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Exploring the Volume-Outcome Relationship for

Off-Pump Coronary Artery Bypass Graft Procedures

CARDIOVASCULAR
Mary E. Plomondon, PhD, Adrianne W. Casebeer, PhD, Lynn M. Schooley, MA,
Brandie D. Wagner, Gary K. Grunwald, PhD, Gerald O. McDonald, MD,
Frederick L. Grover, MD, and A. Laurie W. Shroyer, PhD
Eastern Colorado Health Care System, Department of Veterans Affairs Medical Center, University of Colorado at Denver and
Health Sciences Center, Denver, Colorado, and Department of Veterans Affairs Central Office, Office of Patient Care Services,
Washington, DC

Background. The relationship between the surgical 180-day mortality. Both a hospitals average OPCABG
case volume and risk-adjusted clinical outcomes has volume per 6-month period and the hospitals most
been examined for different surgical specialties. The recent 6-month OPCABG volume were examined.
purpose of this study was to explore the relationship Results. Hospital OPCABG average volume in a
between the off-pump coronary artery bypass graft pro- 6-month period ranged from 0.2 to 47.4 procedures;
cedure volumes (OPCABG) with risk-adjusted outcomes whereas the most recent 6-month OPCABG hospital
within the Department of Veterans Affairs (VA) 44 car- volume ranged from 0 to 76 OPCABG per site. No
diac surgery programs. relationship between the volume measures and the out-
Methods. Based on VA Continuous Improvement in come variables was found.
Cardiac Surgery Program data, the results of 5,076 Conclusions. We did not find an association between
OPCABG surgical procedures performed between Octo- OPCABG volume with short-term mortality, periopera-
ber 1998 and September 2003 were analyzed. Hierarchical tive morbidity, or intermediate-term (180-day) mortality.
logistic regression models evaluated the relationship
between OPCABG procedure volume with risk-adjusted (Ann Thorac Surg 2006;81:54754)
30-day operative mortality, perioperative morbidity, and 2006 by The Society of Thoracic Surgeons

S tudies that examine the relationship between the


hospital-based volumes for a surgical procedure
with clinical outcome are of particular interest to Depart-
project prospectively collects risk and outcome data on
all patients undergoing cardiac surgery at the 44 VA
cardiac surgery centers [15]. The present study reviewed
ment of Veteran Affairs (VA) policy makers to evaluate all records for veterans undergoing an OPCABG proce-
criteria to use on screening for opportunities to assure dure at a VA cardiac surgery center between October 1,
patient safety and to improve quality of care. Recently, 1998, and September 30, 2003 (n 5,076).
there have been an increasing number of published
studies examining these relationships [114]. The results Outcomes
of these published studies have been mixed. The purpose Three outcome variables were evaluated separately for
of this study was to evaluate for a potential association this study, 30-day operative mortality, perioperative mor-
between hospital off-pump coronary artery bypass graft bidity, and 180-day all cause mortality. In CICSP/
procedure (OPCABG) volume with 30-day operative CICSP-X, the 30-day operative mortality is defined as any
mortality, perioperative morbidity, and 180-day mortal- death occurring during the index hospitalization or
ity; while adjusting for (1) patient characteristics; (2) the within 30 days after surgery as well as any death occur-
hospital where the procedure was performed; and (3) ring more than 30 days after surgery that is the direct
changes in cardiac surgical care practice over time. result of a perioperative surgical complication. The 180-
day all cause mortality is defined as any death occurring
within 180 days after surgery. All mortality assessments
Material and Methods
(both occurrence as well as date of death) were verified
Study Population using the VA Beneficiary Identification and Records
The VA Continuous Improvement in Cardiac Surgery Locator Subsystem (BIRLS). The BIRLS database is both
Program (CICSP) as well as the expansion (CICSP-X) sensitive and specific for determining vital status in
Veteran populations [16]. In addition, any death discrep-
Accepted for publication Aug 15, 2005. ancies identified by the BIRLS match were reconciled by
VA personnel using data from VA electronic medical
Address correspondence to Dr Shroyer, Cardiac Research, Eastern Colo-
rado Health Care System, Denver VA Medical Center, 820 Clermont St,
records, cardiology clinics, and contact to verify vital
Suite 120, Denver, CO 80220; e-mail: laurie.shroyer@med.va.gov or status with the local cardiac surgery programs surgical
laurie.shroyer@uchsc.edu. clinical nurse reviewers. The perioperative morbidity is

