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Ann Thorac Surg 1999;68:1592-1598
© 1999 The Society of Thoracic Surgeons

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Original Articles

Alabama Coronary Artery Bypass Grafting Cooperative Project: baseline data

^a The Alabama Quality Assurance Foundation, University of Alabama at Birmingham, Birmingham, Alabama, USA
^b Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
^c Duke University Medical Center, Durham, North Carolina, USA

Address reprint requests to Dr Holman, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294-0007;
e-mail: wholman{at}holman.cvsr.uab.edu

Presented at the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Quality indicators-... Appendix 2. Definition of... Appendix 3. Alabama Quality... References

 
Background. The Alabama Cooperative CABG Project is a statewide process-oriented analysis of coronary artery bypass grafting (CABG). The purpose of this report is to present the first information generated by this analysis, which will serve as a baseline for subsequent quality improvement projects.

Methods. Medical records of Medicare beneficiaries from Alabama, a comparison state, and a national random sample who had isolated CABG between July 1, 1995, and June 30, 1996, were examined. Fifty-six demographic, procedural, and outcome variables were abstracted. Quality indicators identified by the Alabama Quality Assurance Foundation Study Group included: internal mammary artery use, prescription of aspirin at discharge, duration of postoperative intubation, use of intraaortic balloon pump, readmission to intensive care unit, hospital readmission within 30 days, return to the operating room for bleeding, and in-patient mortality. Benchmark performance rates for quality indicators reflecting care processes were calculated.

Results. Alabama, the comparison state, and the national sample consisted of 4,092, 2,290, and 1,119 patients, respectively. The processes of care and outcome, including risk-adjusted mortality, for CABG across the state of Alabama are generally similar to other states and nationwide samples. However, there was considerable variation at the local hospital level in Alabama for each quality indicator.

Conclusions. The data provide a "snapshot" of practice patterns for CABG in Alabama. A specific quality indicator (duration of intubation) was identified as a focus for statewide improvement. Hospital-specific variations in quality indicators suggested opportunities for improvement in other indicators at a number of hospitals.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Quality indicators-... Appendix 2. Definition of... Appendix 3. Alabama Quality... References

 
In the past decade, there has been increased interest in quantifying the results of medical therapy and improving the value received for health care expenditures. In cardiothoracic surgery these quality improvement efforts led to the creation of several large databases that allow comparisons of local results for cardiac operations with results in larger groups of patients on a risk-adjusted basis [1–3]. Outcome-oriented data analysis has produced a wealth of information regarding regional practice patterns [4, 5], modes of treatment failure [3], and the relationships between individual variables (eg, surgeon volume or patient age) and the incidence of early postoperative death [6–8]. Importantly, decreased mortality rates have followed the dissemination of this information to local practitioners and hospitals [9–11].

Although outcome-oriented data analysis has proven useful, it has inherent limitations. One limitation, as noted by Hannan and associates [9], is the "paucity of information on processes of care that have contributed to differences in outcomes. Thus, it has been impossible to undertake the systematic exploration of the root causes of outcome differences that is the foundation of continuous quality improvement." The Health Care Financing Administration (HCFA), also recognizing this deficiency, requested proposals for regionally based, process-oriented investigations of coronary artery bypass grafting (CABG). The HCFA [12] specifically requested that "projects should focus on improving processes of care that affect outcomes rather than the outcomes themselves (ie, focus on a specific process indicator and whenever possible use the relationship between process and outcome to infer impact)."

A CABG quality improvement project submitted by the Alabama Quality Assurance Foundation, the Peer Review Organization for Alabama, was funded. The purpose of this report is to describe the methods developed for the Alabama Cooperative CABG Project, and present results for the initial round of data abstraction and analyses. These data will be used for comparison when evaluating the results of collective efforts to improve the quality of CABG operations in this state.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Quality indicators-... Appendix 2. Definition of... Appendix 3. Alabama Quality... References

 
The Alabama Cooperative CABG project is an extension of a statewide Cooperative Cardiovascular Project that began in 1994. The Alabama Cooperative CABG project was initiated in August 1995 with meetings to define the study methodology. This included the identification of quality indicators, which are variables that describe a process or outcome related to CABG and that measure an aspect of program excellence.

