ANZSCTS Cardiac Surgery Database Program ANNUAL REPORT ANZSCTS National Report 2015 Page 1

Transcription

1 ANZSCTS Cardiac Surgery Database Program ANNUAL REPORT 2015 ANZSCTS National Report 2015 Page 1

2 The Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) Cardiac Surgery Database Program Annual Report 2015 Authors: Nupur Nag, Noah Solman, Lavinia Tran, Baki Billah, Gilbert Shardey and Christopher Reid on behalf of the ANZSCTS Database Program Steering Committee ANZSCTS National Report 2015 Page 2

3 Foreword This is the ninth National Report of the ANZSCTS Database Program which for over a decade has provided meaningful information on cardiac surgical activity and performance in Victoria, and for the past 9 years from large numbers of patients who had cardiac surgery across Australia. The report comprises unit and surgeon comparisons of key performance indications, in de-identifiable format. Overall, all units and surgeons are within National averages for key performance indicators, maintained over the past decade; indicating a high level of service and care in Australian cardiac surgery. To date, the Program participants include 23 of 24 public hospitals and 8 of 33 private hospitals. We encourage all hospitals to consider joining this quality assurance program to ensure a standardised level of care and optimal outcomes for all patients undergoing cardiac surgery. The Society will continue in its mission to ensure that high quality and safety standards are maintained in all units undertaking cardiac surgical procedures in Australia. Gil Shardey Chairman Steering Committee ANZSCTS Annual Report 2015 Page 3

4 Table of Contents Foreword... 3 List of Figures... 5 List of Tables... 6 Introduction... 7 National Report All Procedures Summary Isolated CABG Surgery Patient Characteristics by Unit Observed, Predicted and Risk Adjusted Mortality Surgeons Performance Mortality for isolated CABG Procedures Influence of Co-Morbidities on Mortality Age Clinical Status Previous Myocardial Infarction (MI) Left Ventricular Dysfunction Diabetes and Pre-existing Renal Impairment Post-operative Complications Effect of age Effect of Clinical Status Effect of Redo, On- or Off-Pump and Renal Function Resource Utilisation Unit Performance - Control Charts for isolated CABG Valve Surgery Observed Mortality (OM) Post-operative complications and resource utilisation for valve procedures Other Cardiac Surgery Concluding Remarks Appendix A All Procedures Risk Adjustment Model Appendix B Analysis of 95% CIs for Risk Adjusted Data Appendix C Interpretation of Funnel Plots Glossary of Terms Bibliography ANZSCTS Annual Report 2015 Page 4

5 List of Figures Figure 1. Proportions of procedure type Figure proportions of procedure type, by unit Figure number of isolated CABG, by unit Figure 4. OM rate for initial versus redo isolated CABG Figure 5. OM rate for on- and off-pump isolated CABG Figure 6. Arterial conduits for a) on-pump and b) off-pump isolated CABG Figure reported clinical status of isolated CABG patients, by unit Figure gender distribution of isolated CABG patients, by unit Figure age distribution of a) male and b) female patients, by unit Figure 10a isolated CABG OM rate versus RAMR, by unit Figure 10b CIs for isolated CABG RAMR, by unit Figure 10c CIs for isolated CABG RAMR, by unit Figure isolated CABG a) OM and b) RAMR, by unit Figure isolated CABG a) OM and b) RAMR, by unit Figure isolated CABG OM for individual surgeons Figure isolated CABG RAMR for individual surgeons Figure isolated CABG OM, by age Figure isolated CABG OM, by clinical status Figure mortality rate by a) type and b) timing of MI Figure mortality rate by LVD Figure a) DNRF, b) permanent stroke, c) re-op for bleeding and d) DSWI, by clinical status.. 30 Figure 20. VENT and ICU time by a) clinical status and b) renal dysfunction Figure 21. LOS and PPLOS times by a) clinical status, b) renal function, and c) pre-procedural MI Figure 22. a) 2015 and b) RAMR for in-hospital or 30-day mortality, by unit Figure 23. a) 2015 and b) DSWI, by unit Figure 24. a) 2015 and b) incidence of RTT for haemorrhage, by unit Figure 25. a) 2015 and b) ICU time, by unit Figure 26. a) 2015 and b) VENT time, by unit Figure OM for single valve procedures a) 2015 and b) , by age Figure 28. Mortality rate for a) single AVR and b) AVR with CABG, by clinical status Figure 29. Mortality rate for AVR with CABG, by patient age Figure 30. Mortality rate for initial and redo Figure 31. ICU and VENT times by valve position a) without and b) with CABG Figure 32. LOS and PPLOS by valve position a) without and b) with CABG Figure OM in valve procedures (a) and in 2015 for b) aortic and c) mitral procedures, per unit Figure re-op for bleeding cases in valve procedures (a) and in 2015 for b) aortic and c) mitral procedures, per unit Figure DSWI cases in valve procedures (a) and in 2015 for b) aortic and c) mitral procedures per unit Figure ICU time for a) aortic and b) mitral procedures per unit Figure VENT time for a) aortic and b) mitral procedures per unit ANZSCTS Annual Report 2015 Page 5