2006 by The Society of Thoracic Surgeons 0003-4975/06/$32.00


Published by Elsevier Inc doi:10.1016/j.athoracsur.2005.08.001
548 PLOMONDON ET AL Ann Thorac Surg
NO VOLUME-OUTCOME RELATIONSHIP FOR OPCABG 2006;81:54754

defined as the presence or absence of any of the follow- hospital to obtain an expected number of deaths (or
ing major complications: endocarditis; renal failure re- morbidities). The ratios of the observed-to-expected
quiring dialysis; mediastinitis; reoperation for bleeding; (O/E) 30-day deaths, 180-day deaths and 30-day morbid-
placed on ventilator for longer than 48 hours; repeat ities (separately) were calculated for each VA surgery
cardiopulmonary bypass; stroke; coma for longer than 24 center. Pearson correlation coefficients were calculated to
CARDIOVASCULAR

hours; or cardiac arrest requiring cardiopulmonary re- examine the correlation between the O/E ratio, for each
suscitation during the inpatient perioperative period or outcome, and the logarithm of average hospital volume.
within 30 days after surgery. This complication assess- Average hospital volume was log transformed due to its
ment is based upon the standard definition used for the skewed distribution. For interpretability, base-2 logs
VA Cardiac Surgery Consultants Committees national (log2) were used so that a change in the average volume
quality assurance endeavors. corresponded to a doubling of average hospital volume.
Finally, hierarchical logistic regression models [17] were
OPCABG Procedural Volume developed to examine the relationship between OPCABG
The primary variable of interest was OPCABG proce- procedural volumes with the three study outcomes: 30-day
dural volume, which was defined in two ways: (1) average operative mortality, perioperative morbidity, and 180-day
hospital OPCABG procedural volume in a 6-month pe- mortality while adjusting for both time period and patient
riod; and (2) the most recent 6-month hospital OPCABG risk factors. Each of these three hierarchical models con-
volume preceding the surgical procedure. The latter tained the logistic transform of the patient risk estimate, the
definition for the most recent 6-month period was based 6-month period when the surgery occurred, the log of
on the approach used by Hamilton and Ho [4], who average volume of all CABG procedures, and the log of
investigated whether practice makes perfect for the average hospital OPCABG volume in combination with a
treatment of hip fracture patients. random hospital indicator to account for unmeasured dif-
ferences among hospitals for this hospital level volume
Risk Variables
analysis. Similar models for each of the studys outcomes
Twenty-four preoperative patient-specific risk character- were constructed using the log of cardiac surgery proce-
istics for mortality and morbidity were categorized as dural volume during the most recent 6-month period also.
either demographic, noncardiac comorbidities, or cardiac- All statistical analyses were conducted using SAS software
related assessments (related to cardiac disease severity),
(SAS Institute, Cary, North Carolina).
as listed in Table 1. Although the rates for missing data
were extremely low, values for missing risk variables
were imputed as the median for continuous variables Results
and the most frequent value for categorical and dichot-
Study Population
omous variables. Other variables included in the analysis
were time (range, 0 to 10), which was defined based upon Table 1 shows summary statistics for all patient risk
the 6-month period in which the procedure was per- factors delineated by volume group. Differences in risk
formed (starting from the point of study initiation in factors across volume groups were clinically small and
October 1, 1998). statistically nonsignificant (three-vessel coronary artery
disease was borderline significantly different across
Statistical Analyses groups, p 0.0478). Table 2 shows summary statistics for
The study population was described by dividing hospi- all complications and outcomes delineated by volume
tals into four volume groups based on the quartiles of group. Likewise, there were very few differences in
hospital OPCABG procedural volume. Hospital sum- complications and mortality across the volume groups.
mary statistics were calculated by averaging the 10 For the entire study, the 30-day operative mortality rate
6-month hospital averages for continuous variables or was 2.6%. Overall, the perioperative morbidity rate for
the hospital percentages for categorical and dichotomous these nine major complications was 9.4%. The studys
variables, within each OPCABG procedural volume 180-day all cause mortality rate was 4.5%.
group, for each risk factor. Tests for equality across
volume groups were performed for each risk factor using Correlation Coefficients
one-way analysis of variance overall F tests based on The correlation coefficients are demonstrated in Table 3
these hospital averages across the 44 hospitals. for the O/E ratios of the three outcomes and the log
Using logistic regression, risk estimates for each of the average OPCABG procedure volume. None of these
three outcomes, 30-day mortality, perioperative morbid- correlations was statistically significant, indicating no
ity, and 180-day mortality were constructed using the demonstrable relationship between OPCABG procedure
patient characteristics listed in Table 1. For each of the volume and risk-adjusted outcomes.
three study outcomes, backward stepwise selection
methods were used to retain only those factors that Hierarchical Logistic Regression Models
remained significant at a p level of 0.05. The Appendix The average hospital OPCABG volume odds ratio and
contains each models details. Using these models, a risk 95% confidence interval from the hierarchical logistic
estimate for each patient and for each outcome was regression models are shown in Table 4 for each of the
calculated. These probabilities were summed for each three outcomes: 30-day operative mortality, periopera-
Ann Thorac Surg PLOMONDON ET AL 549
2006;81:54754 NO VOLUME-OUTCOME RELATIONSHIP FOR OPCABG

