Institutional variation in early mortality following isolated coronary artery bypass graft surgery.

BACKGROUND: Thirty-day mortality following coronary artery bypass grafting (CABG) is a widely accepted marker for quality of care. Although surgical mortality has declined, the utility of this measure to profile quality has not been questioned. We assessed the institutional variation in risk-standardised mortality rates (RSMR) following isolated CABG within Australia and New Zealand (ANZ). METHODS: We used an administrative dataset from all public and most private hospitals across ANZ to capture all isolated CABG procedures recorded between 2010 and 2015. The primary outcome was all-cause death occurring in-hospital or within 30-days of discharge. Hospital-specific RSMRs and 95% CI were estimated using a hierarchical generalised linear model accounting for differences in patient characteristics. RESULTS: Overall, 60,953 patients (mean age 66.1 ± 10.1y, 18.7% female) underwent an isolated CABG across 47 hospitals. The observed early mortality rate was 1.69% (n = 1029) with 81.8% of deaths recorded in-hospital. The risk-adjustment model was developed with good discrimination (C-statistic = 0.81). Following risk-adjustment, a 3.9-fold variation was observed in RSMRs among hospitals (median:1.72%, range:0.84-3.29%). Four hospitals had RSMRs significantly higher than average, and one hospital had RSMR lower than average. When in-hospital mortality alone was considered, the median in-hospital RSMR was 1.40% with a 5.6-fold variation across institutions (range:0.57-3.19%). CONCLUSIONS: Average mortality following isolated CABG is low across ANZ. Nevertheless, in-hospital and 30-day mortality vary among hospitals, highlighting potential disparities in care quality and the enduring usefulness of 30-day mortality as an outcome measure. Clinical and policy interventions, including participating in clinical quality registries, are needed to standardise CABG care.

Tensile force exerted by suture during renorrhaphy using current techniques.

Partial nephrectomy has become the preferred treatment option for small renal masses. In particular, minimally invasive partial nephrectomy (MIPN) using laparoscopic or robotic approaches has shown decreased blood loss, shorter hospital stay, and faster return to normal activity compared to open surgery. However, MIPN still carries risk of postoperative complications including hemorrhage and urine leakage. Closure of the renal remnant, often called renorrhaphy, is a critical step to avoid these complications. The purpose of the study was to provide quantitative data on suture properties during partial nephrectomy. Multiple suture techniques have been proposed for renal closure during robotic-assisted partial nephrectomy. There is no consensus for preferred closure technique and this decision is at the discretion of the surgeon. Simulated partial nephrectomies were performed on porcine kidneys. Renorrhaphy was completed with barbed suture using a simple running, interrupted sliding-clip, or horizontal mattress technique. Suture tension was obtained prior to tissue failure with force sensors measuring in newtons (N). The interrupted sliding-clip and horizontal mattress techniques performed similarly with median force values of 11.06 N and 12.20 N, respectively. The simple running technique performed with a median force of 3.62 N. ANOVA proved statistical significance. Interrupted sliding-clip and horizontal mattress sutures exert similar forces prior to tissue failure during renorrhaphy. Both techniques were able to achieve forces great enough to overcome the hydrostatic pressure of perfused renal tissue. Simple running sutures failed at significantly lower forces. When closing renal defects after partial nephrectomy, sliding-clip and horizontal mattress should be utilized over simple running sutures.