Cardiac surgery report cards: comprehensive review and statistical critique

doi:10.1016/S0003-4975(01)03222-2

The Annals of Thoracic Surgery

Volume 72, Issue 6, December 2001, Pages 2155-2168

https://doi.org/10.1016/S0003-4975(01)03222-2 Get rights and content

Abstract

Public report cards and confidential, collaborative peer education represent distinctly different approaches to cardiac surgery quality assessment and improvement. This review discusses the controversies regarding their methodology and relative effectiveness.

Report cards have been the more commonly used approach, typically as a result of state legislation. They are based on the presumption that publication of outcomes effectively motivates providers, and that market forces will reward higher quality. Numerous studies have challenged the validity of these hypotheses. Furthermore, although states with report cards have reported significant decreases in risk-adjusted mortality, it is unclear whether this improvement resulted from public disclosure or, rather, from the development of internal quality programs by hospitals. An additional confounding factor is the nationwide decline in heart surgery mortality, including states without quality monitoring. Finally, report cards may engender negative behaviors such as high-risk case avoidance and “gaming” of the reporting system, especially if individual surgeon results are published.

The alternative approach, continuous quality improvement, may provide an opportunity to enhance performance and reduce interprovider variability while avoiding the unintended negative consequences of report cards. This collaborative method, which uses exchange visits between programs and determination of best practice, has been highly effective in northern New England and in the Veterans Affairs Administration. However, despite their potential advantages, quality programs based solely on confidential continuous quality improvement do not address the issue of public accountability. For this reason, some states may continue to mandate report cards. In such instances, it is imperative that appropriate statistical techniques and report formats are used, and that professional organizations simultaneously implement continuous quality improvement programs.

The statistical methodology underlying current report cards is flawed, and does not justify the degree of accuracy presented to the public. All existing risk-adjustment methods have substantial inherent imprecision, and this is compounded when the results of such patient-level models are aggregated and used inappropriately to assess provider performance. Specific problems include sample size differences, clustering of observations, multiple comparisons, and failure to account for the random component of interprovider variability. We advocate the use of hierarchical or multilevel statistical models to address these concerns, as well as report formats that emphasize the statistical uncertainty of the results.

Section snippets

Background

Just as Deming and Juran led an industrial quality revolution during the second half of the 20th century, quality improvement has emerged over the last decade as one of the dominant themes in modern health care. Specific areas of interest have included access, appropriateness, geographic variations in care, reduction of medical error and costs, cost-effectiveness, long-term functional status, and quality of the provider–patient relationship 1, 2, 3, 4, 5, 6. Although quality can be assessed on

Market-driven quality improvement (“report cards”)

Report cards have been the more widely used approach to cardiac surgery quality assessment and improvement. They are based on the presumption that publication of outcomes effectively motivates providers, and that market forces will reward higher quality. Numerous studies have challenged the validity of these hypotheses. Furthermore, controversies persist regarding the statistical methodology of report cards, their presentation format, and their actual impact on cardiac surgery quality.

The CQI approach to cardiac surgery quality improvement

Despite the reduction in mortality observed in states with cardiac surgery report cards, this approach has also produced fear, distrust, gaming, and other negative behaviors on the part of providers, which may paradoxically impede continued quality improvement 7, 126. Jencks [127] has stated that it is unreasonable to expect honest self-examination under the threat of media disclosure. In 1989, several years before public report cards were made available in New York or Pennsylvania, Berwick

The balance between public accountability and peer-based quality improvement

A continuous quality improvement approach may offer the best possibility for improving outcomes and reducing variability among hospitals without the unintended negative consequences of report cards. However, it appears inevitable that some states and payers will demand access to cardiac surgery outcome data, despite evidence that such information is imperfect and is rarely used to select providers. As formulated by Epstein [132], the issue is whether to rely on the market impact of such report

Recommendations

Whenever feasible, state and regional cardiac surgical organizations should implement continuous quality improvement programs. These should include exchange site visits, benchmarking, and determination of best practice. This process and systems–oriented approach is the best way to raise the performance level of all cardiac surgery programs; it affirms the commitment of our specialty to excellence, and it should be the cornerstone of any quality improvement effort.