6 List of Tables Table 1. Hospitals contributing to ANZSCTS Database Program...7 Table 2. Distal anastomoses for on-pump versus off-pump Table reported versus derived clinical status effect on mortality Table mortality rate by diabetes and renal function Table post-operative complications (% of cases) by age Table post-operative complications (% of cases) by clinical status Table post-operative complications (% of cases) by redo, use of cardiopulmonary bypass (CPB), and renal function Table 8a. Summary of procedures Table 8b. Other Valve Procedures Table 9a post-operative complications (% of cases) following valve procedures Table 9b post-operative complications (% of cases) following valve with CABG procedures Table 10a post-operative complications (% of cases) by age single valve without CABG Table 10b post-operative complications (% of cases) by age single valve with CABG Table 11a post-operative complications (% of cases) by clinical status single valve without CABG Table 11b post-operative complications (% of cases) by clinical status single valve with CABG Table 12. Other procedures and mortalities in ANZSCTS Annual Report 2015 Page 6

7 Introduction Contributing Units In 2001, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) developed a program to collect data in reference to, and report on, cardiac surgery in Australian hospitals. This is the ninth Annual Report of the Program. It describes data from surgery performed at 31 participating specialist cardiac surgery units (Table 1). An overview of the patients who underwent surgery, the types of surgery performed, complications encountered, and other details relating to risk and outcomes of surgery, are presented. In future, we hope to recruit all Australian and New Zealand units performing cardiac surgery, to ensure a standard high level of care and optimal outcomes for patients. Table 1. Hospitals contributing to ANZSCTS Database Program Hospital Contributing since Number of procedures ^ Number of procedures 2015 VICTORIA Alfred Hospital Austin Hospital Cabrini Medical Centre Epworth Private Hospital Geelong Hospital Jessie McPherson Monash Medical Centre Peninsula Private Royal Melbourne Hospital St Vincent s Public Hospital SOUTH AUSTRALIA Flinders Medical Centre Royal Adelaide Hospital QUEENSLAND Gold Coast University Hospital Holy Spirit Northside Hospital Mater Health Services Prince Charles Hospital Princess Alexandra Hospital Townsville Hospital # NEW SOUTH WALES John Hunter Hospital Lake Macquarie Private Hospital # Liverpool Hospital Prince of Wales Hospital # Royal Prince Alfred Hospital Royal North Shore Hospital St George Hospital # St Vincent s Public Hospital # Westmead Hospital AUSTRALIAN CAPITAL TERRITORY Canberra Hospital # WESTERN AUSTRALIA Fiona Stanley Sir Charles Gairdner Hospital St John of God, Subiaco Total contributing hospitals & procedures ^ Calendar year, numbers are accurate as of data lock 5 th April # Excluded in 2014 ANZSCTS Annual Report 2015 Page 7

8 Data Preparation Data for the 2015 calendar year includes all cases performed in participating units from January 1 through December 31, Final data related to this report was received by the ANZSCTS Data Management Team on April 5, Submitted data was checked for completeness and Data Managers in each unit were given opportunities to amend any errors in their unit s data. Any changes to the data after April 5, 2016 are not reflected in this report. Cases with missing data fields for clinical status and procedure type are excluded from the analyses. For 2015, 22 cases were excluded for this reason. Variable definitions All definitions are based on version 3 of the Data Definitions Manual which may be requested from the ANZSCTS Database team. The following three variables are clarified given their interpretable definitions Clinical Status Clinical Status data was assessed for adherence to the data definitions. For the 2014 Annual Report Urgent and Emergency cases were recoded to align with 2014 data definitions, in years prior, only reported urgency was reflected in the Annual Report. In 2015, this data was reverted to reported urgency. The concept of derived versus reported clinical status is explored in Table 6. Mortality Mortality is defined as all deaths in hospital prior to discharge, and all deaths post discharge but within 30 days of the surgical date. Redo operation Redo operation is defined as any additional cardiac surgery the patient undergoes post their initial surgery, within their current admission. ANZSCTS Annual Report 2015 Page 8

9 National Report 2015 The National Report provides a detailed assessment of data, providing an overview of trends and inter-relationships between key performance indicators (KPIs). The report is subdivided, based on procedure type, into the following four sections: All procedures summary o Annual proportions of procedure type Isolated coronary artery bypass graft (CABG) surgery o Patient characteristics o Grafts applied o Mortality o Post-operative complications o Post-operative clinical indicators Valve surgery (with and without CABG) o Procedure type summary o Mortality o Post-operative complications o Post-operative clinical indicators Other cardiac surgery (not covered in the previous sections and performed in the same surgical episode) o Procedure type summary o Mortality ANZSCTS Annual Report 2015 Page 9

10 All Procedures Summary In 2015, the ANZSCTS Database has 31 participating sites, 23 public and 8 private. Data from these sites show that the majority of patients having cardiac surgery in Australia, undergo an isolated CABG procedure (Figure 1). In 2015, the distribution of patients having isolated CABG, isolated valve, CABG + valve, and other procedures are 51%, 21%, 10% and 18%, respectively. This is also reflected in the proportion of surgical procedures performed within each participating unit (Figure 2) where isolated CABG is the most common procedure performed. Figure 1. Proportions of procedure type Figure proportions of procedure type, by unit ANZSCTS Annual Report 2015 Page 10

