A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group.

OBJECTIVE: To determine whether an organized intervention including data feedback, training in continuous quality improvement techniques, and site visits to other medical centers could improve the hospital mortality rates associated with coronary artery bypass graft (CABG) surgery. DESIGN: Regional intervention study. Patient demographic and historical data, body surface area, cardiac catheterization results, priority of surgery, comorbidity, and status at hospital discharge were collected on CABG patients in Northern New England between July 1, 1987, and July 31, 1993. SETTING: This study included all 23 cardiothoracic surgeons practicing in Maine, New Hampshire, and Vermont during the study period. PATIENTS: Data were collected on 15,095 consecutive patients undergoing isolated CABG procedures in Maine, New Hampshire and Vermont during the study period. INTERVENTIONS: A three-component intervention aimed at reducing CABG mortality was fielded in 1990 and 1991. The interventions included feedback of outcome data, training in continuous quality improvement techniques, and site visits to other medical centers. MAIN OUTCOME MEASURE: A comparison of the observed and expected hospital mortality rates during the postintervention period. RESULTS: During the postintervention period, we observed the outcomes for 6488 consecutive cases of CABG surgery. There were 74 fewer deaths than would have been expected. This 24% reduction in the hospital mortality rate was statistically significant (P = .001). This reduction in mortality rate was relatively consistent across patient subgroups and was temporally associated with the interventions. CONCLUSION: We conclude that a multi-institutional, regional model for the continuous improvement of surgical care is feasible and effective. This model may have applications in other settings.

Responding to the challenge. A status report on shared decision-making programs.

Interactive video programs have been developed to provide patients with tailored information about treatment choices for their medical conditions. The article provides a status report on the use and production of these programs. Evaluation results are presented in terms of patient satisfaction, patient preference shifts and impacts on clinical practice. The future of shared medical decision-making is discussed.

Developing shared decision-making programs to improve the quality of health care.

We strongly believe in the importance of patient involvement in a medical decision. The interactive SDPs appear to be an effective way to facilitate this involvement. One key to the acceptance of these programs by patients and physicians is that they be--and be perceived as--fair, accurate, and balanced. Herein we have described the well-defined protocol for developing, evaluating, and updating SDPs. The first of the foundation's programs dealing with benign prostatic hyperplasia has been well received by patients and clinicians and has been demonstrated to have an impact on practice patterns. Efforts are under way to evaluate four additional programs, leading to widespread availability of the first five SDPs by fall of 1992.

A methodology for QI in the coronary artery bypass grafting procedure involving comparative process analysis.

This report describes an example of applying comparative process analysis to improve surgical procedures. This approach to health care quality improvement relies on combining techniques from the technical disciplines of systems analysis and systems engineering with concepts embodied in the philosophies of total quality management. Coronary artery bypass grafting (CABG) has been examined in a cooperative observational study involving an engineer, cardiac surgeons, perfusionists, nurses, and an anesthesiologist. A baseline process flow for the CABG procedure was developed, against which interinstitutional variations among the five participating medical centers have been identified. On the basis of analysis of the variations, efforts are under way to develop a strategy for incremental continuous improvement in the CABG procedure in each of the five institutions. On the basis of the perceived success of the first phase of the activity, a second phase, wider in scope, has been undertaken.