Engaging the Front Line: Tapping into Hospital-Wide Quality and Safety Initiatives.

Healthcare increasingly is moving from volume- to value-based care, with an emphasis on linking a larger percentage of payments to the quality of care provided. There is a renewed interest in designing a focused, strategic approach to quality and safety education and engagement of trainees in hospital-wide quality, safety, and patient experience initiatives. Hospitals, trainees, and patients benefit as a result of engaging frontline learners in these activities. Hospitals can leverage the intelligence from the front line to contribute to improved hospital safety, increased employee and patient engagement, and better identification of vulnerable areas of safety risks. Trainees benefit from increased engagement by acquiring fundamentals in quality and safety; are able to satisfy Clinical Learning Environment Review recommendations; have an opportunity to practice a number of skill sets (leadership, communication, collaboration); and complete quality and safety hands-on projects. Patients benefit from a more engaged work force, safer environment for their healthcare, and an improved overall experience. In this article, the current state of the Johns Hopkins Department of Anesthesiology and Critical Care Medicine's efforts to engage its front line in quality, safety, and patient experience initiatives that are in evolutionary phases of implementation is presented. Evolutionary concepts relate to the Johns Hopkins Health System and the aim of its training program to continuously improve and innovate.

Trends in blood utilization in United States cardiac surgical patients.

BACKGROUND: We sought to determine whether publication of blood conservation guidelines by the Society of Thoracic Surgeons in 2007 influenced transfusion rates and to understand how patient- and hospital-level factors influenced blood product usage. STUDY DESIGN AND METHODS: We identified 4,465,016 patients in the Nationwide Inpatient Sample database who underwent cardiac operations between 1999 and 2010 (3,202,404 before the guidelines and 1,262,612 after). Hierarchical linear modeling was used to account for hospital- and patient-level clustering. RESULTS: Transfusion rates of blood products increased from 13% in 1999 to a peak of 34% in 2010. Use of all blood components increased over the study period. Aortic aneurysm repair had the highest transfusion rate with 54% of patients receiving products in 2010. In coronary artery bypass grafting, the number of patients receiving blood products increased from 12% in 1999 to 32% in 2010. Patients undergoing valvular operations had a transfusion rate of 15% in 1999, increasing to 36% in 2010. Patients undergoing combined operations had an increase from 13% to 40% over 11 years. Risk factors for transfusion were anemia (odds ratio [OR], 2.05; 95% confidence interval [CI], 2.01-2.09), coagulopathy (OR, 1.54; 95% CI, 1.51-1.57), diabetes (OR, 1.32; 95% CI, 1.28-1.36), renal failure (OR, 1.29; 95% CI, 1.26-1.32), and liver disease (OR, 1.23; 95% CI, 1.16-1.31). Compared to the Northeast, the risk for transfusion was significantly lower in the Midwest; higher-volume hospitals used fewer blood products than lower-volume centers. Cell salvage usage remained below 5% across all years. CONCLUSION: Independent of patient- and hospital-level factors, blood product utilization continues to increase for all cardiac operations despite publication of blood conservation guidelines in 2007.

Compliance with Surgical Care Improvement Project for Body Temperature Management (SCIP Inf-10) Is Associated with Improved Clinical Outcomes.

BACKGROUND: In an effort to measure and improve the quality of perioperative care, the Surgical Care Improvement Project (SCIP) was introduced in 2003. The SCIP guidelines are evidence-based process measures designed to reduce preventable morbidity, but it remains to be determined whether SCIP-measure compliance is associated with improved outcomes. METHODS: The authors retrospectively analyzed the electronic medical record data from 45,304 inpatients at a single institution to assess whether compliance with SCIP Inf-10 (body temperature management) was associated with a reduced incidence of morbidity and mortality. The primary outcomes were hospital-acquired infection and ischemic cardiovascular events. Secondary outcomes were mortality and hospital length of stay. RESULTS: Body temperature on admission to the postoperative care unit was higher in the SCIP-compliant group (36.6° ± 0.5°C; n = 44,064) compared with the SCIP-noncompliant group (35.5° ± 0.5°C; n = 1,240) (P < 0.0001). SCIP compliance was associated with improved outcomes in both nonadjusted and risk-adjusted analyses. SCIP compliance was associated with a reduced incidence of hospital-acquired infection (3,312 [7.5%] vs.160 [12.9%] events; risk-adjusted odds ratio [OR], 0.68; 95% CI, 0.54 to 0.85), ischemic cardiovascular events (602 [1.4%] vs. 38 [3.1%] events; risk-adjusted OR, 0.60; 95% CI, 0.41 to 0.92), and mortality (617 [1.4%] vs. 60 [4.8%] events; risk-adjusted OR, 0.41; 95% CI, 0.29 to 0.58). Median (interquartile range) hospital length of stay was also decreased: 4 (2 to 8) versus 5 (2 to 14) days; P < 0.0001. CONCLUSION: Compliance with SCIP Inf-10 body temperature management guidelines during surgery is associated with improved clinical outcomes and can be used as a quality measure.

