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Outcomes of Concomitant Aortic Valve Replacement and Coronary Artery Bypass Grafting at Teaching Hospitals Versus Nonteaching Hospitals
Study Questions:
What is the relationship of hospital teaching status and the presence of a thoracic surgery residency program with outcomes after combined aortic valve replacement (AVR)/coronary artery bypass grafting (CABG)?
Methods:
Using the Nationwide Inpatient Sample database, patients were identified who underwent concomitant AVR/CABG from 1998 to 2007 at nonteaching hospitals, teaching hospitals without a thoracic surgery residency program, and teaching hospitals with a thoracic surgery residency program. Multivariate analysis was performed to identify intergroup differences. Risk-adjusted multivariable logistic regression analysis was used to assess independent predictors of in-hospital mortality and complication rates.
Results:
The three groups of patients did not differ significantly in their baseline characteristics. Patients who underwent AVR/CABG had higher overall risk-adjusted complication rates in nonteaching hospitals (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.39-1.80; p < 0.0001) and teaching hospitals without a thoracic surgery residency program (OR, 1.42; 95% CI, 1.26-1.60; p < 0.0001) than in thoracic surgery residency program hospitals. However, no difference was observed in the adjusted mortality rate for nonteaching hospitals (OR, 0.95; 95% CI, 0.87-1.04; p = 0.25) or teaching hospitals without a thoracic surgery residency program (OR, 1.00; 95% CI, 0.92-1.08; p = 0.98) when compared with thoracic surgery residency program hospitals. Robust statistical models were used for analysis, with c-statistics of 0.98 (complications) and 0.82 (mortality).
Conclusions:
The authors concluded that patients who require complex cardiac operations may have better outcomes when treated at teaching hospitals with a thoracic surgery residency program.
Perspective:
Concomitant AVR/CABG is a commonly performed yet complex cardiac operation. In this study, the overall in-hospital complication rates were 58% higher in nonteaching hospitals and 42% higher in teaching hospitals without a thoracic surgery residency program than in hospitals with a thoracic surgery residency program; however, risk-adjusted mortality was not different among the three groups. Although involvement of trainee physicians might be presumed to result in suboptimal care, these data suggest the contrary. The differences in outcomes might be related to better acquaintance at teaching hospitals with the latest data in evidence-based care of postoperative patients with complex needs. Although the statistical model used in this study was adjusted for hospital volume, it was not adjusted for surgeon volume, and this could have played a role in the different outcomes.
Keywords: Thoracic Surgery, Hospitals, Teaching
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