NEJM: Quality focus needed to improve CV surgery outcomes
While it comes as no surprise that hospital outcomes have improved over the last decade due to innovations in technologies and performance-based initiatives, outcomes across U.S. hospitals still vary. A study focused on high-risk surgeries, such as cardiovascular (CV) surgery, found that hospitals still need work and should be better focused on quality-care initiatives to further improve patient survival, according to research published June 1 in the New England Journal of Medicine.

In 2000, minimum volume standards for surgical procedures were integrated as a “value-based purchasing initiative,” the authors wrote. However, whether such efforts have altered referral patterns for high-risk surgery remains unknown and hurdles still exist, including regionalization, lack of access and balancing financial incentives.

To better understand trends in use of high-volume hospitals for high-risk surgeries, Jonathan F. Finks, MD, of the Center for Healthcare Outcomes and Policy and department of surgery at the University of Michigan, Ann Arbor, and colleagues sifted through Medicare data to examine trends in operative mortality rates and volume for eight procedures.

The eight procedures assessed were:
  • Abdominal aortic aneurysm (AAA) repair;
  • CABG surgery;
  • Carotid endarterectomy (CEA);
  • Aortic valve replacement;
  • Esophagectomy;
  • Pancreatectomy;
  • Lung resection; and
  • Cystectomy.

Finks et al identified patients ages 65 to 99 who underwent one of the eight aforementioned procedures between 1999 and 2008 from the national Medicare Provider Analysis and Review (MEDPAR) files. “We aimed to track the trends in hospital volume for these procedures to see if there has been any move toward concentration of procedures in high-volume hospitals or regionalization of care,” Finks told Cardiovascular Business.

More than 3.2 million Medicare patients underwent one of the eight high-risk surgeries examined during the study. The authors reported that hospital volumes for the four cancers procedures and AAA repair increased over the study period; however, CABG and CEA volumes saw a sharp decline.

In fact, the number of Medicare patients undergoing a CABG procedures decreased by more than one-third despite an increase in the number of hospitals performing this procedure: from 1,073 to 1,195.

Finks speculated that financial incentives could be the culprit as to why the number of hospitals performing these procedures increased. “Financial-based incentives have encouraged hospitals to start cardiac programs,” Finks said. Additionally, he said that interventional cardiology programs require back-up cardiac sugery programs, so this may be part of the driving force as to why a greater number of hospitals are performing these procedures.

Volumes for aortic-valve replacement procedures also swelled during the 10-year span, which the researchers supposed could be due to the growth in the number of procedures performed. Finks said that other procedures that saw increasing volumes could be due to “volume creep and market concentration.”

Additionally, Finks said that the drop in CABG and CEA procedures could be attributed to the rise in percutaneous techniques, such as carotid artery stenting or PCI.

In the study, risk-adjusted operative mortality rates declined for all eight procedures. For CV procedures, mortality fell between 8 percent (CEA) and 36 percent (AAA repair). The authors attributed this decline to changes in case mix. Additionally, the researchers noted that procedural codes for endovascular repair (the percutaneous repair to AAA) were instated in 2001, which may have led to the increase in AAA volume but decreases in mortality.

“What we found is about 60 percent in the decline of mortality with AAA repair was related to the rise in endo repair,” Finks said.  “With cardiovascular surgery in general, mortality improved across the board for all procedures. With the cancer operations mortality fell because a greater number of patients were having these procedures done in higher volume, safer hospitals.”

However, Finks noted that CV surgery volumes were not directly linked to the improvement in mortality. He added that endovascular surgery likely contributed to the improvement of outcomes for AAA repair. The stronger focus on patient safety and strategies to improve patient care also have helped improve safety.

In the realm of cardiovascular surgery, Finks said that national data registries, like that initiated by the Society of Thoracic Surgeons, collect patient information and procedural outcomes to work to improve quality and care. Regional collaboratives like the Northern New England Cardiovascular Disease Study Group, among others, also strive to improve surgical outcomes through registries.

While outcomes have improved over the last decade, Finks offered that there is still an increasing need to expand and improve strategies in the operating room. Operating room checklists and safety cultures could be the first step in creating quality improvements and reaching national benchmarks of care.

“These efforts and more are likely to have a broad effect in improving safety for all operations,” Finks concluded. In addition, he said that feedback programs and collaborative quality-improvement initiatives could be more advantageous than volume-based referrals.

“Payors, policymakers and professional organizations should prioritize programs that have the potential to reduce mortality in all contexts,” Finks et al concluded.

The study was funded by a grant from the National Institute of Aging.