ANZSCTS Cardiac Surgery Database Program. National Report [Type text] Page 1

Transcription

1 ANZSCTS Cardiac Surgery Database Program National Report [Type text] Page

2 The Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) National Cardiac Surgery Database Program Annual Report Authors: Lavinia Tran, Dhenisha Dahya, Molla Huq, Baki Billah, Andrew Newcomb, Gilbert Shardey, Christopher Reid on behalf of the ANZSCTS National Database Program Steering Committee ANZSCTS National Report Page

3 Foreword Progress towards a National Cardiac Surgery Quality Assurance Program has been constantly developing over the past decade. Commencing in with the establishment of the Victorian Database Program, the program has continued to mature and develop towards truly National coverage. This is the fifth National Report of the ANZSCTS Database Program. That is, the fifth year when information from meaningful numbers of patients who had cardiac surgery in States other than Victoria contributed to the database. The format of data presentation in the report enables individual units to compare their performance to the other participants. Hospital and surgeon comparative data, where given, is coded. Each hospital will be informed of the codes relevant to it and only to it. Statistical analysis of unit and surgeon performance for coronary artery surgery is given. The data in the Web-based National Unit Report module may be used by each Unit to compare its outcomes- on a broad range of parameters with that of the entire group. Indeed, Units may use the web-based Report to do so for individual surgeons. The Society will continue in its mission to ensure and maintain high quality and safety standards are being met in all Units across Australia undertaking cardiac surgical procedures. Gil Shardey Chairman Steering Committee ANZSCTS National Report Page 3

4 TABLE OF CONTENTS FOREWORD... 3 LIST OF FIGURES... 5 LIST OF TABLES DATA PRESENTATION NATIONAL REPORT... 9 COMPREHENSIVE SURGEON S REPORT... ISOLATED CABG SURGERY... PATIENT CHARACTERISTICS BY UNIT... 9 RISK ADJUSTED MORTALITY... FUNNEL PLOTS BY UNIT... 4 CONTROL CHARTS FOR ISOLATED CABG... 4 CUSUM CURVES FOR RISK-ADJUSTED 3-DAY MORTALITY - ISOLATED CABG OTHER GROUP DATA DATA FOR THE ENTIRE CARDIAC SURGICAL POPULATION IN-HOUSE REPORTING MODULE - REPORT FROM ALL UNITS COMBINED NATIONAL WEB REPORT... 9 PROCESSES... Data Management... Current Peer Review Mechanism for identification of Unit Outliers... Data Collection Form... 3 GENERAL DESCRIPTION... 3 SUBMISSION OF DATA TO THE ANZSCTS DATA MANAGEMENT CENTRE... 3 OPT-OFF PROCEDURE... 9 APPENDIX A ALL PROCEDURES MODEL RISK ADJUSTMENT... APPENDIX B ANALYSIS OF 95% CONFIDENCE INTERVALS FOR RISK ADJUSTED DATA USED IN THIS REPORT.... APPENDIX C CUSUM TEST... ANZSCTS National Report Page 4

5 List of Figures Figure : Observed mortality rate for isolated CABG... Figure : Mortality rates for initial and redo isolated CABG surgery... 3 Figure 3: Observed mortality rate for isolated CABG On-Pump... 4 Figure 4: Observed mortality rate for isolated CABG Off-Pump... 4 Figure 5: All arterial grafts in isolated CABG On Pump... 6 Figure 6: Conduits used in isolated CABG On-Pump... 7 Figure 7: Conduits used in isolated CABG Off-Pump... 7 Figure 8A: Total number of isolated CABG by Unit... 9 Figure 8B: Patients by gender and Unit... 9 Figure 8C: Percentage of patients >7yrs old by Unit... Figure 8D: Patients by clinical status and Unit... Figure 8E: LV function by Unit... Figure 9A: Mortality after isolated CABG by unit... Figure 9B: Confidence intervals for RAMR following isolated CABG during... 3 Figure : Mortality rate for isolated CABG in relation to age... 5 Figure A: Mortality rate for isolated CABG in relation to clinical status... 6 Figure B: Urgent Cases that had surgery within 7hours of Angiogram... 6 Figure A: Mortality rate for isolated CABG by pre-operative AMI Figure B: Mortality rate for isolated CABG by type of AMI Figure 3: Mortality rate for isolated CABG by LV function Figure 4: Morbidity by clinical status and unit A) New Renal Failure B) Permanent Stroke Figure 5: Post-operative complications by unit A) Deep sternal wound infection prior to discharge B) Deep sternal wound infection within 3days of surgery... 4 C) Return to theatre for bleeding within 3 days of surgery... 4 Figure 6: Mortality rate for isolated Valve(s) procedures Figure 7: Mortality rate for all Valves with CABG procedures Figure 8: Mortality rate for Aortic Valve Replacement as an isolated procedure... 6 Figure 9: Mortality rate for Aortic Valve Replacement with CABG procedures... 6 Figure : Mortality rate for Mitral Valve as an isolated procedure... 6 Figure : Mortality rate for Mitral Valve with CABG procedures... 6 Figure : Mortality for Aortic Valve Replacement by unit - single valve (initial operation)... 6 Figure 3: Mortality for Mitral Valve Replacement by unit - single valve (initial operation)... 6 Figure 4: Mortality rate for single AVR with CABG procedures Figure 5: Mortality rate for Aortic Valve Replacement with CABG procedures, in relation to the urgency of surgery A) New renal failure rate by valve position and unit... 7 B) New renal failure by valve position and unit... 7 C) Re-op for bleeding by valve position and unit... 7 D) Re-op for bleeding by valve position and unit... 7 ANZSCTS National Report Page 5

6 List of Tables Table - Hospitals contributing to ANZSCTS Cardiac Surgery Registry... Table a - Number of Procedures... Table b Number of Procedures Table a - Number of distal anastomoses... 5 Table b - Number of distal anastomoses Table 3a - Arterial grafts... 6 Table 3b -Arterial grafts Table 4a - Conduits used... 8 Table 4b - Conduits used Table 5 Mortality by age... 5 Table 6 Mortality by clinical status... 7 Table 7 Mortality by pre-operative AMI... 8 Table 8 Mortality by LV function... 9 Table 9 - Mortality - Gender Mortality - Off pump... 3 Table - Mortality - Diabetes Mortality - Renal function... 3 Table Post-operative complications by age (% of cases)... 3 Table Post-operative complications by clinical status (% of cases)... 3 Table 3a - Complications by: redo, off pump, renal function (% of cases) Table 3b - Complications by: redo, off pump, renal function 8-(% of cases) Table 4 Resource utilisation by age (median value) Table 5 - Resource utilisation by clinical status (median value) Table 6 - Resource utilisation by: gender, redo, off pump, renal function (median value) Table 7a - Single valve operations Table 7b - Multiple valve operations Table 8a - Type of valve prosthesis - Single Valve with or without CABG Table 9b Aortic Root Reconstruction Procedures Table - Valve aetiology by age Single Aortic Valve with or without CABG (% of cases). 56 Table - Valve aetiology by age - Mitral Valve with or without CABG (% of cases) Table Summary of procedures Table 3 Mortality by age for single valve without CABG Table 4 Mortality by age for single AVR + CABG Table 5 Mortality by clinical status for AVR + CABG 9 and Table 6 Mortality by redo for AVR + CABG Table 7 Post-operative complications by valve position Isolated single valve (% of cases). 66 Table 8 Post-operative complications by valve position Single valve with CABG 9 and (% of cases) Table 9 Resource utilisation by valve position Isolated single valve (median value) Table 3 Resource utilization by valve position Single valve with CABG (median value) Table 3a - Post-operative complications by age - Single valve with CABG (% of cases)... 7 Table 3b - Post-operative complications by age - Single valve with CABG (% of cases) Table 3 Resource utilisation by age - Single valve with CABG (median value) Table 33 Resource utilisation by age - Multiple valves (median value) Table 34 - Other surgery types Table 35a Major complication by age in cardiac surgical patients (% of cases) Table 35b Major complication by age in cardiac surgical patients (% of cases) Table 36a Major complication by procedure type in cardiac surgical patients (% of cases) Table 36b Major complication by procedure type in cardiac surgical patients (% of cases)... 8 Table 37a - Major complication by LV function in cardiac surgical patients (% of cases)... 8 Table 37b - Major complication by LV function in cardiac surgical patients (% of cases)... 8 Table 38 - Major complication by diabetes in cardiac surgical patients and (% of cases)... 8 Table 39 - Major complication by preoperative renal function and (% of cases)... 8 Table 4a Major complication by clinical status (% of cases) Table 4b Major complication by clinical status (% of cases) Table 4 - Major complication by redo procedure in cardiac surgical patients 9 and (% of cases) Table 4a - Major complication by respiratory disease in cardiac surgical patients (% of cases) 84 ANZSCTS National Report Page 6