11 Isolated CABG Surgery Since isolated CABG is the most common procedure (Figure 1), this report will focus on KPIs for that procedure. Of the 31 participating units, units 21 and 29 performed the highest number of isolated CABG procedures (350 and 450 cases respectively; Figure 3) and units 23 and 24, the lowest (approximately 60 in each). Figure number of isolated CABG, by unit Six year analysis shows the observed mortality rate (OM) (Figure 4) for initial isolated CABG surgery has remained consistently low at below 2%, while for redo surgery, has ranged from 2-6%. Figure 4. OM rate for initial versus redo isolated CABG ANZSCTS Annual Report 2015 Page 11

12 The percentage of on- and off-pump isolated CABG procedures has remained consistent over 6 years, with both procedure types having a mortality of less than 2%. In 2015, 93% and 7% of isolated CABG procedures were performed as on- and off-pump respectively, with mortality rate being lower for off- than on-pump procedures (Figure 5). Figure 5. OM rate for on- and off-pump isolated CABG Compared to on-pump, off-pump isolated CABG surgery involves fewer mean number of grafts, and a significantly higher percentage of all arterial grafts and of T or Y grafts (Table 2). Gastroepiploic artery (GEPA) procedures are similar between the two groups, while saphenous vein graft (SVG) procedures are higher in on-pump procedures. These observations have remained similar since Table 2. Distal anastomoses for on-pump versus off-pump On-pump Off-pump Mean no. grafts All arterial grafts (%) T or Y grafts (%) GEPA procedures (%) SVG procedures (%) ANZSCTS Annual Report 2015 Page 12

13 Since 2010, on- and off-pump procedures had similar use of single left (L) or right (R) internal thoracic artery (ITA) in total (65% versus 57% respectively; Figure 6), while bilateral (B) ITA and Right Arterial Defect (RAD) use differed. Compared to on-pump, off-pump procedures used a higher proportion of BITA (6% versus 18% respectively), and a lower proportion of RAD (29% versus 23% respectively). a. b. Figure 6. Arterial conduits for a) on-pump and b) off-pump isolated CABG ANZSCTS Annual Report 2015 Page 13

14 2015 Patient Characteristics by Unit Patient characteristics influence outcomes of surgery, with main contributing factors being clinical status, gender, and age. As KPIs presented in this report, except mortality, are not risk-adjusted to account for these confounders, we show herein the trends observed in these three categories. The definition of clinical status Urgent has raised discussion where some suggest it is best defined as per our definition of surgery within 72 hours from angiography or within 72 hours after an unplanned admission while other dispute this time limitation as case load and available resources available each unit influences the timing of the procedure. In this report the data is presented as a hospital reported measure and not derived from the database. In 2015, the distribution of isolated CABG procedures based on clinical status was similar for most units, Elective patients being most prevalent (Figure 7). However, units 1, 8, 17, 20, 21, 22, 28, and 29 reported a large number of patients in the Urgent category. Due to the small number of patients in the Emergency and Salvage groups, these have been combined for the purpose of this report. Figure reported clinical status of isolated CABG patients, by unit ANZSCTS Annual Report 2015 Page 14

15 A significantly higher proportion of men, compared to women, underwent treatment in 2015 (Figure 8). Figure gender distribution of isolated CABG patients, by unit The highest proportion of male and female patients undergoing isolated CABG are aged and years, respectively (Figure 9). a. b. Figure age distribution of a) male and b) female patients, by unit ANZSCTS Annual Report 2015 Page 15

16 Observed, Predicted and Risk Adjusted Mortality Patient mortality is analysed based on observed, predicted, and risk-adjusted rates. OM is the mortality reported by the unit; predicted mortality is based on the All Procedures Risk Adjustment Model (Appendix B); and risk-adjusted mortality rate (RAMR) compares predicted mortality per unit with the National mortality average. Predicted mortality and RAMR are used to account for the degree of risk associated with surgery, which varies with the characteristics of patients. Therefore, if a unit has a higher OM than predicted mortality, this suggests that its actual mortality rate is higher than it should have been, given its case mix. In 2015, overall, the OM is less than the predicted mortality (Figure 10a). This implies that, based on the All Procedures Risk Model, the performance of the contributing units combined, is better than would be predicted from their case-mix. This is supported by the observation that nineteen of the units had an OM less than, ten greater than, and two the same as, predicted mortality. The majority of units fall below the National average for observed and predicted mortality rates, and also below RAMR. Moreover, OM rate is lower than reported for US ( for 29 of 31 units, and lower than reported for UK ( for 21 of 31 units, suggesting comparable outcomes between Australian and international cardiothoracic units. Figure 10a isolated CABG OM rate versus RAMR, by unit ANZSCTS National Report 2015 Page 16

17 Based on 95% confidence intervals (CIs), only unit 4 is above the National RAMR average (Figure 10b) suggesting relative to other units. Five units, 3 of which reported no mortality (units 5, 6, and 22), had a lower RAMR, indicating relatively better outcomes in Data analysis of RAMR shows seven of 31 units (3, 5, 11, 14, 16, 17) achieved significantly below National average mortality outcomes (Figure 10c). RAMR average Observed mortality average RAMR 95% CI for RAMR RAMR % Unit Figure 10b CIs for isolated CABG RAMR, by unit RAMR average Observed mortality average RAMR 95% CI for RAMR 4 3 RAMR % Unit Figure 10c CIs for isolated CABG RAMR, by unit ANZSCTS National Report 2015 Page 17

