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.
- quality improvement
- performance measures
- health services research
Data availability statement
No data are available.
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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.
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