Search

Acute kidney injury (AKI) frequently complicates cardiac surgery and is more common among Black patients. We evaluated determinants of race-based differences in AKI rates.Serum creatinine-based criteria were used to identify adult cardiac surgical patients having postoperative AKI in the Perfusion Measures and Outcomes (PERForm) Registry (July 1, 2014, to June 30, 2019). Patient characteristics, operative details, and outcomes were compared by race (Black vs White) after excluding patients with preoperative dialysis, missing preoperative or postoperative creatinine, or other races. A mixed effects model (adjusting for demographics, comorbidities, surgical factors) used hospital as a random effect to predict postoperative stage 2 or 3 AKI. Propensity score analyses were conducted to evaluate robustness of the primary analyses.The study cohort included 34 520 patients (8% Black). More Black patients than White patients were female (43% vs 27%, P.001), and had hypertension (93% vs 87%, P.001) and diabetes mellitus (51% vs 41%, P.001). Acute kidney injury of stage 2 or greater occurred in 1697 patients (5%), more often among Black than White patients (8% vs 5%, P.001). Intraoperatively, Black patients had lower nadir hematocrits (23 vs 26, P.001), and were more likely to be given transfusions (22% vs 14%, P.001). After adjustment, Black race (compared with White) independently predicted odds for postoperative AKI (adjusted odds ratio 1.50; 95% confidence interval, 1.26 to 1.78). The multivariable findings were similar in propensity score analyses.Despite accounting for differences in risk factors and intraoperative practices, Black patients had a 50% increased odds for having moderate-severe postoperative AKI compared with White patients. Additional evaluations are warranted to identify potential targets to address racial disparities in AKI outcomes.

Prior work has established that high socioeconomic deprivation is associated with worse short- and long-term outcomes for patients undergoing coronary artery bypass grafting (CABG). The relationship between socioeconomic status and 90-day episode spending is poorly understood. In this observational cohort analysis, we evaluated whether socioeconomically disadvantaged patients were associated with higher expenditures during 90-day episodes of care after isolated CABG.We linked clinical registry data from 8728 isolated CABG procedures from January 1, 2012, to December 31, 2018, to Medicare fee-for-service claims data. Our primary exposure variable was patients in the top decile of the Area Deprivation Index. Linear regression was used to compare risk-adjusted, price-standardized 90-day episode spending for deprived against nondeprived patients as well as component spending categories: index hospitalization, professional services, post acute care, and readmissions.A total of 872 patients were categorized as being in the top decile. Mean 90-day episode spending for the 8728 patients in the sample was $55 258 (SD, $26 252). Socioeconomically deprived patients had higher overall 90-day spending compared with nondeprived patients ($61 579 vs $54 557; difference, $3003; P = .001). Spending was higher in socioeconomically deprived patients for index hospitalizations (difference, $1284; P = .005), professional services (difference, $379; P = .002), and readmissions (difference, $1188; P = .008). Inpatient rehabilitation was the only significant difference in post-acute care spending (difference, $469; P = .011).Medicare spending was higher for socioeconomically deprived CABG in Michigan, indicating systemic disparities over and above patient demographic factors.

OBJECTIVES Measures to prevent surgical complications are critical components of optimal patient care, and adequate management when complications occur is equally crucial in efforts to reduce mortality. This study aims to elucidate clinical realities underlying in-hospital variations in failure to rescue (FTR) after cardiac surgery. METHODS Using a statewide database for a quality improvement program, we identified 62 450 patients who had undergone adult cardiac surgery between 2011 and 2018 in 1 of the 33 Michigan hospitals performing adult cardiac surgery. The hospitals were first divided into tertiles according to their observed to expected (O/E) ratios of 30-day mortality: low-mortality tertile (O/E 0.46–0.78), intermediate-mortality tertile (O/E 0.79–0.90) and high-mortality tertile (O/E 0.98–2.00). We then examined the incidence of 15 significant complications and the rates of death following complications among the 3 groups. RESULTS A total of 1418 operative deaths occurred in the entire cohort, a crude mortality rate of 2.3% and varied from 1.3% to 5.9% at the hospital level. The death rates also diverged significantly according to mortality score tertiles, from 1.6% in the low-mortality group to 3.2% in the high-mortality group (P CONCLUSIONS This study demonstrates that timely recognition and appropriate treatment of complications are as important as preventing complications to further reduce operative mortality in cardiac surgery. FTR tools may provide vital information for quality improvement initiatives.

BACKGROUND. Despite the risk of new persistent opioid use after cardiac surgery, postdischarge opioid use has not been quantified and evidence-based prescribing guidelines have not been established. METHODS. Opioid-naive patients undergoing primary cardiac surgery via median sternotomy between January and December 2019 at 10 hospitals participating in a statewide collaborative were selected. Clinical data were linked to patient-reported outcomes collected at 30-day follow-up. An opioid prescribing recommendation stratified by inpatient opioid use on the day before discharge (0, 1–3, or ≥4 pills) was implemented in July 2019. Interrupted time-series analyses were performed for prescription size and postdischarge opioid use before (January to June) and after (July to December) guideline implementation. RESULTS. Among 1495 patients (729 prerecommendation and 766 postrecommendation), median prescription size decreased from 20 pills to 12 pills after recommendation release (P < .001), while opioid use decreased from 3 pills to 0 pills (P < .001). Change in prescription size over time was +0.6 pill/month before and −0.8 pill/month after the recommendation (difference = −1.4 pills/month; P = .036). Change in patient use was +0.6 pill/month before and −0.4 pill/month after the recommendation (difference = −1.0 pills/month; P = .017). Pain levels during the first week after surgery and refills were unchanged. Patients using 0 pills before discharge (n = 710) were prescribed a median of 0 pills and used 0 pills, while those using 1 to 3 pills (n = 536) were prescribed 20 pills and used 7 pills, and those using greater than or equal to 4 pills (n = 249) were prescribed 32 pills and used 24 pills. CONCLUSIONS. An opioid prescribing recommendation was effective, and prescribing after cardiac surgery should be guided by inpatient use.