In states where legislation

References (133)

N.T. Kouchoukos et al.
Report of the Ad Hoc Committee on Physician-Specific Mortality Rates for Cardiac Surgery
Ann Thorac Surg
(1993)
R.H. Jones et al.
Identification of preoperative variables needed for risk adjustment of short-term mortality after coronary artery bypass graft surgery. The Working Group Panel on the Cooperative CABG Database Project
J Am Coll Cardiol
(1996)
J.V. Tu et al.
Assessing the outcomes of coronary artery bypass graft surgeryhow many risk factors are enough? Steering Committee of the Cardiac Care Network of Ontario
J Am Coll Cardiol
(1997)
F.L. Grover et al.
Quality initiatives and the power of the databasewhat they are and how they run
Ann Thorac Surg
(1995)
R.P. Lippmann et al.
Coronary artery bypass risk prediction using neural networks
Ann Thorac Surg
(1997)
D.M. Shahian et al.
Applications of statistical quality control to cardiac surgery
Ann Thorac Surg
(1996)
D.J. Malenka et al.
A regional collaborative effort for CQI in cardiovascular disease. Northern New England Cardiovascular Study Group
J Qual Improv
(1995)
G.T. O’Connor
Physician leadership in cardiac outcomes reporting
Ann Thorac Surg
(2000)
W.C. Nugent et al.
Playing by the numbershow collecting outcomes data changed my life
Ann Thorac Surg
(1994)
E.L. Hannan et al.
New York State’s Cardiac Surgery Reporting Systemfour years later
Ann Thorac Surg
(1994)

E.D. Peterson et al.

The effects of New York’s bypass surgery provider profiling on access to care and patient outcomes in the elderly

J Am Coll Cardiol

(1998)

S.W. Dziuban et al.

How a New York cardiac surgery program uses outcomes data

Ann Thorac Surg

(1994)

S.W. Dziuban

Using information from databases to improve clinical practicelessons learned under fire

Ann Thorac Surg

(1997)

V.A. Ferraris

The dangers of gathering data

J Thorac Cardiovasc Surg

(1992)

E.L. Hannan et al.

Public release of cardiac surgery outcomes data in New Yorkwhat do New York State cardiologists think of it?

Am Heart J

(1997)

J.M. Bentley et al.

How Pennsylvania hospitals have responded to publicly released reports on coronary artery bypass graft surgery

J Comm J Qual Improv

(1998)

K.V. Arom et al.

Establishing and using a local/regional cardiac surgery database

Ann Thorac Surg

(1997)

W.L. Holman et al.

Alabama coronary artery bypass grafting Cooperative Projectbaseline data. Alabama CABG Cooperative Project Study Group

Ann Thorac Surg

(1999)

J.R. Goss et al.

Washington State’s model of physician leadership in cardiac outcomes reporting

Ann Thorac Surg

(2000)

F.L. Grover et al.

Factors predictive of operative mortality among coronary artery bypass subsets

Ann Thorac Surg

(1993)

F.L. Grover et al.

The Veterans Affairs Continuous Improvement in Cardiac Surgery Study

Ann Thorac Surg

(1994)

K.E. Hammermeister et al.

Using outcomes data to improve clinical practicewhat we have learned

Ann Thorac Surg

(1994)

K.E. Hammermeister

Participatory continuous improvement

Ann Thorac Surg

(1994)

G. Marshall et al.

Bayesian-logit model for risk assessment in coronary artery bypass grafting

Ann Thorac Surg

(1994)

F.L. Grover et al.

Calculating risk and outcomethe Veterans Affairs Database

Ann Thorac Surg

(1996)

J. Daley et al.

Validating risk-adjusted surgical outcomessite visit assessment of process and structure. National VA Surgical Risk Study

J Am Coll Surg

(1997)

T.B. Ferguson et al.

The STS National DatabaseCurrent changes and challenges for the new millennium

Ann Thorac Surg

(2000)

A.L. Shroyer et al.

Updates to the Data Quality Review ProgramThe Society of Thoracic Surgeons Adult Cardiac National Database

Ann Thorac Surg

(1998)

A.L. Shroyer et al.