In addition to Alabama Quality Assurance Foundation staff, the study committee consisted of six cardiovascular surgeons and two interventional cardiologists from the state of Alabama, one epidemiologist, one radiologist, two gerontologists, and one biostatistician. The committee identified quality indicators that represent process measures, mixed process and outcome measures, and outcome measures. These quality indicators were aspirin therapy at discharge; use of the internal mammary artery for myocardial revascularization; duration of intubation after CABG; intraoperative use of an intraaortic balloon pump; reoperation for excessive bleeding; readmission rate to the intensive care unit (ICU) after ICU discharge; hospital readmission rate within 30 days after discharge; and risk-adjusted in-hospital mortality. The process variables, including internal mammary artery use and prescription of aspirin at discharge, were considered to be indicated in all CABG patients unless a specific contraindication was documented, as in Appendix 1. The prevalence for each dichotomous variable and quality indicator was determined. The means for continuous variables were calculated. The duration of intubation from the end of operation was defined as a median, rather than a mean, time of intubation after CABG. After the initial round of data abstraction, two additional quality indicators were identified. They were use of an intraaortic balloon pump at any time during the hospitalization, and the percentage of patients intubated for less than 6 hours after CABG.

Abstraction was performed by a Clinical Data Abstraction Center (CDAC) of the Health Care Financing Administration (HCFA) from charts obtained for Alabama Medicare patients who had isolated CABG procedures (ICD-9 codes 36.10-36.20, excluding diagnostic-related group [DRG] 104, 105, and 468). Provisions were made for subsequent internal quality control of data abstraction at the level of the CDAC by periodically reabstracting 20% of the charts under review. Missing data for all risk factors occurred in less than 5% of patients except for creatinine (6%), blood urea nitrogen (9%), and left ventricular ejection fraction (14%). Missing dichotomous variables were listed as "no," whereas missing continuous variables were assigned the mean value for that variable.

For the initial phase of the Alabama Cooperative CABG project, a retrospective sample of Medicare patients who underwent CABG was selected. This sample consisted of all Medicare patients discharged from participating hospitals between July 1995 and June 1996 with a DRG of 106 (coronary artery catheterization and CABG during the same admission) or DRG 107 (only CABG during the admission). In addition, two comparison groups of CABG patients from outside Alabama were identified. The first group was Medicare patients from a comparison state who had undergone CABG. This state has approximately the same number of Medicare beneficiaries as Alabama, and CABG is performed on Medicare beneficiaries in the comparison state at virtually the same rate as in Alabama Medicare beneficiaries. The comparison state sample consisted of 60% of all Medicare beneficiaries discharged from hospitals in between November 1997 and February 1998. These 2,288 medical records were abstracted by the CDAC. In addition to the comparison state, a random sampling of national data was obtained from HCFA for 1,919 CABG patients in this time period.

Baseline characteristics and clinical outcomes were compared between the individual hospitals and the statewide Alabama data by ² tests for discrete variables and by nonparametric analysis of variance (Kruskal-Wallis) for continuous variables. In addition, in-hospital mortality rates were also compared among regions and among individual hospitals after risk adjustment. Specifically, we developed a statistical model that predicted a patient’s expected risk for operative mortality based on preoperative clinical factors. Potential clinical risk factors were chosen based on a number of previously published CABG risk models [13–15]. Initially, we performed univariate logistic regression analysis to determine whether candidate variables were associated with in-hospital mortality. Factors that were predictive in these analyses were then entered into a stepwise logistic regression analysis to develop the final multivariable CABG mortality model. Our final model includes 11 important risk factors (Table 1). The discrimination ability of the model, as accessed by its area under the receiver-operator curve or C-index was 0.754, and the Hosmer and Lemeshow p value was 0.0695. The correlation coefficient (r²) for risk unadjusted versus risk-adjusted mortality for this model was 0.904.

	Results

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Quality indicators-... Appendix 2. Definition of... Appendix 3. Alabama Quality... References

 
The charts of 4,090 Alabama Medicare beneficiaries who had undergone CABG were abstracted, together with 2,288 charts from the comparison state, and 1,919 charts from a random national sample. Abstraction internal quality control, quantified by CDAC-based reabstraction, ranged from 92% to 98%.

The number of patients per Alabama hospital is illustrated in Figure 1. The mean age of the patients in Alabama was 70 years, and 71 years in the other two groups. The patients were predominantly male (65% Alabama, 66% comparison state, 67% nationally), and white (89% Alabama, 93% comparison state, 93% nationally). The age group distribution, frequency of selected comorbid conditions, distribution of body mass index, presence of cardiac dysfunction, and coronary artery disease status are shown in Table 2, with definitions of these variables presented in Appendix 2.

View larger version (18K): [in this window] [in a new window]   Fig 1. Number of patients undergoing coronary artery bypass grafting (CABG) per hospital (see text for details).

View larger version (13K): [in this window] [in a new window]   Fig 2. Unadjusted coronary artery bypass grafting (CABG) mortality by region. (Overall = aggregate state and national data; Comparison = comparison state; National = national sample.)

View larger version (14K): [in this window] [in a new window]   Fig 3. Risk-adjusted coronary artery bypass grafting (CABG) mortality by region. (Overall = aggregate state and national data; Comparison = comparison state; National = national sample.) (p = 0.78 for risk-adjusted mortalities of Alabama versus comparison state, and p = 0.91 for risk-adjusted mortalities of Alabama versus national sample.)