Table 1. Coronary Artery Bypass Graft Surgery (CABG) Patient Characteristics in 44 Department of Veterans Affairs Cardiac
Surgery Programs (Mean [SD] or Percent)
OPCABG Volume (Average Procedures in 6 Months)

10.2 10.216.6 16.630.2 30.2

CARDIOVASCULAR
(1,322 Patients at (1,204 Patients at (1,067 Patients at (1,483 Patients at
Variable 25 Hospitals) 10 Hospitals) 5 Hospitals) 4 Hospitals) p Value

Demographic/noncardiac
Age (years) 64.23 (3.99) 63.89 (1.60) 65.61 (1.89) 64.12 (.83) 0.8031
Male sex 99.3% 99.3% 99.1% 98.7% 0.7772
Body surface area (m2) 2.01 (0.06) 2.02 (0.03) 2.00 (0.03) 2.03 (0.01) 0.7283
Chronic obstructive pulmonary disease 30.0% 24.6% 21.2% 28.4% 0.4902
Peripheral vascular disease 29.9% 22.6% 28.0% 26.1% 0.6637
Cerebral vascular disease 20.1% 23.2% 24.2% 28.8% 0.4021
Serum creatinine (mg/dL) 1.27 (0.18) 1.29 (0.10) 1.34 (0.08) 1.25 (0.03) 0.7585
Diabetes 34.2% 35.8% 37.5% 37.3% 0.8525
Current smoker 30.1% 26.6% 25.5% 33.8% 0.8201
Functional status: partially or totally 16.3% 7.7% 14.7% 16.4% 0.5452
dependent
Cardiac
Prior myocardial infarction 53.4% 53.8% 50.0% 55.8% 0.9116
Prior percutaneous coronary 1.2% 0.7% 4.4% 0.8% 0.2617
intervention
Prior heart surgery 8.1% 6.7% 7.5% 4.4% 0.7708
Preoperative use of intra-aortic balloon 5.7% 5.0% 5.8% 4.5% 0.9916
pump
Pulmonary rales 4.8% 4.3% 6.4% 8.1% 0.5359
Canadian Cardiovascular Society 70.1% 77.1% 55.5% 57.0% 0.2906
anginal class III/IV
New York Heart Association functional 6.5% 5.4% 2.9% 4.1% 0.8629
class III/IV
Left ventricular ejection fraction 0.6985
(range)
0.55 52.3% 56.3% 42.8% 51.7%
0.450.55 23.4% 19.7% 27.4% 20.9%
0.350.45 17.8% 13.5% 17.5% 15.2%
0.250.35 7.1% 7.4% 8.3% 8.6%
0.25 2.5% 3.1% 3.9% 3.6%
Three-vessel coronary artery disease 55.1% 65.1% 64.2% 66.0% 0.0478
Preoperative ST-segment depression 11.2% 16.4% 19.8% 11.7% 0.5793
on electrocardiogram
Surgical priority 0.8450
Elective 83.8% 84.3% 90.9% 85.5%
Urgent 11.3% 13.0% 6.7% 11.9%
Emergent 4.9% 2.7% 2.5% 2.6%
Current use of diuretics 30.1% 25.1% 25.3% 32.3% 0.7621
Current use of digoxin 8.2% 6.4% 5.6% 6.5% 0.8623
Preoperative intravenous nitroglycerin 9.9% 6.6% 8.7% 8.8% 0.7841