7 Table 4b - Major complication by respiratory disease in cardiac surgical patients (% of cases) 85 Table 43a - Previous cerebrovascular disease - atrial arrhythmia - CPB time (% of cases) Table 43b - Previous cerebrovascular disease - atrial arrhythmia - CPB time (% of cases) Table 44 Deep Sternal Infection within 3 days of surgery BITA Obesity Return to theatre by year (% of cases) ANZSCTS National Report Page 7

8 Data Presentation This report analyses data collected from the ANZSCTS Cardiac Surgery Database in the calendar year. Data from previous years (7-) includes all cases from participating units: Data for 7 calendar year includes all cases from ten participating units; 6 Vic public, Mater Health Services, Cabrini Health, Data for 8 calendar year includes all cases from sixteen participating units; 6 Vic public, Mater Health Services, Cabrini Health, Flinders Medical Centre, Lake Macquarie Private and 6 NSW public units. Data for 9 calendar year includes all cases from hospitals including: 6 Vic public, Cabrini Health, Jesse McPherson Private hospital, 8 NSW public, Lake Macquarie Private hospital, Canberra hospital, Flinders Medical Centre, Townsville hospital, Mater Health Services. NB. Two hospitals only submitted months and 6 months worth of data. Data for calendar year includes all cases from 3 hospitals including: 6 Vic public, Cabrini Health, Jesse McPherson Private hospital, 8 NSW public, Canberra hospital, Flinders Medical Centre, Townsville hospital, Mater Health Services. NB. One hospital submitted 6 months worth of data, and another submitted 8 months of data. Data for calendar year includes all cases from 5 hospitals including: 6 VIC public, Cabrini Hospital, Jessie McPherson Private Hospital, Epworth Healthcare, 8 NSW Public Hospitals, Lake Macquarie Private Hospital, The Canberra Hospital, Flinders Medical Centre, Townsville Hospital, Mater Health Services, Royal Perth Hospital. N.B. RNSH did not submit data for November and December. In addition one hospital did not submit completed ICU/Intubation times and therefore their information is not included in ICU/Intubation analyses. Final data related to this report was received by the ANZSCTS Data Management Centre in March. In future, the three-monthly data lock will be rigorously enforced to ensure that the Report is prepared more expeditiously. In this report, unless stated otherwise, mortality includes all deaths in hospital prior to discharge at any time plus all deaths post-discharge but within 3 days of the date of surgery. Cases with missing data fields for operation status and procedure type were excluded from the analysis. In 36 cases were excluded. ANZSCTS National Report Page 8

9 National Report This is the fifth report of the National Program. It describes the data from surgery performed in. At the time of this report, the following units had registered with the National database program and had contributed data in. Importantly, of the 4 Public Units in Australia have registered. Participating (8) Public Hospitals () Austin, VIC Royal Melbourne, VIC Monash Medical Centre, VIC St Vincent's, VIC Geelong, VIC The Alfred, VIC John Hunter, NSW Prince of Wales, NSW Westmead, NSW St George, NSW St Vincent's, NSW Liverpool, NSW Royal North Shore, NSW Royal Prince Alfred, NSW Flinders Medical Centre, SA Canberra, ACT Townsville, QLD Royal Perth, WA Sir Charles Gairdner, WA Royal Adelaide, SA* Private Hospitals Epworth, VIC Mater Health Services QLD Lake Macquarie, NSW Cabrini Health, VIC Jessie McPherson, VIC Peninsula Private, VIC* Holy Spirit Northside, QLD St John of God, WA* Non-participating () Public Hospitals (5) Prince Charles, QLD Princess Alexandra, QLD Fremantle, WA Royal Hobart, TAS Private Hospitals Melbourne, VIC Knox, VIC St Vincent s Private Hospital, VIC Warringal, VIC St George Private Hospital, NSW Strathfield, NSW Westmead, NSW Prince of Wales Private Hospital, NSW Sydney Adventist, NSW Wakefield, SA Mount, WA Hollywood, WA Ashford hospital, SA John Flynn, QLD Brisbane Waters, QLD Greenslopes, QLD St Andrew s Hospital, QLD *Joined in ANZSCTS National Report Page 9

10 Table - Hospitals contributing to ANZSCTS Cardiac Surgery Registry Total Number of Hospital Contributing procedures submitted -* Austin Hospital, VIC Yes 3689 Geelong Hospital, VIC Yes 488 Monash Medical Centre, VIC Yes 4374 Royal Melbourne Hospital, VIC Yes 6733 St Vincent s Hospital, VIC Yes 4833 The Alfred Hospital, VIC Yes 5635 Flinders Medical Centre, SA Yes 38 Mater Health Services, North Queensland Yes 336 Townsville Hospital, QLD Yes 7 Lake Macquarie Private Hospital, NSW Yes 67 John Hunter Hospital, NSW Yes 979 Prince of Wales Hospital, NSW Yes 867 St George Hospital, NSW Yes 8 St Vincent s Hospital, NSW Yes 997 Royal North Shore Hospital, NSW Yes 3 Royal Prince Alfred Hospital, NSW Yes 734 Liverpool Hospital, NSW Yes 33 Westmead Hospital, NSW Yes 97 The Canberra Hospital, ACT Yes 667 Cabrini Medical Centre, VIC Yes 37 Jessie McPherson, VIC Yes 54 Royal Perth Hospital, WA Yes 57 Sir Charles Gairdner Hospital, WA Yes 5 Holyspirit Northside Hospital, QLD Yes 3 Epworth Private Hospital, VIC Yes 588 Prince Charles Hospital, QLD No Princess Alexandra Hospital, QLD No Fremantle Hospital, WA No Royal Hobart Hospital, TAS No Melbourne Private Hospital, VIC No Knox Private Hospital, VIC No St Vincent s & Mercy Private Hospital, VIC No Warringal Private Hospital, VIC No North Shore Private Hospital, NSW No St George Private Hospital, NSW No Strathfield Private Hospital, NSW No Westmead Private Hospital, NSW No Prince of Wales Private Hospital, NSW No Sydney Adventist Private Hospital, NSW No Wakefield Private Hospital, SA No Mount Lawley Private Hospital, WA No Hollywood Private Hospital, WA No Ashford hospital Private Hospital, SA No Brisbane Waters Private Hospital, QLD No Greenslopes Private Hospital, QLD No Royal Adelaide Hospital, SA No John Flynn, QLD No Total contributing hospitals 5 *Calendar year. ANZSCTS National Report Page