Racial disparities in health care have come to the forefront. We hypothesized that Black race was associated with worse preoperative risk, lower repair rates, and worse outcomes among patients who underwent mitral valve surgery.All patients who underwent mitral valve repair or replacement with or without coronary artery bypass grafting from 2011 to 2020 in a statewide collaborative database were stratified into 3 racial groups, White, Black, and other. Preoperative characteristics, procedure type, and outcomes were evaluated.A total of 9074 mitral valve operations were performed at 33 centers (Black 1009 [11.1%], White 7862 [86.6%]). Preoperative combined Society of Thoracic Surgeons morbidity and mortality was higher for Black patients (Black 32%, White 22%, other 23%, [P .001]) because of a greater proportion of diabetes, hypertension, and chronic lung disease. White patients were more likely to undergo mitral repair (White 66%, Black 53.3%, other 57%; P .001). Operative mortality was similar across racial groups (White 3.7%, Black 4.6%, other 4.5%; P = .36). After adjusting for preoperative factors, mitral etiology, and hospitals, race was not associated with mitral valve repair, complications, or mortality, but Black patients had higher odds of extended care facility utilization and readmission.Contrary to our hypothesis, there was no difference in the odds of repair or operative mortality across races after accounting for risk and etiology. However, Black patients were more likely to be readmitted after discharge. These findings support a greater focus on reducing disparities in mitral valve surgery.

Background: Payment reform efforts have sought to minimize the use of skilled nursing facilities (SNF) after coronary artery bypass grafting (CABG). Little is known about the characteristics and long-term consequences of CABG patients that are discharged to SNF. The purpose of this study was to identify clinical predictors and long-term outcomes associated with SNF use after isolated CABG. Methods and Results: Clinical data from the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative were linked to Medicare fee-for-service claims for 8280 Michigan residents undergoing isolated CABG that had no prior SNF use and were discharged alive between 7/1/2012-12/31/2018. A total of 1876 patients (22.7%) had any SNF use identified in claims within one year of discharge with a mean of 27.1 SNF days (SD=30.2). Mean Society of Thoracic Surgeons calculated preoperative risk of mortality was higher for SNF users compared to non-users (3.6% vs 2.0%, p Conclusions: One in five isolated CABG patients in Michigan used SNF within a year of discharge and represented a demographically and clinically distinct population of patients with worse long-term survival. Efforts to reduce SNF use following CABG could result in serious unintended effects on outcomes in this at-risk population.

Background Pneumonia is the most prevalent healthcare-associated infection after coronary artery bypass grafting (CABG), but the relative effectiveness of strategies to reduce its incidence remains unclear. We evaluated the relationship between healthcare-associated infection recommendations and risk of pneumonia after CABG. Methods Pneumonia prevention practice recommendations were developed based on literature review and analysis of semistructured interviews with key health care personnel across centers with low ( 6.1%) rates of pneumonia. These practices were implemented among 2482 patients undergoing CABG from 2016 to 2017 across 18 centers. The independent effect of each practice in reducing pneumonia was assessed using multivariable logistic regression, adjusting for baseline risk and center. A composite (bundle) score was calculated as the number of practices (0 to 4) each patient received. Results Recommended pneumonia prevention practices included lung protective ventilation management, early extubation, progressive ambulation, and avoidance of postoperative bronchodilator therapy. Pneumonia occurred in 2.4% of patients. Lung protective ventilation (adjusted odds ratio [ORadj], 0.45; 95% confidence interval [CI], 0.22-0.92), ambulation (ORadj, 0.08; 95% CI, 0.04-0.17), and postoperative ventilation of less than 6 hours (ORadj, 0.47; 95% CI, 0.26-0.87) were significantly associated with lower odds of pneumonia. Postoperative bronchodilator therapy (ORadj, 4.83; 95% CI, 2.20-10.7) was significantly associated with higher odds. Risk-adjusted rates of pneumonia, operative mortality, and intensive care unit length of stay were lower in patients with higher bundle scores (all P-trend Conclusions These pneumonia prevention recommendations may serve as effective targets for avoiding postoperative healthcare-associated infections.

Over the last 12 years, surgeon representatives from the 33 participating hospitals of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC), along with data specialists, surgical and quality improvement (QI) teams, have met at least 4 times a year to improve health-care quality and outcomes of cardiac and general thoracic surgery patients. The MSTCVS-QC nature of interactive learning has allowed all members to examine current data from each site in an unblinded manner for benchmarking, learn from their findings, institute clinically meaningful changes in survival and health-related quality of life, and carefully follow the effects. These meetings have resulted in agreement on various interventions to improve patient selection, periprocedural strategies, and adherence with evidence-based directed medication regimens, Factors contributing to the quality movement across hospitals include statewide-recognized clinicians who are eager to involve themselves in QI initiatives, dedicated health-care professionals at the hospital level, trusting environments in which failure is only a temporary step on the way toward achieving QI goals, real-time analytics of accurate data, and payers who strongly support QI efforts designed to improve outcomes.

BACKGROUND: The evidence base favoring utilization of multiple arterial conduits in coronary artery bypass grafting has strengthened in recent years. Nevertheless, utilization of arterial conduits in the US lags behind that of many European peers. We describe a statewide collaborative based approach to improving utilization.METHODS: Four metrics of arterial revascularization were devised. These were displayed and discussed at quarterly statewide quality collaborative meetings from January 2016 onwards, integrated with an educational program regarding attendant benefits. We undertook retrospective review of isolated coronary artery bypass grafting statewide from 2012-2019 to assess impact.RESULTS: A total of 38,523 cases met inclusion/exclusion criteria. Statewide incidence of multiple arterial grafting increased from 7.4% at baseline to 21.7% in 2019 (P < .001), implementation across hospitals varied widely, ranging from 67.6% to 0.0%. Utilization of total arterial revascularization increased 1.9% to 4.4% (P < .001) between time frames. Utilization of both radial artery and bilateral internal thoracic artery conduit increased significantly from 5.3% to 13.2% (P < .001) and 2.1% to 8.5% (P < .001), respectively; radial artery utilization was significantly higher than bilateral internal thoracic artery for each year (P < .001 for all comparisons).CONCLUSIONS: Our statewide quality improvement initiative improved rates of utilization of multiple arterial grafting by all metrics. Barriers to current utilization were identified to guide future quality improvement efforts. This reproducible approach is readily transferable to improve quality of care in other domains and geographical areas.

Whether all patients will require an opioid prescription after cardiac surgery is unknown. We performed a multicenter analysis to identify patient predictors of not receiving an opioid prescription at the time of discharge home after cardiac surgery.Opioid-naïve patients undergoing coronary artery bypass grafting and/or valve surgery through a sternotomy at 10 centers from January to December 2019 were identified retrospectively from a prospectively maintained data set. Opioid-naïve was defined as not taking opioids at the time of admission. The primary outcome was discharge without an opioid prescription. Mixed-effects logistic regression was performed to identify predictors of discharge without an opioid prescription, and postdischarge opioid prescribing was monitored to assess patient tolerance of discharge without an opioid prescription.Among 1924 eligible opioid-naïve patients, mean age was 64 ± 11 years, and 25% were women. In total, 28% of all patients were discharged without an opioid prescription. On multivariable analysis, older age, longer length of hospital stay, and undergoing surgery during the last 3 months of the study were independent predictors of discharge without an opioid prescription, whereas depression, non-Black and non-White race, and using more opioid pills on the day before discharge were independent predictors of receiving an opioid prescription. Among patients discharged without an opioid prescription, 1.8% (10 of 547) were subsequently prescribed an opioid.Discharging select patients without an opioid prescription after cardiac surgery appears well tolerated, with a low incidence of postdischarge opioid prescriptions. Increasing the number of patients discharged without an opioid prescription may be an area for quality improvement.