18 Funnel plots provide a means of comparing individual surgeon performance. Number of cases are indicated on the x-axis, and percentage deaths on y-axis. On funnel plot analysis of mortality, units 4 and 20 are significantly above the National average for OM (Figure 11a), and unit 4 remained above the National average after riskadjustment (Figure 11b), suggesting under performance in unit 4 relative to other units. Upon risk adjustment unit 18 fell outside the 95% CIs, suggesting mortality higher than expected for its case mix. Analysis of data shows units 8, 19, and 20 fall above the 95% CI limit of the National OM rate (Figure 12a), and units 8, 15, 18 and 19 do so on RAMR (Figure 12b). a. b. 8 Units 95% CI 6 Units 95% CI 99.7% CI 99.7% CI 6 Percentage death (%) Percentage death (%) Number of cases Figure isolated CABG a) OM and b) RAMR, by unit Number of cases a. b. 5 Units 5 Units 95% CI 95% CI 99.7% CI 99.7% CI 4 4 Percentage death (%) Percentage death (%) Number of cases Figure isolated CABG a) OM and b) RAMR, by unit Number of cases ANZSCTS National Report 2015 Page 18

19 Surgeons Performance Mortality for isolated CABG Procedures Each surgeon is represented by a period; surgeons outside of either of the 95% or 99.7% CI, represented by dashed lines, are marked in red. These surgeons are notified of their performance. Surgeons may request to know their individual identifying number. In 2015, the isolated CABG OM of 10 of 126 surgeons participating in the ANZSCTS Database Program were outside the 95% Cis, with one surgeon being outside the 99.7% Cis (Figure 13). Surgeons 15 (2 deaths of 44 cases), 17 (4 deaths of 81 cases), 30 (2 deaths of 51 cases), 32 (3 deaths of 69 cases), 42 (1 death of 6 cases), 53 (3 deaths of 75 cases), 54 (2 deaths of 49 cases), 98 (3 deaths of 85 cases) and 117 (2 deaths of 30 cases) are outside the 95% CIs, and surgeon 85 (4 deaths of 61 cases) is outside the 99.7% CIs. After risk adjustment, surgeons 15, 30, 32, 42, 53, 85, and 98 were no longer outside the 95% CIs suggesting that they operated on higher risk cases. Surgeons 54 and 117 however, were still above 95% CIs. Surgeons 17, 20 (1 deaths of 26 cases), 74 (2 deaths of 85 cases), 99 (2 deaths of 56 cases), were above 95% CIs after risk adjustment, indicating that they performed fewer higher risk cases (Figure 14). Data for all aforementioned surgeons will be monitored in Surgeons 95% CI 99.7% CI Percentage death (%) Number of cases Figure isolated CABG OM for individual surgeons ANZSCTS National Report 2015 Page 19

20 50 40 Surgeons 95% CI 99.7% CI Percentage death (%) Number of cases Figure isolated CABG RAMR for individual surgeons ANZSCTS National Report 2015 Page 20

21 Influence of Co-Morbidities on Mortality The effect of age, clinical status, left ventricular (LV) dysfunction, prior history of myocardial infarction (MI) and diabetes, are reviewed in the subsequent graphs and tables. Age Mortality increases with advancing age. This has remained consistent since 2010 (Figure 15). Of note, since 2010, annual morality rate of patients over 80 years of age, shows a decline from 5% to 2.5%. Figure isolated CABG OM, by age ANZSCTS National Report 2015 Page 21

22 Clinical Status Mortality rate increases with increased urgency of clinical status (Figure 16). Elective and Urgent cases have retained a consistently low annual mortality rate (<2%) since 2010, while Emergency cases have shown a decline from 10% to 4%. Note: Salvage procedures are not shown due to low number of annual cases (<0.2%). Figure isolated CABG OM, by clinical status The intent behind clinical status classification is to identify a group of patients whose surgical risk is increased by virtue of a medically urgent situation, yet which is not sufficiently exigent as to be considered an Emergency or Salvage procedure. Urgent clinical status for 2014 was a derived calculation based on time from angiography to surgery being <72h to account for the potential misrepresentation of Urgent cases. There has been continued discussion of the validity of this derivation. This 2015 Annual Report analyses the effect of these three methods of defining Urgent clinical status on mortality (Table 3). The three methods considered are: reported clinical status, derived clinical status method 1 (procedure within 72 hours of angiography) and derived clinical status method 2 (procedure within 72 hours of angiography or of an unplanned admission). Table 3 shows that, compared to reported data, the number of Urgent patients in 2015 decreases by 70%, when Urgent clinical status is derived by method 1, and by 46% when derived by method 2. ANZSCTS National Report 2015 Page 22