tive 30-day morbidity, and 180-day mortality. The patient do not demonstrate relationships between average hospital
risk estimate was the only consistently significant factor volume and outcomes, adjusting for patient risk and time
found in these analyses for each of the studys three trends. Finally, as seen in Figure 1, the 180-day risk-
outcomes. Time covariate showed a slightly decreasing adjusted mortality rate varies widely among the lower
trend; however, this trend was not statistically significant volume hospitals with cardiac surgery programs without
for OPCABG procedure. any obvious trend related to volume. The 30-day risk-
Average hospital OPCABG procedural volume odds ra- adjusted mortality and perioperative morbidity figures
tios were less than one, but were not significant for any of were similar, with wide variation among the lower volume
these outcomes. As in the correlation analysis, these results hospitals and no obvious trend related to volume.
550 PLOMONDON ET AL Ann Thorac Surg
NO VOLUME-OUTCOME RELATIONSHIP FOR OPCABG 2006;81:54754

Table 2. Coronary Artery Bypass Graft Surgery (CABG) Patient Complications and Outcomes in the 44 Department of
Veterans Affairs Cardiac Surgery Programs (Mean [SD] or Percent)
OPCABG Volume (Average Surgeries in 6 Months)

10.2 10.216.6 16.630.2 30.2


CARDIOVASCULAR

(1,322 Patients at (1,204 Patients at (1,067 Patients at (1,483 Patients at


Variable 25 Hospitals) 10 Hospitals) 5 Hospitals) 4 Hospitals) p Value

Complications
Endocarditis 0.2% 0.0% 0.0% 0.1% 0.6016
Renal failure requiring dialysis 0.6% 1.3% 0.8% 0.8% 0.3480
Mediastinitis 0.6% 1.4% 1.0% 0.7% 0.1785
Reoperation for bleeding 1.4% 1.3% 2.3% 1.7% 0.7163
On ventilator 48 hours 7.7% 6.7% 6.3% 6.5% 0.9699
Repeat cardiopulmonary bypass 0.1% 0.4% 0.6% 0.2% 0.0247
Coma 0.4% 0.4% 0.4% 0.7% 0.8748
Stroke 2.3% 1.5% 1.6% 2.1% 0.7979
Cardiac arrest requiring cardiopulmonary 3.5% 2.0% 1.4% 2.2% 0.9101
resuscitation
Tracheostomy 0.2% 0.4% 0.6% 0.4% 0.4924
Mechanical circulatory support 1.7% 1.5% 0.5% 1.4% 0.9505
Outcomes
30-Day operative mortality 2.5% 2.6% 2.2% 2.3% 0.9933
Perioperative morbidity 11.0% 9.4% 9.2% 9.4% 0.9512
180-Day mortality 5.1% 4.0% 4.1% 4.5% 0.8266

The 95% confidence intervals (CI) for log average The relationship between CABG procedural volume
volume odds ratios provide precision information that and outcome has been studied in a variety of settings;
clarifies interpretation. For example, doubling of average however, only one of these studies has specifically looked
hospital volume was associated with a change in the odds at the volume of off-pump CABG procedure and outcome
ratio for 30-day operative mortality of 0.94 (95% CI: 0.76 to [7]. Using administrative data from 72 hospitals, low-
1.15). Thus, if an association does exist, the odds ratio for volume centers were defined as those with less than 100
a doubling of average hospital volume is unlikely to lie off-pump procedures per year (n 6) and high-volume
outside of this range. Similar precision results were as those with 100 or more off-pump procedures per year
found for models including hospital OPCABG proce- (n 66). They found no association between volume and
dural volume during the previous 6-month period and mortality. Although an association between volume and
hence are not reported here. morbidity was found, distinguishing between comorbidi-
ties and complications is very difficult when using ad-
ministrative data [18].
Comment The results from studies examining the relationship
The objective of this study was to determine if a relation- between volume and outcome among all CABG proce-
ship existed between hospital OPCABG procedural volume dures are mixed. Clinical data from The Society of
and 30-day operative mortality, perioperative morbidity, or Thoracic Surgeons (STS) National Cardiac Database was
180-day mortality after adjusting for clinical patient risk,
trends over time, and hospital-specific effects. No such
volume-outcome relationship was demonstrated. Table 4. Hierarchical Logistic Regression Models Estimating
Association of Average Department of Veterans Affairs
Cardiac Surgery Programs CABG Volume With Outcomes
Table 3. Relationships of Risk-Adjusted Outcomes (Observed
to Expected [O/E] Ratios) With Log of Average OPCABG Odds Ratio (95% CI)
Surgery Volume in 44 Department of Veterans Affairs for Doubling
Cardiac Surgery Programs Variable Volume p Value