Background: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) since its initial approval in 2011, the frequency and outcomes of surgical explantation of TAVR devices (TAVR-explant) is poorly understood. Methods: Patients undergoing TAVR-explant between January 2012 and June 2020 at 33 hospitals in Michigan were identified in the Society of Thoracic Surgeons Database and linked to index TAVR data from the Transcatheter Valve Therapy Registry through a statewide quality collaborative. The primary outcome was operative mortality. Indications for TAVR-explant, contraindications to redo TAVR, operative data, and outcomes were collected from Society of Thoracic Surgeons and Transcatheter Valve Therapy databases. Baseline Society of Thoracic Surgeons Predicted Risk of Mortality was compared between index TAVR and TAVR-explant. Results: Twenty-four surgeons at 12 hospitals performed TAVR-explants in 46 patients (median age, 73). The frequency of TAVR-explant was 0.4%, and the number of explants increased annually. Median time to TAVR-explant was 139 days and among known device types explanted, most were self-expanding valves (29/41, 71%). Common indications for TAVR-explant were procedure-related failure (35%), paravalvular leak (28%), and need for other cardiac surgery (26%). Contraindications to redo TAVR included need for other cardiac surgery (28%), unsuitable noncoronary anatomy (13%), coronary obstruction (11%), and endocarditis (11%). Overall, 65% (30/46) of patients underwent concomitant procedures, including aortic repair/replacement in 33% (n=15), mitral surgery in 22% (n=10), and coronary artery bypass grafting in 16% (n=7). The median Society of Thoracic Surgeons Predicted Risk of Mortality was 4.2% at index TAVR and 9.3% at TAVR-explant ( P =0.001). Operative mortality was 20% (9/46) and 76% (35/46) of patients had in-hospital complications. Of patients alive at discharge, 37% (17/37) were discharged home and overall 3-month survival was 73±14%. Conclusions: TAVR-explant is rare but increasing, and its clinical impact is substantial. As the utilization of TAVR expands into younger and lower-risk patients, providers should consider the potential for future TAVR-explant during selection of an initial valve strategy.

Background Cardiovascular outcomes are worse among individuals from areas with limited socioeconomic resources. This study evaluated the relationship between high socioeconomic deprivation and isolated coronary artery bypass grafting (CABG) outcomes. Methods We linked statewide Society of Thoracic Surgeons Adult Cardiac Surgery Database data to Medicare fee-for-service records for 10,423 Michigan residents undergoing isolated CABG between 01/2012-12/2018. High socioeconomic deprivation was defined as residing in the highest decile of zip code-level area deprivation index (ADI). Multivariable logistic regression estimated the relationship between top ADI decile and major morbidity, in-hospital mortality, and operative mortality. Survival analyses evaluated long-term survival comparing patients in the top versus not in the top ADI decile. Results A total of 1,036 patients were in the top decile of ADI (ADI>82.4), and were more likely to be female, black, and have a higher predicted risk of mortality. Patients in the top ADI decile had significantly higher rates of major morbidity (17.4% versus 11.4%, adjusted odds ratio =1.26, 95% CI: 1.04-1.54, p=0.021) and in-hospital mortality (3.2% versus 1.3%, adjusted odds ratio=1.84, 95% CI: 1.18-2.86, p=0.007), but not operative mortality. The adjusted hazard of mortality was 16% higher for patients residing in the top ADI decile (95% CI: 1.01-1.33, p=0.032). Conclusions Isolated CABG patients residing in the highest areas of socioeconomic deprivation differed with respect to demographic and clinical characteristics, and experienced worse short and long-term outcomes compared with those not in the top ADI decile.

Background: Postacute care is a major driver of cardiac surgical episode spending, but the sources of variation in spending have not been explored. The objective of this study was to identify sources of variation in postacute care spending within 90-days of discharge following coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) and the relationship between postacute care spending and other postdischarge utilization. Methods and Results: A retrospective analysis was conducted of public and private administrative claims for Michigan residents insured by Medicare fee-for-service and Blue Cross Blue Shield of Michigan/Blue Care Network commercial and Medicare Advantage plans undergoing CABG (n=11 208) or AVR (n=6122) in 33 nonfederal acute care Michigan hospitals between January 1, 2015 and December 31, 2018. Postacute care use was present in 9662 (86.2%) CABG episodes and 4242 (69.3%) AVR episodes, with respective mean (SD) 90-day spending of $4398±$6124 and $3465±$5759. Across hospitals, mean postacute care spending ranged from $3280 to $8186 for CABG and $2246 to $7710 for AVR. Inpatient rehabilitation and skilled nursing facility care accounted for over 80% of the variation spending between low and high postacute care spending hospitals. At the hospital-level, postacute care spending was modestly correlated across procedures and payers. Spending associated with readmissions, emergency department visits, and outpatient facility care was significantly different between low and high postacute care spending hospitals in CABG and AVR episodes. Conclusions: There was wide hospital variation in postacute care spending after cardiac surgery, which was primarily driven by differential use and intensity in facility-based postacute care. Optimizing facility-based postacute care after cardiac surgery offers unique opportunities to reduce potentially unwarranted care variation.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has increased in volume as an alternative to surgical aortic valve replacement (SAVR). Comparisons of total episode expenditures, while largely ignored thus far, will be key to the value proposition for payers. METHODS: We evaluated 6,359 Blue Cross Blue Shield of Michigan and Medicare fee-for-service beneficiaries undergoing TAVR (17 hospitals, n=1,655) or SAVR (33 hospitals, n=4,704) in Michigan between 2012 and 2016. Payments through 90 post-discharge days between TAVR and SAVR were price-standardized and risk-adjusted. Centers were divided into terciles of procedural volume separately for TAVR and SAVR, and payments were compared between lowest and highest terciles. RESULTS: Payments (± standard deviation) were higher for TAVR than SAVR ($69,388 ± $22,259 vs. $66,683 ± $27,377, p

