Regional organization for outcomes research.

Methods for achieving improvement in medical and surgical outcomes are often discussed, but rarely achieved. We report on a regional voluntary consortium founded in 1987 to provide information about the management of cardiovascular disease in northern New England. Members include all cardiothoracic surgeons and interventional cardiologists in the region, as well as administrators and scientists associated with the five institutions that provide advanced cardiac services in this region. The group maintains registries for coronary artery bypass grafting, coronary angioplasty, and heart valve surgery and has investigated institutional differences in mortality rates; the development and use of clinical prediction rules; the reasons for excess mortality among women undergoing bypass graft surgery; and time trends in the use of myocardial revascularization. This consortium is an inter-institutional model for the continuous improvement of medical and surgical care.

Traumatic rupture of the thoracic aorta.

Fifteen patients with blunt traumatic rupture of the aorta, secondary to automobile accidents, that occurred less than seven days prior to admission were treated between 1967 and 1976. The diagnosis was suspected on the basis of roentgenographic evidence of upper mediastinal widening. Aortography demonstrated a localized deformity and dilation of the aorta isthmus just distal to the subclavian artery in all but one patient whose lesion occurred in the mid-descending thoracic aorta. The salvage of one of five patients with free rupture by the prompt institution of total cardiopulmonary bypass has prompted us to begin each operation with the capability of using either left heart bypass or cardiopulmonary bypass. An associated rupture of the right atrium of one patient was successfully controlled. Nine of 12 patients survived the operation, eight were discharged from the hospital, and six were alive and well as least one year later.

Pericardial flap prevents sternal wound complications.

By interposing a pedicle of pericardium between the heart and sternum, mediastinitis may be prevented and sternal healing facilitated. Between Jan 1, 1984, and mid-1986, before we began using the pericardial flap, the overall incidence of mediastinitis and/or sternal wound dehiscence was 2.73% (26 of 952 patients). This rate did not differ significantly among three surgeons (2.53%, 2.95%, and 2.69%). During mid-1986, two of the three surgeons adopted the use of the pericardial flap and used it on 226 of 270 patients. None of these 270 patients developed mediastinitis or sternal wound dehiscence. The third surgeon did not adopt the use of the flap and operated on 100 patients during the same period. In this group, there were three cases of mediastinitis. This difference was statistically significant. No specific complications attributable to construction of a pericardial flap were identified in our patients. We conclude that the routine use of a pericardial flap is a safe, simple, and effective means of preventing mediastinitis and/or sternal dehiscence following cardiac surgery.

Should a patient with a treated cancer be offered an open heart operation?

The unknown but presumably reduced life expectancy of patients with malignant neoplasms may dissuade surgeons from performing necessary coronary and valvular heart operations. There is also concern for recrudescence of cancer as a result of an impaired immune system after cardiopulmonary bypass. We analyzed the records of 2,190 patients who underwent cardiac operations requiring extracorporeal circulation between 1988 and 1990. Of these, 46 patients had previously been treated for malignancy other than nonmelanoma skin cancer. Open heart operations were performed in patients with cardiac symptoms only in the absence of tumor recurrence. Tumor staging indicated reduced life expectancy in all patients. Thirty-eight patients (82.7%) had myocardial revascularization; 8 patients (17.3%) underwent valve operations. Postoperatively, all but 2 patients were free from complications. In-hospital mortality was 4.3% (2/46). One patient died of cardiogenic shock after combined aortic and mitral valve replacement; the second patient succumbed to pulmonary embolism after reoperative coronary artery bypass grafting. Actuarial survival at 3 years was 96%, and all patients reported a satisfactory quality of life. This experience suggests that cardiac operations in selected patients with previously treated cancer are safe and offer clinical improvement at a reasonable operative risk.

Autologous pericardial flap for prevention of reentry injury in cardiac reoperations.

Cardiac injury during sternal reentry to the heart is a rare but dangerous complication of cardiac reoperations. Positioning a pericardial flap between the heart and sternum at the time of the initial operation may consistently facilitate cardiac reoperation by providing a reliable plane of dissection and by reducing adhesion formation.

Subxiphoid approach for insertion of ICDs after previous median sternotomy.

To avoid the risks both of repeat median sternotomy and of thoracotomy, the modified subxiphoid approach was adopted for insertion of implantable cardioverter-defibrillators in 10 patients who had previously undergone cardiac operations via median sternotomy. Effective implantable cardioverter-defibrillator systems were implanted in all patients. There were no operative deaths and no hemorrhagic or respiratory complications. One patient underwent repositioning of a dislodged superior vena caval electrode, and an infected generator pocket developed in 1 patient. Early extubation was routine. Two patients were observed in the coronary care unit for the first postoperative night. Postoperative pain was controlled with oral analgesic agents. The subxiphoid approach is safe and effective, and it carries a substantially lower risk of complications than other techniques, even in this high-risk group of patients. By minimizing the need for admission to the intensive care unit, invasive monitoring, and prolonged ventilatory support, by reducing surgical complications, and by shortening the hospital stay, the subxiphoid approach saved an average of $3,295 per patient.

