RESUMO
BACKGROUND: Coronary artery bypass graft (CABG) surgery is performed because of anticipated survival benefit, improvement in quality of life, or both. We performed this study to explore variations in clinical indications for CABG surgery among California hospitals and surgeons. METHODS: Using California CABG Outcomes Reporting Program data, we classified all isolated CABG cases in 2003-2004 as having "probable survival enhancing indications (SEIs)", "possible SEIs" or "non-SEIs." Patient and hospital characteristics associated with SEIs were examined. RESULTS: While 82.9% of CABG were performed for probable SEIs, the range extended from 68% to 96% among hospitals and 51% to 100% among surgeons. SEI rates were higher among patients aged >or= 65 compared with those aged 18-64 (Adjusted Odds Ratio [AOR] > 1.29 for age groups 65-69, 70-74 and >or= 75; all p < 0.001), among Asians and Native Americans compared with Caucasians (AOR 1.22 and 1.15, p < 0.001); and among patients with hypertension, peripheral vascular disease, diabetes, cerebrovascular disease and congestive heart failure compared to patients without these conditions (AOR > 1.09, all p < 0.001). Variations in indications for surgery were more strongly related to patient mix than to surgeon or hospital effects (intraclass correlation [ICC] = 0.04 for hospital; ICC = 0.01 for surgeon). CONCLUSION: California hospitals and surgeons vary in their distribution of indications for CABG surgery. Further research is required to identify the roles of market factors, referral patterns, patient preferences, and local clinical culture in producing the observed variations.
Assuntos
Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Prática Profissional , Adolescente , Adulto , Idoso , California , Doença da Artéria Coronariana/diagnóstico , Feminino , Hospitais , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Encaminhamento e Consulta , Índice de Gravidade de Doença , Análise de Sobrevida , Cirurgia Torácica , Adulto JovemAssuntos
Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Doença da Artéria Coronariana/prevenção & controle , Infarto do Miocárdio/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Terapia Combinada , Doença da Artéria Coronariana/cirurgia , Fidelidade a Diretrizes , Humanos , Infarto do Miocárdio/cirurgia , Guias de Prática Clínica como Assunto , RecidivaRESUMO
BACKGROUND: Avoiding cardiopulmonary bypass in coronary artery bypass grafting is thought to reduce early mortality and morbidity. METHODS: We used our prospective database to compare all patients having off-pump coronary surgery (n = 389) with those having on-pump coronary surgery (n = 2412) between March 15, 1995, and November 1, 2000. Patients were grouped by age (years) in decades (>90, 80-89, 70-79, 60-69, <60 years). The Northern New England risk model was applied. Thirty-two independent variables were entered into a stepwise logistic regression analysis with the end points being surgical mortality and postoperative stroke. RESULTS: Patients undergoing off-pump operations were older (70.9 +/- 12 vs 68.1 +/- 11 years; P <.001), and their Northern New England predicted risk was higher (11.9% +/- 13% vs 9.2% +/- 10%; P <.001). However, patients having on-pump bypass had significantly more bypass grafts constructed (3.3 +/- 0.8 vs 1.9 +/- 0.8; P <.001) and triple-vessel coronary artery disease (58% vs 28%; P <.001). There were no significant differences in postoperative mortality, stroke rate, complications, and length of stay between the groups. Logistic regression analysis did not show that cardiopulmonary bypass was a risk factor for either surgical mortality (odds ratio, 1.08; P =.83) or stroke (odds ratio, 1.59; P =.27). CONCLUSION: Off-pump coronary bypass did not reduce early mortality and morbidity. Early and late results should be compared in a prospective randomized study.