While large volumes of red blood cell transfusions are given to preserve life for cardiac surgical patients, indications for lower volume transfusions (1-2 units) are less well understood. We evaluated the relationship between center-level organizational blood management practices and center-level variability in low volume transfusion rates.All 33 nonfederal, Michigan cardiac surgical programs were surveyed about their blood management practices for isolated, nonemergent coronary bypass procedures, including: (1) presence and structure of a patient blood management program, (2) policies and procedures, and (3) audit and feedback practices. Practices were compared across low (N = 14, rate: 0.8%-10.1%) and high (N = 18, rate: 11.0%-26.3%) transfusion rate centers.Thirty-two (97.0%) of 33 institutions participated in this study. No statistical differences in organizational practices were identified between low- and high-rate groups, including: (1) the membership composition of patient blood management programs among those reporting having a blood management committee (P= .27-1.0), (2) the presence of available red blood cell units within the operating room (4 of 14 low-rate versus 2 of 18 high-rate centers report that they store no units per surgical case, P= .36), and (3) the frequency of internal benchmarking reporting about blood management audit and feedback practices (low rate: 8 of 14 versus high rate: 9 of 18; P= .43).We did not identify meaningful differences in organizational practices between low- and high-rate intraoperative transfusion centers. While a larger sample size may have been able to identify differences in organizational practices, efforts to reduce variation in 1- to 2-unit, intraoperative transfusions may benefit from evaluating other determinants, including organizational culture and provider transfusion practices.

As transcatheter aortic valve replacement (TAVR) therapy transitions from inoperable or high-risk patients to those considered moderate risk, a contemporary evaluation of AVR in this latter group is warranted.Using the Michigan Cardiothoracic Surgical Quality Collaborative Database, we analyzed outcomes and identified predictors of a composite end point (30-day death, stroke, and dialysis) for 2,979 patients (2007 to 2015) undergoing AVR (n = 1,196) or AVR and coronary artery bypass grafting (n = 1,783) with a preoperative The Society of Thoracic Surgeons predicted risk of mortality (PROM) of 4% to 8% (mean, 5.5%; interquartile range, 4.5% to 6.3%).The 30-day mortality was 3.9%. Independent predictors of death included stage 4 chronic kidney disease and the presence of pulmonary hypertension (both p 0.05), but not year of procedure, despite a significant trend in decreased PROM during the study period (p = 0.003). Morbidity included stroke in 2.3%, and renal failure, defined as Acute Kidney Injury Network stage 1 to 3, in 43.7%, although only 5.4% required dialysis. Prolonged ventilator support was required by 21.0%. After a mean length of stay of 10 days (interquartile range 6 to 11 days), 36.4% were discharged to extended care facilities. Independent predictors of the composite outcome included the Society of Thoracic Surgeons PROM (p0.001 for trend) and pulmonary hypertension (p0.001). Compared with those presenting with pure aortic stenosis, mixed aortic stenosis and aortic insufficiency was independently protective of the composite outcome (odds ratio, 0.58; p 0.001), whereas pure aortic insufficiency was not (odds ratio, 0.87; p = 0.58). The composite end point frequency was not significantly different in the 17 hospitals developing TAVR programs (TAVR 9.6% vs non-TAVR 9.6%, p = 0.98).This population-based contemporary assessment suggests moderate-risk patients undergoing AVR experience favorable outcomes. Although increasing PROM is important in preoperative evaluation of risk, preexisting pulmonary hypertension and indication for operation are among other factors that should be considered as TAVR expands into this group of patients.

Postoperative pneumonia is the most prevalent of all hospital-acquired infections after isolated coronary artery bypass graft surgery (CABG). Accurate prediction of a patient's risk of this morbid complication is hindered by its low relative incidence. In an effort to support clinical decision making and quality improvement, we developed a preoperative prediction model for postoperative pneumonia after CABG.We undertook an observational study of 16,084 patients undergoing CABG between the third quarter of 2011 and the second quarter of 2014 across 33 institutions participating in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. Variables related to patient demographics, medical history, admission status, comorbid disease, cardiac anatomy, and the institution performing the procedure were investigated. Logistic regression through forward stepwise selection (p0.05 threshold) was utilized to develop a risk prediction model for estimating the occurrence of pneumonia. Traditional methods were used to assess the model's performance.Postoperative pneumonia occurred in 3.30% of patients. Multivariable analysis identified 17 preoperative factors, including demographics, laboratory values, comorbid disease, pulmonary and cardiac function, and operative status. The final model significantly predicted the occurrence of pneumonia, and performed well (C-statistic: 0.74). These findings were confirmed through sensitivity analyses by center and clinically important subgroups.We identified 17 readily obtainable preoperative variables associated with postoperative pneumonia. This model may be used to provide individualized risk estimation and to identify opportunities to reduce a patient's preoperative risk of pneumonia through prehabilitation.

We characterized the midterm impact of transcatheter aortic valve replacement (TAVR) on surgical aortic valve replacement (SAVR) volume, patient profiles, and outcomes in Michigan.We analyzed data obtained after SAVR (n = 15,288) and TAVR (n = 1,783) using the Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative from 2006 to 2015. During this period, 17 of 33 hospitals developed TAVR programs.Annual SAVR volume increased by 38.1% at TAVR hospitals and by 20.4% at non-TAVR hospitals, (p trend0.001). In TAVR hospitals, the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) decreased before (4.7% ± 5.1%) and after (3.5% ± 3.6%) initiation of TAVR (p0.001). Rates of 30-day mortality (pre-TAVR, 3.9% vs post-TAVR, 2.7%; p0.001) and renal failure (pre-TAVR, 5.2% vs post-TAVR, 3.3%; p0.001) but not stroke (pre-TAVR, 1.9% vs post-TAVR, 1.7%; p = 0.47) were lower after TAVR implementation. Length of stay decreased from 9.0 to 8.5 days (p0.001). When analyzing high-risk patients undergoing SAVR (ie, PROM8%), neither mortality, stroke, nor renal failure was different (all p0.15). Despite a reduction in the STS-PROM, non-TAVR hospitals did not display changes in mortality, stroke, or renal failure for either the entire or the high-risk SAVR cohorts after initiation of TAVR in Michigan.TAVR implementation in Michigan has dramatically increased overall SAVR volume. This phenomenon has occurred with a concomitant decrease in preoperative risk profile and has improved early SAVR outcomes, particularly at TAVR hospitals, but surprisingly not in patients considered at high preoperative risk. As TAVR use increases, these issues may be further clarified and elucidated.