1995 coronary artery bypass risk modelThe Society of Thoracic Surgeons Adult Cardiac National Database

Ann Thorac Surg

(1998)

R.E. Clark

The STS Cardiac Surgery National Databasean update

Ann Thorac Surg

(1995)

R.E. Clark

Calculating risk and outcomeThe Society of Thoracic Surgeons Database

Ann Thorac Surg

(1996)

F.H. Edwards et al.

The Society of Thoracic Surgeons National Cardiac Surgery Databasecurrent risk assessment

Ann Thorac Surg

(1997)

F.G. Estafanous et al.

Increased risk and decreased morbidity of coronary artery bypass grafting between 1986 and 1994

Ann Thorac Surg

(1998)

E.D. Peterson et al.

Challenges in comparing risk-adjusted bypass surgery mortality resultsresults from the Cooperative Cardiovascular Project

J Am Coll Cardiol

(2000)

J.F. Burgess et al.

Medical profilingimproving standards and risk adjustments using hierarchical models

J Health Econ

(2000)

L.I. Iezzoni

Using risk-adjusted outcomes to assess clinical practicean overview of issues pertaining to risk adjustment

Ann Thorac Surg

(1994)

P.M. Steen

Approaches to predictive modeling

Ann Thorac Surg

(1994)

J. Daley

Criteria by which to evaluate risk-adjusted outcomes programs in cardiac surgery

Ann Thorac Surg

(1994)

G.A. Diamond

What price perfection? Calibration and discrimination of clinical prediction models

J Clin Epidemiol

(1992)

D. Blumenthal

Part 1. Quality of carewhat is it?

N Engl J Med

(1996)

R.H. Brook et al.

Quality of health care.Part 2: measuring quality of care

N Engl J Med

(1996)

M.R. Chassin

Quality of health care.Part 3: improving the quality of care

N Engl J Med

(1996)

D. Blumenthal

Quality of health care.Part 4: the origins of the quality-of-care debate

N Engl J Med

(1996)

M.R. Chassin et al.

The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality

JAMA

(1998)

T. Bodenheimer

The American health care systemthe movement for improved quality in health care

N Engl J Med

(1999)

J.S. Carey et al.

Quality improvement in thoracic surgery

Bull Am Coll Surg

(1998)

E.J. Topol et al.

Scorecard cardiovascular medicine. Its impact and future directions

Ann Intern Med

(1994)

R.H. Jones

In search of the optimal surgical mortality

Circulation

(1989)

J. Ivanov et al.

Ready-made, recalibrated, or remodeled? Issues in the use of risk indexes for assessing mortality after coronary artery bypass graft surgery

Circulation

(1999)

G. Marshall et al.

Assessment of predictive models for binary outcomesan empirical approach using operative death from cardiac surgery

Stat Med

(1994)

Cited by (239)