Transfusion of older red blood cells is associated with decreased graft survival after orthotopic liver transplantation.

Investigations have demonstrated conflicting results regarding the influence of the red blood cell (RBC) storage duration on outcomes. We evaluated whether graft failure or mortality after orthotopic liver transplantation (OLT) increased when recipients were transfused with older RBCs. This study included 637 patients who underwent OLT between January 2001 and June 2011. Baseline and perioperative data were obtained from our blood bank, the Unified Transplant Center database, and the United Network for Organ Sharing database. Recipients whose transfused RBCs were all stored for ≤ 15 days were grouped in a younger group, and recipients who were transfused with RBCs stored for >15 days were placed in an older group. The relationship between graft survival/mortality and the age of intraoperatively transfused RBCs was studied by Kaplan-Meier estimation with a log-rank test and multivariate Cox proportional hazards regression. Three hundred thirty-four patients and 303 patients were grouped in the younger and the older RBC groups, respectively, on the basis of the ages of intraoperatively transfused RBCs. Kaplan-Meier estimates of graft survival/mortality as a function of the posttransplant time were significantly different: the older group experienced the outcome sooner than the younger group [P = 0.02 (log-rank test)]. After covariate adjustments, the risk of graft failure/mortality was significantly different at any given time after transplantation between patients receiving intraoperative transfusions of older RBC units and patients receiving intraoperative transfusions of younger RBC units (hazard ratio = 1.65, 95% confidence interval = 1.18-2.31). In conclusion, patients who received intraoperative transfusions of RBCs with longer storage times had an increased risk of adverse outcomes.

Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis.

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium-with diverse expertise and representation-representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens' values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource's varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery.

BACKGROUND: Severe hyperglycemia is associated with adverse outcomes after cardiac surgery. Whether intraoperative and postoperative glucose concentrations equally impact outcomes is unknown. The objective of this investigation was to compare the ability of perioperative glucose concentrations and glycemic variability to predict adverse outcomes. Risk associated with decreasing increments of glucose concentrations, hypoglycemia, and diabetic status was also examined. METHODS: This retrospective analysis of prospectively collected data included 4,302 patients who underwent cardiac surgery between October 3, 2005 and May 31, 2007 at the Cleveland Clinic. Time-weighted mean intraoperative (GlcOR) and postoperative (GlcICU) glucose concentrations were calculated. Patients were categorized as follows: Glc more than 200, 171-200, 141-170, and less than or equal to 140 mg/dl. Coefficient of variation was used to calculate glycemic variability. Logistic regression model with backward selection assessed the relationship between glucose concentrations, variability, and adverse outcomes while adjusting for potential confounders. Another model assessed the predictability of GlcOR and GlcICU on adverse outcomes. RESULTS: Both GlcOR and GlcICU predicted risk for mortality and morbidity. Increased postoperative glycemic variability was associated with increased risk for adverse outcomes. Severe hyperglycemia (GlcOR and GlcICU > 200 mg/dl) was associated with worse outcomes; however, decreasing increments of GlcOR did not consistently reduce risk. GlcOR less than or equal to 140 mg/dl was not associated with improved outcomes compared with severe hyperglycemia, despite infrequent hypoglycemia. Diabetic status did not influence the effects of hyperglycemia. CONCLUSION: Perioperative glucose concentrations and glycemic variability are important in predicting outcomes after cardiac surgery. Incremental decreases of intraoperative glucose concentrations did not consistently reduce risk. Despite rare hypoglycemia, intraoperative glucose concentrations closest to normoglycemia were associated with worse outcomes.

Preoperative statin therapy is not associated with a reduced incidence of postoperative acute kidney injury after cardiac surgery.