Pneumonia, a known complication of coronary artery bypass grafting (CABG), significantly increases a patient's risk of morbidity and mortality. Although not well characterized, red blood cell (RBC) transfusions may increase a patient's risk of pneumonia. We describe the relationship between RBC transfusion and postoperative pneumonia after CABG.A total of 16,182 consecutive patients underwent isolated CABG between 2011 and 2013 at 1 of 33 hospitals in the state of Michigan. We used multivariable logistic regression to estimate the relative odds of pneumonia associated with the use or number of RBC units (0, 1, 2, 3, 4, 5, and ≥ 6). We adjusted for predicted risk of mortality, preoperative hematocrit values, history of pneumonia, cardiopulmonary bypass duration, and medical center. We confirmed the strength and direction of these relationships among selected clinical subgroups in a secondary analysis.Five hundred seventy-six (3.6%) patients had pneumonia and 6,451 (39.9%) received RBC transfusions. There was a significant association between any RBC transfusion and pneumonia (adjusted odds ratio [ORadj], 3.4; p0.001). There was a dose response between number of units and odds of pneumonia, with a ptrend less than 0.001. Patients receiving only 2 units of RBCs had a 2-fold (ORadj, 2.1; p0.001) increased odds of developing pneumonia. These findings were consistent across clinical subgroups.We found a significant volume-dependent association between an increasing number of RBCs and the odds of pneumonia, which persisted after risk adjustment. Clinical teams should explore opportunities for preventing a patient's risk of RBC transfusions, including reducing hemodilution or adopting a lower transfusion threshold in a stable patient.

With the introduction of version 2.73, several new patient risk factors are now captured in The Society of Thoracic Surgeons' (STS) Adult Cardiac Surgery Database. We sought to evaluate the potential association of these risk factors with mortality.We reviewed all patients with an STS predicted risk of mortality in our statewide quality collaborative database from July 2011 to September 2013 (N = 19,743). Univariate analyses were used to determine significant associations between mortality and the new risk factors in version 2.73. We then performed multivariable analysis, incorporating the STS predicted risk of mortality into our regression.In the univariate model, patients with illicit drug use, syncope, unresponsive neurologic state, cancer within the last 5 years, current smoking history, other tobacco use, or sleep apnea had no significant difference in mortality (p0.05). Patients with liver disease, elevated Model for End-Stage Liver Disease score, mediastinal radiation, prolonged 5-meter walk test, home oxygen use, inhaled medications or bronchodilator therapy, decreased forced expiratory volume, and history of recent pneumonia had significant increases in operative mortality (p0.05). In multivariable analysis incorporating the STS predicted risk models, liver disease, elevated Model for End-Stage Liver Disease score, prolonged 5-meter walk test, home oxygen use, bronchodilator therapy, and abnormal pulmonary function tests were independently predictive of mortality.Several of the new STS data variables were significantly associated with operative mortality after cardiac surgery. The addition of these patient factors improves our understanding of evolving patient demographics and comorbid conditions and their impact on perioperative risk. This will improve both shared decision making and assessments of provider performance.

Coronary artery bypass grafting (CABG) is scheduled to become a mandatory Medicare bundled payment program in January 2018. A contemporary understanding of 90-day CABG episode payments and their drivers is necessary to inform health policy, hospital strategy, and clinical quality improvement activities. Furthermore, insight into current CABG payments and their variation is important for understanding the potential effects of bundled payment models in cardiac care.To examine CABG payment variation and its drivers.This retrospective cohort study used Medicare and private payer claims to identify patients who underwent nonemergent CABG surgery from January 1, 2012, through October 31, 2015. Ninety-day price-standardized, risk-adjusted, total episode payments were calculated for each patient, and hospitals were divided into quartiles based on the mean total episode payments of their patients. Payments were then subdivided into 4 components (index hospitalization, professional, postacute care, and readmission payments) and compared across hospital quartiles. Seventy-six hospitals in Michigan representing a diverse set of geographies and practice environments were included.Ninety-day CABG episode payments.A total of 5910 patients undergoing nonemergent CABG surgery were identified at 33 of the 76 hospitals; of these, 4344 (73.5%) were men and mean (SD) age was 68.0 (9.3) years. At the patient level, risk-adjusted, 90-day total episode payments for CABG varied from $11 723 to $356 850. At the hospital level, the highest payment quartile of hospitals had a mean total episode payment of $54 399 compared with $45 487 for the lowest payment quartile (16.4% difference, P .001). The highest payment quartile hospitals compared with the lowest payment quartile hospitals had 14.6% higher index hospitalization payments ($34 992 vs $30 531, P .001), 33.9% higher professional payments ($8060 vs $6021, P .001), 29.6% higher postacute care payments ($7663 vs $5912, P .001), and 35.1% higher readmission payments ($3576 vs $2646, P = .06). The drivers of this variation are diagnosis related group distribution, increased inpatient evaluation and management services, higher utilization of inpatient rehabilitation, and patients with multiple readmissions.Wide variation exists in 90-day CABG episode payments for Medicare and private payer patients in Michigan. Hospitals and clinicians entering bundled payment programs for CABG should work to understand local sources of variation, with a focus on patients with multiple readmissions, inpatient evaluation and management services, and postdischarge outpatient rehabilitation care.

Thirty-one states approved Medicaid expansion after implementation of the Affordable Care Act. The objective of this study was to evaluate the effect of Medicaid expansion on cardiac surgery volume and outcomes comparing one state that expanded to one that did not.Data from the Virginia (nonexpansion state) Cardiac Services Quality Initiative and the Michigan (expanded Medicaid, April 2014) Society of Thoracic and Cardiovascular Surgeons Quality Collaborative were analyzed to identify uninsured and Medicaid patients undergoing coronary bypass graft or valve operations, or both. Demographics, operative details, predicted risk scores, and morbidity and mortality rates, stratified by state and compared across era (preexpansion: 18 months before vs postexpansion: 18 months after), were analyzed.In Virginia, there were no differences in volume between eras, whereas in Michigan, there was a significant increase in Medicaid volume (54.4% [558 of 1,026] vs 84.1% [954 of 1,135], p0.001) and a corresponding decrease in uninsured volume. In Virginia Medicaid patients, there were no differences in predicted risk of morbidity or mortality or postoperative major morbidities. In Michigan Medicaid patients, a significant decrease in predicted risk of morbidity or mortality (11.9% [8.1% to 20.0%] vs 11.1% [7.7% to 17.9%], p = 0.02) and morbidities (18.3% [102 of 558] vs 13.2% [126 of 954], p = 0.008) was identified. Postexpansion was associated with a decreased risk-adjusted rate of major morbidity (odds ratio, 0.69; 95% confidence interval, 0.51 to 0.91; p = 0.01) in Michigan Medicaid patients.Medicaid expansion was associated with fewer uninsured cardiac surgery patients and improved predicted risk scores and morbidity rates. In addition to improving health care financing, Medicaid expansion may positively affect patient care and outcomes.

