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In-Hospital Death After Coronary Artery Bypass Grafting: Preventable or Not?

An implicit chart review and analysis highlights the importance of asking this question, even in institutions with low all-cause mortality rates.

To improve quality of care, researchers in Ontario assessed the relation between publicly reported in-hospital mortality after coronary artery bypass grafting surgery and the proportion of such deaths deemed preventable. Data were culled from medical records of 40 deaths that occurred at each of eight hospitals (plus 27 deaths that occurred at a cardiac surgery center) participating in a surgical registry from April 2000 through March 2002. Charts were abstracted by trained nurses and reviewed by two experienced cardiac surgeons.

Among 347 deaths reviewed, 52 (15%) were judged preventable by both reviewers, and an additional 59 (17%) were deemed preventable by one of the two and by a third independent reviewer. Quality-of-care problems identified included inappropriate timing of surgery, inappropriate decision to operate, deviation from standard perioperative management, and missed evidence of preventability. No correlation was found between the institutions’ risk-adjusted all-cause mortality rates (range, 1.3%–3.1%) and their proportions of preventable deaths. Preventable death was identified more frequently in patients with a lower predicted operative risk than in those with a higher predicted risk.

Comment: Despite relatively low rates of all-cause mortality in these high-volume centers, about one third of in-hospital deaths after CABG were judged preventable by surgeon reviewers. Detailed adverse-event audits may enable more targeted quality improvement than all-cause mortality comparisons, which can ignore quality-of-care problems that exist across all or most hospitals in a region. As noted in an accompanying editorial, a systematic, comprehensive, adverse-event assessment via implicit review should be part of every hospital’s quality improvement efforts.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology June 18, 2008

Citation(s):

Guru V et al. Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates. Circulation 2008 Jun 10; 117:2969.

• Original article (Subscription may be required)
• Medline abstract (Free)

Krumholz HM. Seeking better outcomes in coronary artery bypass grafting: Lessons from past experience. Circulation 2008 Jun 10; 117:2963.

• Original article (Subscription may be required)
• Medline abstract (Free)