Pearson 30-Day operative mortality 0.94 (0.76, 1.15) 0.5191


Correlation Perioperative morbidity 0.91 (0.81, 1.02) 0.1149
Variable Coefficient p Value 180-Day mortality 0.92 (0.77, 1.09) 0.3177
30-Day operative mortality O/E ratio 0.1608 0.3030
Each model contained the logit of patient risk estimate, a linear time
Perioperative morbidity O/E ratio 0.1713 0.2721 trend, and a random hospital effect as well as log2 average hospital
180-Day mortality O/E ratio 0.0731 0.6413 volume.
CABG coronary artery bypass graft surgery; CI confidence
OPCABG off-pump coronary artery bypass graft. interval.
Ann Thorac Surg PLOMONDON ET AL 551
2006;81:54754 NO VOLUME-OUTCOME RELATIONSHIP FOR OPCABG

Fig 1. Risk-adjusted 180-day mortality rate by


hospital cardiac surgery programs annual coro-
nary artery bypass graft (CABG) off-pump pro-
cedural volume. (Circles volume group 1;
dashes volume group 2; triangles volume

CARDIOVASCULAR
group 3; crosses volume group 4.)

recently used to test the association between hospital average hospital OPCABG volume and mortality or mor-
CABG volume and all cause mortality [14]. The study bidity may potentially be due to low precision and power.
included 267,089 procedures among 439 hospitals with However, the 95% confidence intervals for associations of
average yearly volumes from 39 to 1,754 procedures. The average hospital volume with outcomes rule out that a
analyses were risk adjusted for both patient and hospital large association is likely to exist in VA-based cardiac
level characteristics. Although a modest association be- surgery program settings. Furthermore, VA cardiotho-
tween CABG volume and all cause mortality was found, racic surgeons most commonly also perform CABG pro-
the association did not remain among certain subpopu- cedures at their affiliated University hospital. The OPCABG
lations, such as patients younger than 65 and patients volumes included in this analysis were limited to VA
with a low preoperative risk. The authors concluded that hospital OPCABG procedures performed. Thus, VA hos-
volume is not an adequate quality indicator for CABG pital OPCABG volume may not adequately measure the
surgery. In another study that used National Medicare number of OPCABG procedures performed by each
claims data, an association between the CABG procedure surgeon. Perhaps the most informative measure of OP-
and mortality was found [8]. However, these results are CABG volume, which was not available for this study,
based on administrative data and can only be generalized may be the attending cardiac surgeon-specific OPCABG
to the Medicare population. Lastly, the New York States volumea variable that is not captured within the VA
Cardiac Surgery Reporting data were used to examine CICSP/CICSP-X national database. Prior VA-based stud-
CABG surgery volume and outcome [10]. The analyses ies using the CICSP database also found no continuous
were adjusted for both patient clinical characteristics and relationship between volume and risk-adjusted outcome.
hospital level data. Mortality rates were lower among Inherent variability due to small sample size suggests
hospitals performing between 200 and 800 procedures a that risk-adjusted outcomes should be more closely mon-
year and lower among surgeons who perform between 50 itored at VA hospitals that perform fewer CABG proce-
and 200 procedures a year. However, possible selection dures in a year. Hence, the VA Cardiac Surgery Consul-
bias could exist since this study was performed in only tant Committee policies aggregate volume for CABG
one state, and the state has certificate of need regula- procedure but not based on operative approachfor
tions that decrease the number of low-volume centers. monitoring quality. Owing to data reliability concerns,
Therefore, there were very few hospitals with less than the off-pump to on-pump as well as on-pump to off-
an average annual volume of 200 CABG procedures. pump conversion rates were unable to be adequately
While an association between volume of CABG proce- addressed in this analysis. The CICSP/CICSP-X data did
dure and mortality was found, again the authors recog- not allow for the identification of off-pump cases that
nize the difficulty in implementing a volume-outcome were converted to on-pump; therefore, all conversions
policy, namely, travel and time constraints and disrup- were defined as on-pump in this study.
tion of physician continuity of care. Strengths of this study include the use of prospectively
Although the results of the CABG volume-outcome studies collected clinical data for patient risk adjustment and the
are mixed, many of the authors agree to caution against the evaluation of both short-term and intermediate-term mor-
implementation of a procedural volume policy. Although tality, as well as short-term morbidity, as outcomes. Based
procedural volume is easily measurable, it remains a ques- on the small widths of the confidence intervals for the odds
tionable indicator of quality. Attention should remain on ratios for differences in hospital volume, this study had a
collecting clinical data for analyzing risk-adjusted outcomes large enough study population to ensure adequate preci-
with the goal of improving care across all surgical centers. sion to rule out a large association between hospital OP-
This VA-based study has several inherent limitations. CABG procedural volume and 30-day operative mortality,
It is possible that the finding of no association between perioperative morbidity, or 180-day mortality.
552 PLOMONDON ET AL Ann Thorac Surg
NO VOLUME-OUTCOME RELATIONSHIP FOR OPCABG 2006;81:54754