23 Table reported versus derived clinical status effect on mortality Mortality (mortality/procedure, %) Clinical status Elective Urgent Emergency Salvage 2015 Reported 39/4275, /2109, 1.4 7/163, 4.3 2/11, 18.2 Derived method 1^ 58/5824, /560, 1.8 7/163, 4.3 2/11, 18.2 Derived method 2 # 52/5293, /1177, 1.5 5/77, 6.5 2/11, Reported stat 30/3547, /1470, /154, 6.5 4/10, 40.0 Derived stat method 1^ 43/4549, /468, /154, 6.5 4/10, 40.0 Derived stat method 2 # 41/4256, /863, 2.1 6/52, /10, Reported stat 31, 3611, /1748, /138, 7.2 2/11, 18.2 Derived stat method 1^ 48/4861, /498, /138, 7.2 2/11, 18.2 Derived stat method 2 # 46/4414, /1004, 1.7 6/79, 7.6 2/11, Reported stat 28/2992, /1638, /177, 5.6 3/9, 33.3 Derived stat method 1^ 47/4218, 1.1 6/412, /177, 5.6 3/9, 33.3 Derived stat method 2 # 41/3774, /953, 1.9 4/80, 5.0 3/9, Reported stat 30/3078, /1566, /147, 8.8 2/9, 22.2 Derived stat method 1^ 50/4153, /491, /147, 8.8 2/9, 22.2 Derived stat method 2 # 49/3755, /970, 2.1 6/66, 9.1 2/9, Reported stat 33/3156, /1449, /209, /8, 25.0 Derived stat method 1^ 49/4262, 1.1 6/343, /209, /8, 25.0 Derived stat method 2 # 51/3854, /850, /110, /8, 25.0 Total Reported stat 191/20659, /9980, /988, /58, 25.9 Derived stat method 1^ 295/27867, /2772, /988, /58, 25.9 Derived stat method 2 # 280/25346, /5817, /464, /58, 25.9 ^ Derived Urgent by angiography within 72 hours of procedure # V2 Derived clinical status base on v3 definition manual ANZSCTS National Report 2015 Page 23

24 Previous Myocardial Infarction (MI) OM rate for patients having MI prior to isolated CABG is near double compared to patients with no prior MI (Figure 17a); the highest risk group being patients having ST Elevation Myocardial Infarction (STEMI) prior to surgery. While mortality rate has remained stable across years for without MI and Non-STEMI (NSTEMI) patients, mortality rate for patients with STEMI shows decline since As expected, mortality rate post isolated CABG in patients with a prior MI is highest if the infarction occurs less than 24h prior to the procedure (Figure 17b), and ranged from 5-25% since Patients having MI 1-7d, 8-21d and > 21d prior to isolated CABG, have similar mortality rate compared to each other, and have remained consistently low at below 2.5% since, a. b. Figure mortality rate by a) type and b) timing of MI ANZSCTS National Report 2015 Page 24

25 Left Ventricular Dysfunction Increasingly severe left ventricular dysfunction (LVD) is associated with increasing mortality following isolated CABG. However, only approximately one-fifth of patients have moderate or severe LVD (Figure 18). OM rate is lowest for patients with normal contractility or mild dysfunction, slightly higher for those with moderate LVD, and highest for patients with severe LV dysfunction. This observation has remained consistent since Figure mortality rate by LVD ANZSCTS National Report 2015 Page 25

26 Diabetes and Pre-existing Renal Impairment Pre-existing diabetes and renal impairment are related to poor outcomes following isolated CABG. Compared to their control cohorts annual mortality rate, post isolated CABG, is higher for patients with either diabetes or with poor renal function as defined by pre-operative creatinine levels of >200µmol/L and pre-operative estimated glomerular filtration rate (egrf) levels <60mL/min/1.73m 2 (Table 4). Post isolated CABG mortality rates for diabetic patients have declined from 2.1% in 2010 to 1.4% in 2015; while for patients with poor renal function mortality rate has fluctuated year to year. Table mortality rate by diabetes and renal function Diabetes Pre-op creatinine Pre-op egfr 2015^ # Yes No <200µmol/L 200µmol/L 60ml /min/1.73m 2 >60ml /min/1.73m 2 n % mortality n % mortality n % mortality n % mortality n % mortality n % mortality Total ^1 missing case # 2 missing cases n % mortality ANZSCTS National Report 2015 Page 26

27 Post-operative Complications There are several post-operative complications associated with any type of cardiothoracic surgery; risk influenced by variables including patient age, clinical status, surgery type, renal function and previous cardiac surgery. The incidence of most complications associated with isolated CABG procedures is low (<5% of total cases; Table 5). The average incidence of these complications in 2015 is in par with that reported for (data not shown). Effect of age Advancing age is generally associated with an increased likelihood of post-operative complications (Table 5). Table post-operative complications (% of cases) by age Age <40yr 40-49yr 50-59yr 60-69yr 70-79yr >80yr Total n ^ New renal failure (NRF) Cerebrovascular complication Permanent stroke Deep sternal wound infection (DSWI) Septicaemia Return to theatre (RTT) (all cases) Re-op for bleeding Peri-operative acute myocardial infarction (AMI) New cardiac arrhythmia (NCA) Pneumonia Gastrointestinal tract (GIT) complication Multi-system failure Anticoagulant complication RBCs transfused Non-RBC products ^3 missing cases ANZSCTS National Report 2015 Page 27

