Performance Measurement And Improvement For Coronary Artery Bypass Grafting

Coronary artery bypass grafting(CABG)is the most effective treatment for ischemic heart disease.As the burden of ischemic heart disease in China has significantly increased,it is a nationwide demand for high-quality healthcare for cardiac surgery.China’s CABG surgery volume has rapidly expanded,with an annual surgical volume of more than 40,000 cases,but there are significant regional and inter-unit differences in medical accessibility and surgical care quality.In-hospital mortality rates in different surgical centers varied significantly,ranging from 0.7%to 5.8%.Therefore,reducing the heterogeneity in the healthcare quality of CABG surgery in China and improving the overall medical quality are important topics of the current development of cardiac surgery.In recent years,China has adopted a series of measures to improve the quality of cardiac surgical care,such as developing clinical practice guidelines,expert consensus and clinical pathways for surgical procedures including CABG,and established administrative claims database.However,hospital-level quality measurement was not sufficiently performed in the current initiatives.The main reason is that the existing quality evaluation only included the conventional surgical process,excluded the key process or techniques that benefit patients undergoing cardiac surgery.Thus,we aimed to establish the key performance measures for the evaluation of hospital-level healthcare quality for CABG.Performance measurement is the fundamental part of quality improvement initiatives,and there were many successful international experiences.Various agencies and organizasions including medical insurance agencies,academic organizations,and news media focusing medical and healthcare quality had established performance measures for CABG,and have continuously measured and reported hospital-level performance data.These efforts had helped to promote the quality improvement,and benefit patients by reducing adverse events.Therefore,we have conducted a series of studies for the development of the Chinese key performance measures for CABG,and measured the performance by using the real-world data from a national clinically.The main findings are as follows.Part Ⅰ.Development and Validation of Performance Measures for Coronary Artery Bypass GraftingObjective:The aims of this study were to develop and verify the quality measures for coronary artery bypass grafting(CABG)in China based on evidence-based medical evidence and consensus of domestic authoritative experts,and to evaluate quality of CABG among the participating centers of the Chinese Cardiac Surgery Registry(CCSR).Methods:We comprehensively reviewed the latest clinical practice guidelines and evidence-based medical evidence,and selected factors that have a causal effect on patient outcomes,including structural indicators,surgical skills,treatment techniques and key steps,as well as the most important adverse events in clinical settings as the candidate quality measures.We have established a standard specification for quality measures,which were further evaluated and selected by experts committee based on evidence-based recommendations,feasibility of data collection and use of the measures.Using the 2017 data from the CCSR,we evaluated the distribution of the measures among the participating centers and the correction between individual measures.We evaluated the differences in the performance of the participating centers.After stratification of the hospitals according to the composite performance measure,we compared the performance differences of the hospital quality.Results:Based on domestic and international clinical guidelines and evidence-based medical evidence,a total of 29 candidate measures were screened with reference to similar international indicator systems,including 1 structure measure,17 process measures,and 11 outcome measures.After discussion,experts selected 12 indicators,including 5 process measures and 7 outcome measures.There were significant differences between the participating on the performance for the healthcare quality measures.The correlation coefficients between single indicators range from 0.01 to 0.56.For the surgical technique dimension,secondary prevention dimension and postoperative complications dimension,the performance for the individual measure in the dimension is significantly correlated with the composite performance for the dimension,and the correlation coefficients are all greater than 0.6.After stratifying the participating centers according to the composite measure,there were significant differences in the performance for each dimension between the top 25%of the centers and the bottom 25%ones.The medians(interquartile range)of surgical technique utilization rate of the top 25%and the bottom 25%of the centers were 47.0%(27.3%-66.6%)and 17.1%(4.6%-29.0%)(P<0.001);for secondary prevention medication compliance,the median rates were 89.4%(IQR,84.4%-95.0%)and 67.4%(IQR,47.5%-89.8%)(P=0.003);for mortality rates,the medians were 0.7%(IQR,0.3%-1.1%)and 5.8%(IQR,3.5%-7.9%)(P<0.001);for the incidence of complications,the medians were 1.9%(IQR,1.2%-2.7%)and 7.9%(IQR,4.1%-10.1%)(P<0.001).Conclusion:We have developed and validated the performance measures for CABG.Using the measures,we observed significant heterogeneity in the performance for CABG among the participating centers in the CCSR,which warranted further improvement initiatives.Part Ⅱ.Statistical Methodologies for Performance Measurement of Coronary Artery Bypass GraftingObjective:We have developed the performance measures for coronary artery bypass grafting(CABG)in China.In the present study,we focus on the statistical and methodologic issues for