No associations between VA OPCABG procedural vol- from the VA National Surgical Quality Improvement
ume and short-term mortality or morbidity or 180-day Program. Ann Surg 1999;230:414.
mortality were found. The Department of Veterans Af- 6. Sollano JA, Gelijns AC, Moskowitz AJ, et al. Volume-
outcome relationships in cardiovascular operations: New
fairs Central Offices primary focus is the assurance of York State, 1990-1995. J Thorac Cardiovasc Surg 1999;117:
veteran safety. In context of this goal and the findings of
CARDIOVASCULAR

419 28.
this study, the VA Cardiac Surgery Consultants Commit- 7. Brown PP, Mack MJ, Simon AW, et al. Comparing clinical
tee will continue to monitor OPCABG procedures to outcomes in high-volume and low-volume off-pump coro-
assure each cardiac surgery programs quality. Based on nary bypass operation programs. Ann Thorac Surg 2001;
72(Suppl):1009 15.
this studys findings, however, no minimum volume
8. Birkmeyer JD, Siewers AE, Emily VA, et al. Hospital volume
OPCABG threshold for review is planned to be added to and surgical mortality in the United States. N Engl J Med
the existing policy thresholds or procedures at this time. 2002;346:1128 37.
9. Halm ES, Lee C, Chassin MR. Is volume related to outcomes
in health care? A systematic review and methodologic cri-
Funding for this study was provided by VA Health Services tique of the literature. Ann Intern Med 2002;137:51120.
Research and Development Grant IHY 99214-1 (Dr Shroyer, 10. Hannan EL, Wu C, Ryan TJ, et al. Do hospitals and surgeons
Principal Investigator) and by the VA Office of Patient Care with higher coronary artery bypass graft surgery volumes
Services at VA Headquarters, Washington, DC. University of
still have lower risk-adjusted mortality rates? Circulation
Colorado at Denver and Health Sciences Center Campus Grad-
2003;108:795 801.
uate School student stipend support was provided under the
11. Carey JS, Robertson JM, Misbach GA, Fisher AL. Relation-
guidance of Dr Shroyer, in part, to support Dr Plomondons
participation in this project. ship of hospital volume to outcome in cardiac surgery
programs in California. Am Surg 3003;69:63 8.
12. Luft HS, Bunker JP, Enthoven AC. Should operations be
regionalized? The empirical relation between surgical vol-
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Appendix
Logistic Regression Models Used to Estimate Patient Risk
Table 1. Thirty-Day Operative Mortality Model
Parameter Standard Odds 95% Confidence
Variable Estimate Error Ratio Limits p Value

Intercept 7.97 0.72 .0001


Age 0.05 0.01 1.05 1.031.07 .0001
Chronic obstructive pulmonary disease 0.66 0.18 1.94 1.352.78 0.0004
Serum creatinine (1.53.0) 0.57 0.20 1.77 1.182.64 0.0056
Serum creatinine (3.0) 1.00 0.45 2.73 1.146.55 0.0245
Current use of diuretics 0.38 0.19 1.46 1.002.13 0.0496
Preoperative intravenous nitroglycerin 0.56 0.25 1.76 1.072.88 0.0255
New York Heart Association functional class III/IV 0.62 0.29 1.86 1.063.26 0.0305
LVEF (0.450.55) 0.22 0.24 1.25 0.782.02 0.3585
LVEF (0.350.45) 0.63 0.24 1.87 1.163.02 0.0099
LVEF (0.250.35) 0.31 0.34 1.37 0.712.65 0.3508
LVEF 0.25 1.20 0.33 3.31 1.726.38 0.0003

LVEF left ventricular ejection fraction.