Changes in patients undergoing coronary artery bypass grafting: 1987-1990. Northern New England Cardiovascular Disease Study Group.

A prospective study of 7,590 consecutive patients undergoing isolated coronary artery bypass grafting at five medical centers in Maine, New Hampshire, and Vermont between July 1987 and December 1990 assessed changes in patient characteristics over time. Variables included age, sex, surgical priority, ejection fraction, left ventricular end-diastolic pressure, and left main coronary artery stenosis of 90% or greater. Trends were assessed for each variable and for predicted mortality using linear regression. The mean age increased significantly, whereas ejection fraction decreased. The percentage of urgent cases increased, whereas the elective cases became less frequent. No changes were observed in the percentages of emergent cases, female patients, or patients with severe left main coronary artery disease. The predicted in-hospital mortality rose significantly from 4.2% to 5.2% (p < 0.001). The increase in urgent surgical intervention was the most substantial contributor. Subgroup analyses did not support a systematic misclassification of elective patients into the urgent group. This study demonstrates that the characteristics of the cohort of patients undergoing coronary artery bypass grafting changed substantially from 1987 to 1990. These changes should be considered when interpreting surgical outcomes.

Results of a regional study of modes of death associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group.

BACKGROUND: It is well known that surgeon-specific in-hospital mortality rates for coronary artery bypass grafting vary, but this aggregate measure does not suggest specific opportunities for improvement. METHODS: We performed a regional prospective study of 8,641 consecutive patients undergoing isolated coronary artery bypass grafting by all of the 23 cardiothoracic surgeons practicing in northern New England during the study period. Mode of death was assigned by an end points committee using predetermined definitions. Surgeons were ranked according to risk-adjusted mortality rates and grouped in terciles, and cause-specific mortality rates were determined. RESULTS: The mortality rate was 3.3% in the lowest surgeon mortality tercile and 5.8% in the highest tercile. Fatal heart failure accounted for 80.0% of the difference in aggregate mortality rates, ranging from 1.9% in lowest surgeon mortality tercile to 4.0% in the highest tercile (p < 0.001). Rates of other causes did not differ significantly across surgeon mortality terciles. Differences in rates of fatal heart failure could not be explained by differences in preoperative left ventricular dysfunction or other patient characteristics. CONCLUSIONS: Most of the difference in observed mortality rates across surgeons is attributable to differences in rates of heart failure.

A hemodynamic comparison of Omniscience and Medtronic Hall aortic prostheses.

BACKGROUND AND AIMS OF THE STUDY: Preliminary reports have suggested hemodynamic disparities between single leaflet tilting disc prostheses. We tested the hypothesis that similarities in prosthetic design may not necessarily indicate hemodynamic equivalence. MATERIALS AND METHODS: In a retrospective analysis, we compared the functional characteristics of two single tilting disc (Omniscience and Medtronic Hall) prostheses implanted in the aortic position in 30 patients matched for valve size and left ventricular systolic function. RESULTS: Echocardiographic and Doppler analysis blinded to patient and valve type indicated similar quantitative left ventricular ejection fractions (64% +/- 6% for both) and cardiac outputs (4.8 +/- 1.2 vs. 4.6 +/- 1.2 l/min, p = 0.65) in the Onmiscience and Medtronic Hall groups, respectively. Transprosthetic instantaneous peak gradients were greater for Omniscience than for Medtronic Hall valves (44 +/- 8 vs. 35 +/- 11 mmHg, p < or = 0.02), as were the mean values (24 +/- 6 vs. 18 +/- 6 mmHg, p = 0.01). Even when 21 and 23 mm prostheses were analyzed separately to allow for unequal sewing ring diameters in the smallest valve sizes (Omniscience = 19 mm, Medtronic Hall = 20 mm), higher gradients were noted in the Omniscience prostheses. Effective orifice areas were smaller in the Omniscience than Medtronic Hall prostheses whether data from all prostheses (0.92 +/- 0.11 cm2 vs. 1.09 +/- 0.18 cm2, p < or = 0.05), or only data from 21 and 23 mm valves (0.94 +/- 0.11 cm2 vs. 1.10 +/- 0.18 cm2, p < 0.05) were included. Similarly, the dimensionless obstructive index, a parameter independent of left ventricular flow and annular size, was reduced in the Omniscience valves, indicating greater obstruction, whether all valves (0.31 +/- 0.04 vs. 0.36 +/- 0.07, p < or = 0.01) or only 21 and 23 mm valves (0.31 +/- 0.04 vs. 0.36 +/- .04, p < 0.001) were analyzed. CONCLUSION: Despite prosthetic design similarities, resting hemodynamic assessment indicates greater stenosis in Omniscience than Medtronic Hall valves when placed in the aortic position. The long term effects of these differences in terms of ventricular diastolic and systolic function and mass regression requires further evaluation.

