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Advanced Technology for CABG
In the past decade, improvements in techniques, practices, and processes for coronary artery bypass grafting (CABG) have been abundant. The widespread use of more sophisticated surgical techniques and medical follow up means patients today are likely to have better outcomes from CABG than in the past (Circulation, August 31, 2004: 110(9);1168-1176).
Brigham and Women's Hospital offers newer techniques for coronary artery bypass procedures when appropriate, including:
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Annual CABG Procedure Volume
Procedure volume shows the number of cases performed per year by a surgeon, or at a particular facility, and may be used to denote clinical expertise. Numerous studies demonstrate that higher volume of a particular procedure, such as CABG, is significantly linked to better outcomes, according to The Leapfrog Group. The Leapfrog Group recommends 450 CABG procedures per year as the minimum volume standard in order to achieve better surgical outcomes (Annals of Surgery, October 2003: 238(4); 447-457).
Brigham and Women's Hospital performed 761 coronary artery bypass procedures in the 12-month period ending 6/30/07.
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Inpatient Mortality for CABG
The mortality rate (measured as a percentage) provides general information about the quality of care delivery, and can be an important quality indicator. However, some hospitals care for patients with a greater severity of illness and therefore may have a higher mortality rate. To help account for this, a risk-adjusted mortality rate is available, which takes into account the different types of patients that go to different hospitals. According to the most recent national data available from the Society of Thoracic Surgeons’™ (STS) National Database, the average risk-adjusted mortality rate for CABG was 1.8% (STS National Database ).
The STS risk-adjusted inpatient mortality rate for CABG at Brigham and Women's Hospital was 1.6% in 2006, which was better than the national average rate of 1.8%.
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30-Day All Causes Mortality for CABG
The "30-Day All Causes" mortality rate measures how well patients do both in and out of the hospital. Patient deaths from any cause (within 30 days after surgery) are included in this rate. When looking at mortality rates, it is important to remember that some hospitals care for sicker-than-average patients. To help account for this, a risk-adjusted mortality rate is available, which takes into account the different types of patients that go to different hospitals. According to the Society of Thoracic Surgeons’™ (STS) National Database, the US average risk-adjusted 30-day all causes mortality rate for CABG was 2.1% in 2006.
The STS risk-adjusted 30-day mortality rate for CABG at Brigham and Women's Hospital was 1.8% in 2006, which was better than the national rate of 2.1%.
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Percent of CABG Patients with Aspirin Prescribed at Discharge
Aspirin significantly reduces the risk of vein graft closure during the first postoperative year (Circulation, August 31, 2004: 110(9); 1168-1176). Individuals who are at increased risk for bleeding, however, may not be candidates for aspirin therapy because aspirin thins the blood, further increasing the risk of bleeding.
97% of CABG eligible patients who receive vein grafts at Brigham and Women's Hospital have aspirin prescribed at discharge. This measures includes only patients who had isolated (stand-alone) CABG procedures.
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Percent of CABG Procedures Using Internal Mammary Artery Grafts
Either veins or arteries may be used to bypass obstructed coronary arteries. With vein grafts, a section is usually taken from one or both legs. With artery grafts, the internal mammary artery (an artery in the chest) or a section of another artery, such as the radial artery near the wrist, may be used.
Use of the internal mammary artery (IMA) to bypass the left anterior descending (LAD) coronary artery has been considered the “gold standard” since 1985 (New England Journal of Medicine, January 2, 1986: 314 (1); 1-6 ). The National Quality Forum includes the use of IMA grafts as a standard in its National Voluntary Consensus Standards for Hospital Care: An Initial Performance Measure Set, published in 2003. The routine use of the left IMA for bypassing the LAD coronary artery with supplemental saphenous vein grafts (taken from a leg vein) to other coronary artery lesions (obstructions) is generally accepted as the standard grafting method (Circulation, August 31, 2004: 110(9); 1168-1176).