Survey of New Zealand Arthroplasty Surgeons on Surgeon-Level Outcome Reporting
2023, Journal of Arthroplasty
Surgeon-specific outcome monitoring has become increasingly prevalent over the last 3 decades. The New Zealand Orthopaedic Association monitors individual surgeon performance through 2 mechanisms: arthroplasty revision rates derived from the New Zealand Joint Registry and a practice visit program. Despite remaining confidential, surgeon-level outcome reporting remains contentious. The purpose of this survey was to evaluate the opinions of hip and knee arthroplasty surgeons in New Zealand on the perceived importance of outcome monitoring, current methods used to evaluate surgeon-specific outcomes, and potential improvements identified through literature review and discussion with other registries.
The survey consisted of 9 questions on surgeon-specific outcome reporting, using a five-point Likert scale, and 5 demographic questions. It was distributed to all current hip and knee arthroplasty surgeons. There were 151 hip and knee arthroplasty surgeons who completed the survey, a response rate of 50%.
Respondents agreed that monitoring arthroplasty outcomes is important and that revision rates are an acceptable measure of performance. Reporting risk-adjusted revision rates and more recent timeframes were supported, as was including patient-reported outcomes when monitoring performance. Surgeons did not support public reporting of surgeon-level or hospital-level outcomes.
The findings of this survey support the use of revision rates to confidentially monitor surgeon-level arthroplasty outcomes and suggest that concurrent use of patient-reported outcome measures would be acceptable.
The implications of fragmented practice in hepatopancreatic surgery
2023, Surgery (United States)
Familiarity with the surgical work environment has been demonstrated to improve outcomes. We sought to investigate the impact of the rate of fragmented practice on textbook outcomes, a validated composite outcome representing an “optimal” postoperative course.
Patients who underwent a hepatic or pancreatic surgical procedure between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The rate of fragmented practice was defined as the surgeon’s volume over the study period relative to the number of facilities practiced at. The association between the rate of fragmented practice and textbook outcomes was assessed using multivariable logistic regression.
A total of 37,599 patients were included (pancreatic: n = 23,701, 63.0%; hepatic: n = 13,898, 37.0%). After controlling for relevant characteristics, patients who underwent surgery by surgeons in higher rate of fragmented practice categories had lower odds of achieving a textbook outcome (reference: low rate of fragmented practice; intermediate rate of fragmented practice: odds ratio = 0.88 [95% confidence interval 0.84–0.93]; high rate of fragmented practice: odds ratio = 0.58 [95% confidence interval 0.54–0.61]) (both P < .001). Of note, the adverse effect of a high rate of fragmented practice on the achievement of textbook outcomes remained substantial, regardless of the county-level social vulnerability index [high rate of fragmented practice; low social vulnerability index: odds ratio = 0.58 (95% confidence interval 0.52–0.66); intermediate social vulnerability index: odds ratio = 0.56 (95% confidence interval 0.52–0.61); high social vulnerability index: odds ratio = 0.60 (95% confidence interval 0.54–0.68)] (all P < .001). Patients in intermediate and high social vulnerability index counties had 19% and 37% greater odds of undergoing surgery by a high rate of fragmented practice surgeon (reference: low social vulnerability index; intermediate social vulnerability index: odds ratio = 1.19 [95% confidence interval 1.12–1.26]; high social vulnerability index: odds ratio = 1.37 [95% confidence interval 1.28–1.46]).
Owing to the impact of the rate of fragmented practice on postoperative outcomes, decreasing fragmentation of care may be an important target for quality initiatives and a means to alleviate social disparities in surgical care.
Impact of shock aetiology and hospital characteristics on the clinical profile, management and prognosis of patients with non ACS-related cardiogenic shock
2023, Hellenic Journal of Cardiology
A significant proportion of cases of cardiogenic shock (CS) are due aetiologies other than acute coronary syndromes (non ACS-CS). We assessed differences regarding clinical profile, management, and prognosis according to the cause of CS among nonselected patients with CS from a large nationwide database.
We performed an observational study including patients admitted from the hospitals of the Spanish National Health System (SNHS) with a principal or secondary diagnosis code of CS (2016-2019). Data were obtained from the Minimum Basic Data Set (MBDS). Hospitals were classified according to the availability of cardiology related resources, as well as the availability of Intensive Cardiac Care Unit (ICCU).
A total of 10,826 episodes of CS were included, of whom 5,495 (50.8%) were non-ACS related. Non ACS-CS patients were younger (71.5 vs. 72.4 years) and had a lower burden of arteriosclerosis-related comorbidities. Non ACS-CS cases underwent less often invasive procedures and presented lower in-hospital mortality (57.1% vs. 61%,p < 0.001). The most common main diagnosis among non ACS-CS was acute decompensation of chronic heart failure (ADCHF) (35.4%). A lower risk-adjusted in-hospital mortality rate was observed in high volume hospitals (52.6% vs. 56.7%; p < 0.001), as well as in centers with ICCU (OR: 0.71; CI 95%: 0.58-0.87; p < 0.001).
