Coronary artery bypass graft surgery care globalization: The impact of national care on fatal and nonfatal outcome

doi:10.1016/j.jtcvs.2006.12.031

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Coronary artery bypass graft surgery—care globalization: The impact of national care on fatal and nonfatal outcome

Elisabeth Ott, MD^a^,c^,_*, C. David Mazer, MD^a^,d, Iulia C. Tudor, PhD^b, Linda Shore-Lesserson, MD^a^,e, Stephanie A. Snyder-Ramos, MD^a^,f, Barry A. Finegan, MB^a^,g, Patrick Möhnle, MD^a^,c, Charles B. Hantler, MD^a^,h, Bernd W. Böttiger, MD^a^,f, Ray D. Latimer, MA, MBBS, FRCA^a^,i, Warren S. Browner, MD, MPH^j, Jack Levin, MD^a^,k, Dennis T. Mangano, PhD, MD^b Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation^_*

^a Multicenter Study of Perioperative Ischemia Research Group, San Bruno, Calif
^b Ischemia Research and Education Foundation, San Bruno, Calif
^c Departments of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany
^d St Michael’s Hospital, University of Toronto, Toronto, Canada
^e Montefiore Medical Center, New York, NY
^f University of Heidelberg, Germany
^g University of Alberta, Edmonton, Alberta, Canada
^h Washington University School of Medicine, St Louis, Mo
ⁱ Papworth Hospital, Cambridge, United Kingdom
^j California Pacific Medical Center Research Institute, San Francisco, Calif
^k Department of Laboratory Medicine, University of California School of Medicine, San Francisco, Calif.

Received for publication April 26, 2005; revisions received November 8, 2006; accepted for publication December 6, 2006.

^_* Address for reprints: Elisabeth Ott, MD, c/o Editorial Office, The Ischemia Research and Education Foundation, 1111 Bayhill Drive, Suite 480, San Bruno, CA 94066. (Email: diane{at}iref.org).

Objective: In an international, prospective, observational study, we contrastedadverse vascular outcomes among four countries and then assessedpractice pattern differences that may have contributed to theseoutcomes.

Methods: A total of 5065 patients undergoing coronary artery bypass graftsurgery were analyzed at 70 international medical centers, andfrom this pool, 3180 patients from the 4 highest enrolling countrieswere selected. Fatal and nonfatal postoperative ischemic complicationsrelated to the heart, brain, kidney, and gastrointestinal tractwere assessed by blinded investigators.

Results: In-hospital mortality was 1.5% (9/619) in the United Kingdom,2.0% (9/444) in Canada, 2.7% (34/1283) in the United States,and 3.8% (32/834) in Germany (P = .03). The rates of the compositeoutcome (morbidity and mortality) were 12% in the United Kingdom,16% in Canada, 18% in the United States, and 24% in Germany(P < .001). After adjustment for difference in case-mix (usingthe European System for Cardiac Operative Risk Evaluation) andpractice, country was not an independent predictor for mortality.However, there was an independent effect of country on compositeoutcome. The practices that were associated with adverse outcomeswere the intraoperative use of aprotinin, intraoperative transfusionof fresh-frozen plasma or platelets, lack of use of early postoperativeaspirin, and use of postoperative heparin.

Conclusions: Significant between-country differences in perioperative outcomeexist and appear to be related to hematologic practices, includingadministration of antifibrinolytics, fresh-frozen plasma, platelets,heparin, and aspirin. Understanding the mechanisms for theseobservations and selection of practices associated with improvedoutcomes may result in significant patient benefit.

Abbreviations and Acronyms CABG = coronary artery bypass graft;EuroSCORE = European System for Cardiac Operative Risk Evaluation

Surgery for Acquired Cardiovascular Disease

Coronary artery bypass graft surgery—care globalization: The impact of national care on fatal and nonfatal outcome