Public reporting for coronary artery bypass graft surgery: The quest for the optimal scorecard.

OBJECTIVE: A number of publicly available rating algorithms are used to assess hospital performance in coronary artery bypass grafting (CABG). However, concerns remain that these algorithms fail to correlate with each other and inadequately capture the case complexity of individual center practices. METHODS: Composite star ratings for isolated CABG from the Society of Thoracic Surgeons public reporting database were extracted for 2018-2019. U.S. News & World Report Best Hospitals was used to extract CABG ratings as well as overall cardiology and heart surgery ranking, and the Centers for Medicare & Medicaid Services Hospital Compare was used to extract CABG volume and 30-day mortality. Spearman correlation coefficients were used to assess possible relationships. Expert opinion on risk adjustment and program evaluation was incorporated. RESULTS: Correlations between Society of Thoracic Surgeons star rating and U.S. News & World Report overall ranking in cardiology and heart surgery (r = 0.15) and Centers for Medicare & Medicaid Services 30-day mortality (r = -0.27) were poor. Society of Thoracic Surgeons star rating correlated weakly with U.S. News & World Report CABG ratings (r = 0.33) and with Centers for Medicare & Medicaid Services CABG volume (r = 0.32), whereas the latter 2 correlated moderately (r = 0.52) with each other. Of the 75 centers with accredited cardiac surgery training programs, 13 (17%) did not participate in Society of Thoracic Surgeons public reporting. Important gaps were identified in risk assessment, and potential solutions are proposed. CONCLUSIONS: Correlations between current CABG public reporting systems are weak. Further work is needed to refine and standardize CABG rating systems to more adequately capture the scope and complexity of an individual center's clinical practice and to better inform patients.

Costs of Endoscopic vs Open Vein Harvesting for Coronary Artery Bypass Grafting: A Secondary Analysis of the REGROUP Trial.

Importance: Value-based purchasing creates pressure to examine whether newer technologies and care processes, including new surgical techniques, yield any economic advantage. Objective: To compare health care costs and utilization between participants randomized to receive endoscopic vein harvesting (EVH) or open vein harvesting (OVH) during a coronary artery bypass grafting (CABG) procedure. Design, Setting, and Participants: This secondary economic analysis was conducted alongside the 16-site Randomized Endo-Vein Graft Prospective (REGROUP) clinical trial funded by the Department of Veterans Affairs (VA) Cooperative Studies Program. Adults scheduled for urgent or elective bypass involving a vein graft were eligible. The first participant was enrolled in September 2013, with most sites completing enrollment by March 2014. The last participant was enrolled in April 2017. A total of 1150 participants were randomized, with 574 participants receiving OVH and 576 receiving EVH. For this secondary analysis, cost and utilization data were extracted through September 30, 2020. Participants were linked to administrative data in the VA Corporate Data Warehouse and activity-based cost data starting with the index procedure. Interventions: EVH vs OVH, with comparisons based on intention to treat. Main Outcomes and Measures: Discharge costs for the index procedure as well as follow-up costs (including intended and unintended events; mean [SD] follow-up time, 33.0 [19.9] months) were analyzed, with results from different statistical models compared to test for robustness (ie, lack of variation across models). All costs represented care provided or paid by the VA, standardized to 2020 US dollars. Results: Among 1150 participants, the mean (SD) age was 66.4 (6.9) years; most participants (1144 [99.5%] were male. With regard to race and ethnicity, 6 participants (0.5%) self-reported as American Indian or Alaska Native, 10 (0.9%) as Asian or Pacific Islander, 91 (7.9%) as Black, 62 (5.4%) as Hispanic, 974 (84.7%) as non-Hispanic White, and 6 (0.5%) as other race and/or ethnicity; data were missing for 1 participant (0.1%). The unadjusted mean (SD) costs for the index CABG procedure were $76 607 ($43 883) among patients who received EVH and $75 368 ($45 900) among those who received OVH, including facility costs, insurance costs, and physician-related costs (commonly referred to as provider costs in Centers for Medicare and Medicaid and insurance data). No significant differences were found in follow-up costs; per 90-day follow-up period, EVH was associated with a mean (SE) added cost of $302 ($225) per patient. The results were highly robust to the statistical model. Conclusions and Relevance: In this study, EVH was not associated with a reduction in costs for the index CABG procedure or follow-up care. Therefore, the choice to provide EVH may be based on surgeon and patient preferences. Trial Registration: ClinicalTrials.gov Identifier: NCT01850082.