Ann Thorac Surg PLOMONDON ET AL 553
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Table 2. Perioperative Morbidity Model


Parameter Standard Odds 95% Confidence
Variable Estimate Error Ratio Limits p Value

CARDIOVASCULAR
Intercept 4.17 0.36 .0001
Age 0.02 0.01 1.02 1.011.03 .0001
Chronic obstructive pulmonary disease 0.39 0.10 1.47 1.201.81 0.0002
Serum creatinine (1.53.0) 0.44 0.12 1.56 1.231.98 0.0002
Serum creatinine ( 3.0) 1.08 0.24 2.95 1.834.75 .0001
Preoperative electrocardiogram ST-segment 0.63 0.31 1.88 1.033.46 0.0410
depression
Preoperative intravenous nitroglycerin 0.43 0.15 1.54 1.142.09 0.0049
Canadian Cardiovascular Society anginal class 0.29 0.10 0.75 0.610.91 0.0046
III/IV
Three-vessel coronary artery disease 0.32 0.11 1.38 1.121.71 0.0030
Functional status: partially or totally dependent 0.36 0.13 1.44 1.121.86 0.0049
LVEF (0.450.55) 0.02 0.13 0.98 0.771.26 0.8859
LVEF (0.350.45) 0.34 0.13 1.41 1.081.82 0.0105
LVEF (0.250.35) 0.03 0.19 1.03 0.711.49 0.8931
LVEF 0.25 0.48 0.23 1.62 1.042.53 0.0337
LVEF left ventricular ejection fraction.

Table 3. 180-Day Mortality Model


Parameter Standard Odds 95% Confidence
Variable Estimate Error Ratio Limits p Value

Intercept 7.02 0.54 .0001


Age 0.05 0.01 1.05 1.031.06 .0001
Chronic obstructive pulmonary disease 0.69 0.14 1.99 1.512.64 .0001
Serum creatinine (1.53.0) 0.79 0.16 2.19 1.612.99 .0001
Serum creatinine (3.0) 1.64 0.29 5.17 2.929.14 .0001
Current use of diuretics 0.33 0.15 1.40 1.051.87 0.0239
Functional status: partially or totally dependent 0.57 0.16 1.77 1.292.44 0.0005
LVEF (0.450.55) 0.16 0.19 1.18 0.821.70 0.3785
LVEF (0.350.45) 0.55 0.19 1.74 1.202.52 0.0033
LVEF (0.250.35) 0.07 0.28 1.07 0.621.83 0.8107
LVEF 0.25 1.31 0.26 3.71 2.236.15 .0001
LVEF left ventricular ejection fraction.

INVITED COMMENTARY
Initial studies using administrative databases reported mortality rates exists among hospitals within similar
an inverse relationship between cardiac surgery proce- volume categories. The volumemortality relationship
dural volume and mortality. More recent studies using may be mitigated in clinical data due to the superiority of
both administrative and clinical databases have ques- clinical data in adjusting for severity of illness. The
tioned the strength of this relationship. The enthusiasm Medicare dataset was designed for reimbursement pur-
for volume as a marker for quality has been tempered in poses and omits many of the strongest predictors of
part due to (1) the range of mortality rates in both mortality identified in clinical datasets (ie, left ventricular
low-volume and high-volume hospital groups, and (2) ejection fraction, multiple prior cardiac procedures, left
the much weaker relationship demonstrated in clinical main coronary artery disease, three-vessel coronary ar-
databases. Although on average, high-volume hospitals tery disease). In addition, the timing of important events
have lower coronary artery bypass grafting (CABG) mor- such as how long before surgery a preoperative myocar-
tality rates than low-volume hospitals, wide variation in dial infarction occurred cannot be determined. This de-

2006 by The Society of Thoracic Surgeons 0003-4975/06/$32.00


Published by Elsevier Inc doi:10.1016/j.athoracsur.2005.09.080

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