The challenge of achieving 1% operative mortality for coronary artery bypass grafting: A multi-institution Society of Thoracic Surgeons Database analysis

Damien J. Lapar, Giovanni Filardo, Ivan K. Crosby, Alan M. Speir, Jeffrey B. Rich, Irving L. Kron, Gorav Ailawadi

Research output: Contribution to journalArticle

15 Citations (Scopus)

Abstract

Objectives Cardiothoracic surgical leadership recently challenged the surgical community to achieve an operative mortality rate of 1.0% for the performance of isolated coronary artery bypass grafting (CABG). The possibility of achieving this goal remains unknown due to the increasing number of high-risk patients being referred for CABG. The purpose of our study was to identify a patient population in which this operative mortality goal is achievable relative to the estimated operative risk.

Results A total of 34,416 patients (average patient age, 63.9 ± 10.7 years; 27% [n = 9190] women) incurred an operative mortality rate of 1.87%. Median STS predicted risk of mortality was 1.06% (interquartile range, 0.60%-2.13%) and median surgeon CABG volume was 544 (interquartile range, 303-930) operations over the study period. After risk adjustment for the confounding influence of surgeon volume and operative year, the association between STS PROM and operative mortality was highly significant (P <.0001). More importantly, the adjusted spline function revealed that an STS PROM threshold value of 1.27% correlated with a 1.0% probability of death, accounting for 57.3% (n = 19,720) of the total study population. Further, the STS PROM demonstrated a limited predictive capacity for operative mortality for STS PROM > 25% as observed to expected mortality began to diverge.

Conclusions Achieving the goal of 1.0% operative mortality for primary, isolated CABG is feasible in appropriately selected patients in the modern surgical era. However, this goal may be achieved in only 60% of CABG patients without other improvements in processes of care. Calculated STS PROM can be used to strongly identify patients with estimated mortality risk <1.27% to achieve this goal, but it appears limited in its predictive capacity for those patients with estimated risk >25.0%. These data provide a foundation for further study to determine if 1.0% mortality for CABG is achievable nationwide.

Original languageEnglish (US)
Pages (from-to)2686-2696
Number of pages11
JournalJournal of Thoracic and Cardiovascular Surgery
Volume148
Issue number6
DOIs
StatePublished - Dec 1 2014
Externally publishedYes

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Coronary Artery Bypass
Databases
Mortality
Risk Adjustment
Population

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

The challenge of achieving 1% operative mortality for coronary artery bypass grafting : A multi-institution Society of Thoracic Surgeons Database analysis. / Lapar, Damien J.; Filardo, Giovanni; Crosby, Ivan K.; Speir, Alan M.; Rich, Jeffrey B.; Kron, Irving L.; Ailawadi, Gorav.

In: Journal of Thoracic and Cardiovascular Surgery, Vol. 148, No. 6, 01.12.2014, p. 2686-2696.

Research output: Contribution to journalArticle

Lapar, Damien J. ; Filardo, Giovanni ; Crosby, Ivan K. ; Speir, Alan M. ; Rich, Jeffrey B. ; Kron, Irving L. ; Ailawadi, Gorav. / The challenge of achieving 1% operative mortality for coronary artery bypass grafting : A multi-institution Society of Thoracic Surgeons Database analysis. In: Journal of Thoracic and Cardiovascular Surgery. 2014 ; Vol. 148, No. 6. pp. 2686-2696.
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abstract = "Objectives Cardiothoracic surgical leadership recently challenged the surgical community to achieve an operative mortality rate of 1.0{\%} for the performance of isolated coronary artery bypass grafting (CABG). The possibility of achieving this goal remains unknown due to the increasing number of high-risk patients being referred for CABG. The purpose of our study was to identify a patient population in which this operative mortality goal is achievable relative to the estimated operative risk.Results A total of 34,416 patients (average patient age, 63.9 ± 10.7 years; 27{\%} [n = 9190] women) incurred an operative mortality rate of 1.87{\%}. Median STS predicted risk of mortality was 1.06{\%} (interquartile range, 0.60{\%}-2.13{\%}) and median surgeon CABG volume was 544 (interquartile range, 303-930) operations over the study period. After risk adjustment for the confounding influence of surgeon volume and operative year, the association between STS PROM and operative mortality was highly significant (P <.0001). More importantly, the adjusted spline function revealed that an STS PROM threshold value of 1.27{\%} correlated with a 1.0{\%} probability of death, accounting for 57.3{\%} (n = 19,720) of the total study population. Further, the STS PROM demonstrated a limited predictive capacity for operative mortality for STS PROM > 25{\%} as observed to expected mortality began to diverge.Conclusions Achieving the goal of 1.0{\%} operative mortality for primary, isolated CABG is feasible in appropriately selected patients in the modern surgical era. However, this goal may be achieved in only 60{\%} of CABG patients without other improvements in processes of care. Calculated STS PROM can be used to strongly identify patients with estimated mortality risk <1.27{\%} to achieve this goal, but it appears limited in its predictive capacity for those patients with estimated risk >25.0{\%}. These data provide a foundation for further study to determine if 1.0{\%} mortality for CABG is achievable nationwide.",
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AU - Lapar, Damien J.