More recently, it has been established that the IMA may be safely used in more situations than previously thought, such as during emergency operations, in elderly patients, and in the presence of certain conditions such as severe left ventricular dysfunction (poor pumping ability of the left ventricle), chronic obstructive pulmonary disease with enlarged lungs, and an obstructed left subclavian artery (located under the collarbone) (Circulation, January 2001: 103(4); 507-512).
IMA grafts were used, when indicated, in 97% of all CABG procedures performed in 2006 at Brigham and Women's Hospital.
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Post-Operative Infection Rate for CABG
There are several ways to reduce the risk of wound infections in patients undergoing CABG. Antibiotic administration before surgery greatly reduces the risk of postoperative infection. Therapy should be administered just prior to the incision and again in the operating room if the operation exceeds 3 hours. Many centers closely monitor antibiotic timing in an effort to reduce the risk of surgical infection (Circulation. August 31, 2004; 110: 1168-1176). According to the most recent national data from the Society of Thoracic Surgeons’ National Database, the average post-operative infection rate for isolated CABG procedures in 2006 was 1.8% average for all U.S. hospitals, and 2.1% for large teaching hospitals like Brigham and Women's Hospital. (STS National Database).
The post-operative infection rate for CABG at Brigham and Women's Hospital was 1.8% in 2006, better than the 2.1% average rate of large teaching hospitals. This measure includes any type of post-operative infection, but only isolated (stand-alone) CABG procedures.
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Smoking Cessation
Smoking is a modifiable risk factor for heart disease. National guidelines strongly recommend smoking counseling to help people who smoke to quit smoking (National Cancer Institute Prevention and Cessation of Cigarette Smoking: Control of Tobacco Use). Tobacco Cessation Guidelines from the United States Department of Health and Human Services provide helpful tips on smoking cessation for patients.
At Brigham and Women's Hospital, 22% of eligible persons undergoing CABG received referrals for smoking cessation counseling prior to discharge in 2006. In 2007, a new policy was initiated to address smoking cessation counseling for all patients. We look forward to sharing the results of that effort with you as soon as data becomes available!
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Percent of CABG Patients Discharged with Statins
Statin therapy is treatment with a particular type of medication called a “statin,” used to lower cholesterol levels in the blood. According to the American College of Cardiology/American Heart Association practice guidelines for CABG surgery, “all patients undergoing CABG should receive statin therapy unless otherwise contraindicated” (Circulation, August 31, 2004: 110(9); 1168-1176). In addition, most patients who begin taking medication to lower blood lipid (a type of fatty substance) levels when discharged from the hospital after a CABG procedure continue to take the medication and are followed up in the primary care setting (American Journal of Critical Care, September 2004: 13(5); 411-415 ).
In 2006, 97% of CABG patients discharged from Brigham and Women's Hospital were given a prescription for a statin and/or other antihyperlipidemic (lipid lowering) medication.
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Percent of CABG Patients Receiving Prophylactic Antibiotics Within One Hour Prior to Surgical Incision
Surgical site infections affect approximately 500,000 persons per year according to a Centers for Disease Control and Prevention report. Numerous factors such as age and general health status of persons undergoing surgery can affect rates of infection at any given hospital. Because there are numerous drug-resistant bacteria today, it is important to use antibiotics sparingly. The goal for antibiotic use prior to surgical procedures is to prevent surgical site infections and thereby reduce overall antibiotic use.
Research exploring the practice of giving pre-operative antibiotics appeared in the American Journal of Surgery(June, 1996; 171: 548-552), and demonstrated the importance of antibiotic timing for prevention (prophylaxis) of surgical infections. According to the Joint Commission on Accreditation for Healthcare Organization's Surgical Infection Prevention Core Performance Measures, patients undergoing CABG should receive a prophylactic antibiotic within one hour prior to the surgical incision being made.
94% of Brigham and Women's Hospital’s CABG patients received prophylactic antibiotics within one hour prior to the surgical incision in the 12 month period ending 6/30/07.
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Quality Measures for Other Cardiovascular Procedures & Diseases:
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