Article ; Online: Balancing quality and quaternary care imperative using a high-risk case review committee in adults.
Interactive cardiovascular and thoracic surgery
2022 Volume 35, Issue 6
Abstract: 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 ...
| Abstract | 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. |
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| MeSH term(s) | Adult ; Humans ; Advisory Committees ; Coronary Artery Bypass/adverse effects ; Quality Improvement ; Hospitals ; Surgeons ; Treatment Outcome ; Retrospective Studies |
| Language | English |
| Publishing date | 2022-10-31 |
| Publishing country | England |
| Document type | Journal Article |
| ZDB-ID | 2095298-3 |
| ISSN | 1569-9285 ; 1569-9293 |
| ISSN (online) | 1569-9285 |
| ISSN | 1569-9293 |
| DOI | 10.1093/icvts/ivac268 |
| Database | MEDical Literature Analysis and Retrieval System OnLINE |
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