11 Comprehensive Surgeon s Report Number of patients Number of procedures This section provides a detailed assessment of the data. It provides a facility to look for emerging trends and inter-relationships between variables. The Surgeons Report includes detailed information about: Isolated CABG Surgery Data is presented on: o Mortality o Grafts applied o Patient characteristics o Post-operative complications o Post-operative clinical indicators Valve Surgery This section includes data on valve procedures, performed with and without Coronary Artery Bypass Grafts. Data is presented on: o Mortality o Procedure type o Prosthesis use o Post-operative complications o Post-operative clinical indicators Other Cardiac Operations This section provides outcome data for operations other than Valve and Coronary Artery Bypass Graft procedures, or where combinations of procedures, not covered in the previous section, were performed in the same surgical episode. Contributing Factors to Population Outcomes This section provides outcome data for all cardiac surgery procedures in relation to a number of risk factors. ANZSCTS National Report Page

12 Number of Procedures Mortality Rate (%) Isolated CABG Surgery Figure : Observed mortality rate for isolated CABG 55 5 Number of IsoCABG procedures Mortality rate Years Figure : Despite an increase in the average age of the operated population and the associated perceived increase in co-morbid processes, observed mortality for isolated coronary surgery has remained between and per cent over the past three years. Table a - Number of Procedures Total Number of procedures Redo Surgery Number Mortality Number Mortality Procedure type Number of procedures % of Isolated CABG Number % of Procedure type Number of procedures % of Redo Number % of Procedure type (redo) Isolated CABG On Pump Isolated CABG Off Pump % 74.7% 9.% 5 4.% % 5.% 9.% 8.3% TOTAL 4776.% 79.7% 33.% 6 4.5% ANZSCTS National Report Page

13 Number of Procedures Mortality rate (%) Isolated CABG Surgery Table b Number of Procedures 8- Total Number of procedures Redo Surgery Number Mortality Number Mortality Procedure type Number of procedures % of Isolated CABG Number % of Procedure type Number of procedures % of Redo Number % of Procedure type (redo) Isolated CABG On Pump Isolated CABG Off Pump 4 9.% 7.8% % 3 3.% 6 9.% 7.5% 7 3.9%.% TOTAL 58*.% 4.8% 436.% 3 3.% *55 missing data, missing data Figure : Mortality rates for initial and redo isolated CABG surgery 5 45 Initial Surgery Mortality (initial) Redo Surgery Mortality (Redo) Figure : Approximately 3-4% of isolated CABG are redo procedures. The mortality for redo-cabg is variably greater than for the initial procedure. ANZSCTS National Report Page 3

14 Number of Procedures Mortality Rate (%) Number of Procedures Mortality Rate (%) Isolated CABG Surgery Figure 3: Observed mortality rate for isolated CABG On-Pump 45 4 Number of Procedures Mortality rate Figure 4: Observed mortality rate for isolated CABG Off-Pump 5 Number of procedures Mortality rate ANZSCTS National Report Page 4

15 Isolated CABG Surgery Table a - Number of distal anastomoses Procedure type Isolated CABG On Pump Isolated CABG Off Pump Total number of procedures X X X 3 X 4 X 5 X 6 X 7 Mean no. grafts TOTAL Table b - Number of distal anastomoses 8- Procedure type Isolated CABG On Pump Isolated CABG Off Pump Total number of procedures X X X 3 X 4 X 5 X 6 X 7 Mean no. grafts TOTAL 58* *55 missing data Table : Over the last 6 years of ANZSCTS data collection, the average number of grafts have been approximately 3.3 for on-pump procedures and around.3.5 for off-pump. Almost 6% of off-pump but only 3% of on-pump patients had one or two grafts. ANZSCTS National Report Page 5

16 % of Procedures Isolated CABG Surgery 4 Figure 5: All arterial grafts in isolated CABG On Pump Figure 5: The general decrease in the proportion of patients having all arterial grafts reflects the practice of a large group of Units that joined after 7. Table 3: A greater proportion of off-pump CABG patients have all arterial grafts. T or Y grafts were performed in 33.3% off-pump CABG but only 6.8% of on-pump CABG s in. Table 3a - Arterial grafts Procedure type Total number of procedures Number of procedures Year All arterial % of procedure type Number of procedures T or Y grafts % of procedure type Isolated CABG On Pump Isolated CABG Off Pump TOTAL Table 3b -Arterial grafts 8- Procedure type Total number of procedures Number of procedures All arterial % of procedure type Number of procedures T or Y grafts % of procedure type Isolated CABG On Pump Isolated CABG Off Pump TOTAL 58* *55 missing data ANZSCTS National Report Page 6

17 % Procedures % Procedures Isolated CABG Surgery Figure 6: Conduits used in isolated CABG On-Pump Year BITA LITA or RITA Figure 7: Conduits used in isolated CABG Off-Pump BITA LITA or RITA RAD (x or x) Year ANZSCTS National Report Page 7

18 Isolated CABG Surgery Table 4a - Conduits used Procedure type Isolated CABG On Pump Isolated CABG Off Pump Total number of procedures Number of IMA conduits (mutually exclusive) Number of RAD (mutually exclusive) LITA RITA BITA RAD x RAD x Number of GEPA procedures Number of SVG procedures TOTAL Table 4b - Conduits used 8- Procedure type Isolated CABG On Pump Isolated CABG Off Pump Total number of procedures Number of IMA conduits (mutually exclusive) Number of RAD (mutually exclusive) LITA RITA BITA RAD x RAD x Number of GEPA procedures Number of SVG procedures TOTAL 58* *55 missing data ANZSCTS National Report Page 8

19 % of Patients No. of procedures Isolated CABG Surgery Patient Characteristics by Unit 35 Figure 8A: Total number of isolated CABG by Unit A B C D E F G H I J K L M N O P Q R S T U V W X Y Unit Figure 8B: Patients by gender and Unit Females Male % 8% 6% 4% % % A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit ANZSCTS National Report Page 9

20 % of Patients % of Patients Isolated CABG Surgery 6 Figure 8C: Percentage of patients >7yrs old by Unit A B C D E F G H I J K L M N O P Q R S T U V W X Y Unit Figure 8D: Patients by clinical status and Unit Emergency/Salvage Urgent Elective % 8% 6% 4% % % A B C D E F G H I J K L M N O P Q R S T U V W X Y Unit ANZSCTS National Report Page

21 % of Patients Isolated CABG Surgery Figure 8E: LV function by Unit % Severe Moderate Mild Normal 8% 6% 4% % % A B C D E F G H I J K L M N O P Q R S T U V W X Y Unit ANZSCTS National Report Page

22 % Mortality Isolated CABG Surgery Risk Adjusted Mortality Figure 9A: Mortality after isolated CABG by unit OMR Predicted mortality RAMR US 9- - observed UK observed..5. A B C D E F G H I J K L M N O P Q R S T U V W X Y Unit Figure 9A includes both observed or actual and predicted and risk-adjusted mortality. Since the degree of risk associated with the operation varies widely for different patients who undergo cardiac surgery and patient characteristics will differ between hospitals, Risk-Adjustment is necessary to allow comparison of mortality between hospitals. The Risk-Adjusted Mortality Rate compares the mortality rates for the units involved in this analysis. A RAMR lower than the average implies that the unit performs better and one higher than average implies that it performs worse than the average (see also appendix A). In, 4/5 hospitals had predicted mortality which was lower than the observed, suggesting that their observed mortality was higher than expected based on the riskalgorithm (All Procedures Model) used. However Figure 9B indicates that statistically, based on a 95% CI, their performances are still within acceptable limits. ANZSCTS National Report Page

