Cutting bypass variation, collaborative saves lives
New England group boasts lowest mortality rates
When surgeons in northern New England first learned about their varying mortality rates after bypass surgery, they didn’t trust the numbers. They felt sure the differences were due to patient characteristics — that surgeons with higher mortality rates treated sicker patients.
Five hospitals and their chiefs of cardiac surgery began collecting data, and what they learned startled them.
"There are different processes of care that create different results," says Gerald O’Connor, PhD, DSc, associate director of the Center for the Evaluative Clinical Sciences at Dartmouth Medical School in Hanover, NH. "These are real differences."
Most importantly, the New England surgeons did something about the disparities they discovered. They studied the data, compared processes of care, and learned about the principles of continuous quality improvement. Mortality rates dropped by 24%.1
The Northern New England Cardiovascular Disease Study Group, which continues to meet three times a year and collect data continuously, has become a model of how physicians can work together to reduce variation and improve care.
The surgeons’ original data came from mortality reports of the Health Care Financing Administration, and their intent was to disprove the variation.
"Nobody really was starting out to change the world," says O’Connor, a leader of the consortium since its inception in 1987. "We started out trying to do something simple. But there was great leadership by the five chiefs of cardiac surgery at the time. Those folks are all still with us now."
Data tell why patients die
Information became a powerful tool for the study group. Although individual surgeons may have only three or four deaths a year out of 140 bypass cases, the aggregate of 25 cardiothoracic surgeons produces valuable data.
The study group receives about 8,000 data collection forms a year and maintains a database of close to 80,000 procedures, including bypass, valve procedures, and coronary angioplasty. The group now includes 31 interventional cardiologists, administrators, nurses, anesthesiologists, perfusionists, and scientists at six institutions in Massachusetts, New Hampshire, Maine, and Vermont.
The physicians collect extensive data on every case, and the study group produces reports three times a year with comparisons of the surgeon’s patients, the hospital as a whole, and the region. (See copy of the cardiac bypass data collection form, inserted in this issue.)
Detailed information has enabled the surgeons to analyze what may cause differences in mortality. Why are patients dying?
"Low cardiac output syndrome explained 80% of variability across surgeons,"2 says O’Connor.
Further analysis showed that "most of the people who died of low output failure went into the operation with normally pumping hearts," explains David Malenka, MD, a cardiologist and associate professor of medicine at Dartmouth Medical School.
"That means we’re having trouble preserving the myocardium, keeping it alive," he says. The study group identified aspects of care that were likely to contribute to that problem and is investigating what part of the operation needs to be improved, he says.
So while a recent study showed that northern New England has the lowest mortality rate in the country following bypass surgery (tied with New York state, which also has a data registry), O’Connor and his colleagues aren’t satisfied.
"We’re improving at twice the national average," he says. "We could feel pretty good about that except that we feel half the people who die now don’t need to die."
Improving care and saving lives didn’t come from data feedback alone. With the help of Donald Berwick from the Institute for Healthcare Improvement, surgeons learned about the steps of continuous quality improvement.
Next, Joseph F. Kasper, ScD, an aerospace engineer turned health care improvement consultant guided the group in improvement techniques used in business. Rather than benchmarking against a "best practice" hospital, each hospital’s care team (including the surgeon, perfusionist, OR nurse, and others) visited one other facility simply to observe. "All of the hospitals and surgeons were courageous," says Kasper. "It took a lot of courage for the surgeons to say, Come in and see what I do.’
"I asked for everyone to get back to me as quickly as they could with thoughts and observations about what was different from their home institution, what was the same, what they’d like to have," he recalls. "The reporting that came back was incredibly information dense. They saw an awful lot."
Although the teams weren’t specifically looking for the "best," it was easy to see some elements contributed to better outcomes, says Kasper. "The institutions that appeared to have the best outcomes were the institutions where there was clear communication, where it was clear who owned what component of the process," he says. "[They were] institutions where each operation was done the same way every time, over and over again."
The teams also learned from the visitors’ comments. "At Dartmouth, when the four other centers visited us, three of them said, You folks don’t have a process for postoperative care,’" recalls O’Connor. "We thought we did, but nobody else could see it. Everybody [on the bypass team] had their own process. It looked fine from the inside, but no one could see it from the outside."
Dartmouth now has a clinical pathway for postoperative bypass care.
Ultimately, the data help surgeons and cardiologists when they talk to patients about the risks and benefits of surgery or angioplasty. Instead of citing the medical literature, physicians can say, "Given our experience at Dartmouth, here’s what you can expect," notes Malenka.
As the study group expands its focus, it also is moving into preventive care issues. "We are trying to launch an effort across all the institutions that revascularize patients to put into place some kind of process of care to try to ensure that by one year after revascularization that all patients are at goal for LDL [of 100 or less]," says Malenka.
"We know that lower cholesterol makes a difference in outcomes," he says. "We keep seeing these patients over and over again. Prevention is where it’s at."
Meanwhile, with a grant from the American Heart Association, the study group is trying to spread its success to other parts of the country. Similar efforts have already emerged in Minnesota, Virginia, and the Veterans Administration Medical System. In addition, the Society of Thoracic Sur-geons is working with the study group on pilot studies, says O’Connor.
"What worked for five hospitals in northern New England might work very well as an engine of change for other hospitals [and surgeons] that want to cooperate with each other," says Kasper. "The variation across the country is even greater than [it was] within northern New England."
References
1. O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. JAMA 1996; 275:841-846.
2. O’Connor GT, Birkmeyer JD, Dacey LJ, et al. Results of a regional study of modes of death associated with coronary artery bypass grafting. Ann Thorac Surg 1998; 66:1,323-1,328.
2. In addition to data feedback, a critical
aspect of the Northern New England
Cardiovascular Disease Study Group involved:
A. identifying best practices
B. visiting other facilities to observe
their processes of care
C. developing protocols for all
participating facilities
D. developing a report card for
consumers
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