BACKGROUND: Our objective was to examine the association between preoperative statin therapy and the prevalence of postoperative acute kidney injury (AKI) in patients undergoing cardiac surgery with the use of cardiopulmonary bypass. METHODS: We performed a retrospective investigation of 10,648 consecutive patients undergoing coronary artery bypass grafting using cardiopulmonary bypass and/or valve surgery between January 2002 and December 2006. Patients were divided into 2 groups depending on preoperative therapy with statin drugs. The primary outcome was postoperative AKI based on the RIFLE (Risk, Injury, Failure, Loss, End-stage) criteria. Secondary outcomes included requirement for postoperative dialysis and hospital mortality. Multivariable logistic regression models were developed for the primary and secondary outcomes. To control for selection bias related to statin therapy, a propensity score was developed using a greedy matching technique. RESULTS: The incidence of AKI was 12.1% (n = 1286). AKI occurred in 13.31% of patients receiving preoperative statins (819 of 6152 patients) versus 10.41% in the no statin group (467 of 4487 patients) (P < 0.001). The incidence of postoperative dialysis was 1.71% (n = 182). Postoperative dialysis was needed in 1.75% of patients in the statin group (108 of 6157 patients) compared with 1.65% of patients (74 of 4491 patients) in the no statin group (P = 0.68). Hospital mortality after surgery occurred in 1.71% (n = 182) of patients. The incidence of mortality for patients in the statin group was 1.71% (105 of 6157 patients) and this was not different from mortality in the no statin group of 1.71% (77 of 4491 patients) (P = 0.97). In multivariate logistic regression analysis, statin therapy was not associated with AKI (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.84-1.12; P = 0.68), postoperative dialysis (OR 0.80, 95% CI 0.55-118; P = 0.23), or hospital mortality (OR 0.803, 95% CI 0.56-1.16; P = 0.24). In 2646 propensity-matched pairs, the incidence of AKI was 12.0% in the statin group versus 12.8% in the no statin group (P = 0.38). The statin group had a 1.63% incidence of postoperative dialysis versus 2.08% in the no statin group (P = 0.22). In the same propensity-matched population, hospital mortality occurred in 1.63% of patients in the statin group compared with 2.1% in the no statin group (P = 0.19). CONCLUSION: These results suggest that previously reported reductions in perioperative mortality for patients taking preoperative statins and undergoing cardiac surgery is likely not mediated through a reduction in postoperative AKI.

Addressing the Opioid Crisis One Surgical Patient at a Time: Outcomes of a Novel Perioperative Pain Program.

Opioid prescriptions in the surgical setting have been implicated as contributors to the opioid epidemic. The authors hypothesized that a multidisciplinary approach to perioperative pain management for patients on chronic opioid therapy could decrease postoperative opioid requirements while reducing postoperative pain scores and improving functional outcomes. Therefore, a Perioperative Pain Program (PPP) for chronic opioid users was implemented. This study presents outcomes from the first 9 months of the PPP. Sixty-one patients met the inclusion criteria. Opioid consumption in morphine milligram equivalent (MME) was calculated and physical and health status of patients was assessed with the Brief Pain Inventory, Short-Form McGill Pain Questionnaire, and Short Form-12. Preliminary results showed significant reduction in MME, improved pain scores, and improved function for surgical patients on chronic opioids. PPP effectively reduced opioid usage without negatively influencing patient-reported outcomes, such as physical pain score assessment and health-related quality of life.

Effect of red blood cell storage duration on major postoperative complications in cardiac surgery: A randomized trial.

BACKGROUND: Although observational studies suggest an association between transfusion of older red blood cell (RBC) units and increased postoperative risk, randomized trials have not supported this. The objective of this randomized trial was to test the effect of RBC storage age on outcomes after cardiac surgery. METHODS: From July 2007 to May 2016, 3835 adults undergoing coronary artery bypass grafting, cardiac valve procedures, or ascending aorta repair, either alone or in combination, were randomized to transfusion of RBCs stored for ≤14 days (younger units) or for ≥20 days (older units) intraoperatively and throughout the postoperative hospitalization. According to protocol, 2448 patients were excluded because they did not receive RBC transfusions. Among the remaining 1387 modified intent-to-treat patients, 701 were randomized to receive younger RBC units (median age, 11 days) and the remaining 686 to receive older units (median age, 25 days). The primary endpoint was composite morbidity and mortality, analyzed using a generalized estimating equation (GEE) model. The trial was discontinued midway owing to enrollment constraints. RESULTS: A total of 5470 RBC units were transfused, including 2783 in the younger RBC storage group and 2687 in the older RBC storage group. The GEE average relative-effect odds ratio was 0.77 (95% confidence interval [CI], 0.50-1.19; P = .083) for the composite morbidity and mortality endpoint. In-hospital mortality was lower for the younger RBC storage group (2.1% [n = 15] vs 3.4% [n = 23]), as was occurrence of other adverse events except for atrial fibrillation, although all CIs crossed 1.0. CONCLUSIONS: This clinical trial, which was stopped at its midpoint owing to enrollment constraints, supports neither the efficacy nor the futility of transfusing either younger or older RBC units. The effects of transfusing RBCs after even more prolonged storage (35-42 days) remains untested.