23 RAMR% Isolated CABG Surgery Figure 9B: Confidence intervals for RAMR following isolated CABG during 95% CI for risk-adjusted mortality rate RAMR average Observed mortality average - A B C D E F G H I J K L M N O P Q R S T U V W X Y Unit RAMR 95% CI for RAMR Figure 9B: The 95% CI for risk-adjusted mortality rate for each unit suggests all units are close to the group average. There is no statistically significant difference at that level between the mortality rates for the various units compared to the group (See Appendix B). ANZSCTS National Report Page 3

24 Percentage death Percentage death Isolated CABG Surgery Funnel Plots by Unit Unit Observed Mortality Isolated CABG 6 Units Sign. 5% Sign..% Number of cases Unit RAMR Isolated CABG 6 Units Sign. 5% Sign..% Number of cases ANZSCTS National Report Page 4

25 Isolated CABG Surgery Figure : Mortality rate for isolated CABG in relation to age % Mortality 4 3 <4 yrs 4-49 yrs 5-59 yrs 6-69 yrs 7-79 yrs 8+ yrs Age Group Figure and Table 5: There is a progressive increase in operative mortality with advancing age. Mortality for the highest risk group, the 8+ yrs, is decreasing over the past three years. Table 5 Mortality by age Mortality (mortality/n,%) <4yrs 4-49yrs 5-59yrs 6-69yrs 7-79yrs 8+yrs /46,. 4/339,. 9/94,. /65,. 3/395,.3 4/43, 3.5 /6,. 4/33,. 7/37,.7 5/599,.9 37/46,.6 /393, /44, 4.5 6/35,.9 8/86,. 6/373,. 3/34,.4 3/36, /35,. /38,. 5/78,.7 3/49,. 3/49,.7 6/63,.3 7 /8, 3.6 /98,. 9/5,.7 3/94,.4 /86,.6 3/89, 6.9 ANZSCTS National Report Page 5

26 No. of urgent cases % within 7hrs of angiography % mortality rate Isolated CABG Surgery Figure A: Mortality rate for isolated CABG in relation to clinical status 4 Elective Urgent Emergency Year Figure a: Clinical urgency also significantly influences mortality at approximately around % for elective, % for urgent and 9% for emergency surgery in. Figure B: Urgent Cases that had surgery within 7hours of Angiogram 8 Number of Urgent Cases % within 7hrs of angiogram % % 8% 7% 6% 5% 4% 3% % % % A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital Unit The ANZSCTS Database definition of Urgent includes the requirement that the procedure is performed within 7 hours of angiography. It appears that a majority of patients are incorrectly classified as Urgent by most Units. ANZSCTS National Report Page 6

27 No. of Procedures % Mortality Isolated CABG Surgery Table 6 Mortality by clinical status Mortality (mortality/n, %) Elective Urgent Emergency Salvage 3/36,. 3/56,. 3/47, 8.8 /9,. 39/355,. 4/449,.7 /6, 9.7 /8, /498,.4 3/55,. 7/83, 9.3 /7, /987,. /43,.5 3/3, 9.9 /4,. 7 /48,.4 7/6,.5 8/, 7.3 /3, 33.3 Figure A: Mortality rate for isolated CABG by pre-operative AMI 7-9 Cases Mortality No Yes <6hrs 6-4 hrs -7 days 7- days > days Pre-op MI Time since AMI Figure a: Over the past five years, the surgical risk after AMI is approximately.5% or almost two and a half times that without AMI. The risk is high at intervals <4 hours after AMI, then falls rapidly to.6% in the -7 day group and to.5% in the > day group. Table 7 details the mortality related to pre-operative AMI this year. ANZSCTS National Report Page 7

28 No. of Procedures % Mortality Isolated CABG Surgery Table 7 Mortality by pre-operative AMI Mortality (mortality/n, %) Pre-op AMI Time since AMI Yes No <=6 hrs 6-4 hrs -7 days 7- days >= days 6/598,.3 9/77,.9 3/46, 6.5 9/6, 4.5 /837,.6 /746,.6 4/95,.5 6/68,.4 3/9,. 6/65, 9. 7/8, 8.5 6/68,.3 8/768,.3 5/4, /38,.6 5/95,.3 6/3,. 4/5, 8. 3/55,.4 /64, 3. 6/95,.7 8 4/89,. 5/659,.9 6/9,.7 /48, 4. 4/443, 3. 8/533,.5 /87,. 7 4/46, 3. 5/38,. 3/, 4.3 4/36,. /37, 3.6 9/356,.5 5/696,. Figure B: Mortality rate for isolated CABG by type of AMI Cases Mortality rate No MI NSTEMI STEMI Pre-op AMI Group The type of pre-operative AMI has been recorded for the past two years. The histogram indicates that overall, the presence of a STEMI increases mortality more than a Non-STEMI. There are insufficient numbers as yet, to further analyse the STEMI group. ANZSCTS National Report Page 8

29 No. of Procedures % Mortality Isolated CABG Surgery Figure 3: Mortality rate for isolated CABG by LV function Cases Mortality Normal Mild Moderate Severe LV Dysfunction Figure 3: Reduced ventricular function remains a significant determinant of perioperative mortality. Table 8 Mortality by LV function Mortality (mortality/n %) LV Dysfunction Normal Mild Moderate Severe /79,.9 3/57,.5 9/669,.8 3/56, 8.3 /3,.9 /556,.3 /74,.8 8/85, /969,. 7/366,. /647, 3. 3/3, /748,.6 8/87,.7 6/466, 3.4 5/8,.7 7 9/53,.7 3/77, 3. 4/36, 3.9 8/, 7.8 ANZSCTS National Report Page 9

30 Isolated CABG Surgery Table 9 - Mortality - Gender Mortality - Off pump Gender (n, %) Procedure type (n, %)* Male Female Off-Pump On-Pump 5/383,.3 8/963,.9 53/388,.4 3/937, /387,.8 6/96, /76,.4 6/79,. 7 36/36,.7 /5, 4. Total 39/5879,.5 3/436, 3. *55 missing data 5/45,. 74/436,.7 8/477,.7 77/4337,.8 7/376,.9 77/3786,. /73,.7 53/379,.6 3/,.5 54/456,. 5/74,.4 335/89,.8 Table - Mortality - Diabetes Mortality - Renal function Diabetes (n, %) Pre-op creatinine (n, %) Pre-op egfr (n, %) Yes Yes <ml >=ml > 6 ml/min 6 ml/min 34/74,. 34/74,. 69/46,.5 /76, /368,. 43/94, /696,.9 33/696,.9 8/4665,.7 4/53,.6 37/366,. 48/58, /446,.9 4/446,.9 8/486,. 4/7, 3. 4/343,.3 44/97, /66,.3 7/66,.3 49/3383,.4 6/69, 3.6 3/673,. 3/879,.6 7 /83,.6 /83,.6 47/568,.8 /88,.4 4/947,. 33/79, 4.7 Total 58/6863*,.3 58/6863*,.3 38/93,.7 34/73, 4.8 7/58,. 88/467, 4. *7 missing data Table 9 and : The overall mortality rate for the 5 year period is significantly affected by female gender, diabetes and renal impairment. ANZSCTS National Report Page 3

31 Isolated CABG Surgery Table Post-operative complications by age (% of cases) Age Group <4yrs 4-49yrs 5-59yrs 6-69yrs 7-79yrs 8+yrs Total n * New Renal Failure Cerebrovascular Complication Permanent Stroke Deep Sternal Infection (3 days post-op) Septicaemia Return to theatre (all cases) Re-op for Bleeding Peri-operative AMI New Cardiac Arrhythmia Pneumonia GIT complication Multi-system Failure Anticoagulant complication Red Blood Cells transfused Non-RBC blood products *4 missing data Table : Advancing age is consistently associated with an increased likelihood of most post-operative complications. It also associated with an increased likelihood of transfusion requirements. ANZSCTS National Report Page 3