	Comment

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Quality indicators-... Appendix 2. Definition of... Appendix 3. Alabama Quality... References

The statewide data indicate that the processes of care and outcomes for CABG in the state of Alabama are generally similar to those in a comparison state and in a national sample. It was noteworthy, however, that there exists a wide range for each of the quality measures across individual hospitals in Alabama. These variations in process measurements have suggested opportunities for improvement at the individual hospital level. It is also noteworthy that variations in practice patterns (eg, duration of intubation and prevalence of internal mammary artery use) existed between Alabama and the comparison state.

Appreciating the distinction between outcome and process measures is important for understanding why the Alabama Cooperative CABG Project is unique from other strictly outcome-oriented surveys of CABG. An outcome measure is defined as a variable that indicates the results of performing, or not performing, a process or function in the care of a patient. Examples of pure outcome variables are mortality and infection rates. A process measure is a variable that defines the performance of a specific act or function. There is typically a scientific basis or consensus opinion for believing that the appropriate performance of the process will increase the probability of achieving a desired outcome. For instance, prescription of aspirin at the time of discharge after CABG, and use of the internal mammary artery as a conduit are considered to be desirable, unless a specific contraindication exists. The Alabama Cooperative CABG study was designed to collect process-oriented data that can be used to direct changes in patient care, with a reasonable expectation that the process changes will lead to improvements in outcome. Plans for quality improvement, which are based on process-oriented analyses, are expected to take action at two levels.

At the level of the individual hospital, the process data were examined in comparison with regional and national data. Nonconformance with regional and national practice patterns suggested possible improvements, which were formalized as quality improvement plans that were subsequently implemented. Continued monitoring of outcome variables (eg, risk-adjusted mortality, reintubation rates, length of stay, and readmission rates) at the individual hospitals will provide feedback on the result of these changes in processes of care.

At a regional level, analysis of statewide data is expected to suggest changes in the practice of CABG that can be coordinated across many hospitals and surgeons in Alabama. The results of these changes will be monitored by measuring statewide outcome statistics. After the initial report of the Alabama Cooperative CABG Study results, the decision was made to work as a state to decrease the duration of intubation after CABG. Risk-adjusted mortality, reintubation rates, length of stay after CABG, readmission rate to the ICU, and hospital readmission rates will be tracked along with duration of intubation to monitor the result of this change in the process of care. In addition to developing local and statewide quality improvement plans, members of local hospital quality improvement teams began making site visits to hospitals in Alabama to observe the care of cardiac surgical patients and exchange information regarding cardiac operation protocols with the host hospital staff. Statewide progress in CABG quality improvement will be discussed at semiannual meetings of the Alabama Cooperative CABG Study participants. The specific aims of the meetings are to disseminate information from ongoing data analyses, and plan new quality improvement initiatives. Previous experience from several large cooperative studies in cardiac surgery and cardiology suggests that measurable statewide improvement in the quality of CABG will occur as a result of these efforts [9, 10, 16, 17]. The information generated by the Alabama Cooperative CABG Study will also be important for tracking the effects of changes in health care that impact the practice of cardiac operation in this state. Examples of changes that may occur or have already occurred include decreases in reimbursement for CABG, advances in surgical and anesthetic techniques, and the advent of alternative therapies for ischemic heart disease (Appendix 3).

	Acknowledgments

 
The analyses upon which this publication is based were performed under contract number 500-96-P605, entitled "Operation of Utilization and Quality Peer Review Organization for the State of Alabama," sponsored by the Health Care Financing Administration, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Health Care Financing Administration, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore, required no special funding on the part of this Contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.

	Appendix 1. Quality indicators—numerator/denominator

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Quality indicators-... Appendix 2. Definition of... Appendix 3. Alabama Quality... References

 
Inclusion criteria: Patients discharged after CABG from the time period between July 1, 1995, and June 30, 1996, with the ICD-9-CM codes of 36.10 to 36.20 (except those cases with DRG 104, DRG 105, or DRG 468).

1. Internal mammary artery (IMA) for revascularization: Numerator: The number of patients indicated to receive an IMA graft who received an IMA graft. Denominator: The number of patients indicated to receive the IMA graft. Exclusions: An emergency case; history of mastectomy; previous use of IMA; acute, evolving myocardial infarction.

2. Aspirin therapy at discharge: Numerator: The number of patients indicated to receive aspirin at discharge who received aspirin at discharge. Denominator: The number of patients indicated to receive aspirin at discharge. Exclusions: Patients who had a history of bleeding or coagulation disorder; internal bleeding within the past 6 months; an increased risk of bleeding (admission platelet count of < 100,000, history of hemorrhagic stroke); an active peptic ulcer disease, presently under treatment; an allergy to acetylsalicylic acid or taking warfarin at discharge.