Failure to Rescue After Cardiac Surgery at Minority-Serving Hospitals: Room for Improvement.

BACKGROUND: Despite living closer to high-performing centers, minority patients reportedly receive care at lower-quality hospitals. Investigating opportunities for improvement at minority-serving hospitals may help attenuate disparities in care among cardiothoracic surgery patients. We sought to investigate the relationship between hospital quality and failure to rescue (FTR). METHODS: Over 451,000 cardiac surgery patients from 2000 to 2011 at minority-serving hospitals (MSHs) were identified from the Nationwide Inpatient Sample. After stratifying patients by hospital mortality quartile, outcomes at poorly performing MSHs were compared with those at high-performing MSHs. Propensity score matching was used for comparisons. RESULTS: Though patients at poorly performing centers were more likely Black, there were no significant differences in admission status (urgent vs elective), income, insurance, or risk before matching. There were no differences in comorbidities between low-performing and high-performing MSHs including chronic lung disease, coagulopathy, hypertension, and renal failure. While complications remained similar across mortality quartiles (29%, 32%, 31%, and 36%, respectively; P < .0001), FTR increased in a stepwise manner (5.4%, 8.7%, 11.2%, and 15.5%, respectively; P < .0001). The same was true after propensity score matching-FTR nearly tripled in the highest-mortality centers (14.4% vs 5.3%; P < .0001), while complications only increased 1.2-fold from 31.1% to 36.7% (P = .0058). This finding persisted even when stratified by procedure type and by complication. CONCLUSIONS: Improving timely management of complications after cardiac surgery may serve as a promising opportunity for increasing quality of care at MSHs. When considering centralization of care in cardiac surgery, equal emphasis should be placed on collaboration between tertiary care centers and low-quality MSHs to mitigate disparities in care.

New-onset postoperative atrial fibrillation impact on 5-year clinical outcomes and costs.

OBJECTIVE: The impact of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) surgery on long-term clinical outcomes and costs is not known. This subanalysis of the Veterans Affairs "Randomized On/Off Bypass Follow-up Study" compared 5-year outcomes and costs between patients with and without POAF. METHODS: Of the 2203 veterans in the study, 100 with pre-CABG atrial fibrillation (93) or missing data (7) were excluded (4.8%). Unadjusted and risk-adjusted outcomes were compared between new-onset POAF (n = 551) and patients without POAF (n = 1552). Five-year clinical outcomes included mortality, major adverse cardiovascular events (MACE, comprising mortality, repeat revascularization, and myocardial infarction), MACE subcomponents, stroke, and costs. A stringent P value of ≤.01 was required to identify statistical significance. RESULTS: Patients with POAF were older and had more complex comorbidities. Unadjusted 5-year all-cause mortality was 16.3% POAF versus 11.9% no-POAF, P = .008. Unadjusted cardiac-mortality was 7.4% versus 4.8%, P = .022. There were no differences between groups in any other unadjusted outcomes including MACE or stroke. After risk adjustment, there were no significant differences between groups in 5-year all-cause mortality (POAF odds ratio, 1.19; 99% confidence interval, 0.81-1.75) or cardiac mortality (odds ratio, 1.51, 99% confidence interval, 0.88-2.60). Adjusted first-year post-CABG costs were $15,300 greater for patients with POAF, but 2- through 5-year costs were similar. CONCLUSIONS: No 5-year risk-adjusted outcome differences were found between patients with and without POAF after CABG. Although first-year costs were greater in patients with POAF, this difference did not persist in subsequent years.

Microplegia vs 4:1 Blood Cardioplegia: Effectiveness and Cost Savings in Complex Cardiac Operations.

