERY BYPASS GRAFT SURGERY

There is an incremental increase in hospital resources consumed by surviving Medicare Beneficiaries (MBs) experiencing a major complication during admission for CABG. This retrospective study uses the 2010 MEDPAR File to identify 102,427 MBs who survived isolated CABG (without valve surgery).