More than a half of cases of CS were due to non-ACS causes. Non ACS-CS cases are a very heterogeneous group, with different clinical profile and management. Management at high-volume hospitals and availability of ICCU were associated with lower risk adjusted mortality among non ACS-CS patients.
Heart failure and in-hospital mortality in elderly patients after elective noncardiac surgery in Spain
2022, Medicina Clinica
Patients with heart failure (HF) undergoing noncardiac surgical procedures is rising worldwide. This study was aiming at analyzing the impact of heart failure (HF) on the outcomes (mortality, complications, readmissions, and length of stay) of elderly patients undergoing elective major noncardiac surgical procedures in Spain.
A retrospective observational study of patients undergoing noncardiac surgery was conducted. The Minimum Basic Data Set (MBDS) was used to collect information about the demographic characteristics of patients discharged from hospitals of the Spanish National Health System (SNHS), variables related to patients’ medical conditions and surgeries conducted during the episode.
A total of 996,986 selected procedures in the discharge record were identified in the period 2007–2015. HF was recorded as a secondary diagnosis in 22,367 discharges (2.24%). The mean age of patients was 76.6 ± 7.27 years, with a difference in patients without and with HF: 76.5 (95% CI: 76.47–76.50) vs 82.8 (95% CI: 82.71–82.90). The number of selected surgical procedures increased by 13.2% (117,487 in 2015 vs. 103,744 in 2007), and the proportion of presence HF as a comorbidity increased by 24.4% (2.4% in 2015 v 1.9% in 2007). The proportion of women was higher in the HF group: 53.2% (95% CI: 53.18–53.22) vs 64.3% (95% CI: 64.20–64.44), with a longer average length of stay: 7.9 (95% CI: 7.9–7.9) vs 14.9 (95% CI 14.7–15.0) days, and women had a higher proportion of comorbidities. HF was found to be an independent risk factor in-hospital mortality in the multilevel risk adjustment model (OR = 2.3; 95% CI: 2.2–2.4).
Patients with HF undergoing any of the selected surgical procedures are older; there was women predominance and there is also an important burden of comorbidities than patients without HF undergoing these surgical procedures. HF in the selected procedures, increasing in-hospital mortality, mean length of stay, and the occurrence of adverse events in the Spanish population. The percentage of patients with HF who underwent the selected surgical procedures increased in the study period.
El número de pacientes con insuficiencia cardíaca (IC) que se someten a procedimientos quirúrgicos no cardíacos está aumentando en todo el mundo. El objetivo de este estudio es analizar el impacto de la IC en los resultados (mortalidad, complicaciones, reingresos y duración de la estancia) de los pacientes de edad avanzada sometidos a procedimientos quirúrgicos mayores electivos no cardíacos en España.
Se realizó un estudio observacional retrospectivo de pacientes sometidos a cirugía no cardíaca. Se utilizó el Conjunto Mínimo Básico de Datos (CMBD) para recoger información sobre las características demográficas de los pacientes dados de alta en los hospitales del Sistema Nacional de Salud (SNS), variables relacionadas con las condiciones médicas de los pacientes y las cirugías realizadas durante el episodio.
Se identificaron un total de 996.986 procedimientos seleccionados en el registro de altas en el periodo 2007-2015. La IC se registró como diagnóstico secundario en 22.367 altas (2,24%). La edad media de los pacientes fue de 76,6 ± 7,27 años, con una diferencia en los pacientes sin y con IC: 76,5 IC 95%: 76,47 - 76,50) vs. 82,8 (IC 95%: 82,71 – 82,90). El número de procedimientos quirúrgicos seleccionados aumentó un 13,2% (117.487 en 2015 vs. 103.744 en 2007), y la proporción de presencia de IC como comorbilidad aumentó un 24,4% (2,4% en 2015 vs. 1,9% en 2007). La proporción de mujeres fue mayor en el grupo de IC: 53,2% (IC 95%: 53,18 – 53,22) vs. 64,3% (IC 95%: 64,20 – 64,44), con una duración media de la estancia mayor 7,9 (IC 95%: 7,9 – 7,9) vs. 14,9 (IC 95%: 14,7 – 15,0), y las mujeres tenían una mayor proporción de comorbilidades. La IC resultó ser un factor de riesgo independiente de mortalidad intrahospitalaria en el modelo de ajuste de riesgo multinivel (OR = 2,3; IC 95%: 2,2-2,4).
Los pacientes con IC que se someten a alguno de los procedimientos quirúrgicos seleccionados son de mayor edad, hubo predominio de mujeres y también mayores comorbilidades que los pacientes sin IC que se someten a estos procedimientos quirúrgicos. La IC en los procedimientos seleccionados aumenta la mortalidad intrahospitalaria, la duración media de la estancia y la aparición de eventos adversos en la población española. El porcentaje de pacientes con IC que se sometieron a los procedimientos quirúrgicos seleccionados aumentó en el periodo de estudio.
The effect of weekends and public holidays on the care of acute coronary syndrome in the Spanish National Health System
2022, Revista Espanola de Cardiologia
Analizar si el ingreso en fin de semana o festivo (IFSF), frente al ingreso en días laborables, influye en el tratamiento (angioplastia, intervención coronaria percutánea [ICP]) y los resultados (mortalidad hospitalaria) de los pacientes hospitalizados por síndrome coronario agudo en el Sistema Nacional de Salud.
Estudio observacional retrospectivo de pacientes ingresados por infarto agudo de miocardio con elevación del segmento ST (IAMCEST) o con síndrome coronario agudo sin elevación del segmento ST (SCASEST) en los hospitales del Sistema Nacional de Salud durante el periodo 2003-2018.
