Continuous Quality Improvement in Coranary Artery Bypass Graft - CQI in CABG

Description:

The goal of the trial was to determine whether a low-intensity CQI intervention would improve the use of 2 treatments associated with improved outcomes in CABG.

Hypothesis:

CQI intervention would result in an increased use of the two specified treatments previously shown to be associated with reduced mortality for CABG.

Study Design

Study Design:

Patients Enrolled: 359 sites, 267,917 patients.
Mean Follow Up: 2 years.

Primary Endpoints:

Change in the site-level rate of beta-blocker use prior to CABG from pre to postintervention compared with the control arm. Change in the site-level rate of IMA grafts for CABG in patients over age 75 from pre to postintervention compared with the control arm.

Secondary Endpoints:

Change in the patient-level rate of beta-blocker use prior to CABG from pre to postintervention compared with the control arm. Change in the patient-level rate of IMA grafts for CABG in patients over age 75 from pre to postintervention compared with the control arm. Subgroup analysis by site volume.

Drug/Procedures Used:

Sites were randomized to CQI intervention for: 1) preoperative beta-blocker use (n=124), 2) internal mammary artery (IMA) grafts for CABG in patients over age 75 (n=120), or 3) control (n=115). An additional 40 sites were intervened for improvement in both measures. The intervention included identification of a surgeon leader for the site, a call to action letter to the physician, an action plan for the CQI, educational materials, and feedback throughout the intervention. There were 3 intervention periods.

Principal Findings:

Beta-blocker use preoperatively in CABG patients increased from 59.6% to 66.9% in the intervention arm and from 59.8% to 63.4% in the control arm (p=0.04). IMA graft use in the elderly changed from 77.0% preintervention to 85.7% postintervention, although the increase was not significantly different from the control arm (p=0.20), which increased from 78.3% to 83.7%. In a patient-level analysis, beta-blocker use prior to CABG increased significantly compared with the control arm over time (p=0.0006). IMA graft use in the elderly did not change significantly over time compared with the control arm (p=0.11). In a site-level subgroup analysis, lower volume sites had a significant improvement in both preoperative beta-blocker use (p=0.04) and IMA graft use in the elderly (p=0.02) with the intervention.

Interpretation:

Prior studies have shown a significant reduction in 30-day mortality with both beta-blocker use prior to CABG and use of IMA grafts in patients age >75 years. While these treatments have been shown to be effective, gaps in the use of such therapies remain. The present study showed that with a minimal intervention of physician leader identification and education, use of therapies previously shown to be effective can be increased on a national level. While the increase in use of IMA grafts in the elderly in the intervention arm compared with the control arm did not reach statistical significance, it is important to note that a sizable increase in this therapy was observed in the control arm, suggesting that factors other than the CQI intervention were changing the use of this practice.

References:

JAMA. 2003;290:49-56. Presented at AHA 2002, late breaking clinical trials.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Mammary Arteries, Coronary Artery Bypass


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