3. Duration of intubation: Median time: The median intubation time for those patients who were intubated during operation. Time calculation starts at the end of operation and ends when patients are taken off ventilator support. Exclusions: Patients intubated before induction of CABG anesthesia.

4. Intraoperative use of an intraaortic balloon pump: Numerator: The number of patients who had an intraaortic balloon pump inserted during operation. Denominator: The number of patients who underwent CABG and did not have an intraaortic balloon pump inserted before operation. Preoperative = Before the first incision. Intraoperative = First incision until patient leaves the operating room. Postoperative = After the patient leaves the operating room. Exclusions: Patient had intraaortic balloon pump before operation.

5. Readmission to the intensive care unit: Numerator: The number of patients who were admitted to the intensive care unit after initially being discharged. Denominator: The number of patients who underwent CABG.

6. Reoperation for bleeding: Numerator: The number of patients who returned to operation due to bleeding or tamponade. Denominator: The number of patients who underwent CABG.

7. Readmission to hospital within 30 days after discharge: Numerator: The number of patients who were readmitted to the hospital for any reason within 30 days of discharge after CABG. Denominator: The number of patients who underwent CABG. Exclusions: Patients who died in-hospital and who were not listed in the Alabama Medicare beneficiary file.

	Appendix 2. Definition of variables

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Quality indicators-... Appendix 2. Definition of... Appendix 3. Alabama Quality... References

 
Age group distribution: Four age categories are used to describe the study population.

Body mass index: The body mass index (BMI) was calculated for each patient (weight in kilograms divided by height squared in meters). Underweight is defined as BMI < 20 kg/m². Normal weight for men is a BMI of 20 to 27.7 kg/m². Normal weight for women is a BMI of 27.3 to 32.2 kg/m². Overweight for men is a BMI 27.8 to 31.0 kg/m², and for women is 27.3 to 32.2 kg/m². Obese for men is a BMI > 31 kg/m², and for women is a BMI > 32.2 kg/m².

Coronary artery disease status: The presence of angina, left main stenosis > 50%, and the presence of a myocardial infarction within 6 months before CABG were included as comorbid conditions.

Cardiac function: Left ventricular function assessment included the presence of symptoms of congestive heart failure within 2 weeks before CABG, left ventricular ejection fraction < 45%, and presence of cardiogenic shock immediately before operation.

Noncardiac comorbidities: These included a diagnosis of chronic obstructive pulmonary disease; smoking tobacco; diabetes mellitus; peripheral vascular disease; and renal failure requiring dialysis.

	Appendix 3. Alabama Quality Assurance Foundation members

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Quality indicators-... Appendix 2. Definition of... Appendix 3. Alabama Quality... References

 
We acknowledge the important contributions of the Alabama Quality Assurance Foundation (AQAF) Study Group and AQAF staff members to this project. Study Group Members: Constantine L. Athanasuleas, MD, (Chairman), Larry S. Dean, MD, William L. Holman, MD, Hurley W. Knott, MD, Albert D. Pacifico, MD, Edward J. Planz, MD, Stancel M. Riley, MD, Kenneth J. Wool, MD. AQAF Staff: Richard M. Allman, MD, Monique Sansom, BSN, Catarina Kiefe, MD, PhD, Cheryl Williams, RN, Sherron H. Kell, MD, Robert Farmer, BS, Anthony Horn, MS, Eric Peterson, MD (Duke University Medical Center), Robert G. Sherrill, MD, James F. DeLong, MD, Nadine A. Schiesz, RN, Wen Xu, PhD.

We also thank the following hospitals in Alabama for their commitment to quality improvement in cardiac operation: Birmingham: Baptist Medical Center Montclair, Baptist Medical Center Princeton, Brookwood Medical Center, Carraway Methodist Medical Center, Medical Center East, St. Vincent Hospital, University of Alabama Hospital; Dothan: Flowers Hospital, South East Alabama Medical Center; Florence: Eliza Coffee Hospital; Gadsden: Gadsden Regional Hospital, Riverview Hospital; Huntsville: Huntsville Hospital; Mobile: Mobile Infirmary, Providence Hospital, Springhill Memorial Hospital, University of South Alabama Hospital; Montgomery: Montgomery Baptist Medical Center; Opelika: East Alabama Medical Center; Tuscaloosa: DCH Regional Medical Center.

	References

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Quality indicators-... Appendix 2. Definition of... Appendix 3. Alabama Quality... References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): William L. Holman Eric D. Peterson Constantine L. Athanasuleas Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Holman, W. L. Articles by Sherrill, R. G. Search for Related Content PubMed PubMed Citation Articles by Holman, W. L. Articles by Sherrill, R. G.