Hospital Disease-Specific Care Certification Programs and Quality of Care: A Narrative Review.

BACKGROUND: Disease-specific care certification (DSCC) programs have been developed to improve the quality and performance of programs or services that may be based within or associated with a hospital or other health care organization. A comprehensive summary of evidence for DSCC programs and their reported effect on the quality of care was prepared in a narrative review, the first of its kind on this topic. METHODS: A systematic search was performed to identify articles that reported about DSCC. Any article that reported DSCC and certifications, published between 2003 and August 2015 (with an update in March 2016), and conducted in the United States was included. Databases searched included PubMed, MEDLINE, and CINAHL. RESULTS: The articles were reviewed in terms of four topics: early development of DSCC, the journey toward DSCC, the relationship between DSCC and organizing process of care, and the relationship between DSCC and outcomes of care. Fifteen articles noted a positive relationship between DSCC programs and quality of care, only 6 of which reported empirical data. Therefore, a systematic review and meta-analysis were not warranted. Only 3 articles involved use of sophisticated statistical modeling with adequate control variables to investigate the effect of DSCC, which makes it difficult to conclude that the change in hospitals' or patients' outcomes were related to the certification. CONCLUSIONS: The majority (13) of the articles focused on Joint Commission DSCC, with the remaining assessing Society of Cardiovascular Patient Care "accreditation" (certification). Only two studies, each study using a cross-sectional design, that empirically examined the relationship between DSCC and outcomes of care-mortality of care and readmission. More research studies are needed to evaluate the effectiveness of DSCC programs in improving outcomes of care, particularly patient-centered outcome measures, such as patient satisfaction and self-care.

Depression is associated with increased mortality 10 years after coronary artery bypass surgery.

OBJECTIVE: To determine if depression is independently associated with cardiac and all-cause mortality 10 years after coronary artery bypass graft (CABG) surgery. Although many studies have examined the relationship of depression and mortality in patients with myocardial infarction, there is less understanding of the relationship between depression and long-term mortality after CABG surgery. METHODS: In a prospective study, we collected data on 309 patients hospitalized after CABG surgery. Before discharge, patients were assessed for depression using the Diagnostic Interview Schedule and the Beck Depression Inventory (BDI). Subsequently, mortality data were obtained from the National Center for Health Statistics and supplemented with phone interviews. RESULTS: Sixty-three (20%) patients met modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depressive disorder (MDD) and 87 (28%) had BDI scores of ≥10, indicating elevated depressive symptoms. Time-to-event or last follow-up phone contact ranged from 9 days to 11.5 years (median, 9.3 years). The overall mortality rate was 37.9% (117 of 309), with 20.1% (62 of 309) due to cardiac causes. Cox proportional hazard modeling showed that age (hazard ratio [HR], 1.04; p = .005), left ventricular ejection fraction (EF) (EF <0.35 [HR], 3.9; p < .001; EF, 0.35-0.49 [HR], 1.9; p = .03), and MDD (HR, 1.8; p = .04) were independent predictors of cardiac mortality. The BDI and the cognitive-affective symptoms subset of BDI symptoms were also predictors of cardiac mortality. Age, EF, and diabetes predicted all-cause mortality, but MDD did not. CONCLUSIONS: Depression, assessed both in structured interview and by BDI, was significantly associated with elevated cardiac mortality 10 years after CABG surgery.

Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques.

BACKGROUND: Minimally invasive coronary artery bypass grafting (miniCABG) decreases in-hospital morbidity versus traditional sternotomy CABG. We performed a prospective cohort study (NCT00481806) to assess the impact of miniCABG on costs and metrics that influence quality of life after hospital discharge. METHODS: One hundred consecutive miniCABG cases performed using internal mammary artery (IMA) grafting +/- coronary stenting were compared with a matched group of 100 sternotomy CABG patients using IMA and saphenous veins, both treating equivalent number of target coronaries (2.7 vs. 2.9), off-pump. We compared perioperative costs, time to return to work/normal activity, and risk of major adverse cardiac/cerebrovascular events (MACCE) at 1 year: myocardial infarction (elevated troponin or EKG changes), target vessel occlusion (CT angiography at 1 year), stroke, or death. RESULTS: For miniCABG, robotic instruments and stents increased intraoperative costs; postoperative costs were decreased from significantly less intubation time (4.80 +/- 6.35 vs. 12.24 +/- 6.24 hours), hospital stay (3.77 +/- 1.51 vs. 6.38 +/- 2.23 days), and transfusion (0.16 +/- 0.37 vs. 1.37 +/- 1.35 U) leading to no significant differences in total costs. Undergoing miniCABG independently predicted earlier return to work after adjusting for confounders (t = -2.15; P = 0.04), whereas sternotomy CABG increased MACCE (HR, 3.9; 95% CI, 1.4-7.6), largely from lower target-vessel patency. CONCLUSIONS: MiniCABG shortens patient recovery time, minimizes MACCE risk at 1 year, and showed superior quality and outcome metrics versus standard-of-care CABG. These findings occurred without increasing costs and with superior target vessel graft patency.

Patients' Perceptions of a Game About Warfarin and Vitamin K: A Pilot Study.