Pharmaco-cholangiography with anticholinergic drugs in the dog.

The effect of atropine and pipenzolate bromide (PB) in different dosage levels was investigated in intravenous cholangiography with 0.6 ml/kg iodipamide infused over 30 minutes in six cholecystectomized dogs (20-36 kg) equipped with Thomas cannulas through which the common bile duct could be cannulated. Doses of 1 mg atropine and 20 mg PB, half the dose given intravenously just prior to the contrast agent and the other half with the iodipamide infusion, had the greatest effect in decreasing the bile flow (atropine-24% at 60, PB-23% at 30 minutes) and increasing the bile iodine concentration (atropine + 16%, PB + 14%). The biliary iodipamide excretion rate was not affected.

Current issues in multispecialty group practice: the Lahey Hitchcock Clinic merger experience.

The merger of two large not-for-profit multispecialty group practices in 1995 forced the two founding organizations into a deeper understanding of their heritage and mission. Common features of Lahey Hitchcock and similar organizations of their vintage are discussed. Issues addressed include governance, desirable leadership characteristics and growth, "incentivizing change," and workforce planning.

Looking at care from the inside out: a conceptual approach to geriatric care.

Today, managing care from the "outside in" is the predominant model for changing health care. The risk of this outside-in approach is that the health care system may lose sight of the people and communities for which it serves and cares. In this article, an "inside-out" model for viewing health care in a geriatric population is presented from the perspective of patients and providers, placing the provider in a proactive rather than reactive role. By focusing attention on the outcomes or value a patient is experiencing, providers are challenged to consider new ways of managing care.

Transforming patient feedback into strategic action plans.

Patients' perceptions provide valuable insight into areas for improvement and opportunities for strategic planning. Using both quantitative and qualitative research methods, the topics of what drives patient satisfaction, what delights patients, and what disappoints patients were examined. A case study approach was used to develop strategic recommendations for two market segments. For primary care patients, recommendations revolve around "provider caring" and "choice." For specialty patients, recommendations concentrate on "provider caring," "provider competence," and "office wait time."

Clinical process cost analysis: a promising tool for clinical improvement.

In today's environment, health care organizations are expected to provide the best possible care at the lowest possible cost. Neither aspect can be considered independently, but correlating the two with traditional systems of cost analysis is very difficult. This article presents a new method for linking costs to the process of care that also promises to be a powerful tool for clinical improvement and redesign.

Continually improving the health and value of health care for a population of patients: the panel management process.

Today's primary care provider faces the challenge of caring for individual patients as well as caring for populations of patients. This article offers a model--the panel management process--for understanding and managing these activities and relationships. The model integrates some of the lessons learned during the past decade as we have worked to gain an understanding of the continual improvement of health care after we have understood that care as a process and system.

Increasing the value of cardiac care: the Dartmouth approach.

UNLABELLED: A cardiac services team at Dartmouth-Hitchcock Medical Center (DHMC) launched multiple efforts to improve the quality and value of their services. The team developed a critical path for coronary artery bypass grafting (CABG) and tracked important clinical outcomes, such as mortality rates and wound complications. The team also studied the patient's view of the process. Staff used focus groups and surveys to distill the "voice of the customer" into six quality characteristics and developed methods to better involve patients in clinical decision making and evaluation of treatment efficacy. RESULTS: CABG mortality declined from 5.7 percent in 1992 to 2.7 percent in 1994, 16 months after the critical path was developed. Mean total intubation time for patients following open-heart surgery was reduced from 22 hours to 14 hours. Median postoperative length of stay decreased from seven days to six for elective CABG patients. The number of patients discharged in five days or less increased from 20 percent to 40 percent. Readmission to the hospital following discharge remained stable, despite the shorter length of stay.

Building a quality future.

How can healthcare leaders stay ahead of the curve? What can they do to see what the future holds and to secure a place for their employees and their organizations? They must begin doing today what they need to do to survive tomorrow. Furthermore, they must take wise action today or there will be no tomorrow. This article looks into the future and connects it with what we must see and do today. The article begins with a glimpse of the future and with an exploration of what people really want from health and healthcare. Next, it examines what appear to be inexorable megatrends and healthcare trends that are sweeping through society. This leads us to consider the quality and value imperatives that must be faced to secure a stake in the healthcare delivery. We will discuss a model for managing care for individual patients and small populations by focusing on where patients, populations, and caregivers meet--at the front lines of patients care. We conclude with some advice on how to build sustainable organizations by exploiting the inevitable.