BACKGROUND: Microplegia has been studied during isolated coronary artery bypass grafting and valve surgery but not in more complex operations. Objectives of this study were to demonstrate safety and effectiveness of microplegia relative to Buckberg cardioplegia during these operations. METHODS: From January 2012 to January 2017, 242 patients underwent multicomponent operations with simplified microplegia delivered via syringe pump and 10,512 with modified Buckberg cardioplegia. Operations included aortic root, arch, or ascending aorta replacement in 424 (94%) patients, aortic valve surgery in 324 (72%) patients, and concomitant coronary artery bypass grafting in 47 (10%) patients. Outcomes were compared in 226 propensity-matched pairs. RESULTS: There was no difference in median postoperative troponin T between groups after adjusting for aortic clamp time. Microplegia patients received significantly less crystalloid with their cardioplegia (mean 27 ± 8.0 mL/operation vs 735 ± 357 mL/operation; P < .001) and had lower peak intraoperative glucose (196 ± 40 mg/dL vs 248 ± 69 mg/dL; P < .001). Microplegia and Buckberg groups had similar in-hospital mortality (2.7% [n = 6] vs 2.2% [n = 5]; P = .8), stroke (2.2% [n = 5] vs 3.6% [n = 8]; P = .4), renal failure (8% [n = 18] vs 5.8% [n = 13]; P = .4), prolonged ventilation (23% [n = 51] vs 24% [n = 54]; P = .7), median postoperative length of stay (both 8.1 days; P > .9), and median red cell units administered to patients requiring transfusion (4 units vs 3 units; P = .14). The mean cost of cardioplegia per case with microplegia was 1/26th that of Buckberg cardioplegia. CONCLUSIONS: Our simplified microplegia technique offers several advantages over Buckberg cardioplegia without compromising myocardial protection or safety in complex, multicomponent operations with extended aortic clamp times.

Costs Five Years After Off-Pump or On-Pump Coronary Artery Bypass Surgery.

BACKGROUND: Coronary artery bypass grafting (CABG) is a common surgical treatment for ischemic heart disease. Little is known about the long-term costs of conducting the surgery on-pump or off-pump. METHODS: As part of the Randomized On/Off Bypass follow-up study, we followed 2,203 participants randomized to on-pump (n = 1,099) and off-pump (n = 1,104) CABG for 5 years using Department of Veterans Affairs and Medicare administrative data. We examined annual costs through 5 years, standardized to 2016 dollars, using multivariate regression models, controlling for site and baseline patient factors. RESULTS: In the first year, including the CABG surgery, annual average costs were $66,599 (SE, $1,946) for the on-pump group and $70,552 (SE, $1,954) for the off-pump group. In years 2 to 5, average costs ranged from $15,000 to $20,000 per year. There was no significant difference between on-pump and off-pump across the 5 years. We explored differences among high-risk subgroups (diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, renal dysfunction, ejection fraction < 35%, over age 70 years), and found no treatment assignment by time interactions, except for a nonsignificant trend in patients with diabetes. CONCLUSIONS: At 5 years, the average costs of off-pump and on-pump CABG patients did not statistically differ. Costs do not favor one approach and the decision should be based on clinical risks, especially in subgroups. Future research is warranted to examine post-CABG costs and outcomes for diabetic patients over time.

The impact of obesity on cardiac surgery outcomes.

BACKGROUND: A survival benefit for obese patients has been observed in various medical and surgical populations. We examined the effect of obesity on outcomes after cardiac surgery from a large national database. METHODS: A total of 6 648 334 adult patients were identified from the Nationwide Inpatient Sample who underwent cardiac surgery between 1998 and 2011, of who 598 450 were obese. Multivariable regression analysis and propensity score matching were used for comparisons of outcomes and costs. RESULTS: In-hospital mortality was 2.0% for obese patients versus 2.3% for non-obese patients (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.84, 0.94). Obese patients were at increased risk for acute renal failure (OR, 1.20; CI, 1.16, 1.23) and wound infection (OR, 1.29; CI, 1.18, 1.40), but less likely to require blood transfusion (OR, 0.96; CI, 0.94, 0.98). Mean length of stay was the same (8.7 days), with greater mean total charges for obese patients ($103 645 vs $101 763, P < 0.001). CONCLUSION: Obesity is associated with lower in-hospital mortality rates, but a higher incidence of acute renal failure and wound infections.

Comparison of Outcomes and Costs Associated With Aspirin ± Clopidogrel After Coronary Artery Bypass Grafting.