BACKGROUND: Digital games to promote healthy behaviors are rapidly expanding in the healthcare industry. One area where health game can be useful is in educating patients about oral anticoagulants such as warfarin. The goal of this pilot study was to develop a game about warfarin and vitamin K interactions and evaluate its usability among adult patients receiving warfarin therapy. SUBJECTS AND METHODS: The game was developed by an interdisciplinary team. The content of the game was based on published evidence-based practice about anticoagulation education. Kolb's experiential learning theory served as the theoretical foundation of the game, which we developed in Flash and Actionscript 2(®) (Adobe Systems, San Jose, CA) programming and scripting languages, and it is playable on various platforms, including Windows and Macintosh, via Internet Explorer, Mozilla Firefox, and Safari Web browsers. Twenty patients were surveyed using a 7-point Likert scale to evaluate their experience on the Perceived Health Web Site Usability Questionnaire (PHWSUQ). The PHWSUQ measures satisfaction, ease of learning the site, and usefulness. Possible responses ranged from 1 (very unsatisfied) to 7 (very satisfied) and from strongly disagree (1) to strongly agree (7). RESULTS: The overall mean score on the PHWSUQ was 53.6 out of 70 (SD, 11.3), or 76.6 percent. The mean scores for "satisfaction," "ease of use," and "usefulness" subscales were 80.2 percent, 71.2 percent, and 77.4 percent, respectively. CONCLUSIONS: The findings suggest that patients were satisfied with the game, which indicates that adult patients on warfarin are open to game use as an educational tool to learn health information.

Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass.

OBJECTIVES: Less-invasive options are available for surgical treatment of multivessel coronary artery disease. We hypothesized that stenting combined with grafting of the left anterior descending artery with the left internal thoracic artery through a minithoracotomy (hybrid procedure) would provide the best outcome. METHODS: Patients with equivalent numbers of coronary lesions (2.8 +/- 0.4) underwent either hybrid (n = 15) or off-pump coronary artery bypass through a sternotomy (n = 30). Early and 1-year outcomes were compared. Blood drawn from the aorta and coronary sinus immediately postoperatively was analyzed for activation of coagulation (prothrombin fragment 1.2 and activated Factor XII), myocardial injury (myoglobin), and inflammation (interleukin 8) by using an enzyme-linked immunosorbent assay. Target-vessel patency was determined by means of computed tomographic angiographic analysis. RESULTS: The hybrid procedure was associated with significantly shorter lengths of intubation and stays in the intensive care unit and hospital and perioperative morbidity (P < .05). Intraoperative costs were increased but postoperative costs were reduced for the hybrid procedure compared with off-pump coronary artery bypass through a sternotomy. As a result, overall total costs were not significantly different between the groups. After adjusting for potential confounders, assignment to the hybrid group was an independent predictor of shortened time to return to work (t = -2.12, P = .04). Patient satisfaction after the hybrid procedure, as judged on a 6-point scale, was greater versus that after off-pump coronary artery bypass through a sternotomy. Finally, the hybrid procedure showed significantly reduced transcardiac gradients of markers of coagulation, myocardial injury, and inflammation and a trend toward significant improvement in target-vessel patency. CONCLUSIONS: Perhaps because of reduced myocardial injury, inflammation, and activation of coagulation, patients undergoing the hybrid procedure had better perioperative outcomes and satisfaction, with excellent patency at 1 year's follow-up. These promising preliminary findings warrant further investigation of this procedure.

Aprotinin shows both hemostatic and antithrombotic effects during off-pump coronary artery bypass grafting.

BACKGROUND: Hemostatic drugs are widely thought to be unnecessary and potentially detrimental in off-pump coronary artery bypass graft surgery (OPCABG), despite well-established use in on-pump surgery. In a randomized, prospective OPCABG trial, we assessed efficacy and safety of aprotinin through a comprehensive assessment of graft patency and hematologic function. METHODS: Sixty patients were randomly assigned to full-dose aprotinin or placebo. Heparin was titrated to a kaolin-based activated clotting time of greater than 300 seconds. Exclusionary criteria included creatinine greater than 2 mg/dL, conversion to on-pump CABG, and preoperative GPIIb/IIIa inhibition. Hematologic assessments were obtained preoperatively, at the end of surgery, and on days 1 and 3: mean platelet volume, thrombin generation (prothrombin fragment 1.2 assay), and aspirin resistance using a modified thrombelastography, whole blood aggregometry, 11-dehydro-thromboxane B2 levels, and flow cytometry. Thrombotic events were defined as postoperative myocardial infarction by electrocardiography or elevated troponin I, clinical stroke by examination and head computed tomography, and bypass graft failure by multichannel computed tomography angiography on day 5. RESULTS: Aprotinin was associated with a significant reduction in intraoperative and postoperative blood loss compared with placebo but had no effect on transfusion rates. Patients treated with aprotinin had significantly fewer thrombotic events (3% versus 23%, p < 0.05, Fisher's exact test) and less postoperative aspirin resistance (20% versus 46%, respectively, p < 0.05, Fisher's exact test). Postoperative prothrombin fragment 1.2 level was reduced by aprotinin use. CONCLUSIONS: Aprotinin reduced perioperative bleeding after OPCABG. Preserved aspirin sensitivity in the aprotinin group may explain the observed reduction in thrombotic events and might be related to the suppression of perioperative and transmyocardial thrombin formation.