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Article
March 20, 1996

A Regional Intervention to Improve the Hospital Mortality Associated With Coronary Artery Bypass Graft Surgery

Gerald T. O'Connor, PhD, DSc; Stephen K. Plume, MD; Elaine M. Olmstead; et al Jeremy R. Morton, MD; Christopher T. Maloney, MD; William C. Nugent, MD; Felix Hernandez Jr, MD; Robert Clough, MD; Bruce J. Leavitt, MD; Laurence H. Coffin, MD; Charles A. S. Marrin, MB,BS; David Wennberg, MD, MPH; John D. Birkmeyer, MD; David C. Charlesworth, MD; David J. Malenka, MD; Hebe B. Quinton; Joseph F. Kasper, ScD, MBA; Felix Hernandez, MD; Hebe Quinton; Deborah Carey-Johnson, RN, MS; Cynthia M. Downs, RN, MSN; Joseph J. Hessel, MD; Robert M. Hoffman, MD; Edward R. Johnson, MD; Helen McKinnon, RN; Cathy Mingo, RN, MS; Craig Pedersen, PA; Wendy Perkins, LPN; Matthew L. Rowe, MD; Katrina Sargent; Ted Silver, MD; Peter Ver Lee, MD; Craig Warren, CCP; Shelley Barber, RN; Pamela Brown, RN; Richard G. Brandenburg, PhD; Steve Colmanaro, PA; Walter D. Gundel, MD; Richard S. Jackson, MD; David Johnson, MD; Ann Laramee, RN; William C. Paganelli, MD, PhD; Diane Pappalardo, MHSA; Daniel S. Raabe, MD; Christopher Terrien, MD; Paul Vaitkus, MD; Matthew Watkins, MD; Virginia Beggs, MS, ARNP; William Burke, RCVT; Edward Catherwood, MD; Lawrence J. Daeey, MD; Candis Darcey, MS; Gordon Defoe, CCP; Thomas Dodds, MD; Mary Fillinger, MD; Bruce Friedman, MD; Bruce Hettleman, MD; Terry Kneeland, MPH; Elizabeth Maislen, ARNP; Nathaniel Niles, MD; Nancy J. O'Connor, MS; John Robb, MD; William Schults; William F. Sullivan; Jon Wahrenberger, MD; Beth Wolf; Yvon Baribeau, MD; Ann Becker, RN; Craig C. Berry, MD; Kevin Berry, MD; William A. Bradley, MD; S. Cuddy, RN; Robert C. Dewey, MD; Frank Fedele, MD; Louis I. Fink, MD; Erik J. Funk, MD; Alan E. Garstka, MD; Dan Halstead, CCP; Michael J. Hearne, MD; J. Beatty Hunter, MD; Alan D. Kaplan, MD; Peggy Lambert, RN; Patrick M. Lawrence, MD; Jeffery Lockhart, MD; Kathy McNeil, RN; Edward Palank, MD; M. Judith Porelle, RN; Donna Pulsifer, RN; Joanne Robichaud, RN; James Schnitz, MD; Shirley Shea, MN, JD, MD; Benjamin M. Westbrook, MD; Thomas P. Wharton, MD; Kirke W. Wheeler, MD; Dee White, RN; Robert B. Keller, MD; David C. Soule; Mary Abbott, MS, RN; Lawrence Adrian, PA; Warren D. Alpern, MD; Eric Anderson; Richard A. Anderson, MD; Linda Banister, RN; Claire Berg, RN; Seth Blank, MD; Carl E. Bredenberg, MD; Michael Brennan, PA; Linda Brewster, MSN; David Burkey, MD; Alice Cirillo, RN; Cantwell Clark, MD; Jane Cleaves, RN; Deborah Courtney, RN, MS; Joshua Cutler, MD; Desmond Donegal, MD; Pat Fallo, RN; Daniel Hanley, MD; Jane Kane, RN; Saul Katz, MD; Mirle A. Kellett Jr, MD; Robert Kramer, MD; Costas T. Lambrew, MD; F. Stephen Larned, MD; Chris A. Lutes, MD; Edward R. Nowicki, MD; John R. O'Meara, MD; Harold Osher, MD; Patricia Peasley, RN; Cathy Prouty, RN; Reed D. Quinn, MD; Dennis Redfield, RN; Karen Reynolds, MPH; Thomas Ryan Jr, MD; Jean Saunders, MSN, MPH; Alyce Schultz, RN, PhD; Susan Seekins, RN; Russell Stogsdill, PA; Paul W. Sweeny, MD; Karen Tolan, RN; Nancy Tooker, RN; Joan F. Tryzelaar, MD; Marie Turcotte, RN; Kathy Viger, RN; Cynthia Westlund, RN; Richard L. White, MD; Wanda Whittet, RN; Carol Zografos, CCP
Author Affiliations

From the Dartmouth-Hitchcock Medical Center, Hanover, NH (Drs O'Connor, Plume, Nugent, Marrin, Birkmeyer, Malenka, Ms Olmstead, and Mr Quinton); Maine Medical Center, Portland (Dr Morton); Catholic Medical Center, Manchester, NH (Drs Maloney and Charlesworth); Eastern Maine Medical Center, Bangor (Drs Hernandez and Clough); Fletcher Allen Health Care, Burlington, Vt (Dr Leavitt); Maine Medical Assessment Foundation, Belfast (Dr Wennberg); and Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH (Dr Kasper).
Writing Group; Eastern Maine Medical Center; Fletcher Allen Health Care; Dartmouth-Hitchcock Medical Center; Catholic Medical Center; Maine Medical Assessment Foundation; Maine Medical Center

JAMA. 1996;275(11):841-846. doi:10.1001/jama.1996.03530350023029
Abstract

Objective.  —To determine whether an organized intervention including data feedback, training in continuous quality improvement techniques, and site visits to other medical centers could improve the hospital mortality rates associated with coronary artery bypass graft (CABG) surgery.

Design.  —Regional intervention study. Patient demographic and historical data, body surface area, cardiac catheterization results, priority of surgery, comorbidity, and status at hospital discharge were collected on CABG patients in Northern New England between July 1, 1987, and July 31, 1993.

Setting.  —This study included all 23 cardiothoracic surgeons practicing in Maine, New Hampshire, and Vermont during the study period.

Patients.  —Data were collected on 15 095 consecutive patients undergoing isolated CABG procedures in Maine, New Hampshire, and Vermont during the study period.

Interventions.  —A three-component intervention aimed at reducing CABG mortality was fielded in 1990 and 1991. The interventions included feedback of outcome data, training in continuous quality improvement techniques, and site visits to other medical centers.

Main Outcome Measure.  —A comparison of the observed and expected hospital mortality rates during the postintervention period.

Results.  —During the postintervention period, we observed the outcomes for 6488 consecutive cases of CABG surgery. There were 74 fewer deaths than would have been expected. This 24% reduction in the hospital mortality rate was statistically significant (P=.001). This reduction in mortality rate was relatively consistent across patient subgroups and was temporally associated with the interventions.

Conclusion.  —We conclude that a multi-institutional, regional model for the continuous improvement of surgical care is feasible and effective. This model may have applications in other settings.(JAMA. 1996;275:841-846)

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