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Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study
  1. Danwei Zhang1,
  2. Dachuan Gu1,2,
  3. Chenfei Rao1,2,
  4. Heng Zhang1,2,
  5. Xiaoting Su1,
  6. Sipeng Chen1,
  7. Hanping Ma1,
  8. Yan Zhao1,
  9. Wei Feng1,2,
  10. Hansong Sun1,2,
  11. Zhe Zheng1,2,3
  1. 1National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
  2. 2Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
  3. 3National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
  1. Correspondence to Dr Zhe Zheng, National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, and Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College. No.167 North Lishi Road, Xicheng District, Beijing, 100037, People's Republic of China, Beijing, People's Republic of China; zhengzhe{at}fuwai.com

Abstract

Background With increasing surgical workload, it is common for cardiac surgeons to perform coronary artery bypass grafting (CABG) after other procedures in a workday. To investigate whether prior procedures performed by the surgeon impact the outcomes, we compared the outcomes between CABGs performed first versus those performed after prior procedures, separately for on-pump and off-pump CABGs as they differed in technical complexity.

Methods We conducted a retrospective cohort study of patients undergoing isolated CABG in China from January 2013 to December 2018. Patients were categorised as undergoing on-pump and off-pump CABGs. Outcomes of the procedures performed first in primary surgeons’ daily schedule (first procedure) were compared with subsequent ones (non-first procedure). The primary outcome was an adverse events composite (AEC) defined as the number of adverse events, including in-hospital mortality, myocardial infarction, stroke, acute kidney injury and reoperation. Secondary outcomes were the individual components of the primary outcome, presented as binary variables. Mixed-effects models were used, adjusting for patient and surgeon-level characteristics and year of surgery.

Results Among 21 866 patients, 10 109 (16.1% as non-first) underwent on-pump and 11 757 (29.6% as non-first) off-pump CABG. In the on-pump cohort, there was no significant association between procedure order and the outcomes (all p>0.05). In the off-pump cohort, non-first procedures were associated with an increased number of AEC (adjusted rate ratio 1.29, 95% CI 1.13 to 1.47, p<0.001), myocardial infarction (adjusted OR (ORadj) 1.43, 95% CI 1.13 to 1.81, p=0.003) and stroke (ORadj 1.73, 95% CI 1.18 to 2.53, p=0.005) compared with first procedures. These increases were only found to be statistically significant when the procedure was performed by surgeons with <20 years’ practice or surgeons with a preindex volume <700 cases.

Conclusions For a technically challenging surgical procedure like off-pump CABG, prior workload adversely affected patient outcomes.

  • surgery
  • quality improvement
  • performance measures
  • health services research

Data availability statement

No data are available.

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Footnotes

  • DZ and DG are joint first authors.

  • Collaborators Chinese Cardiac Surgery Registry Collaborative Group.

  • Contributors Conception and design: ZZ, DZ, DG. Acquisition, analysis and interpretation of data: all authors. Drafting the manuscript: DZ, DG. Revising the manuscript for important intellectual content: all authors. Statistical analysis: DZ, SC. Obtained funding: ZZ. Administrative, technical, material support: ZZ. Supervision: ZZ. Guarantor: ZZ.

  • Funding This study was funded by the National Key Research and Development Program (grant number: 2016YFC1302000), Beijing Municipal Commission of Science and Technology Project (grant number: D171100002917001), and the Graduate Innovation Fund of Peking Union Medical College (grant number: 2019-1002-30).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.