How to Maintain Outcomes & Quality in CABG

Clifford W. Barlow (FRCS, DPhil)Southampton General Hospital

Southampton, UK

Quality?Quality and Outcomes differ for different individuals

Are you operating for survival or symptoms

Short-term: Survival (30 day or ‘in-hospital’) Complications (bleeding, stroke, peri-

operative MI)Length of Stay

Long-term: SurvivalMajor Adverse Clinical Events (MI,

stroke)Re-intervention (PCI or CABG)

Evidence is a two way streetSyntax Study (evidence ‘in’)-provides best evidence about which patients need

CABG - ‘forgotten’ aspect arising from Syntax is Heart

Team role

Should surgeons be expected to provide evidence?-what we do and how well we do it? (evidence ‘out’)-current UK practice of publication of Outcome data

(Hospital and Surgeon Specific Data (SSD))

Innovation and Research are not contra –indicated but potentially can be enhanced by both ‘in and out’ evidence

Evidence ‘in’ - Syntax-Appropriate referral is essential for quality

-Syntax Study provides undisputable evidence that a majority of 3 vessel disease patients benefit from CABG(survival, MACCE events, re-intervention) -Emphasis should not solely focus on CABG vs PCI debate but stimulate further investigation into the debate about who needs revascularization (ischemic myocardium)

‘Heart Team’-Role of Heart Team - ‘forgotten’ Syntax recommendation(incl. Surgeon/Interventional Cardiologist)-Syntax Score provides angiographic evidence-Individual patient needs differ-Number of publications emphasize the importance of individual patient factors/frailty scores (eg Syntax II) -Treatment recommendation by Heart Team, rather than individual practitioner, to ensure most appropriate intervention strategy for individual patient

Evidence ‘out’ – Surgeon Specific Data (SSD)

- Trigger: Children’s Heart Surgery, Bristol UK, 1984- 1995

- Kennedy Enquiry emphasized importance of transparency, openness and honesty in cardiac surgical practice and outcomes

-Gradual evolution, from 2002, of hospitaland, more controversially, surgeon specificdata (SSD) release in UK

-Intention two fold:Improve quality of careInform patients that care safe

Current UK Public Cardiac SSD Release-Society for Cardiothoracic Surgery in the UK and Ireland (SCTS) has taken lead in hospital and surgeon specific data (SSD) release

-Bristol events/ Sir Bruce Keogh, Medical Director of NHS, initiated process (individual surgeon data collection commenced 2003)

-Process in evolution but ‘CABG came first’

-Advantages and disadvantages -ongoing debate and controversy

-Motivation remains to improve qualityby providing understandable, uniform, appropriate outcome data to patientsand physicians

Hospital ‘Case Mix’Southampton General Hospital

Surgeon(Dimitrios – case mix

CABG AVR CABG & AVR

MV CABG & MV

OTHER0

10

20

30

40

50

60

UK SOTON

Unit Risk Profile - SGH

In-Hospital Mortality- SGH

Individual (SSD) Case Mix

CABG AVR CABG & AVR

MV MV & CABG

OTHER0

10

20

30

40

50

60

UK CW BARLOW

Individual (SSD)Risk Profile

In- Hospital Mortality - CWB

Current Controversy with SSD Release in the UKStrongly conflicting views within all surgical specialties but led by Cardiac Surgeons about publication of SSD

Controversy about advantages and disadvantages of SSD

Also, is early mortality the best primary measure of quality?

Further changes in both content and mode of data release are proposed

Disadvantages of surgeon specific data (SSD) publication-Recent reported drop in mortality after CABG is not causally related to SSD

-UK practice currently publishes All Case mortality data (not isolated procedures eg. CABG)

-Time periods (3 years released annually) do not show continuity

-Poor quality data and ‘gaming’ alters standard deviations and impacts ‘honest’ units

-Creation of League Tables

Do ‘best surgeon’ tabloid articles improve quality and help patients?

Disadvantages SSD (2)-Politically driven not evidence based-Anecdotal evidence risk averse behaviour by surgeons-’Outlier’ Surgeon is ‘second victim’ if wrongly identified (worsens performance) -Recent UK release all specialties – only 3 of 5000 judged underperforming (meaningless)

Disadvantages SSD (3)-Is a 0% mortality desirable or achievable?

-Can this mechanism of unit and SSD release be extrapolated and meaningful in different healthcare systems? (different revalidation, case mix, resources, means improving quality)

Advantages of publishing SSDUK CABG Mortality and Patient Risk Profile – 2002 to 2012

2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

1

2

3

4

5

6

Average Log Euroscore Actual Mortality

Advantages SSD (2)-Team Working-Sharing information drives improvement-Transparency – guides decision making patients/physicians-Incumbent on surgeon to be able to describe what he does and how well

Advantages SSD (3)-No evidence risk-averse behaviour (overall patient risk profiles have increased)-Early identification of problems allows early corrective measures for hospitals and surgeons-Professional Cardiac Surgical Society driven SSD release ‘armours’ surgeons against potentially devastating newspaper tabloid scandals

First ‘Essential’ Recommendation for Surgeon Specific Data Release

Elective and Urgent cases only – not Emergent

Units/Hospitals must have resources to ensure data accuracy

Internal/External ‘national sense checks’

Monitoring unit/surgeon outcomes against national ‘norms’

Second ‘Essential’ - Outliers

-Unit and Surgeon outcome divergence from expected is a statistical end point

-Trigger to investigate accuracy of ‘outlier’ data and only then to publish

-Some data will always be less accurate (eg age vs. unstable angina)

-Identification of an outlier should trigger a process of support not punishment to improve quality

Third ‘Essential’ for SSDOngoing Innovation and Research

Essential that evidence from clinical studies (eg Syntax) should not entrench practice but encourage ongoing research (Evidence ‘in’)

Similarly SSD release should not allow defensive practice (Evidence ‘out’)

In CABG the major areas of future focus are:1. The importance and means of establishing extent and location of ischemic myocardium (FAME Study)2. Graft choice (RAPCO Study Update, ART Trial) 3. Technique (OPCAB),Exposure etc)

ConclusionsQuality in CABG must be assessed with both:1. Short-term outcomes (survival, LOS, complications)2. Long-term outcomes (survival, MACCE events, re-

intervention)

There is growing evidence as to which patients need revascularisation and whether that should be CABG (Syntax)

Future research (ART trial) will further define optimal CABG strategy in terms of conduit, technique and access

Unit and Surgeon specific outcome data release can potentially improve transparency and drive quality(CABG specific, accurate, uniform, risk-adjusted, non-punitive)