This study examined the relationship between transfusion of 1 or 2 units of red blood cells (RBCs) and the risk of morbidity and mortality after isolated on-pump coronary artery bypass grafting (CABG).A total of 22,785 consecutive patients underwent isolated on-pump CABG between January 1, 2008, and December 31, 2011 in Michigan. We excluded 5,950 patients who received three or more RBC units. Twenty-one preoperative variables significantly associated with transfusion by univariate analysis were included in a logistic regression model predicting transfusion, and propensity scores were calculated. Transfusion and the propensity score covariate were included in additional logistic regression models predicting mortality and each of 11 postoperative outcomes.Operative mortality for the study cohort of 16,835 patients was 0.8% overall, 0.5% for the 10,884 patients with no transfusion, and 1.3% for the 5,951 patients who received transfusion of 1 or 2 units (odds ratio 2.44; confidence interval 1.74 to 3.42; p0.0001). The association between transfusion and mortality lessened after propensity adjustment but remained highly significant (odds ratio 1.86; confidence interval 1.21 to 2.87; p = 0.005). Of the 11 postoperative outcomes studied, all but sternal wound infection and need for dialysis were also significantly associated with transfusion.Transfusion of as little as 1 or 2 units of RBCs is common and is significantly associated with increased morbidity and mortality after on-pump CABG. The relationship persists after adjustment for preoperative risk factors. These results suggest that aggressive attempts at blood conservation and avoidance of even small amounts of RBC transfusion may improve outcomes after CABG.

Expanding therapies for aortic stenosis have focused on high-risk and inoperable patients, suggesting that an evaluation of outcomes of conventional aortic valve replacement (AVR) or AVR and coronary artery bypass grafting (CABG) is timely and warranted.Outcomes for 6,270 AVR (3,487) or AVR/CABG (2,783) procedures performed in Michigan (2008-2011) were analyzed using a statewide cardiothoracic surgical database. Hospital and surgeon volume-outcome relationships were assessed.Independent predictors of early mortality (all p0.05) included age, female sex, predicted risk of mortality, and hospital volume, with a hinge point of a 4-year volume of 390 procedures (high-volume hospital [HVH], 2.41% versus low-volume hospital [LVH], 4.34%; p0.001). At this hinge point, observed to expected ratio (O/E) for operative mortality after AVR was lower in HVHs for patients with a predicted risk of mortality (PRoM) greater than 4.7%. In contrast, no surgeon-volume outcome relationship was identified, even when stratified by preoperative patient-risk profile. With respect to other measures, HVHs reported lower rates of prolonged ventilation (24.9% versus LVH, 30.9%; p0.001), postoperative transfusion (46.1% versus LVH, 59.0%; p0.001), pneumonia (6.6% versus LVH, 9.0%; p = 0.01), and multisystem organ failure (0.7% versus LVH, 1.8%; p = 0.012).This population-based analysis suggests that volume-outcome relationships exist for AVR. The predominant effect on mortality appears based on the setting of the procedure and occurs primarily in the high-risk patient. These results provide an opportunity to review approaches for high-risk patients undergoing AVR, including resource availability and system experience as the spectrum of treatment options expands to transcatheter therapies.

ObjectivePerioperative red blood cell transfusion is associated with increased morbidity and mortality after coronary artery bypass grafting (CABG). Whether transfusion is a cause of these outcomes or serves as a surrogate for a high-risk patient population remains uncertain. This retrospective study tested the hypothesis that increased preoperative risk profile of patients receiving transfusion would explain the relationship between red blood cell transfusion and operative mortality in isolated CABG.MethodsA total of 31,818 patients undergoing isolated CABG were entered into a statewide collaborative database between January 2006 and June 2010. With the Society of Thoracic Surgeons risk calculator, patient cohorts were stratified into 4 groups by predicted risk of mortality (PROM) of less than 2%, 2% to 5%, more than 5% to 10% and more than 10%. The association between blood transfusion and mortality was tested at each stratum with a χ2 test. A Breslow-Day test for homogeneity of odds ratios was used to test whether the 4 odds ratios of the strata were similar, and a Cochran-Mantel-Haenszel test was used to test the association between blood transfusion and mortality while controlling for predicted risk mortality strata.ResultsIn all, 17,720 (55.7%) of all patients were transfused during the hospitalization. Incidence of transfusion increased stepwise with risk level; 93.3% of patients with PROM greater than 10% received blood. Operative mortality was 2.1% overall, 0.6% among the 44.3% of patients who were not transfused, and 3.3% in the transfused group (odds ratio, 6.19; P

The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) Quality Collaborative is a voluntary, surgeon-directed quality initiative involving all cardiac surgery programs in Michigan. Understanding that internal mammary artery (IMA) use during coronary artery bypass grafting is an important process measure associated with improved outcomes, this analysis reviews our methodology to understand IMA use and increase appropriate IMA use statewide.Adult cardiac Society of Thoracic Surgeons data were collected at each Michigan site and submitted quarterly to the Duke Clinical Research Institute and the MSTCVS. Seven cardiac surgery programs with IMA use less than 90% in isolated coronary artery bypass grafting were identified as low IMA users. An improvement plan was adopted at the state level and included quarterly monitoring of IMA use, documenting the rationale for IMA exclusion, evidence-based lectures, feedback letters to sites, and physician-led site visits if no improvement was noted.From 2005 through 2008, 29,114 patients underwent coronary artery bypass grafting in Michigan. Internal mammary artery utilization varied widely at the beginning of this investigation, ranging from 66.2% to 98.4%. Seven Michigan programs were identified as low IMA users. Using the MSTCVS Quality Collaborative's process-improvement plan, collectively the seven low IMA users increased IMA grafting from 82.0% to 92.7% (p0.0001). Michigan IMA use increased from 91.9% to 95.8% (p0.0001) and is now higher than The Society of Thoracic Surgeons' average.The MSTCVS Quality Collaborative identified programs with low IMA use and created an environment to enhance IMA utilization during coronary artery bypass grafting, a significant operative process. These findings illustrate the value of a statewide surgeon-directed quality initiative in improving processes and outcomes for patients.