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AU - Speir, Alan M.

AU - Rich, Jeffrey B.

AU - Kron, Irving L.

AU - Ailawadi, Gorav

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N2 - Objectives Cardiothoracic surgical leadership recently challenged the surgical community to achieve an operative mortality rate of 1.0% for the performance of isolated coronary artery bypass grafting (CABG). The possibility of achieving this goal remains unknown due to the increasing number of high-risk patients being referred for CABG. The purpose of our study was to identify a patient population in which this operative mortality goal is achievable relative to the estimated operative risk.Results A total of 34,416 patients (average patient age, 63.9 ± 10.7 years; 27% [n = 9190] women) incurred an operative mortality rate of 1.87%. Median STS predicted risk of mortality was 1.06% (interquartile range, 0.60%-2.13%) and median surgeon CABG volume was 544 (interquartile range, 303-930) operations over the study period. After risk adjustment for the confounding influence of surgeon volume and operative year, the association between STS PROM and operative mortality was highly significant (P <.0001). More importantly, the adjusted spline function revealed that an STS PROM threshold value of 1.27% correlated with a 1.0% probability of death, accounting for 57.3% (n = 19,720) of the total study population. Further, the STS PROM demonstrated a limited predictive capacity for operative mortality for STS PROM > 25% as observed to expected mortality began to diverge.Conclusions Achieving the goal of 1.0% operative mortality for primary, isolated CABG is feasible in appropriately selected patients in the modern surgical era. However, this goal may be achieved in only 60% of CABG patients without other improvements in processes of care. Calculated STS PROM can be used to strongly identify patients with estimated mortality risk <1.27% to achieve this goal, but it appears limited in its predictive capacity for those patients with estimated risk >25.0%. These data provide a foundation for further study to determine if 1.0% mortality for CABG is achievable nationwide.

AB - Objectives Cardiothoracic surgical leadership recently challenged the surgical community to achieve an operative mortality rate of 1.0% for the performance of isolated coronary artery bypass grafting (CABG). The possibility of achieving this goal remains unknown due to the increasing number of high-risk patients being referred for CABG. The purpose of our study was to identify a patient population in which this operative mortality goal is achievable relative to the estimated operative risk.Results A total of 34,416 patients (average patient age, 63.9 ± 10.7 years; 27% [n = 9190] women) incurred an operative mortality rate of 1.87%. Median STS predicted risk of mortality was 1.06% (interquartile range, 0.60%-2.13%) and median surgeon CABG volume was 544 (interquartile range, 303-930) operations over the study period. After risk adjustment for the confounding influence of surgeon volume and operative year, the association between STS PROM and operative mortality was highly significant (P <.0001). More importantly, the adjusted spline function revealed that an STS PROM threshold value of 1.27% correlated with a 1.0% probability of death, accounting for 57.3% (n = 19,720) of the total study population. Further, the STS PROM demonstrated a limited predictive capacity for operative mortality for STS PROM > 25% as observed to expected mortality began to diverge.Conclusions Achieving the goal of 1.0% operative mortality for primary, isolated CABG is feasible in appropriately selected patients in the modern surgical era. However, this goal may be achieved in only 60% of CABG patients without other improvements in processes of care. Calculated STS PROM can be used to strongly identify patients with estimated mortality risk <1.27% to achieve this goal, but it appears limited in its predictive capacity for those patients with estimated risk >25.0%. These data provide a foundation for further study to determine if 1.0% mortality for CABG is achievable nationwide.

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