Context Efforts to improve quality of care in the cardiac surgery field have
focused on reducing the risk-adjusted mortality associated with common surgical
procedures, such as coronary artery bypass grafting (CABG). However, the best
methodological approach to improvement is under debate.
Objective To test an intervention to improve performance of CABG surgery.
Design and Setting Quality improvement project based on baseline (July 1, 1995–June
30, 1996) and follow-up (July 1–December 31, 1998) performance measurements
from medical record review for all 20 Alabama hospitals that provided CABG
Patients Medicare patients discharged after CABG surgery in Alabama (n = 5784),
a comparison state (n = 3214), and a national sample (n = 3758).
Intervention Confidential hospital-specific performance feedback and assistance with
multimodal improvement interventions, including the option to share relevant
experience with peers.
Main Outcome Measures Duration of intubation, reintubation rate, aspirin therapy at discharge,
use of the internal mammary artery (IMA), hospital readmission rate, and risk-adjusted
Results Proportion of extubation within 6 hours increased from 9% to 41% in
Alabama, decreased from 40% to 39% in the comparison state, and increased
from 12% to 25% in the national sample. Use of IMA increased from 73% to 84%,
48% to 55%, and 74% to 81%, respectively, in the 3 samples, but aspirin use
increased only in Alabama (from 88% to 92%). The amount of improvement in
all 3 of these process measures was greater in Alabama than in the other samples
(IMA use for Alabama vs comparison state was P =
.001 and for Alabama vs national sample, P = .02;
and P<.001 for all other comparisons). Risk-adjusted
mortality decreased in Alabama (4.9% to 2.9%), but this decrease was not statistically
significantly different from mortality changes in the other groups (odds ratio,
0.76; 95% confidence interval, 0.54-1.07 vs national sample).
Conclusion Confidential peer-based regional performance feedback and process-oriented
analysis of shared experience are associated with some improvement in quality
of care for patients who underwent CABG surgery.