Quality of Care/Patient Safety

Physician-led, low-key quality improvement efforts can improve care for patients undergoing coronary bypass surgery

A new study found improved care for patients undergoing coronary artery bypass graft (CABG) surgery as a result of a continuous quality improvement (CQI) effort by cardiac surgeons at hospitals across the United States. Using the platform of their adult National Cardiac Database, the Society of Thoracic Surgeons invited cardiac surgeon leaders at these hospitals to lead the way for improving CABG care.

This effort was supported in part by the Agency for Healthcare Research and Quality (HS10403). T. Bruce Ferguson, Jr., M.D., and other Society leaders provided cardiac surgeons and their associates at hospitals randomized to CQI efforts with national benchmarks for CABG care and site-specific feedback.

Between January 2000 and July 2002, the researchers randomized 359 academic and non-academic hospitals (treating 267,917 patients using CABG surgery) to a control group or to one of two CQI groups: preoperative beta-blockade therapy or internal mammary artery (IMA) grafting in patients 75 years or older. Beta-blockade therapy is protective in most patients with cardiovascular disease, but the benefit of its use in CABG patients were unproven at the beginning of the trial. Some surgeons are reluctant to use it in CABG surgery because it can weaken the strength of cardiac muscle contractions. In addition, this therapy requires significant collaboration between the surgical team and cardiology and anesthesiology colleagues to make sure the CABG patients are on the medication. Use of IMA grafting improves survival, but its use in patients over age 75 years was controversial at the trial inception because of a presumption of increased procedural risk (prolonged ventilation, preoperative bleeding) and lack of long-term survival benefit in these elderly patients.

From January 2000 to July 2002, use of both care process measures increased nationally (beta-blockade from 60 to 66 percent and IMA grafting from 78 to 83 percent). Use of beta-blockade increased more significantly at beta-blockade intervention sites versus control sites (7.3 vs. 3.6 percent). Use of IMA grafting also increased more at IMA intervention sites versus control sites (8.7 vs. 5.4 percent). Importantly, both interventions had more impact at lower CABG volume sites, perhaps because the Society sponsorship helped to make CQI materials and leadership available to these smaller centers.

See "Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: A randomized controlled trial," by Dr. Ferguson, Eric D. Peterson, M.D., M.P.H., Laura P. Coombs, Ph.D., and others, in the July 2, 2003, Journal of the American Medical Association 290(1), pp. 49-56.

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