Patients undergoing coronary artery bypass grafting (CABG) are at risk for a variety of infections. Investigators have focused on predictors of these adverse sequelae, but less attention has been focused on characterizing hospital-level variability in these outcomes.Between July 2011 and December 2013, The Society of Thoracic Surgeons Adult Cardiac Surgery Database shows 365,686 patients underwent isolated CABG in 1,084 hospitals. Hospital-acquired infections (HAIs) were defined as pneumonia, sepsis/septicemia, deep sternal wound infection/mediastinitis, vein harvest/cannulation site infection, or thoracotomy infection. Hospitals were ranked by their HAI rate as low (≤ 10th percentile), medium (10th to 90th percentile), and high (90th percentile). Differences in perioperative factors and composite morbidity and mortality end points across these groups were determined using the Wilcoxon rank sum and χ(2) tests.HAIs occurred among 3.97% of patients overall, but rates varied across hospital groups (low:0.84%, medium: 0.84% to 8.41%, high:8.41%). Pneumonia (2.98%) was the most common HAI, followed by sepsis/septicemia (0.84%). Patients at high-rate hospitals more often smoked, had diabetes, chronic lung disease, New York Heart Association Functional Classification III to IV, and received blood products (p0.001); however, they less often were prescribed the appropriate antibiotics (p0.001). Major morbidity and mortality occurred among 12.3% of patients, although this varied by hospital group (low: 8.6%, medium: 12.3%, high: 17.9%; p0.001).Substantial hospital-level variation exists in postoperative HAIs among patients undergoing CABG, driven predominantly by pneumonia. Given the relatively small absolute differences in comorbidities across hospital groups, our findings suggest factors other than case mix may explain the observed variation in HAI rates.

Prior studies have implicated transfusion as a risk factor for mortality in coronary artery bypass graft surgery (CABG). To further our understanding of the true association between transfusion and outcome, we specifically analyzed the subgroup of patients who died after undergoing CABG.A total of 34,362 patients underwent isolated CABG between January 2008 and September 2013 and were entered into a statewide collaborative database; 672 patients (2.0%) died and form the basis for this study. Univariate analysis compared preoperative and intraoperative variables, as well as postoperative outcomes, between those with and without transfusion in both unadjusted cohorts and those matched by predicted risk of mortality (PROM). Mortality was further evaluated with phase of care analysis.Of the 672 deaths, 566 patients (84.2%) received a transfusion of red blood cells. The PROM was 7.5% for the transfused patients versus 4.3% for those not transfused (p0.001). Transfused patients were older, more often female, had more emergency, on-pump, and redo procedures, and had a lower preoperative and on-bypass nadir hematocrit. Most other demographics were similar between the groups. Postoperatively, transfused patients were ventilated longer, had more renal and multisystem organ failure, and were more likely to die of infectious and pulmonary causes after longer intensive care unit and overall lengths of stay.Significant differences in PROM and the postoperative course leading to death between those with and without transfusion suggest the role of transfusion may be secondary to other patient-related factors. Recognizing that the relationship between transfusion and outcome after CABG remains incompletely understood, these findings are suggestive of a complex interaction of many variables.

Background— Health-care–acquired infections (HAIs) are a leading cause of morbidity and mortality after cardiac surgery. Prior work has identified several patient-related risk factors associated with HAIs. We hypothesized that rates of HAIs would differ across institutions, in part attributed to differences in case mix. Methods and Results— We analyzed 20 896 patients undergoing isolated coronary artery bypass grafting surgery at 33 medical centers in Michigan between January 1, 2009, and June 30, 2012. Overall HAIs included pneumonia, sepsis/septicemia, and surgical site infections, including deep sternal wound, thoracotomy, and harvest/cannulation site infections. We excluded patients presenting with endocarditis. Predicted rates of HAIs were estimated using multivariable logistic regression. Overall rate of HAI was 5.1% (1071 of 20 896; isolated pneumonia, 3.1% [n=644]; isolated sepsis/septicemia, 0.5% [n=99]; isolated deep sternal wound infection, 0.5% [n=96]; isolated harvest/cannulation site, 0.5% [n=97]; isolated thoracotomy, 0.02% [n=5]; multiple infections, 0.6% [n=130]). HAI subtypes differed across strata of center-level HAI rates. Although predicted risk of HAI differed in absolute terms by 2.8% across centers (3.9–6.7%; min:max), observed rates varied by 18.2% (0.9–19.1%). Conclusions— There was a 18.2% difference in observed HAI rates across medical centers among patients undergoing isolated coronary artery bypass grafting surgery. This variability could not be explained by patient case mix. Future work should focus on the impact of other factors (eg, organizational and systems of clinical care) on risk of HAIs.

Objectives: Red blood cell (RBC) transfusions have been associated with morbidity and mortality in both coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI). As a mechanism for identifying determinants of RBC practice, we quantified the relationship between a center’s PCI and CABG transfusion rate. Methods: We identified all patients undergoing CABG (n= 16568) or PCI (n=94634) at each of 33 centers from 2010 through 2012 in the state of Michigan and compared perioperative RBC transfusion rates for CABG and PCI at each center. Crude and adjusted transfusion rates were modeled separately. We adjusted for common pre-procedural risk factors (12 for CABG, and 23 for PCI) and report Pearson correlation coefficients based on the crude and risk-adjusted rates. Results: RBC transfusion was more common after CABG (mean 46.5%) than PCI (mean 3.3%), with wide variation across centers for both (CABG min:max, 26.5:71.3; PCI min:max, 1.6:6.0). RBC rates were significantly correlated between CABG and PCI in both crude (r=0.47, p=0.005) and adjusted (r=0.53, p=0.002) analyses, Figure. These findings were consistent when restricting to non-emergent cases (r adj =0.44, p=0.001). Conclusions: RBC transfusion rates were significantly correlated between the CABG and PCI at individual hospitals in Michigan, independent of patient case mix. Future work should explore institutional determinants of RBC transfusions.

Objectives: Patients undergoing cardiac surgery may receive blood products during the perioperative period. While increasing attention has been drawn to red blood cell transfusions given its associated cost and morbidity, less work has been devoted to other frequently delivered blood component therapies, including platelets. We sought to identify pre-operative determinants and outcomes of platelet transfusion in the setting of coronary artery bypass grafting (CABG) surgery. Methods: Data from 4,574 patients undergoing on pump, isolated, non-emergent CABG surgery between July 2011 and June 2012 were entered into a statewide collaborative database. Logistic regression models were constructed to assess determinants and impact of platelet transfusions, and calculate crude and risk-adjusted odds ratios (OR). Post-operative outcomes included in-hospital mortality, re-operation for bleeding and prolonged (>24 hours) ventilation. Results: Platelet transfusions occurred among 14.7% (674 of 4574) of CABG procedures. Platelet transfusions were associated with increased odds of death (OR adj 4.2), reoperation for bleeding (OR adj 23.3), and prolonged ventilation (OR adj 3.4), all p Conclusions: Platelet use was associated with increased odds of morbidity and mortality after CABG surgery. We identified 10 pre-operative factors associated with platelet transfusions. This study enhances our understanding of risk factors for traditionally overlooked yet potentially harmful blood components. Given these findings, future work should focus on identifying practices that may assist in reducing rates of platelet transfusions.