Optimal antiplatelet therapy after coronary artery bypass graft (CABG) surgery remains controversial. This study evaluated the role of dual antiplatelet therapy using aspirin and clopidogrel (DAPT) versus antiplatelet therapy using aspirin only (ASA) on post-CABG clinical outcomes and costs. In the Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) trial, clopidogrel use after CABG was prospectively collected beginning in year 2 of this study to include 1,525 of the 2,203 original ROOBY patients who received aspirin after CABG. Discretionarily, surgeons after CABG administered either DAPT or ASA treatments. The ROOBY trial's primary 30-day composite (mortality or perioperative morbidity), 1-year composite (all-cause death, repeat revascularization, or nonfatal myocardial infarction), and costs were compared for these 2 strategies. Of the 1,525 subjects, 511 received DAPT and 1,014 received ASA. DAPT subjects, compared with ASA subjects, had lower rates of preoperative left ventricular ejection fraction of ≥45% (78.8% vs 85.7%, p <0.001), on-pump CABG (36.6% vs 57.1%, p = 0.001), and endoscopic vein harvesting (30.0% vs 42.8%, p <0.001). ASA patients were more likely to have earlier aspirin administration and receive 325 versus 81 mg dosages. The 30-day composite outcome rate was significantly lower for DAPT patients compared with ASA patients (3.3% vs 7.1%, p = 0.003), but the 1-year composite outcome was equal between the 2 groups (12.0% vs12.0%, p = 1.0). At 1 year, there were no cost differences between the 2 groups. Propensity analyses did not significantly alter the results. In conclusion, DAPT appeared safe and was associated with fewer 30-day adverse outcomes than aspirin only and with no 1-year outcome or cost differences.

Nationwide trends and regional/hospital variations in open versus endovascular repair of thoracoabdominal aortic aneurysms.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) has been gaining popularity for the treatment of thoracoabdominal aortic aneurysm (TAAA). We used a nonvoluntary database to examine national trends and regional/hospital variations in the use of TEVAR and open thoracic aortic repair (OTAR) for TAAA. METHODS: From the 2005-2008 Nationwide Inpatient Sample database, we identified all patients with the diagnosis of TAAA who were treated with TEVAR or OTAR. Rates of these procedures were compared between years, across geographic regions, and between hospitals of various bed sizes. RESULTS: Over the study period, the rate of OTAR remained relatively stable (range, 7.5/100 patients in 2005 to 10.1/100 patients in 2008; P = .26), whereas the rate of TEVAR increased dramatically (range, 1.4/100 patients in 2005 to 6.3/100 patients in 2008; P < .0001). In 2008, 29% (211) of all TEVAR procedures and 11% (130) of all OTAR procedures were performed in western regions of the United States (P = .03). Additionally, 13% (95) of all TEVAR procedures and 3% (35) of all OTAR procedures were performed in smaller hospitals (P < .0001). CONCLUSIONS: The use of TEVAR for TAAA repair increased significantly over the study period, whereas OTAR rates remained relatively stable. Our findings suggest that more patients who were otherwise not surgical candidates or did not have traditional surgical indications for OTAR were treated with TEVAR, most commonly in regions or hospitals where OTAR is less often performed. Given the complexity of TAAA cases, these results may have significant implications for patient safety in the current era of heightened health care scrutiny.

Establishment of a transcatheter aortic valve program and heart valve team at a Veterans Affairs facility.

BACKGROUND: The US Food and Drug Administration recently approved a transcatheter aortic valve for patients for whom open heart surgery is prohibitively risky. METHODS: A multidisciplinary heart valve team partnered with administration to launch a transcatheter aortic valve replacement (TAVR) program. Clinical registries were used to show robust valve caseloads and outcomes at our Veterans Affairs (VA) facility and to project future volumes. A TAVR business plan was approved by the VA leadership as part of a multiphase project to upgrade and expand our surgical facilities. RESULTS: The heart valve team completed a training program that included simulations and visits to established TAVR centers. Patients were evaluated and screened through a streamlined process, and the program was initiated successfully. CONCLUSIONS: Establishing a TAVR program at a VA facility requires a multidisciplinary team with experience in heart valve and endovascular therapies and a supportive administration willing to invest in a sophisticated infrastructure.

Impact of functional status on survival after coronary artery bypass grafting in a veteran population.