28 Effect of Clinical Status The risk of developing post-operative complications and need for transfusion is higher in patients with an Emergency and Salvage status, compared to Elective and Urgent status (Table 6). Table post-operative complications (% of cases) by clinical status Clinical Status Elective Urgent Emergency Salvage Total n ^ NRF Cerebrovascular complication Permanent stroke DSWI Septicaemia RTT (all cases) Re-op for bleeding Peri-operative AMI NCA Pneumonia GIT complication Multi-system failure Anticoagulant complication RBCs transfused Non-RBC products ^3 missing cases The annual percentage of cases of Elective, Urgent and Emergency/Salvage patients undergoing isolated CABG procedures has remained consistent since 2010, with the majority being Elective (Figure 19a). Emergency and Salvage clinical status are collected separately, however due to the low numbers, herein these analyses, are combined. The percentage of Derived NRF 1 cases in Elective and Urgent patient groups is between 3-6% annually, while for Emergency/Salvage patients, ranges from 5-10% (Figure 19a). 1 Derived NRF (DNRF) is a derived calculation based on the presence of acute post-operative renal failure based on an increase in serum creatinine after procedure, or the requirement for dialysis (when the patient did not require this pre-operatively. ANZSCTS National Report 2015 Page 28

29 Similarly, the percentage of permanent stroke cases is lowest in Elective and Urgent patient groups, generally being <1% annually; and highest for Emergency/Salvage patients, ranging from 2-3% (Figure 19b). The annual percentage of cases for re-operation for bleeding varies each year within each clinical status group, however has remained consistently low between 1.5-4% of cases since 2010 (Figure 19c). The annual percentage of cases for DSWI is <3% (Figure 19d) for all patient groups. For a breakdown of complications per unit, please refer to the unit performance section for isolated CABG (Figures 22-26). a. b. ANZSCTS National Report 2015 Page 29

30 c. d. Figure a) DNRF, b) permanent stroke, c) re-op for bleeding and d) DSWI, by clinical status ANZSCTS National Report 2015 Page 30

31 Effect of Redo, On- or Off-Pump and Renal Function Patients with pre-operative renal impairment, and those undergoing redo procedures, are at higher risk of post-operative complications and require more frequent use of blood products (Table 7). Incidence of complications is similar for patients undergoing on- and off- pump procedures, however the use of blood products is higher in the former. Table post-operative complications (% of cases) by redo, use of cardiopulmonary bypass (CPB), and renal function Redo 1st procedure Redo CPB Offpump Onpump Pre-op creatinine <200 µmol/l 200 µmol/l Pre-op egfr 60mL /min /1.73m 2 >60mL /min /1.73m 2 Total Procedure n ^ NRF Cerebrovascular complication Permanent stroke DSWI Septicaemia RTT (all cause) Re-op for Bleeding Peri-operative AMI NCA Pneumonia GIT complication Multi-system Failure Anticoagulant complication RBCs transfused Non-RBC products ^3 missing cases ANZSCTS National Report 2015 Page 31

32 Resource Utilisation Resource use provides an indicator for hospitals of budget allocation, time and staff planning, and procedural planning for post-operative care. Two unit indicators of resource utilisation are ventilation (VENT) time and time in intensive care (ICU). The following boxplots (Figure 20a-b) show the 6 year ( ) average time in VENT and ICU based on clinical status (a) and renal impairment (b). Patients with a clinical status of Emergency and Salvage (a) or have pre-operative renal impairment (b), spend increased amount of time in recovery. This corroborates with data showing that these groups of patients are at higher risk of post-operative complications (Table 6 and 7). No difference in VENT of ICU time is observed with redo surgery, CPB or type, or MI prior to surgery (data not shown). a. b. Elective Urgent Emergency Salvage Low Creatinine <200 µmol/l High Creatinine >200 µmol/l Time (h) Time (h) VENT ICU VENT ICU NB: excludes outlier values NB: excludes outlier values Figure 20. VENT and ICU time by a) clinical status and b) renal dysfunction Total length of stay (LOS) and post-procedural length of stay (PPLOS) are indicators of resource utilisation (Figure 21a-c). LOS is the time from admission to discharge, while PPLOS is the time from surgery to discharge. LOS is longest in Urgent patients (Figure 21a), and PPLOS longest in Emergency patients. Salvage patients have a median stay lower than other cohorts given their low survival rate. Patients with pre-operative renal impairment have an increased LOS but similar PPLOS (Figure 21b), suggesting the recovery post-surgery is not affected by renal function. Patients with pre-operative MI have an increased LOS compared to control patients; with NSTEMI patients having longer LOS than STEMI patients (Figure 21c). PPLOS is similar across cohorts suggesting the recovery post-surgery is not affected by prior incidence of MI. CPB and redo surgery have no impact on LOS or PPLOS (data not shown). ANZSCTS National Report 2015 Page 32

33 a. b. Elective Urgent Emergency Salvage Low Creatinine <200 µmol/l High Creatinine >200 µmol/l Time (d) Time (d) LOS NB: excludes outlier values PPLOS LOS NB: excludes outlier values PPLOS c. No MI STEMI NSTEMI Time (d) LOS NB: excludes outlier values PPLOS Figure 21. LOS and PPLOS times by a) clinical status, b) renal function, and c) preprocedural MI ANZSCTS National Report 2015 Page 33