Prognostic Value of Preoperative Red Cell Distribution Width: Fine-Tuning by Mean Corpuscular Volume.

BACKGROUND: Abnormal red cell distribution width (RDW), reflecting heterogeneity of red blood cell (RBC) size, is associated with cardiovascular disease outcomes. However, whether RBC size itself, expressed as mean corpuscular volume (MCV), provides additional prognostic value is unclear. We therefore investigated the relationship between outcomes after cardiac surgery and both RDW and MCV simultaneously. METHODS: From January 2010 to January 2014, 16,097 patients underwent cardiac surgery at Cleveland Clinic and had complete blood count findings available for analysis. Outcomes included RBC transfusion, postoperative complications, and intensive care unit (ICU) and postoperative hospital lengths of stay. Risk-adjusted associations of RDW and MCV with outcomes and their relative importance in predicting outcome were identified by random forest machine learning. RESULTS: High RDW was associated with more RBC transfusions. Except for postoperative atrial fibrillation, risks of complications and ICU and postoperative lengths of stay were at their minimum when RDW was normal, 13% to 14%. The relationship of MCV to complications was U-shaped: high (macrocytosis) and low (microcytosis) values were associated with higher risk. RDW was an important risk factor for most postoperative outcomes and lengths of stay; MCV was less so, but provided prognostic value in addition to RDW alone, particularly when there was macrocytosis. CONCLUSIONS: Abnormal RDW and MCV are associated with higher risk of transfusion and postoperative outcomes after cardiac surgery. RDW is one of the most important variables in predicting outcomes, but MCV provides additional prognostic value. Both should be taken into consideration when estimating the perioperative risk of patients undergoing cardiac surgery.

An Innovative Perioperative Pain Program for Chronic Opioid Users: An Academic Medical Center's Response to the Opioid Crisis.

Increased utilization of prescription opioids for pain management has led to a nationwide public health crisis with alarming rates of addiction and opioid-related deaths. In the surgical setting, opioid prescriptions have been implicated as a contributing factor to the opioid epidemic. The authors developed an innovative model to address aspects of pain management and opioid utilization during preoperative evaluation, acute surgical hospitalization, and postoperative follow-up for chronic opioid users. This program involves multidisciplinary teams that include acute and chronic pain specialists, psychiatrists, integrative medicine specialists, and physical medicine and rehabilitation services. It also features a novel infrastructure for triage and pain management education and treatment. Individualized patient plans are devised that can include preoperative opioid weaning, regional anesthesia that minimizes opioid use, and multimodal techniques for surgical pain treatment. Multidisciplinary programs such as this have the potential to both improve perioperative pain control and prevent escalation of opioid use among chronic opioid users.

Real Age: Red Blood Cell Aging During Storage.

BACKGROUND: During cold storage, some red blood cell (RBC) units age more rapidly than others. Yet, the Food and Drug Administration has set a uniform storage limit of 42 days. Objectives of this review are to present evidence for an RBC storage lesion and suggest that functional measures of stored RBC quality-which we call real age-may be more appropriate than calendar age. METHODS: During RBC storage, biochemical substances and byproducts accumulate and RBC shape alters. Factors that influence the rate of degradation include donor characteristics, bio-preservation conditions, and vesiculation. Better understanding of markers of RBC quality may lead to standardized, quantifiable, and operationally practical measures to improve donor selection, assess quality of an RBC unit, improve storage conditions, and test efficacy of the transfused product. RESULTS: The conundrum is that clinical trials of younger versus older RBC units have not aligned with in vitro aging data; that is, the units transfused were not old enough. In vitro changes are considerable beyond 28 to 35 days, and average storage age for older transfused units was 14 to 21 days. CONCLUSIONS: RBC product real age varies by donor characteristics, storage conditions, and biological changes during storage. Metrics to measure temporal changes in quality of the stored RBC product may be more appropriate than the 42-day expiration date. Randomized trials and observational studies are focused on average effect, but, in the evolving age of precision medicine, we must acknowledge that vulnerable populations and individuals may be harmed by aging blood.

Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration.

BACKGROUND: Confirmation of match between patient and blood product remains a manual process in most operating rooms (ORs), and documentation of dual-signature verification remains paper based in most medical institutions. A sentinel event at Johns Hopkins Hospital in which a seriously ill patient undergoing an emergent surgical procedure was transfused with a unit of incompatible red blood cells that had been intended for another patient in an adjacent OR led the hospital to conduct a quality improvement project to improve the safety of intraoperative blood component transfusions. METHODS: A multidisciplinary quality improvement project team led a four-phase implementation of bedside bar code transfusion verification (BBTV) for intraoperative blood product administration. Manual random sample audits of blood component transfusions were used to examine accuracy of documentation from July 2014 through June 2016. After the transition to the Epic anesthesia information management system (AIMS) in July 2016, automated Epic reports were generated to provide population-level audits. RESULTS: After initiation of BBTV and the addition of Epic AIMS, compliance with obtaining three metrics on documentation of patient identification (two electronic signatures, start and stop times of transfusion, and blood volume transfused) was improved during a one-year period to > 96%. Pre-Epic audits had shown a mean compliance of only 86%, mainly reflecting a lack of paper blood component requisitions. CONCLUSION: By implementing BBTV and using a novel intraoperative documentation process within the Epic AIMS, a safer process of blood transfusion in the ORs was initiated and documentation improved.

A model for an institutional response to the opioid crisis.

The use of opioid analgesics for pain management has increased dramatically over the past decade, with corresponding increases in negative sequelae including overdose and death. Physicians, policymakers, and researchers are focused on finding ways to decrease opioid use and overdose. This crisis calls for a coordinated response that includes the entire healthcare sector. In this work, the authors lay out a blueprint for such a response at the level of the academic medical center. The proposed model is a comprehensive opioid overdose prevention, response, and education program to evaluate, monitor, and address prescription opioid-related adverse events and addiction among all patients within a healthcare system. The approach includes three inter-related elements: (1) creation of an organizational structure that is subdivided into subcommittees to facilitate cross-functional collaboration and implementation. These subcommittees will focus on Research and Design, Implementation, Advisory, and Compliance with the recommendation. (2) Development of an effective communication plan throughout the institution to enable the organization to function seamlessly and efficiently as a single unit, (3) development of a data tracking and reporting system that intended to have a 360° view of all aspects of opioid prescription and downstream patient outcomes. The most effective response system will require an organizational structure that facilitates the ad hoc constitution of cross-functional teams with members drawn from all levels of the organizational hierarchy (executive leadership to frontline staff). Such a structure provides the teams with immediate solutions as developed by the frontline staff and authority to remove institutional barriers that may delay or limit the successful implementation. The model described was developed in our institution by a cross-functional team that included members from the Johns Hopkins School of Medicine and Johns Hopkins University Carey Business School, Department of Operations Management. The multidisciplinary nature of collaboration allowed us to develop a model for an immediate institution-wide response to the opioid crisis, and one that other healthcare organizations could adopt with local modification as a template for execution. The model also meant to serve as a template for an institutional rapid-response that can be seamlessly implemented during any future drug-related crisis or epidemic.

Preoperative Anemia in Cardiac Operation: Does Hemoglobin Tell the Whole Story?