BACKGROUND: Although functional impairment has been shown to be an adverse outcome of frailty, little is known of its effect on patients after cardiac operations. We aimed to assess the effect of limited functional status on long-term survival after coronary artery bypass grafting (CABG). METHODS: We reviewed prospectively gathered data from 1,503 consecutive patients who underwent isolated CABG between 1997 and 2009. We compared the outcomes of 318 patients with limited functional status and 1,185 patients without any functional impairment. The mean follow-up period was 65 months (range, 1 to 157 months). We assessed the relationship between functional status impairment and long-term survival by Cox regression analysis adjusted for confounding factors. RESULTS: Functionally impaired patients were slightly older (63±9 vs 62±8 years, p=0.05) and had more risk factors for adverse outcomes than patients who were functionally unimpaired. After adjustment for potential confounding variables by multivariate logistic regression analysis, preoperative limited functional status was not an independent predictor (odds ratio [95% confidence interval]) of 30-day mortality (1.4 [0.3 to 5.8], p=0.67) or major adverse cardiac events (1.3 [0.5 to 3.3], p=0.71), nor was it predictive of reduced long-term survival (10-year hazard ratio 1.0 [0.7 to 1.4], p=0.85). CONCLUSIONS: Limited functional status was not an independent risk factor for early postoperative complications or death. Long-term survival in patients whose functional status was impaired before they underwent CABG was similar to that of patients who were functionally independent.

Outcomes of concomitant aortic valve replacement and coronary artery bypass grafting at teaching hospitals versus nonteaching hospitals.

OBJECTIVE: Hospitals with a high volume and academic status produce better patient outcomes than other hospitals after complex surgical procedures. Risk models show that concomitant aortic valve replacement and coronary artery bypass grafting pose a greater risk than isolated coronary artery bypass grafting or aortic valve replacement. We examined the relationship of hospital teaching status and the presence of a thoracic surgery residency program with aortic valve replacement/coronary artery bypass grafting outcomes. METHODS: By using the Nationwide Inpatient Sample database, we identified patients who underwent concomitant aortic valve replacement/coronary artery bypass grafting from 1998 to 2007 at nonteaching hospitals, teaching hospitals without a thoracic surgery residency program, and teaching hospitals with a thoracic surgery residency program. Multivariate analysis was performed to identify intergroup differences. Risk-adjusted multivariable logistic regression analysis was used to assess independent predictors of in-hospital mortality and complication rates. RESULTS: The 3 groups of patients did not differ significantly in their baseline characteristics. Patients who underwent aortic valve replacement/coronary artery bypass grafting had higher overall risk-adjusted complication rates in nonteaching hospitals (odds ratio 1.58; 95% confidence interval, 1.39-1.80; P < .0001) and teaching hospitals without a thoracic surgery residency program (odds ratio 1.42; 95% confidence interval, 1.26-1.60; P < .0001) than in thoracic surgery residency program hospitals. However, no difference was observed in the adjusted mortality rate for nonteaching hospitals (odds ratio 0.95; 95% confidence interval, 0.87-1.04; P = .25) or teaching hospitals without a thoracic surgery residency program (odds ratio 1.00; 95% confidence interval, 0.92-1.08; P = .98) when compared with thoracic surgery residency program hospitals. Robust statistical models were used for analysis, with c-statistics of 0.98 (complications) and 0.82 (mortality). CONCLUSION: Patients who require complex cardiac operations may have better outcomes when treated at teaching hospitals with a thoracic surgery residency program.

Costs and quality of life associated with radial artery and saphenous vein cardiac bypass surgery: results from a Veterans Affairs multisite trial.

BACKGROUND: In coronary artery bypass grafting (CABG) surgery, there is uncertainty about whether the radial artery affects quality of life or costs relative to the saphenous vein. This study compared the cost and quality of life for patients randomized to either radial artery or saphenous vein grafts. METHODS: We analyzed the duration and cost of the index surgery and costs and quality of life (Seattle Angina Questionnaire and Health Utility Index) at 1 year for 726 participants. RESULTS: The 2 treatment groups had similar baseline characteristics. Using the radial artery added approximately 31 minutes to the surgery (from skin incision to skin closure; P < .001) compared with a saphenous vein graft. There were no significant differences in terms of costs and quality of life after the index hospitalization or at 1 year. CONCLUSIONS: Coronary artery bypass grafting with the radial artery lasts approximately 31 minutes longer than with the saphenous vein. However, costs and the quality of life were not statistically different.

Why choose cardiothoracic surgery as a career?

