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CABG, PCI Rates Decline in CA

 |  By cclark@healthleadersmedia.com  
   June 14, 2011

Coronary artery bypass graft procedures and percutaneous coronary interventions are falling in California, according to the latest release of the nation's largest database on hospital and surgeon cardiac mortality.

"But while the PCI rate is declining, it's interesting that the PCI mortality rate is inching up a bit, while the mortality rate for CABG continues to decline," said Joe Parker, Director of the Healthcare Outcomes Center at the California Office of Statewide Health Planning and Development, which collects the data and adjusts it for patients' health status.

For example, operative mortality for isolated CABG procedures was 2.24% in 2008, down from 2.4% in 2007. For the four previous years, it was 2.2% in 2006, 3.2% in 2005, 3.3% in 2004 and 2.9 in 2003. This represents a 24% reduction in operative mortality rate since 2003, the first year state law mandated these reports.

CABG procedures have dropped steadily, by 45% since 1996, and percutaneous angiography dropping from its peak of 59,511 in 2004 to 52,089 in 2008.

"We're at the point now where the mortality rate for isolated CABG procedures is actually less than that for PCI," Parker says.

Additionally, Parker says, the number of CABG procedures is falling "much lower than probably would have been anticipated."

Asked why mortality has been dropping, Parker says he thinks that "procedural techniques are being improved, because this is a pretty constant, steady decline."

Significantly, there is a huge variation in mortality by hospital after adjusting for patients' pre-operative health.

The report, which covers bypass graft procedures in 2007 and 2008 for 120 California hospitals where they are performed, is noteworthy because unlike reports in most other states, it names not just the best and worst risk-adjusted and hospitals in 30-day mortality during 2008, but gives mortality rates on other aspects of CABG operations as well. It covers procedures done on patients who were not undergoing cardiopulmonary resuscitation on their way to the operating room.

For example, the data show the best and worst hospitals for nearly 29,000 procedures during 2007-2008 in risk-adjusted incidence of stroke after CABG, a significant complication, and shows, the best and worst hospitals during 2008 in the use of the internal mammary artery during CABG procedures – which has been associated with better outcomes.

The report is the second to list data for stroke in the aftermath of a CABG procedure. The previous one covered 2007, while the current report combines data for both 2007 and 2008.

The report also lists rates of patient death for each of 279 heart surgeons by name for both years, singling out two that had the lowest death rates and eight who had the highest.

The latest release of information from the nation's largest state database on elective cardiac surgery outcomes for hospitals and the individual doctors who perform them has found a statistically significant association between hospitals that perform more than 300 CABG procedures annually and lower mortality, compared to hospitals that perform less than 200 surgeries per year.

Mortality rates for each surgeon are listed by the hospital where the surgeon performed the operation.

Parker says the California database has a lot of value for the rest of the county. "We do a pretty good job of showing what's happening in California that probably reflects in a lot of ways what's happening in the nation," he says.

Another important revelation from this report, Parker says, is that patients who undergo CABG are sicker than they were in the past. Additionally, despite fears from surgeons and their organizations that doctors would avoid operating on patients with multiple co-morbidities whose risks of mortality might make their performance look poor, Parker says "there doesn't seem to be any avoidance of the sickest patients."

According to the report, for 2008, no hospital scored better than average in risk-adjusted CABG mortality, but two hospitals, California Pacific Medical Center Pacific campus in San Francisco, and Centinela Hospital in Inglewood had the worst mortality rates, 9.97% and 10.85%.

Only one hospital, Alta Bates Summit Medical Center Summit Campus in Berkeley, had significantly better risk-adjusted post-operative rates of stroke, a rating it repeated since the last report.

However, eight hospitals had the worst performance rating in post-operative rates of stroke: Bakersfield Memorial Hospital, Dominican Hospital in Santa Cruz, Good Samaritan Hospital of San Jose, Providence-Tarzana Medical Center, Scripps Memorial Hospital in La Jolla and Tri-City Medical Center in Oceanside.

Hospitals with low use of internal mammary artery during CABG procedures were Antelope Valley Hospital in Lancaster, Beverly Hospital, Enloe Medical Center in Chico, St. Helena Hospital in St. Helena, and Sutter Medical Center of Santa Rosa.

Parker says that future state reports may illuminate the precise causes of death associated with CABG procedure, for example operator error versus infection.

The agency's report found that despite the decline in both CABG and PCI procedures, the number of licensed hospital catheterization labs continues to increase, from just over 200 in 1988 to nearly 400 in 2008.

"OSHPD data show that hospitals have compensated by increasing the use of these facilities for procedures other than CABG and PTCA."

Additionally, the number of physicians who were board certified in cardiovascular disease has increased 36% from 1996 to 2008, from 1,634 to 2,226 while the number of interventional cardiologists went from 286 in 2002 to 494 in 2008, a 73% increase.

See Also:
CA Reports Stroke Rates in Bypass Surgery Data

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