32 Isolated CABG Surgery Table Post-operative complications by clinical status (% of cases) Operative Status Elective Urgent Emergency Salvage Total n * New Renal Failure Cerebrovascular Complication Permanent Stroke Deep Sternal Infection (3 days post-op) Return to theatre (all cases) Septicaemia Re-op for Bleeding Peri-operative AMI New Cardiac Arrhythmia Pneumonia GIT complication Multi-system Failure Anticoagulant complication Red Blood Cells transfused Non-RBC blood products *4 missing data Table : Increasingly acute clinical status is similarly associated with an increased likelihood of developing postoperative complications and need for transfusion. ANZSCTS National Report Page 3

33 Isolated CABG Surgery Table 3a - Complications by: redo, off pump, renal function (% of cases) Redo Off-pump Pre-op creatinine Pre-op egfr Total st proc Redo Offpump Onpump. mmol/l. mmol/l > 6 ml/min 6 ml/min Patients n * New Renal Failure Cerebrovascular Complication Permanent Stroke Deep Sternal Infection (3 days post-op) Septicaemia Return to theatre (all cause) Re-op for Bleeding Peri-operative AMI New Cardiac Arrhythmia Pneumonia GIT complication Multi-system Failure Anticoagulant complication Red Blood Cells transfused Non-RBC blood products *4 missing data Tables 3a and b indicate that in redo procedures, on-pump surgery and impaired renal function tend to be associated with greater incidence of most adverse outcomes and the use of blood products. ANZSCTS National Report Page 33

34 Isolated CABG Surgery Table 3b - Complications by: redo, off pump, renal function 8-(% of cases) Redo Off-pump Pre-op creatinine Pre-op egfr Total st proc Redo Offpump Onpump. mmol/l. mmol/l > 6 ml/min 6 ml/min Patients n * New Renal Failure Cerebrovascular Complication Permanent Stroke Deep Sternal Infection (3 days post-op) Septicaemia Return to theatre (all cause) Re-op for Bleeding Peri-operative AMI New Cardiac Arrhythmia Pneumonia GIT complication Multi-system Failure Anticoagulant complication Red Blood Cells transfused Non-RBC blood products *3 missing data ANZSCTS National Report Page 34

35 Isolated CABG Surgery Table 4 Resource utilisation by age (median value) Age Group (years) < Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) ANZSCTS National Report Page 35

36 Isolated CABG Surgery Table 5 - Resource utilisation by clinical status (median value) Elective Urgent Emergency Salvage Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) Table 5: Over this five year period, there does not appear to have been any significant change in the duration of intubation time, of stay in ICU or postoperative length of stay. Emergency and Salvage patient groups have increased resource utilisation requirements. ANZSCTS National Report Page 36

37 Isolated CABG Surgery Table 6 - Resource utilisation by: gender, redo, off pump, renal function (median value) Gender Redo Off pump Pre-op creatinine* Male Female st proc Redo Off pump On pump. mmol/l. mmol/l Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) ANZSCTS National Report Page 37

38 % Permanent Stroke % New Renal Failure Isolated CABG Surgery Figure 4: Morbidity by clinical status and unit A) New Renal Failure Elective Urgent Emergency/Salvage (n) no. of cases A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital Unit B) Permanent Stroke 5 (n) No. of cases Elective Urgent Emergency/Salvage A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital Unit ANZSCTS National Report Page 38

39 % Procedures Isolated CABG Surgery C) Re-operation for Bleeding Figure 5: Post-operative complications by unit 3 A) Deep sternal wound infection prior to discharge (n) No. of cases A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital Unit ANZSCTS National Report Page 39

40 % Procedures % Procedures B) Deep sternal wound infection within 3days of surgery (n) No. of cases A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital Unit 7 6 C) Return to theatre for bleeding within 3 days of surgery 5 (n) No. of cases A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital Unit ANZSCTS National Report Page 4

41 Fraction defective Fraction defective..4.6 Control Charts for Isolated CABG Control charts for in-hospital or 3-day mortality, deep sternal infection, and haemorrhage represent variance from the control for each Unit. ICU time, intubation time, length of stay, and post-procedure length of stay represent variation from the mean. The boundaries represent 3 standard deviations from the mean. The control chart for mortality is the only chart that is risk-adjusted using the All Procedures Model. Control Chart - Observed in-hospital or 3 day Mortality A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit Control limit Fraction defective units are out of control Control Chart - Risk-adjusted in-hospital or 3 day Mortality Rate (RAMR) A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit Control limit Fraction defective units are out of control ANZSCTS National Report Page 4

42 Fraction defective Fraction defective Isolated CABG Surgery Control Chart - Deep Sternal Wound Infection * A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit Control limit Fraction defective unit is out of control This is the second consecutive year that Unit W has been above the upper control limits. Control Chart - Haemorrhage A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit Control limit Fraction defective units are out of control ANZSCTS National Report Page 4

43 Mean Vent Mean ICU Isolated CABG Surgery Note: the following control charts for ICU time, intubation time, length of stay, and post-procedure length of stay are representative of the Mean not the Median as they are presented throughout the report. Control Chart - ICU Stay * A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit Control limit ICU 4 units are out of control Unit T has been outside the upper limits for 3 consecutive years. Control Chart - Intubation time * * A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit Control limit VENT units are out of control Units D and J are outside upper limits. This is the first year both units are outside the upper limits. ANZSCTS National Report Page 43

44 5 Mean LOS Mean LOS Isolated CABG Surgery Control Chart - Total length of stay (LOS) A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit Control limit LOS units are out of control Control Chart - Total length of stay (LOS) A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit Control limit LOS units are out of control All Units were within control limits for total length of stay in ANZSCTS National Report Page 44

45 5 Mean pplos Isolated CABG Surgery Control Chart - Post procedure length of stay A B C D E F G H I J K L M N O P Q R S T U V W X Y Hospital unit Control limit PPLOS units are out of control The difference between total and post-procedure length of stay represents surgical delay times. ANZSCTS National Report Page 45

46 Isolated CABG Surgery Surgeons Control Charts Control Chart - Observed Mortality for Individual surgeons * * * Surgeon Code Control limit Fraction defective 3 units are out of control Control Chart - Risk Adjusted Mortality Rate (RAMR) for Individual surgeons * * * Surgeon Code Control limit Fraction defective 3 units are out of control ANZSCTS National Report Page 46

47 Isolated CABG Surgery 4 Observed Mortality Isolated CABG Surgeons Sign. 5% Sign..% Number of cases RAMR Isolated CABG 4 Surgeons Sign. 5% Sign..% Number of cases One surgeon was excluded from the analysis, as only one CABG surgery was performed in which resulted in mortality. ANZSCTS National Report Page 47

48 CUSUM SCORE CUSUM curves for Risk-adjusted 3-day Mortality - Isolated CABG The CUSUM scores for each case in the combined units and then for separate units fall within the rejection (red) line, the performance of all hospitals is at a satisfactory level (See Appendix C). 6 CUSUM TEST ALL UNITS -Jan- TO 3-Dec DATES Reject CUSUM ANZSCTS National Report Page 48

49 Isolated CABG Surgery ANZSCTS National Report Page 49

50 Isolated CABG Surgery ANZSCTS National Report Page 5

51 Isolated CABG Surgery ANZSCTS National Report Page 5

52 Isolated CABG Surgery The CUSUM test illustrates that some Units, indeed the entire group, approach the upper limit on isolated occasions during the year, but when that happens, the mortality outcome rapidly corrects. ANZSCTS National Report Page 5