The future of cardiothoracic surgery faces a lofty challenge with the advancement of percutaneous technology and minimally invasive approaches. Coronary artery bypass grafting (CABG) surgery, once a lucrative operation and the driving force of our specialty, faces challenges with competitive stenting and poor reimbursements, contributing to a drop in applicants to our specialty that is further fueled by the negative information that members of other specialties impart to trainees. In the current era of explosive technological progress, the great diversity of our field should be viewed as a source of excitement, rather than confusion, for the upcoming generation. The ideal future cardiac surgeon must be a "surgeon-innovator," a reincarnation of the pioneering cardiac surgeons of the "golden age" of medicine. Equipped with the right skills, new graduates will land high-quality jobs that will help them to mature and excel. Mentorship is a key component at all stages of cardiothoracic training and career development. We review the main challenges facing our specialty--length of training, long hours, financial hardship, and uncertainty about the future, mentorship, and jobs--and we present individual perspectives from both residents and faculty members.

Superior nationwide outcomes of endovascular versus open repair for isolated descending thoracic aortic aneurysm in 11,669 patients.

OBJECTIVES: Thoracic endovascular aneurysm repair (TEVAR) was introduced in 2005 to treat descending thoracic aortic aneurysms. Little is known about TEVAR's nationwide effect on patient outcomes. We evaluated nationwide data regarding the short-term outcomes of TEVAR and open aortic repair (OAR) procedures performed in the United States during a 2-year period. METHODS: From the Nationwide Inpatient Sample data, we identified patients who had undergone surgery for an isolated descending thoracic aortic aneurysm from 2006 to 2007. Patients with aneurysm rupture, aortic dissection, vasculitis, connective tissue disorders, or concomitant aneurysms in other aortic segments were excluded. Of the remaining 11,669 patients, 9106 had undergone conventional OAR and 2563 had undergone TEVAR. Hierarchic regression analysis was used to assess the effect of TEVAR versus OAR after adjusting for confounding factors. The primary outcomes were mortality and the hospital length of stay (LOS). The secondary outcomes were the discharge status, morbidity, and hospital charges. RESULTS: The patients who had undergone TEVAR were older (69.5 ± 12.7 vs 60.2 ± 14.2 years; P < .001) and had higher Deyo comorbidity scores (4.6 ± 1.8 vs 3.3 ± 1.8; P < .001). The unadjusted LOS was shorter for the TEVAR patients (7.7 ± 11 vs 8.8 ± 7.9 days), but the unadjusted mortality was similar (TEVAR 2.3% vs OAR 2.3%; P = 1.0). The proportion of nonelective interventions was similar between the 2 groups (TEVAR 15.9% vs OAR 15.8%; P = .9). The TEVAR and OAR techniques produced similar risk-adjusted mortality rates; however, the TEVAR patients had 60% fewer complications overall (odds ratio, 0.39; P < .001) and a shorter LOS (by 1.3 days). The TEVAR patients' hospital charges were greater by $6713 (95% confidence interval $1869 to $11,556; P < .001). However, the TEVAR patients were 4 times more likely to have a routine discharge to home. CONCLUSIONS: The nationwide data on TEVAR for descending thoracic aortic aneurysms have associated this procedure with better in-hospital outcomes than OAR, even though TEVAR was selectively performed in patients who were almost 1 decade older than the OAR patients. Compared with OAR, TEVAR was associated with a shorter hospital LOS and fewer complications but significantly greater hospital charges.

Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is becoming increasingly popular for lung resection in some centers. However, the issue of whether VATS or open thoracotomy is better remains controversial. We compared outcomes of open and VATS lobectomy in a national database. METHODS: Using the 2004 and 2006 Nationwide Inpatient Sample database, we identified 13,619 discharge records of patients who underwent pulmonary lobectomy by means of thoracotomy (n = 12,860) or VATS (n = 759). Student's t and chi(2) tests were used to compare the two groups. Multivariable analysis was used to identify independent predictors of outcome measures. RESULTS: The two groups of patients had similar demographics and preoperative comorbidities. They also had similar in-hospital mortality rates (3.1% versus 3.4%; p = 0.67); lengths of stay (9.3 +/- 0.1 versus 9.2 +/- 0.4 days; p = 0.84); hospitalization costs ($23,862 +/- $206 versus $25,125 +/- $1,093; p = 0.16); and rates of wound infection (0.8% versus 1.3%; p = 0.15), pulmonary complications (32.2% versus 31.2%; p = 0.55), and cardiovascular complications (3.4% versus 3.9%; p = 0.43). However, multivariable analysis showed that the VATS group had a significantly higher incidence of intraoperative complications than the thoracotomy group (odds ratio, 1.6; 95% confidence interval, 1.0 to 2.4; p = 0.04). A higher percentage of patients with annual income greater than $59,000 underwent VATS lobectomy than patients with income less than $59,000 (35.7% versus 25.4%; p < 0.0001). CONCLUSIONS: Patients who underwent VATS lobectomy were 1.6 times more likely to have intraoperative complications than patients who underwent open lobectomy. However, short-term mortality, lengths of stay, and hospitalization costs were similar between the two groups of patients. There seems to be a socioeconomic disparity between VATS and open thoracotomy patients.