34 Unit Performance - Control Charts for isolated CABG Control charts provide a means of viewing individual unit s performance against the National average. Unit numbers are indicated on the x-axis, and are reassigned each year to maintain confidentiality of the unit. Each unit are informed of their identifying number at request. The upper and lower control limits consider incidence over total case volume and are indicated as a grey line on either side of each unit s performance. If a unit s performance on a KPI is above their control limit, they are notified, and an escalation policy is implemented to work together to address the issue in aim to return the outlying unit to within control limits. Control charts for in-hospital or 30-day mortality, DSWI and haemorrhage show variance from the control for each unit. ICU and VENT time, 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 (Appendix A). For risk adjusted in-hospital or 30-day mortality, unit 4 is outside control limits in 2015 (Figure 22a), however all units are within limits for pooled data (Figure 22b). In 2015, for DSWI and haemorrhage all units were within the control limits (Figure 23a and 24a). For pooled data, units 28 and 26 fall outside the upper control limits of DSWI (Figure 23b), and unit 13 falls outside the lower control limits (Figure 24b). For ICU time, units 10, 12 and 15 are outside the upper limit and unit 31 below lower limit in 2015 (Figure 25a), and of those units only unit 15 is within limit for data pooled. For LOS, and PPLOS, all units are within control limits for 2015 and pooled data (data not shown). ANZSCTS National Report 2015 Page 34

35 Fraction defective a. b. Control limit Fraction defective Hospital unit 1 unit is out of control Figure 22. a) 2015 and b) RAMR for in-hospital or 30-day mortality, by unit Fraction defective Control limit Fraction defective Hospital unit 1 unit is out of control a. b. Control limit Fraction defective Control limit Fraction defective Fraction defective Hospital unit 0 units are out of control Figure 23. a) 2015 and b) DSWI, by unit Fraction defective Hospital unit 2 units are out of control Fraction defective a. b. Control limit Fraction defective Hospital unit 0 units are out of control Figure 24. a) 2015 and b) incidence of RTT for haemorrhage, by unit Fraction defective Control limit Fraction defective Hospital unit 1 unit is out of control ANZSCTS National Report 2015 Page 35

36 a. b. Control limit ICU Control limit ICU Mean ICU (h) Hospital unit 4 units are out of control Figure 25. a) 2015 and b) ICU time, by unit Mean ICU (h) Hospital unit 4 units are out of control Mean Vent (h) a. b. Control limit Hospital unit 1 unit is out of control VENT Figure 26. a) 2015 and b) VENT time, by unit Mean Vent (h) Control limit Hospital unit 2 units are out of control VENT ANZSCTS National Report 2015 Page 36

37 Valve Surgery This section examines valve procedures performed in 31 Australian units. A summary of the number of valve procedures performed in 2015, and percentage mortality associated with each, are shown in Table 8. Single valve aortic root reconstructions are reported in Table 8a, while aortic root reconstruction and transcatheter aortic valve replacements (TAVR) are reported in Table 8b. The most common valve procedures performed in 2015 were aortic, then mitral, mortality being 1.7% and 1.1% respectively when performed alone, and 2.4% and 5.1% respectively when combined with CABG. Table 8a. Summary of procedures 2015 Without CABG ^36 procedures are not included as they were miscoded With CABG mortality mortality Valve Procedure n n (%) (%) Aortic Replacement (AVR) Mitral Replacement Repair Tricuspid Pulmonary Mitral & Aortic Mitral & Tricuspid Aortic & Tricuspid Other Double Triple valve surgery Quadruple valve surgery Total valve procedures^ ANZSCTS National Report 2015 Page 37

38 Table 8b. Other Valve Procedures 2015 WITHOUT CABG WITH CABG Pulmonary autograft aortic root replacement (Ross) # TAVRs captured by the ANZSCTS Database are ones performed by cardiothoracic surgeons only n mortality % n mortality % Aortic root replacement with valve conduit Root reconstruction with valve sparing (David) TAVR Transapical # TAVR Transfemoral # Total other valve procedures ANZSCTS National Report 2015 Page 38

39 Observed Mortality (OM) The distribution of type of valve procedures, ranked by patient age, shows aortic valve procedures increase, and mitral valve procedures decrease with increasing age (Figure 27). Tricuspid and pulmonary replacement procedures are not often performed in patients above 50 years of age. Mortality rates appear similarly low across age groups, and are highest for tricuspid procedures, relative to other valve procedures. a. b. Figure OM for single valve procedures a) 2015 and b) , by age ANZSCTS National Report 2015 Page 39

40 The highest proportion of single valve procedures is the AVR. Most AVRs were Elective, with a consistently low mortality rate (<3%) annually since 2010 (Figure 28a). As expected, mortality rate increases in Urgent and Emergency patients. The same observations are seen in AVRs with CABG procedures (Figure 28b). a. b. Figure 28. Mortality rate for a) single AVR and b) AVR with CABG, by clinical status ANZSCTS National Report 2015 Page 40

41 Distribution of patient age for AVRs with CABG (Figure 29) has remained consistent from 2010 to 2015, with the majority of AVR procedures performed being on year old patients. While mortality rates show variation from year to year (0-5%), generally mortality increases with increasing age. Exceptions being 2010 and 2014 where <40y and y groups had high mortality rates. Figure 29. Mortality rate for AVR with CABG, by patient age The number of initial versus redo single AVRs with or without CABG procedures has remained consistent since 2010 (Figure 30). As expected, mortality rate is highest in patients undergoing redo procedures. Figure 30. Mortality rate for initial and redo single AVR with and without CABG ANZSCTS National Report 2015 Page 41

