Dr. Paul Kanaly, M.D. Cardiovascular Surgeon

Introduction

The National Quality Forum is a Washington, D.C., based foundation that brings together a broad spectrum of participants in health care. They try to formulate ideal goals for health care delivery. They have only the force of conscience and are not regulatory. They propose completely voluntary standards taken up by aggressive quality driven institutions that who are trying to raise the bar on quality outcomes. In cardiovascular surgery, they have suggested 21 measures that are outcomes important to consumers or processes that are vital to success in surgery. As a guide to quality, the outcomes measures are most helpful, but as a measure of a quality driven institution, the process measures are a surrogate for the depth and breadth of an organization around quality outcomes.

Processes and Outcomes in Cardiovascular Surgery: Accepting the national challenge for improvement.

The national quality forum has proposed 11 true outcomes and 10 process improvement measures to serve as quality goals for cardiovascular surgical goals around the nation. As previously stated, risk-adjusted mortality for coronary bypass is the gold standard of overall quality and is one of the lead outcomes in the NQF proposal. It is only partly a function of surgical skills; it is a composite result of all of the contributions of the various specialists and services a hospital offers during the hospital stay. It reports how many patients survive to hospital discharge. A different outcome is used to assess the actual skill of the surgeon and operating room team. It is a less well known outcome known as risk-adjusted operative mortality, or how often patients leave the operating room alive. Other outcomes include risk adjusted survival for various types of valve surgeries but very few institutions have sufficient case numbers to give reliable estimates of their true results (see power of estimates in editorial number 7).

There are also other supporting outcomes with adequate case counts that are a partial reflection of surgical skill. These are normally considered complication rates like the frequency of strokes, kidney failure rates, frequency of returning to the operating room for bleeding, and infection rates. Many of these can be influenced by the surgical team's attention to items of detail called process measures. It should be remembered that some of these are naturally occurring random events and are not preventable. To create as large a view of quality processes as possible there are 10 ancillary outcomes in the NQF voluntary reporting guidelines.

The specific list and a rationale for their inclusion are noted in the following discussion. The first is giving the patient medicines to rest his heart before surgery (beta blockers), the second is to give antibiotics to reduce infection, and third to discontinue them before resistance develops. Fourth is to make sure as many patients as possible get off the breathing devices (respirators) before they acquire infections. Fifth is the use of internal mammary arteries to assure long-term improvement from the operation. Next is to maintain long-term function of the bypasses. So sixth and seventh are the stipulations that all patients are to go home on aspirin and cholesterol lowering drugs. It is difficult to find any one measure that reflects the skill of the surgeon or the effectiveness of the supporting team. These 21 outcomes and processes together give a broad view of what is being accomplished and how hard the institution is working to provide a safe environment for patients. The INTEGRIS Heart Hospital has incorporated these outcomes as goals for improvement in the delivery of cardiac surgical care.

Conclusion

The medical environment is very complicated and there is no single measure or groups of measure that is a stand alone reflection of quality. However, there are clinical measures which are partly patient and disease based and partly care team based that can be implemented to reduce deaths and complications to a minimum. No one knows how low the rates of these adverse outcomes might fall but the idea is to take full advantage of today's technologies and achieve the best outcomes possible. By using composite outcomes and processes, the quality reports will then have a broad enough coverage of the elements of quality to truly help the consumer make informed decisions.

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