Quality improvement program decreases mortality after cardiac surgery

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CTSNet classification: 2, 4

To the Editor:

We read with interest the article by Stamou and colleagues,¹ who showed that a quality improvement program decreased mortality after cardiac surgery in a large cohort, using a risk-adjusted methodology. Most importantly, outcomes improved mostly due to fewer cardiac-related deaths. Moreover, there was a lower relative decline in mortality among patients with diabetes than among those without diabetes, indicating the influence of patient individual factors on outcomes. Finally, they conclude that future quality improvement programs should focus on high-risk patients, which they misclassified as those with diabetes. It would be more appropriate if the authors provide information about severity scores widely available in the literature instead.

Quality improvement programs follow institutional or regional/national initiatives. Although the latter are important to monitor and foster improvement of outcomes, the former are fundamental to develop a sustained and cost-effective system locally. Because processes of care vary widely among cardiac surgery programs, there are no “recipes” that can be universally applied, due to system-based particularities. Core components of the quality improvement program described by Stamou and colleagues¹ are important, but such programs should be presented in a problem-based approach. It would be interesting to know the problems responsible for the initial unfavorable outcomes. That would potentially guide other cardiac surgery centers in implementing similar programs. Moreover, information about the financial impact (investment and savings) of those programs is crucial, particularly in times of world economic crisis.

In Brazil, results of cardiac surgery are not as good as in developed countries.² Reasons are multiple, but certainly include different patient profiles, social problems, limited resources, and poorly developed hospital operating systems and integrated patient care. In our center, multimodal strategies were added, aiming for team building and a more organized and integrated hospital system. No substantial resource investment was necessary. The impact of those strategies was analyzed by multivariate logistic regression (unpublished data). Risk-adjusted hospital mortality declined (from 11.5% to 3.6%, P = .003) after these strategies were implemented. Survival benefit was particularly evident in high-risk patients (Euroscore > 7), in which operations performed prior to the quality program were independently associated with greater mortality (odds ratio = 4.8; 95% confidence interval 1.6–17.4; P = .005). There was no difference in low-risk patients (Euroscore < 6). Therefore, multimodal strategies in our center remarkably improved the outcomes of high-risk cardiac surgery patients, as opposed to low-risk patients, which are probably less dependent on the system.

Quality in cardiac surgery is ultimately a surgeon's responsibility and should be part of the training of young surgeons. We would like to congratulate Dr Stamou and colleagues on their excellent work on an extremely important subject.

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References 

1. Stamou SC, Camp SL, Stiegel RM, Reames MK, Skipper E, Watts LT, et al. Quality improvement program decreases mortality after cardiac surgery. J Thorac Cardiovasc Surg. 2008;136:494–499
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2. Ribeiro ALP, Gagliardi SPL, Nogueira JLS, Silveira LM, Colosimo EA, Nascimento CAL. Mortality related to cardiac surgery in Brazil, 2000–2003. J Thorac Cardiovasc Surg. 2006;131:907–909
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