Balancing quality and quaternary care imperative using a high-risk case review committee in adults.

Autor:	Ibrahim M; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA., Acker A; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA., Weiss S; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA., Lawrence K; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA., Ottemiller S; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA., McGarvey J; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA., Epler M; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA., Williams M; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA., Szeto WY; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA., Acker M; Division of Cardiovascular Surgery, Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA.
Jazyk:	angličtina
Zdroj:	Interactive cardiovascular and thoracic surgery [Interact Cardiovasc Thorac Surg] 2022 Nov 08; Vol. 35 (6).
DOI:	10.1093/icvts/ivac268
Abstrakt:	Objectives: Quaternary care centres have an imperative to serve as hospitals of last resort and must also meet professional quality targets. We developed a high-risk committee (HRC) to evaluate cases meeting pre-defined predicted risk cut-offs as a part of an overall quality improvement drive. Methods: We describe the structure, outcomes and effects of the Penn HRC. Using propensity-matching, we investigated whether the committee modifies or screens risk. We used multivariable analysis to examine the impact of unmeasured variables on clinical outcomes in this cohort. Results: Institutional predicted and observed mortality had already been in decline prior to HRC institution in 2017, due to a multi-faceted quality improvement initiative. Between 2017 and 2020, the HRC discussed 205 patients with a median predicted risk of mortality of 10.6% (range 0.4-66%). Coronary artery bypass grafting was the most commonly presented operation. A total of 155 patients underwent operation (risk 10.3%), 12 had surgery deferred for optimization (risk 6%), 50 had surgery declined (risk 11.7%) and 12 patients had a deferred decision for further investigation. Overall 30-day survival was 86% for the entire cohort and 89% for operated patients. A matched analysis of similar patients prior to and following the HRC showed that the HRC did not directly modify outcomes. Most patients had better than expected survival (observed:expected mortality < 1). Predicted risk did not predict 30-day mortality among this high-risk cohort. Conclusions: HRCs serve as an important element in quality improvement by encouraging a thoughtful approach and channelling the collective experience of a group of senior surgeons. It may improve patient selection by identifying a cohort with extremely poor survival, while allowing safe operation with acceptable outcomes among a group with very high operative risk. (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)
Databáze:	MEDLINE
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