ATS: California sees better outcomes after increasing CABG transparency

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After California legislators mandated that the state make data pertaining to CABG procedures and its mortality rates public, researchers at the University of California, Davis have found that despite similar case-mixes, mortality rates have decreased and access to care has not depleted, according to results of a study published in the current issue of the Annals of Thoracic Surgery.

“The impact of this program on operative mortality and access to surgery for high-risk patients has not been clarified,” the authors wrote.

Zhongmin Li, PhD, of the University of California, Davis in Sacramento, Calif., and colleagues evaluated data from the CABG Outcomes Reporting Program database for 2003 and 2006 for changes in surgical volume and observed, predicted, and risk-adjusted operative mortality between hospital surgeons.

Despite similar case-mixes at California hospitals in 2003 and 2006, mortality rates were 26.5 percent lower in 2006 compared to 2003, and CABG volume decreased by 27 percent.

“Our findings suggest no evidence of a negative impact in California from public reporting of hospital outcomes following CABG operations,” said Li, who led the study. “This is very reassuring, since there was some fear at first that this system would reduce access to this important surgery for high-risk patients.”

During the study, the researchers applied 25 variables to estimate preoperative risk for patients based on age, race, body mass index (BMI), existing medical conditions and physiologic measures. The authors used the formula to calculate the predicted risk of death from CABG both in 2003 and 2006.

Between 2003 and 2006 the rate of CABG procedures decreased from 21,276 to 15,657.

“The reductions in CABG volume between 2003 and 2006 were universal among hospitals and surgeons regardless of their performance status in 2003,” the authors wrote.

The results also showed that the observed mortality across the state decreased from 2003 to 2006, from 2.90 to 2.22 percent, respectively.

Additionally, the researchers reported that the empiric odds ratio of operative death between 2003 and 2006 declined by 24 percent. According to the researchers, the operative mortality risk also decreased from 2003 to 2006, 35 percent for the fourth quintile and 26 percent for the fifth quintile.

“Operative mortality is defined as death occurring in the hospital after CABG regardless of length of stay, or death occurring after hospital discharge within 30 days of the operation,” the authors noted.

According to the authors, state legislators had hoped that making these data public would push low-performing providers to augment their facility outcomes while also providing greater transparency to patients.

“There’s always a worry from medical professionals that report cards don’t reflect the higher risk factors of some of the patients they see,” said Ezra A. Amsterdam, professor of cardiovascular medicine at UC Davis. “Fortunately, this study accounts for individual patient risks so that hospitals that serve the sickest patients are not unfairly graded if their death rates are higher because of that.”

The authors speculated that the better CABG outcomes could be due in part to the improved technologies and techniques that have evolved in addition to improved anesthesiology, preoperative and postoperative care.

“This study bears very good news for patients,” Li concluded. “It indicates that access to medical care has not decreased, patients have more options and CABG has become an even safer procedure.”