BACKGROUND: Preoperative anemia, defined by hemoglobin level, is associated with elevated risk after cardiac operation. Better understanding of anemia requires characterization beyond this. This investigation focuses on red cell size and its association with patient characteristics and outcomes after cardiac operation. METHODS: From January 2010 to January 2014, 10,589 patients underwent elective cardiac operations at Cleveland Clinic. Anemia was characterized as normocytic, microcytic, or macrocytic based on mean corpuscular volume (MCV). Models for hospital complications were developed using multivariable logistic regression. Other outcomes were postoperative transfusion and intensive care unit (ICU) and postoperative hospital lengths of stay. RESULTS: A total of 2,715 patients (26%) were anemic. Of these, 2,365 (87%) had normocytic, 219 (8.1%) microcytic, and 131 (4.8%) macrocytic anemia. Non-anemic patients (n = 2,041, 26%) received transfusions compared with 1,553 (66%) normocytic, 148 (68%) microcytic, and 97 (74%) macrocytic anemia patients. Patients with normocytic or macrocytic anemia had more renal failure (normocytic: odds ratio (OR) 1.9, macrocytic: OR 3.5), other complications (normocytic: OR 1.3, macrocytic: OR 2.2) and death (normocytic: OR 2.0, macrocytic: OR 6.2) than non-anemic patients; patients with microcytic anemia had fewer reoperations (OR 0.35) and less postoperative atrial fibrillation (OR 0.50). Anemic patients experienced longer ICU (27 versus 48 hours, p < 0.001) and postoperative hospital (6.1 versus 7.4 days, p < 0.001) length of stay than non-anemic patients. CONCLUSIONS: Cardiac surgical patients are often anemic. Demographic characteristics, comorbidities, and outcomes are dissimilar according to red cell size. Patients with microcytic anemia had the lowest hemoglobin levels, yet the best clinical outcomes among anemic patients. MCV from the standard complete blood count adds additional information beyond hemoglobin for targeted intervention.

Recent metformin ingestion does not increase in-hospital morbidity or mortality after cardiac surgery.

BACKGROUND: Perioperative treatment of type 2 diabetes with metformin, an oral hypoglycemic drug, is thought to increase the risk of life-threatening postoperative lactic acidosis. In contrast, metformin improves serum glucose control and has beneficial cardiovascular effects, which may decrease the risk of adverse outcomes. In this investigation we sought to determine the influence of metformin treatment on mortality and morbidity compared with treatment with other oral hypoglycemic drugs in diabetic patients undergoing cardiac surgery. METHODS: In this retrospective investigation, 1284 diabetic patients, with recent oral hypoglycemic ingestion (presumed to be 8-24 h preoperatively), underwent cardiac surgery from 1994-2004. Propensity scores were calculated from a logistic model which included baseline characteristics and perioperative variables. Four-hundred-forty-three (85%) of the metformin-treated patients were matched on nearest propensity score using greedy matching techniques with 443 nonmetformin-treated patients. Postoperative outcomes were compared between matched metformin- and nonmetformin-treated patients. RESULTS: In-hospital mortality, cardiac, renal, and neurologic morbidities were similar between groups. Metformin-treated patients had less postoperative prolonged tracheal intubation [OR (95% CI), 0.3 (0.1, 0.7), P = 0.003], infection [0.2 (0.1, 0.7), P = 0.007] and overall morbidities [0.4 (0.2, 0.8), P = 0.005]. CONCLUSIONS: These data suggest that recent metformin ingestion is not associated with increased risk of adverse outcome in cardiac surgical patients. Alternatively, metformin treatment may have beneficial effects.

Does a similar procedure result in similar survival for women and men undergoing isolated coronary artery bypass grafting?

OBJECTIVES: To (1) identify sex-related differences in risk factors and revascularization strategies for patients undergoing coronary artery bypass grafting (CABG), (2) assess whether these differences influenced early and late survival, and (3) determine whether clinical effectiveness of the same revascularization strategy was influenced by sex. METHODS: From January 1972 to January 2011, 57,943 adults-11,009 (19%) women-underwent primary isolated CABG. Separate models for long-term mortality were developed for men and women, followed by assessing sex-related differences in strength of risk factors (interaction terms). RESULTS: Incomplete revascularization was more common in men than women (26% vs 22%, P < .0001), but women received fewer bilateral internal thoracic artery (ITA) grafts (4.8% vs 12%; P < .0001) and fewer arterial grafts (68% vs 70%; P < .0001). Overall, women had lower survival than men after CABG (65% and 31% at 10 and 20 years, respectively, vs 74% and 41%; P ≤ .0001), even after risk adjustment. Incomplete revascularization was associated equally (P > .9) with lower survival in both sexes. Single ITA grafting was associated with equally (P = .3) better survival in women and men. Although bilateral ITA grafting was associated with better survival than single ITA grafting, it was less effective in women-11% lower late mortality (hazard ratio, 0.89 [0.77-1.022]) versus 27% lower in men (hazard ratio, 0.73 [0.69-0.77]; P = .01). CONCLUSIONS: Women on average have longer life expectancies than men but not after CABG. Every attempt should be made to use arterial grafting and complete revascularization, but for unexplained reasons, sex-related differences in effectiveness of bilateral arterial grafting were identified.