Se seleccionaron 438.987 episodios de IAMCEST y 486.565 de SCASEST, de los cuales fueron IFSF el 28,8 y el 26,1% respectivamente. El IFSF se mostraba como un factor de riesgo de mortalidad hospitalaria en los modelos ajustados por riesgo del IAMCEST (OR = 1,05; IC95%, 1,03-1,08; p < 0,001) y del SCASEST (OR = 1,08; IC95%, 1,05-1,12; p < 0,001). La tasa de ICP en el IAMCEST fue más de 2 puntos porcentuales mayor en los pacientes ingresados en días laborables durante el periodo 2003-2011 y similar o incluso más baja en 2012-2018, sin cambios significativos para el SCASEST. El IFSF se mostró como factor de riesgo estadísticamente significativo tanto para el IAMCEST como para el SCASEST.
El IFSF puede aumentar el riesgo de muerte hospitalaria en un 5% (IAMCEST) y un 8% (SCASEST). La persistencia del riesgo de mayor mortalidad hospitalaria tras ajustar por la realización de ICP y las demás variables explicativas probablemente indique dficiencias en el tratamiento durante el fin de semana respecto de los días laborables.
To analyze whether admission on weekends or public holidays (WHA) influences the management (performance of angioplasty, percutaneous coronary intervention [PCI]) and outcomes (in-hospital mortality) of patients hospitalized for acute coronary syndrome in the Spanish National Health System compared with admission on weekdays.
Retrospective observational study of patients admitted for ST-segment elevation myocardial infarction (STEMI) or for non–ST-segment elevation acute coronary syndrome (NSTEACS) in hospitals of the Spanish National Health system from 2003 to 2018.
A total of 438 987 episodes of STEMI and 486 565 of NSTEACS were selected, of which 28.8% and 26.1% were WHA, respectively. Risk-adjusted models showed that WHA was a risk factor for in-hospital mortality in STEMI (OR, 1.05; 95%CI,1.03-1.08; P < .001) and in NSTEACS (OR, 1.08; 95%CI, 1.05-1.12; P < .001). The rate of PCI performance in STEMI was more than 2 percentage points higher in patients admitted on weekdays from 2003 to 2011 and was similar or even lower from 2012 to 2018, with no significant changes in NSTEACS. WHA was a statistically significant risk factor for both STEMI and NSTEACS.
WHA can increase the risk of in-hospital death by 5% (STEMI) and 8% (NSTEACS). The persistence of the risk of higher in-hospital mortality, after adjustment for the performance of PCI and other explanatory variables, probably indicates deficiencies in management during the weekend compared with weekdays.
TAVI in the learning curve in Spain. In-hospital results compared with aortic valve replacement
2021, REC: CardioClinics
El implante percutáneo de válvula aórtica (TAVI) se ha postulado como alternativa al reemplazo quirúrgico (SVA). Se compararon ambos utilizando el Conjunto Mínimo Básico de Datos del Sistema Nacional de Salud.
Estudio observacional retrospectivo. Se incluyó a pacientes dados de alta de hospitales del Sistema Nacional de Salud español a los que se realizó SVA o TAVI entre 2014 y 2015. Las variables resultado fueron mortalidad intrahospitalaria, estancia y tasa de complicaciones. Se ajustó la mortalidad por riesgo (regresión logística multinivel) y la estancia por gravedad, contrastando la mortalidad intrahospitalaria entre TAVI y SVA mediante emparejamiento por puntuaciones de propensión.
Se identificaron 17.343 episodios TAVI o SVA, seleccionándose 1.725 TAVI y 8.616 SVA aisladas. Los pacientes TAVI tenían mayor edad media (81,1 ± 6,6 frente a 70,2 ± 11,4 años; p < 0,001), mayor proporción de mujeres (52,2 frente a 42,9%; p < 0,001) y más comorbilidad (índice Charlson: 7,2 ± 1,6 frente a 6,5 ± 1,7; p < 0,001). La mortalidad bruta intrahospitalaria fue 4,46% en TAVI y 4,53% en SVA. La TAVI mostró menor mortalidad intrahospitalaria ajustada por riesgo que la SVA (OR = 0,58; IC95%, 0,44-0,7; p < 0,001), se constató también mediante emparejamiento por puntuaciones de propensión (OR = 0,49; IC95%, 0,36-0,66; χ2, p < 0,001). La estancia media ajustada fue más elevada en SVA.
En el periodo 2014-2015, para una población más compleja que los pacientes sometidos a SVA, la TAVI mostró mejores resultados en cuanto a mortalidad intrahospitalaria y estancia media, si bien presentó mayor incidencia en algunas complicaciones no fatales.
Transcatheter aortic valve implantation (TAVI) has been postulated as an alternative to surgical replacement (SAVR). The results of both procedures were compared using the Minimum Basic Data Set of the National Health System (NHS).
Retrospective observational study. Patients discharged from Spanish National Health System hospitals who underwent a SVA or TAVI procedure between 2014 and 2015. Outcome variables analysed: in-hospital mortality, length of stay and complication rate. In-hospital mortality was adjusted by risk (multilevel logistic regression) and length of stay by severity, also contrasting in-hospital mortality between TAVI and SVA using propensity score matching.
Among 17 343 identified procedures of TAVI or SVA, we selected 1725 TAVI and 8616 isolated valvular SVA. TAVI patients had higher mean age (81.1 ± 6.6 vs 70.2 ± 11.4 years; P < .001), higher proportion of women (52.2% vs 42.9%; P < .001) and more comorbidities (Charlson index: 7.2 ± 1.6 vs 6.5 ± 1.7; P < .001). The raw in-hospital mortality was 4.46% in TAVI and 4.53% in SVA. TAVI showed lower risk-adjusted in-hospital mortality than SVA (OR, 0.58; 95%CI, 0.44-0.7; P < .001), also being found using propensity score matching (OR, 0.49; 95%CI, 0.36-0.66; χ2, P < .001). The adjusted mean stay was higher in SVA.
In the 2014-5 period, for a population more complex than those undergoing SVA, TAVI showed less mortality and mean stay with higher rate of some non-fatal in-hospital events than SVA.