53 Valve Surgery Table 7a - Single valve operations Without CABG WITH CABG Initial Redo Total Total Aortic No Died % No Died % No Died % No Died % Replacement Repair/Reconstruction without Annuloplasty Bentall Procedure David Procedure Valvotomy Ross Procedure Other Valve Proc Aortic Total Mitral Replacement Annuloplasty Repair/Reconstruction with Annuloplasty Repair/Reconstruction without Annuloplasty Other Valve Proc Mitral Total Tricuspid Replacement Annuloplasty Repair/reconstruction with Annuloplasty Tricuspid Total Pulmonary Replacement Other Valve Proc Pulmonary Total Total Single Valve Table 7b - Multiple valve operations Double Valves Mitral & Aortic Mitral & Tricuspid Aortic & Tricuspid Other double valves Double total Triple total Total Multiple Total Single Total Valve * *3 incomplete/inaccurate data, 4 incomplete/inaccurate data ANZSCTS National Report Page 53

54 Valve Surgery Table 8a - Type of valve prosthesis - Single Valve with or without CABG Valve Position Aortic Mitral Tricuspid Pulmonary n 774 % 7* % 3 % 3** % Mechanical # Xenograft # Allograft Autograft Annuloplasty Ring/Band ## Not specified *8 repair reconstruction without annuloplasty not included, 3 miscoded cases not included. ** repair/reconstruction without annuloplasty not included. # of replacements ## of repairs 3 miscoded cases not included ANZSCTS National Report Page 54

55 Valve Surgery Table 9b Aortic Root Reconstruction Procedures WITHOUT CABG WITH CABG No. Died % No. Died % Pulmonary autografts (Ross) Root reconstruction with valve conduit (Bentall) Root reconstruction with valve sparing (David) NB Bentall procedures listed in Tables 7a include only those cases in which Data Managers coded the cases as either Coronary Artery Bypass or Valve Surgery and selected Aortic Valve Procedure=6, Root Reconstruction with Valve Conduit (Bentall procedure). Bentall procedures listed in 9b includes all cases above PLUS cases where Data Managers coded Other cardiac and said yes to Aortic procedure with yes to any one of the following: Aortic aneurysm type ascending, Aortic aneurysm type Arch, and/or Aortic dissection. ANZSCTS National Report Page 55

56 Valve Surgery Table - Valve aetiology by age Single Aortic Valve with or without CABG (% of cases) Age Group <4 yrs 4-49 yrs 5-59 yrs 6-69 yrs 7-79 yrs 8+ yrs Total n * Rheumatic Congenital Idiopathic Calcific Myxomatous degeneration Failed prior repair Prosthetic valve failure Periprosthetic leak Prosthetic valve thrombosis Active infection Previous infection Marfans Annuloaortic ectasia Other degenerative disease Dissection Tumour Trauma Iatrogenic Functional Mitral Functional tricuspid Other *3 missing data ANZSCTS National Report Page 56

57 Valve Surgery Table - Valve aetiology by age - Mitral Valve with or without CABG (% of cases) Age Group <4 yrs 4-49 yrs 5-59 yrs 6-69 yrs 7-79 yrs 8+ yrs Total n * Rheumatic Congenital Ischaemic Idiopathic Calcific Myxomatous degeneration Failed prior repair Prosthetic valve failure Peri-prosthetic leak Prosthetic valve thrombosis Active infection Previous infection Marfans Other degenerative disease Dissection Tumour Trauma Iatrogenic Functional mitral Functional tricuspid Other *5 missing data ANZSCTS National Report Page 57

58 Valve Surgery Table Summary of procedures Valves Only Number of Operations Mortality (n) Mortality (%) Aortic Valve Surgery 78.9 Aortic Valve Replacement Mitral Valve Surgery Mitral Valve Replacement Mitral Valve Repair Tricuspid Valve Surgery Pulmonary Valve Surgery Mitral & Aortic Valve Surgery Mitral & Tricuspid Valve Surgery Aortic & Tricuspid Valve Surgery Other Double Valve Surgery Triple Valve Surgery 3 5. Total Valves Only Valves & CABG Only Aortic Valve Surgery & CABG Aortic Valve Replacement & CABG Mitral Valve Surgery & CABG Mitral Valve Replacement & CABG 7.9 Mitral Valve Repair & CABG Triscuspid Valve Surgery & CABG Pulmonary Valve Surgery & CABG Mitral & Aortic Valve Surgery & CABG 5. Mitral & Tricuspid Valve Surgery & CABG Aortic & Tricuspid Valve Surgery Other Double Valve Surgery & CABG Triple Valve Surgery & CABG Total Valves & CABG Only TOTAL Valve (with or without CABG) Only ANZSCTS National Report Page 58

59 Number of procedures Mortality rate (%) Number of procedures Mortality rate (%) Valve Surgery Figure 6: Mortality rate for isolated Valve(s) procedures 8 Procedures Mortality Years Figure 7: Mortality rate for all Valves with CABG procedures Procedures Mortality Years Figures 6 and 7 demonstrate the addition of CABG to Valve surgery increases the mortality rate. ANZSCTS National Report Page 59

60 Number of procedures Mortality rate (%) Number of procedures Mortality rate (%) Valve Surgery Figure 8: Mortality rate for Aortic Valve Replacement as an isolated procedure 4 No. of procdures Mortality Years Figure 9: Mortality rate for Aortic Valve Replacement with CABG procedures No. of procdures Mortality Years ANZSCTS National Report Page 6

61 Number of procedures Mortality rate (%) Number of procedures Mortality rate (%) Valve Surgery Figure : Mortality rate for Mitral Valve as an isolated procedure 3 8 Replacement proecudures Replacement mortality Repair/Reconstruction procedures Repair/Reconstuction mortality Years Figure : Mortality rate for Mitral Valve with CABG procedures 6 Replacement procedures Replacement mortality Repair/Reconstruction procedures Repair/Reconstruction mortality Years Table and Figures 8- demonstrate that the addition of CABG with Valve surgery increases mortality for Aortic Valve Replacement and for Mitral Valve procedures. ANZSCTS National Report Page 6

62 Number of procedures Number of cases Valve Surgery Figure : Mortality for Aortic Valve Replacement by unit - single valve (initial operation) Without CABG With CABG (n) number of mortalities A B C D E F G H I J K L M N O P Q R S T U V W X Y Units Figure 3: Mortality for Mitral Valve Replacement by unit - single valve (initial operation) 5 Without CABG With CABG (n) number of mortalities A B C D E F G H I J K L M N O P Q R S T U V W X Y Units ANZSCTS National Report Page 6

63 Number of procedures Mortality rate (%) Valve Surgery Table 3 Mortality by age for single valve without CABG Mortality (mortality/n, %) Age Group <4 years 4-49 yrs 5-59 yrs 6-69 yrs 7-79 yrs 8+ yrs Aortic /63 - /63 - /9.8 5/7.3 9/ /7.9 Mitral /59.7 / /97 3. /46.7 5/4 4. 4/56 7. Tricuspid /. / - /4 - /4 5. /6 - / Pulmonary /8 - /5 - / Total /5.3 /4.6 4/.8 7/ /476.9 / Figure 4: Mortality rate for single AVR with CABG procedures 6 Procedures 7 years Mortality 7 years Procedures >7 years Mortality >7 years Years Table 4 Mortality by age for single AVR + CABG 7- Mortality (mortality/n, %) Age Group <4 years 4-49 yrs 5-59 yrs 6-69 yrs 7-79 yrs 8+ yrs / - /5 - / /49. / /5 7.9 /4 - /7 - /9 - /44.4 5/89 5. / /4 - /35.9 5/ /35.3 3/ / - / 5. /94. 3/5 6. 6/ /4 - / - 3/ / /98 6. ANZSCTS National Report Page 63

