Key result
Surgery for low-risk CABG patients in a low-volume facility yielded 0.2% in-hospital mortality and 5% complications, versus 3.4% and 21% for mixed-risk patients in a fully equipped hospital.
Why the study?
Does risk-stratified triage of low-risk CABG patients to a limited facility location result in safe outcomes compared to mixed-risk patients treated in a fully equipped hospital?
Cohort (n=832)
Yes
Does risk-stratified triage of low-risk CABG patients to a limited facility location result in safe outcomes compared to mixed-risk patients treated in a fully equipped hospital?
Absolute Event Rate: 0.2% vs 3.4%
Careful risk stratification and selection of low-risk patients for CABG in a low-volume, limited-facility location yields excellent in-hospital survival and low complication rates.
Risk-stratified low-risk CABG in limited facilities may be feasible; leaves open selection bias versus true safety, needing prospective validation.
OBJECTIVE: We retrospectively investigated the short and mid-term outcome of non-emergent primary isolated coronary artery bypass graft (CABG) surgery in relation to risk stratification in the fully equipped university location (FE) and the low volume, limited facility location (LVLF) of our department. METHODS: Between September 1995 and December 1996, 832 patients were referred to our department to undergo a primary isolated CABG operation. The surgical team selected 482 patients (58%) as being at low-risk. These were treated in the LVLF hospital. The other 350 patients with mixed-risk were treated in the FE hospital. The selection consisted primarily of exclusion of patients with moderate or poor left ventricular function, severe COPD or renal impairment, from surgery in the LVLF location. Finally, the prognostic value of the EuroSCORE and the Parsonnet score was tested on our patient population. RESULTS: Overall in-hospital mortality was 1.6% (13 patients). One patient died in the LVLF group (0.2%) and 12 patients (3.4%) in the FE group. LVLF patients experienced less complications during the hospital period compared to the FE patients (5 versus 21%; P=0.0001). The Parsonnet risk model and the EuroSCORE risk model showed both a good relation with in-hospital mortality. After discharge, an increased risk of late mortality was observed up to 1 year postoperative in the FE group compared to the LVLF group (2.7 versus 0.5%; P=0.01). Risk factors for 5-year mortality were pre-operative renal impairment (blood creatinine >150 micromol/l) (hazard ratio (HR): 2.8; 95% confidence interval (CI): 1.4-5.5), diabetes (HR: 2.1; 95% CI: 1.3-3.5), impaired LVEF (HR: 1.9; 95% CI: 1.2-3.0), COPD (HR: 1.9; 95% CI: 1.1-3.5) and older age (HR: 1.07 per year; 95% CI: 1.01-1.10). Lipid-lowering therapy was a predictor of lower mortality at 5-years (HR: 0.5; 95% CI: 0.4-0.9). CONCLUSION: By careful decision making, selection of low-risk patients for a low volume and limited facility location resulted in excellent in-hospital survival with very low complication rates.
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VANDOMBURG et al. (2002) conducted a cohort in Non-emergent primary isolated coronary artery bypass graft (CABG) surgery (n=832). Surgery in a low volume, limited facility location (LVLF) vs. Surgery in a fully equipped university location (FE) was evaluated on In-hospital mortality. Surgery for low-risk CABG patients in a low-volume facility yielded 0.2% in-hospital mortality and 5% complications, versus 3.4% and 21% for mixed-risk patients in a fully equipped hospital.
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