The July effect: impact of the beginning of the academic cycle on cardiac surgical outcomes in a cohort of 70,616 patients.

BACKGROUND: Because surgical residents' level of experience may be at its nadir early in the academic year, academic seasonality-or the "July effect"-could affect cardiac surgical outcomes. METHODS: Prospectively collected data from the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Program were used to identify 70,616 consecutive cardiac surgical procedures performed between October 1997 and October 2007. Morbidity and mortality rates were compared between early (July 1 to August 31, n = 11,975) and late (September 1 to June 30, n = 58,641) periods in the academic year. A prediction model was constructed by using stepwise logistic regression modeling. RESULTS: The two patient groups had similar demographic and risk variables. Isolated coronary artery bypass grafting accounted for 76.7% of early-period procedures and 75.8% of later-period procedures (p = 0.03). Morbidity rates did not differ significantly between the early (14.0%) and later periods (14.2%; odds ratio [OR], 1.01; 95% confidence interval [CI], 0.96 to 1.07; p = 0.67) and operative mortality was similar, 3.7% vs 3.9% (OR, 0.99; 95% CI, 0.89 to 1.11; p = 0.90). The early portion of the year was associated with longer cardiac ischemia times (84 +/- 40 vs 83 +/- 42 minutes), cardiopulmonary bypass times (126 +/-52 vs 124 +/-56 minutes), and total surgical times (295 +/- 90 vs 288 +/- 90 minutes; p < 0.05 for all). CONCLUSIONS: The early part of the academic year was associated with slightly longer operative times; however, risk-adjusted outcomes were similar in both periods. This finding should lessen concerns about the quality of cardiac surgical care at the beginning of the academic year.

Does the level of experience of residents affect outcomes of coronary artery bypass surgery?

BACKGROUND: At our institution, coronary artery bypass grafting (CABG) operations are performed by staff surgeons or by first- or second-year cardiothoracic residents under the direct supervision of attending surgeons. We evaluated the influence of surgical seniority on outcomes. METHODS: Using prospectively collected data from our departmental database, we identified all primary, isolated CABG operations (n = 1,042) performed between July 1997 and April 2007. Operations were then stratified according to the seniority of the primary surgeon: first-year cardiothoracic resident (CT1), second-year cardiothoracic resident (CT2), or staff surgeon. Data were examined for any association between seniority and surgical outcomes. RESULTS: Staff, CT2, and CT1 surgeons performed 47 (4%), 610 (59%), and 385 (37%) cases, respectively. Efficiency was correlated with experience: for CT1, CT2, and staff surgeons, respectively, operative times averaged 345, 313, and 302 minutes; perfusion times averaged 118, 106, and 96 minutes; and cross-clamp times averaged 68, 58, and 57 minutes (p < 0.05 for all comparisons). The incidences of major morbidity (10.1%, 12.3%, 12.8%) and operative mortality (0.8%, 1.5%, 2.1%) were similar after operations performed by CT1, CT2, and staff surgeons, respectively (p > 0.15 for all). In univariate and multivariate analyses, the seniority of the primary surgeon did not independently predict morbidity or perioperative mortality. On follow-up (mean, 1,485 +/- 1,015 days), there was no significant difference in patient survival (log-rank, p = 0.64). CONCLUSIONS: Lower academic seniority was associated with longer CABG operative times but did not affect outcomes. Thus, training residents to perform CABG is safe and is characterized by progressive improvement in their technical efficiency.