64 Mortality rate (%) Valve Surgery Figure 5: Mortality rate for Aortic Valve Replacement with CABG procedures, in relation to the urgency of surgery Elective Urgent Emergency Clinical Status Table 5 Mortality by clinical status for AVR + CABG 9 and Mortality (mortality/n, %) Clinical Status Elective Urgent Emergency 7/ / 9. /. / /7 4.7 / /48.7 /8 7.8 /9. 8 / / 7.8 /7-7 3/ / /3 - The data in Figure 5 and Table 5 suggest that the mortality of combined Aortic Valve Replacement and CABG for urgent cases is greater than that for elective cases in 7-. Clinically Urgent was more tightly defined in 8-9, however, the definition is not universally adhered to (see figure b). ANZSCTS National Report Page 64

65 Valve Surgery Table 6 Mortality by redo for AVR + CABG Mortality (mortality/n, %) Redo Yes No 5/4.9 6/ / / / / / / / / Table 6 suggests that although the results vary from year to year, the overall risk of redo surgery for AVR + CAG over the past five years is increased, at 7.4% compared to 4.4% for non-redo procedures. ANZSCTS National Report Page 65

66 Valve Surgery Table 7 Post-operative complications by valve position Isolated single valve (% of cases) Valve Position Aortic Mitral Tricuspid or Pulmonary Total n * New Renal Failure Cerebrovascular complication Permanent Stroke Transient Stroke Continuous coma Deep Sternal Infection (3 days post-op) Septicaemia Return to theatre (all cause) Re-op for Bleeding New Cardiac Arrhythmia Pneumonia GIT complication Multi-system Failure Anticoagulant complication Red Blood Cells transfused Non-RBC blood products *9 missing data ANZSCTS National Report Page 66

67 Valve Surgery Table 8 Post-operative complications by valve position Single valve with CABG 9 and (% of cases) Valve Position Aortic Mitral Tricuspid or Pulmonary Total Year n* New Renal Failure Cerebrovascular complication Permanent Stroke Transient Stroke Continuous coma Deep Sternal Infection (3 days post-op) Septicaemia Return to theatre (all cause) Re-op for Bleeding New Cardiac Arrhythmia Pneumonia GIT complication Multi-system Failure Anticoagulant complication Red Blood Cells transfused Non-RBC blood products *4 missing data Tables 7 and 8 indicate that the incidence of major post-operative complications tends to be higher for combined valve and CABG procedures. For the overall data see table 3a. ANZSCTS National Report Page 67

68 Valve Surgery Table 9 Resource utilisation by valve position Isolated single valve (median value) Aortic Mitral Tricuspid or Pulmonary.. 9. Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) ANZSCTS National Report Page 68

69 Valve Surgery Table 3 Resource utilization by valve position Single valve with CABG (median value) Aortic Mitral Tricuspid or Pulmonary Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay 9... (days) ANZSCTS National Report Page 69

70 New renal failure (%) New renal failure (%) Valve Surgery Figure 6: Number of isolated single valve replacement procedures A) New renal failure rate by valve position and unit Aortic Mitral (n) number of new renal failure A B C D E F G H I J K L M N O P Q R S T U V W X Y Units B) New renal failure by valve position and unit Aortic Mitral (n) number of new renal failure A B C D E F G H I J K L M N O P Q R S T U V W Title ANZSCTS National Report Page 7

71 Re-operation for bleeding (%) Re-opration for bleeding (%) Valve Surgery C) Re-op for bleeding by valve position and unit Aortic Mitral (n) number of re-operations A B C D E F G H I J K L M N O P Q R S T U V W X Y Units 5 D) Re-op for bleeding by valve position and unit Aortic Mitral (n) number of re-operations A B C D E F G H I J K L M N O P Q R S T U V W Units ANZSCTS National Report Page 7

72 Valve Surgery Table 3a - Post-operative complications by age - Single valve with CABG (% of cases) Age Group (%) <4 years 4-49 yrs 5-59 yrs 6-69 yrs 7-79 yrs 8+ yrs Total n New Renal Failure Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma Deep Sternal Infection (3 days post-op) Septicaemia Return to theatre (all cause) Re-op for Bleeding Peri-operative AMI New Cardiac Arrhythmia Pneumonia GIT complication Multi-system Failure Anticoagulant complication Red Blood Cells transfused Non-RBC blood products ANZSCTS National Report Page 7

73 Valve Surgery Table 3b - Post-operative complications by age - Single valve with CABG (% of cases) Age Group (%) <4 years 4-49 yrs 5-59 yrs 6-69 yrs 7-79 yrs 8+ yrs Total n New Renal Failure Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma Deep Sternal Infection (3 days post-op) Septicaemia Return to theatre (all cause) Re-op for Bleeding Peri-operative AMI New Cardiac Arrhythmia Pneumonia GIT complication Multi-system Failure Anticoagulant complication Red Blood Cells transfused Non-RBC blood products ANZSCTS National Report Page 73

74 Valve Surgery Table 3 Resource utilisation by age - Single valve with CABG (median value) Age Group (years) < Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) The effect of age on post-operative complications and Resource Utilisation after single valve and CABG surgery is illustrated in Tables 3 and 33. The incidence of most major complications is inconsistently related to age. ANZSCTS National Report Page 74

75 Valve Surgery Table 33 Resource utilisation by age - Multiple valves (median value) Age Group (years) < Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) ANZSCTS National Report Page 75

76 Table 34 - Other surgery types Other Group data Surgery type (NOT mutually exclusive) Total number of procedures Mortality by procedure 9 n (mort) % Left Ventricular Aneurysm - - Acquired VSD Aortic Procedure* Aneurysm Asc only Asc + Arch Arch only - - Desc Thor/Abd only Other 9. Dissection Asc Acute Asc Chronic Desc Acute 5. Desc Chronic - - Acute Traumatic Aortic Transection Cardiac Trauma LVOT Myectomy for HOCM LV Rupture Repair Pericardiectomy 9 4. Pulmonary Thrombo-endarterectomy 9. Carotid Endarterectomy Left Ventricular Reconstruction Pulmonary Embolectomy. Cardiac Tumour Cardiac Transplant Congenital ASD.7 Other 57.8 Permanent LV Epicardial Lead Atrial Arrhythmia Surgery *Some units did not submit Aortic Procedure Type data despite answering yes to Aortic Procedure ANZSCTS National Report Page 76

77 Data for the entire cardiac surgical population The following illustrates aspects of the effect of age, procedure type, left ventricular function, clinical urgency, redo-procedures and some pre-operative co-morbidities on post-operative outcomes and Resource Utilisation. Table 35a Major complication by age in cardiac surgical patients (% of cases) Age Group (years) < Total n New Renal Failure Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma Deep Sternal Infection (3 days post-op) Re-op for Bleeding Resource utilisation (median value) Age Group (years) < Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) ANZSCTS National Report Page 77

78 Data for the entire cardiac surgical population Table 35b Major complication by age in cardiac surgical patients (% of cases) Age Group (years) < Total n New Renal Failure Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma Deep Sternal Infection (3 days post-op) Re-op for Bleeding Resource utilisation (median value) Age Group (years) < Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) ANZSCTS National Report Page 78

79 Data for the entire cardiac surgical population Table 36a Major complication by procedure type in cardiac surgical patients (% of cases) Isolated CABG Valve(s) only Procedure Type Valve(s) + CABG Other Total n New Renal Failure Deep Sternal Infection (3 days post-op) Re-op for Bleeding Red Blood Cells transfused Non-RBC blood products transfused *46 missing Resource utilisation (median value) Isolated CABG Valve(s) only Valve(s) + CABG Other Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) ANZSCTS National Report Page 79