42 Post-operative complications and resource utilisation for valve procedures The incidence of most complications associated with valve procedures, except for arrhythmia and RTT, is low (<5% of total cases; Table 9a). Combined valve + CABG procedures have an increased frequency of post-operative complications (Table 9b). Table 9a post-operative complications (% of cases) following valve procedures Valve Position Aortic Mitral Tricuspid or Pulmonary Total n ^ NRF Cerebrovascular complication Permanent stroke Transient stroke Continuous coma DSWI Septicaemia RTT (all cause) Re-op for bleeding NCA Pneumonia GIT complication Multi-system failure Anticoagulant complication RBCs transfused Non-RBC products ^4 missing cases ANZSCTS National Report 2015 Page 42

43 Table 9b post-operative complications (% of cases) following valve with CABG procedures Aortic Mitral Valve Position Tricuspid or Pulmonary Total n ^ NRF Cerebrovascular complication Permanent stroke Transient stroke Continuous coma DSWI Septicaemia RTT (all cause) Re-op for bleeding NCA Pneumonia GIT complication Multi-system failure Anticoagulant complication RBCs transfused Non-RBC products ^2 missing cases ANZSCTS National Report 2015 Page 43

44 Resource utilisation by valve position from (Figures 31-32) shows that on average, patients who have mitral procedures with CABG spend more time in ICU than patients having other valve and CABG operations (Figure 31b). Patients having valve surgery alone, spend near equivalent time in ICU and under VENT regardless of valve procedure. The effect of age and clinical status on post-operative complications (Tables 10 and 11) single valve and CABG surgery, is shown. a. b. Aortic Mitral Tricuspid or Pulmonary Aortic Mitral Tricuspid or Pulmonary Time (h) Time (h) ICU VENT ICU VENT NB: excludes outlier values NB: excludes outlier values Figure 31. ICU and VENT times by valve position a) without and b) with CABG a. b. Aortic Mitral Tricuspid or Pulmonary Aortic Mitral Tricuspid or Pulmonary Time (d) Time (d) LOS PPLOS LOS PPLOS NB: excludes outlier values NB: excludes outlier values Figure 32. LOS and PPLOS by valve position a) without and b) with CABG ANZSCTS National Report 2015 Page 44

45 Table 10a post-operative complications (% of cases) by age single valve without CABG Age (%) <40 yr <50 yr yr yr yr >80 yr Total n ^ NRF Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma DSWI Septicaemia RTT (all cause) Re-op for bleeding Peri-operative AMI NCA Pneumonia GIT complication Multi-system Failure Anticoagulant complication RBCs transfused Non-RBC products ^2 missing cases ANZSCTS National Report 2015 Page 45

46 Table 10b post-operative complications (% of cases) by age single valve with CABG Age (%) <40 yr <50 yr yr yr yr >80 yr Total n ^ NRF Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma DSWI Septicaemia RTT (all cause) Re-op for bleeding Peri-operative AMI NCA Pneumonia GIT complication Multi-system Failure Anticoagulant complication RBCs transfused Non-RBC products ^2 missing cases ANZSCTS National Report 2015 Page 46

47 Table 11a post-operative complications (% of cases) by clinical status single valve without CABG Clinical Status Elective Urgent Emergency/Salvage # Total n ^ NRF Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma DSWI Septicaemia RTT (all cause) Re-op for bleeding Peri-operative AMI NCA Pneumonia GIT complication Multi-system Failure Anticoagulant complication RBCs transfused Non-RBC products ^4 missing cases # Salvage n=2 ANZSCTS National Report 2015 Page 47

48 Table 11b post-operative complications (% of cases) by clinical status single valve with CABG Clinical Status Elective Urgent Emergency/Salvage # Total n ^ NRF Cerebrovascular complication Permanent Stroke Transient Stroke Continuous Coma DSWI Septicaemia RTT (all cause) Re-op for bleeding Peri-operative AMI NCA Pneumonia GIT complication Multi-system Failure Anticoagulant complication RBCs transfused Non-RBC products ^2 missing cases # Salvage n=3 ANZSCTS National Report 2015 Page 48

49 Since 2010, in patients undergoing isolated aortic or mitral valve procedures, the annual percentage of OM (Figure 33) and re-op for bleeding (Figure 34), has remained below 6%; and for DSWI (Figure 35), below 1.2%. For 2015 aortic procedures, units outside of control limits (Figures 34-37) were as follows: unit 8 for re-op for bleeding; unit 30 for DSWI; units 6, 10, 12, 15, 16 and 26 for ICU time; units 6, 8 and 15 for VENT time. For mitral procedures, units outside of control limits (Figures 33-37) were: unit 8 for OM; units 8 and 12 for DSWI; units 10 and 12 for ICU time; units 15, 17, 23 and 29 for VENT time. All units were within the control limits for other KPIs (RAMR, DNRF, LOS and PPLOS) for both aortic and mitral procedures (data not shown). a. b. c. Control limit Fraction defective Control limit Fraction defective Fraction defective Hospital unit 0 units are out of control Fraction defective Hospital unit 1 unit is out of control Figure OM in valve procedures (a) and in 2015 for b) aortic and c) mitral procedures, per unit ANZSCTS National Report 2015 Page 49