performance measurement,including the risk adjustment and the composite performance measures.Methods:In this study,we used the Chinese Cardiac Surgery Registry(CCSR)data in 2017,including surgical centers with an annual CABG surgery volume of 10 or more,and consecutively include all adult patients who underwent isolated CABG.We estimated a hierarchical Logistic model to predict the risk-adjusted rate of outcomes measures for each center.In order to develop composite performance measures,we used the "all or nothing" or "any or nothing" method to compound the individual measures within the dimensions,and combined the dimension-level composite measures into an overall composite measure.We evaluated the distribution of each individual measure and composite measure across the participating centers,and analyzed the correlation between the individual measures.In addition,we calculated the correlation between each individual measure and the composite measure.After stratifying centers based on the composite measure,we compared the outcomes of patients between the differenc level of centers.Results:Among the 86 centers and 12463 isolated CABG cases in this study,there were significant differences in the individual measures across the centers.Correlation coefficients between individual indicators range from 0.01 to 0.56.For the surgical technique dimension,the secondary prevention dimension,and the postoperative complications dimension,the individual measures in these dimensions were significantly correlated with the dimension-level composite measures.The correlation coefficients were all greater than 0.6.After stratifying the centers in to performance levels,there are significant differences between the upper and bottom level in the rate of use of surgical technique,the rate of compliance with secondary preventive medications,and the rate of mortality and complications.Conclusion:The CABG performance measures and its composite measure distinguished the performance of CABG across various surgical centers,with all individual measures contributing quality information.Part Ⅱ.Effect of Performance Measurement on the Quality of Coronary Artery Bypass Grafting:2013 to 2018Background:To improve the performance of coronary artery bypass grafting(CABG)in China,but the evidence on the quality is scarce.We sought to characterize the changes in related treatment patterns and patient outcomes in a national registry.Methods:We included a cohort of hospitals in the Chinese Cardiovascular Surgery Registry(CCSR),and identified patients who underwent isolated CABGs during 2013 and 2018.We described the trends of surgical process,secondary prevention,and in-hospital mortality across the years,and evaluated the inter-hospital heterogeneity.The risk-standardized rates and 95%confidence interval of mortality were estimated using hierarchical logistic regression models and multiple simulation.Results:In the study sample consisting of 66,971 patients underwent isolated CABG,despite the changes in some clinical profiles,use of arterial grafts(92.5%to 93.4%),minimally invasive incision(2.1%to 3.7%),and off-pump CABG(62.9%to 66.9%)has increased,while use of blood infusion(59.8%to 45.8%)has decreased(all P for trend<0.001).The observed in-hospital mortality had declined from 0.9%in 2013 to 0.6%in 2018(P=0.03).The median(IQR)for hospital-level risk-adjusted mortality rate significantly declined from 1.9%(1.1%to 4.0%)in 2013 to 0.9%(0.5%to 1.7%)in 2018(P<0.001).The standard mean difference for death after CABG surgery at a hospital in the lowest quartile of hospital mortality,compared with CABGs at a hospital in the highest quartile of hospital mortality,were 2.38 in 2013 and 1.68 in 2018.Conclusions:The CCSR has witnessed considerable improvement in the treatment process related to CABG,and decreased in-hospital mortality with reduced inter-hospital heterogeneity in China.Part Ⅲ.Surgeon-Specific Quality Monitoring System for Coronary Artery Bypass GraftingBackground:We developed a multidimensional quality monitoring system using an electronic health care records-derived database,and mobile-based reports for individual cardiovascular surgeons.Methods:This study included surgeons who performed coronary artery bypass graft surgery at a single center in China from January to December 2015.Patient data were automatically derived from structured electronic health records.Surgeon-specific quality measures included inhospital mortality and morbidity,transfusion-free procedure,use of internal mammary artery,postoperative length of stay,and hospitalization cost.The"technique for order of preference by similarity to ideal solution" method was used to create a composite quality measure and rank surgeons on performance.Surgeons were rated into three categories:the top 20%,middle 20%to 80%,and the bottom 20%.Quality data were delivered to surgeons through mobile-based reports.Results:Forty surgeons performed 4288 coronary artery bypass graft surgeries in 2015.For surgeons in the top,middle,and bottom performance categories,there was a trend of increase in risk adjusted inhospital morbidity rate(2.7%,2.9%,and 3.1%,respectively;p=0.51).There were significant differences in the use of internal mammary artery(94.7%,95.8%,90.1%,respectively;p<0.001),riskadjusted postoperative length of stay(7.01 days,7.99 days,and 8.69 days,respectively;p<0.001),and hospitalization cost(81.3 thousand yuan,88.4 thousand yuan,and 102.8 thousand yuan,respectively;p<0.001).Conclusions.We developed a surgeon-specific quality monitoring system using structured electronic health records-derived database,multidimensional measures,and mobile-based reporting.This system will facilitate quality reporting and peer comparison,and strengthen the effect of quality improvement.