80 Data for the entire cardiac surgical population Table 36b Major complication by procedure type in cardiac surgical patients (% of cases) Isolated CABG Valve(s) only Procedure Type Valve(s) + CABG Other Total n New Renal Failure Deep Sternal Infection (3 days post-op) Re-op for Bleeding Red Blood Cells transfused Non-RBC blood products transfused Resource utilisation (median value) Isolated CABG Valve(s) only Valve(s) + CABG Other Intubation Time (hours) Intensive Care Stay (hours) Post-op Length of Stay (days) ANZSCTS National Report Page 8

81 Data for the entire cardiac surgical population Table 37a - Major complication by LV function in cardiac surgical patients (% of cases) LV Dysfunction Normal Mild Moderate Severe Total n New Renal Failure Cerebrovascular complication Permanent Stroke Resource utilisation by LV function 9 (median value) Normal Mild Moderate Severe Intubation Time (hours) Post-op Length of Stay (days) Table 37b - Major complication by LV function in cardiac surgical patients (% of cases) LV Dysfunction Normal Mild Moderate Severe Total n New Renal Failure Cerebrovascular complication Permanent Stroke Resource utilisation by LV function (median value) Normal Mild Moderate Severe Intubation Time (hours) Post-op Length of Stay (days) ANZSCTS National Report Page 8

82 Data for the entire cardiac surgical population Table 38 - Major complication by diabetes in cardiac surgical patients and (% of cases) Diabetes Yes No Total n New Renal Failure Cerebrovascular complication Permanent Stroke Deep Sternal Infection (3 days post-op) Table 39 - Major complication by preoperative renal function and (% of cases) Pre-op EGFR > 6 ml/min 6 ml/min Total New Renal Failure Deep Sternal Infection (3 days post-op) Re-op for Bleeding Median value Post-op Length of stay (days) Pre-op EGFR > 6 ml/min Pre-op EGFR 6 ml/min Total ANZSCTS National Report Page 8

83 Data for the entire cardiac surgical population Table 4a Major complication by clinical status (% of cases) Operative Status Elective Urgent Emergency Salvage Total n New Renal Failure Cerebrovascular complication Permanent Stroke Re-op for Bleeding Median value Elective Urgent Emergency Salvage Post-op Length of Stay (days) Table 4b Major complication by clinical status (% of cases) Operative Status Elective Urgent Emergency Salvage Total n New Renal Failure Cerebrovascular complication Permanent Stroke Re-op for Bleeding Median value Elective Urgent Emergency Salvage Post-op Length of Stay (days) ANZSCTS National Report Page 83

84 Data for the entire cardiac surgical population Table 4 - Major complication by redo procedure in cardiac surgical patients and (% of cases) st Proc Redo Total n New Renal Failure Cerebrovascular complication Permanent Stroke Deep Sternal Infection (3 days post-op) *538 missing Re-op for Bleeding Table 4a - Major complication by respiratory disease in cardiac surgical patients (% of cases) Respiratory Disease No Mild Moderate Severe Total n Deep Sternal Infection (3 days post-op) Median value No Mild Moderate Severe Total Intubation Time ANZSCTS National Report Page 84

85 Data for the entire cardiac surgical population Table 4b - Major complication by respiratory disease in cardiac surgical patients in (% of cases) Respiratory Disease No Mild Moderate Severe Total n Deep Sternal Infection (3 days post-op) Median value No Mild Moderate Severe Total Intubation Time ANZSCTS National Report Page 85

86 Data for the entire cardiac surgical population Table 43a - Previous cerebrovascular disease - atrial arrhythmia - CPB time (% of cases) Previous Cerebrovascular Disease Atrial Arrhythmia Yes No Total Yes No Total n Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma CPB time > hrs > 3 hrs >3 hrs Total n Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma ANZSCTS National Report Page 86

87 Data for the entire cardiac surgical population Table 43b - Previous cerebrovascular disease - atrial arrhythmia - CPB time (% of cases) Previous Cerebrovascular Disease Atrial Arrhythmia Yes No Total Yes No Total n Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma CPB time > hrs > 3 hrs >3 hrs Total n Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma ANZSCTS National Report Page 87

88 Data for the entire cardiac surgical population Table 44 Deep Sternal Infection within 3 days of surgery BITA Obesity Return to theatre by year (% of cases) BITA (%) Obesity (%) Return to theatre (all cause, %) Deep Sternal Infection (3 days post-op) Yes No Total Yes No Total Yes No Total ANZSCTS National Report Page 88

89 In-House reporting module - report from all units combined The ANZSCTS online web system contains an In-House reporting module that provides a report on case numbers and outcomes for the individual unit as required. The following pages display a copy of that report generated by the same software, but with combined data of all the units for the Calendar year. PLEASE NOTE: Minor discrepancies may exist between the National Report and this Reporting Module and are due to differences in filtering processes prior to analysis. ANZSCTS National Report Page 89

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100 Processes The following pages outline formal processes relating to the conduct of the project. These include: Data management Peer Review mechanism Data collection form Patient Information Sheet Opt-off procedure ANZSCTS National Report Page

101 Data Management All data collected as part of the ANZSCTS project is forwarded to the Department of Epidemiology and Preventive Medicine, Monash University. The flow of information into the data centre is outlined in the following figure. Surgical Unit Interim Surgical Unit Surgical Unit Surgical Unit Surgical Unit Unit Registry Error Correction Final Unit Registry Merged Nationa l Registr y ANZSCTS National Report Page

102 Current Peer Review Mechanism for identification of Unit Outliers STEP : Identification of outlier on Control Chart Week STEP 3: CDA reviews local audit report and discusses results with Unit Week 8 STEP 4: Review most recent KPI data: KPI remains out of range Week STEP : Unit contacted and asked to undertake internal review of the past 3 months data and report within 4 weeks Week 4 Result within limits No action required STEP 6: CDA reviews external audit report and discusses results with Unit Week STEP 7: Review most recent KPI data: KPI remains out of range Week 4 STEP 5: Unit contacted and asked to agree to external review of the past 3 months data and report within 4 weeks Week 6 Result within limits No action required Outlier defined as any unit outside 3 standard deviations for any of the 5 performance indicators. STEP 8: Unit contacted and meeting arranged with hospital administration and Department of Health The ANZSCTS Data Review Committee and the ANZSCTS Database Project Manager undertake the external review. ANZSCTS National Report Page

103 Data Collection Form General Description The following pages show the ANZSCTS Data Collection Form. This form contains only the ANZSCTS Minimum Dataset. Individual hospitals may have a slightly different form depending on the type and amount of additional data each hospital wishes to collect. The ANZSCTS Data collection form consists of 3 parts: Pre operative, Intra Operative and Post Operative. Pre Operative: We recommend that this section of the form be completed by the Resident. This part of the form contains information on the patient s demographics, risk factors, pre operative cardiac status and previous interventions. Intra Operative: We recommend that this section of the form be completed by the Surgeon. This part of the form contains information on the patient s haemodynamic data, operative status, and information directly related to the procedure performed. Post Operative: We recommend that this section of the form be completed by the Registrar. This part of the form contains information on post operative complications and mortality. We also recommend that the Data Manager check all parts of the form for completeness, make any amendments as required and notify the Data Management Centre at Baker Heart Research Institute. Each part is contained on separate pages from the other parts. They can therefore be separated from each other for the purposes of data collection if required. Submission of data to the ANZSCTS Data Management Centre When all 3 parts of the form have been completed and checked this should be indicated on the top of the first page. The data is then entered on the onsite database. When entry is completed, it is then sent to the Department of Epidemiology and Preventive Medicine via encrypted . ANZSCTS National Report Page 3

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