View all citing articles on Scopus

¹: This review is an abridged version of a report submitted by the Massachusetts Cardiac Care Quality Commission to the Massachusetts Legislature, May 2001.

View full text

ReviewCardiac surgery report cards: comprehensive review and statistical critique1

Abstract

Section snippets

Background

Market-driven quality improvement (“report cards”)

The CQI approach to cardiac surgery quality improvement

The balance between public accountability and peer-based quality improvement

Recommendations

Ann Thorac Surg

J Am Coll Cardiol

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Qual Improv

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am Heart J

J Comm J Qual Improv

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

J Health Econ

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Clin Epidemiol

Part 1. Quality of carewhat is it?

N Engl J Med

Quality of health care.Part 2: measuring quality of care

N Engl J Med

Quality of health care.Part 3: improving the quality of care

N Engl J Med

Quality of health care.Part 4: the origins of the quality-of-care debate

N Engl J Med

The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality

JAMA

The American health care systemthe movement for improved quality in health care

N Engl J Med

Quality improvement in thoracic surgery

Bull Am Coll Surg

Scorecard cardiovascular medicine. Its impact and future directions

Ann Intern Med

In search of the optimal surgical mortality

Circulation

Ready-made, recalibrated, or remodeled? Issues in the use of risk indexes for assessing mortality after coronary artery bypass graft surgery

Circulation

Assessment of predictive models for binary outcomesan empirical approach using operative death from cardiac surgery

Stat Med

Review
Cardiac surgery report cards: comprehensive review and statistical critique¹