Off-pump coronary bypass surgery (CABG) has been advocated to avoid the physiologic perturbations related to cardiopulmonary bypass and improve outcomes compared with on-pump CABG. Previous reports have been inconsistent, and thus its benefits remain uncertain. This retrospective study compared outcomes between on-pump and off-pump CABG from a large multicenter cohort of propensity-matched patients.The study consisted of 21,640 patients (19,639 [90.8%] on-pump, 2,001 [9.2%] off-pump) who underwent isolated CABG between January 1, 2008, and June 30, 2011, and were entered into a statewide collaborative database. Univariate analysis compared 37 baseline characteristics between on-pump and off-pump procedures. Patients were matched 1:1 based on similarities in propensity scores derived from statistically significant baseline characteristics. Propensity scores and surgery type were used in conditional logistic regression models for predicting each of 14 postoperative outcomes using the sample of 3,898 matched procedures.Patients undergoing off-pump CABG had significantly fewer complications overall, including decreased red blood cell transfusion, stroke, intensive care unit and ventilator time, reoperation for bleeding, and length of stay. There was no difference in renal failure, wound infection, discharge location, or 30-day readmission rate. Although off-pump patients received fewer bypass grafts per patient (2.5 ± 1.2 versus 3.0 ± 1.1; p0.001), operative mortality was similar for the two groups (1.8% on-pump versus 2.3% off-pump; p = 0.30).Off-pump CABG was associated with less morbidity, shorter length of stay, and similar mortality compared with on-pump procedures, suggesting that it can be a safe and effective alternative to standard on-pump CABG. However, the limited use of off-pump CABG in this multicenter analysis may restrict the generalizability of these results, and realistically defines the limited degree of acceptance of this technique in a real-world environment.

Between January 2008 and December 2012, a multicenter quality collaborative initiated a focus on blood conservation as a quality metric, with educational presentations and quarterly reporting of institutional-level perioperative transfusion rates and outcomes. This prospective cohort study was undertaken to determine the effect of that initiative on transfusion rates after isolated coronary artery bypass grafting (CABG).Between January 1, 2008, and December 31, 2012, 30,271 patients underwent isolated CABG in Michigan. Evaluated were annual crude and adjusted trends in overall transfusion rates for red blood cells (RBCs), fresh frozen plasma (FFP), and platelets, and in operative death.Transfusion rates continuously decreased for all blood products. RBC use decreased from 56.4% in 2008 (baseline) to 38.3% in 2012, FFP use decreased from 14.8% to 9.1%, and platelet use decreased from 20.5% to 13.4% (ptrend0.001 for all). A significant reduction occurred in deep sternal wound infection, reoperation for bleeding, renal failure, prolonged ventilation, initial ventilator time, and intensive care unit duration. The percentage of patients discharged home significantly increased (ptrend 0.001). Mortality rates did not differ significantly (ptrend = 0.11).In a multicenter quality collaborative, increased attention to transfusion-related outcomes and blood conservation techniques, coincident with regular reporting and review of perioperative transfusion rates as a quality metric, was associated with a significant decrease in blood product utilization. These reductions were concurrent with significant improvement in most perioperative outcomes. This intervention was also safe, as it was not associated with any increases in mortality.

Although regional and national registries exist to measure and report performance of cardiac surgical programs, few registries exist dedicated to the practice of cardiopulmonary bypass (CPB). We developed and implemented a cardiovascular perfusion registry (Perfusion Measures and outcomes [PERForm] Registry) within the structure of the Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) to improve our understanding of the practice of CPB. The PERForm Registry comprises data elements describing the practice of CPB. Fourteen medical centers within MSTCVS have voluntarily reported these data on procedures in which CPB is used. We validated the case count among procedures performed between January 1, 2011 to December 31, 2011, and validated the values among 20 fields at three medical centers. We queried database managers at all 14 medical centers to identify the infrastructure that contributed to best overall data collection performance. We found that 98% of all records submitted to the PERForm and 95% of those submitted to the Society of Thoracic Surgeons (STS) matched. We found quite favorable agreement in our audit of select fields (95.8%). Those centers with the most favorable performance in this validation study were more likely to use electronic data capture, have a perfusionist as the STS database manager, and have involvement of the STS database manager in the PERForm or STS databases. We successfully and accurately collected data concerning cardiovascular perfusion among 14 institutions in conjunction with the MSTCVS. Future efforts will focus on expanding data collection to all MSTCVS participating institutions as well as more broadly outside of Michigan.

Background This is a study of a method of mortality review, adopted by the Michigan Society of Thoracic and Cardiovascular Surgeons, to enhance understanding of mortality and potentially avoidable deaths after cardiac surgery, utilizing a voluntary statewide database. Methods A system to categorize mortality was developed utilizing a phase of care mortality analysis approach as well as providing criteria to classify mortality as potentially "avoidable." For each mortality, the operating surgeon categorized a cardiac surgery mortality trigger into 1 of 5 time frames: preoperative, intraoperative, intensive care unit (ICU), postoperative floor, and discharge. Results A total of 53,674 adult cardiac operations were performed from January 1, 2006 to June 30, 2010 with a crude mortality of 3.5% (1,905 of 53,674). Of the mortalities analyzed, 35% (618 of 1,780) were preoperative, 25% (451 of 1,780) were ICU, 19% (333 of 1,780) were intraoperative, 11% (198 of 1,780) were floor, and 10% (180 of 1,780) were discharge phase. "Avoidable" mortality triggers occurred in 53% (174 of 333) of the intraoperative, 41% (253 of 618) and (184 of 451) of the preoperative and ICU phases, 42% (83 of 198) of the floor, and 19% (35 of 180) of the discharge phase. Overall potentially avoidable mortality was 41% (729 of 1780). Thirty-six percent (644 of 1,780) of the mortalities were coronary artery bypass grafting patients and 29% (188 of 644) of these were in the preoperative phase, with a mean predicted risk of 16%. Conclusions This analysis identifies the occurrence of potentially avoidable mortalities in the 4 hospital phases of care, with the largest absolute number of avoidable mortalities occurring in the preoperative phase. A focus on these phases of care provides significant opportunity for quality improvement initiatives. Utilizing phase of care mortality analysis stimulates surgeons and hospitals to develop and refine mortality reviews and provides a structured statewide platform for discussion, education, quality improvement, and enhanced outcomes.