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Collaborative practice: a personal journey
EDITORIALS
Collaborative Practice: A Personal Journey William Nugent, MD Section of Cardiothoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire and Department of Surgery, Dartmouth Medical School, Hanover, New Hampshire
I
n this issue of The Annals of Thoracic Surgery, DeFoe and colleagues from the Northern New England Cardiovascular Disease Study Group (NNE) report on the relationship between lowest hematocrit during cardiopulmonary bypass and clinical outcome after coronary artery bypass grafting (CABG) [1]. Of 6,980 consecutive patients who underwent CABG at six medical centers in Maine, New Hampshire, and Vermont and at the BethIsrael Deaconess Hospital between July 1996 and December 1998, those whose hematocrit while on cardiopulmonary bypass was allowed to fall below 19% had higher in-hospital mortality rates, higher intraoperative use of balloon support, and more frequent return to cardiopulmonary bypass after initial attempt at separation. Women, individuals with small body surface areas, and patients who were anemic before operation were most likely to be severely anemic on bypass. See also page 769
This article is important for what it tells us about the consequences of levels of anemia which we previously accepted as harmless. It is equally important for what it tells us about how regional collaboration can help clinicians to improve the care of the patients who trust them with their lives. I was present at the meeting in Portland, Maine, in May 1989, when the NNE reported to its membership that there was a more than twofold difference in mortality rates among member institutions performing CABG operations. Although I feared that releasing such sensitive information would incite witch-hunts and gaming strategies that would destroy the consortium, I reluctantly agreed with the rest of the organization to publish our data [2] only after we promised one another that we would use it solely to improve care. Ten years later, this article represents another fulfillment of that promise. During the 2 years after the NNE’s initial report, site visits among member institutions made us aware of how differently we were practicing cardiac surgery [3]. Retrospective review of charts of patients who died after CABG revealed that postoperative low cardiac output syndrome (LOS), mostly among patients who had normal ventricular function before operation, was the most common initiating event leading to death. Differing incidence of LOS explained 80% of the differences in mortality between surgeons with high mortality rates and surgeons with low mortality rates [4]. Studying differences in blood Address reprint requests to Dr Nugent, Section of Cardiothoracic Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756-0001; e-mail: william.c.nugenthitchcock.org.
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
utilization, suggested by our perfusionists, is part of our effort to better understand LOS within the region. There is a tradeoff between optimizing oxygen delivery and avoiding the hemodynamic and infectious risks of transfusion. Whether, when, and how much blood to transfuse in patients undergoing CABG is a complex decision. Among Northern New England hospitals this clinical uncertainty is reflected in institutional transfusion rates for CABG patients that vary between 28% and 78%. Finding no differences in patient characteristics that would explain this variation, we now recognize that the decision to transfuse has been driven mostly by clinician preference and habit. This study also suggests that the negative impact of anemia has already been incurred by the time the decision to transfuse is made. I anticipate that variation in transfusion rates will narrow while strategies to avoid anemia on bypass replace our traditional processes. These actions will likely save more lives. At its May 2000 meeting in Manchester, New Hampshire, the NNE reported to its membership that last year’s adjusted regional mortality rate for isolated CABG was 2.1%. It also reported that there has been no statistical difference in mortality rates among participating institutions for the last 5 years. Working together, we have made it possible to undergo CABG at any institution in Northern New England at the same high likelihood of survival. Avoiding excessive anemia on bypass is one of many examples of how we have learned to improve the results of our care, findings we could not have made by working alone or only within our own institutions. In Northern New England, collegial trust remains strong, based on our original promise: we collect and share data solely to improve care. Our regional performance has become as important as our individual or institutional performance. The skepticism and paranoia that I felt in 1990 have been replaced by pride in the clinicians who I am privileged to collaborate with and in the work that we have done together.
References 1. DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Ann Thorac Surg 2001;71:769 –76. 2. O’Connor GT, Plume SK, Olmstead EM, et al. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. JAMA 1991;266:803–9. 3. O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA 1996; 275:841– 6. 4. O’Connor GT, Birkmeyer JD, Dacey LJD, et al. Results of a regional study of modes of death associated with coronary artery bypass grafting. Ann Thorac Surg 1998;66:1323–9. Ann Thorac Surg 2001;71:765
• 0003-4975/01/$20.00 PII S0003-4975(00)02461-9
Collaborative Practice: A Personal Journey William Nugent, MD Section of Cardiothoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire and Department of Surgery, Dartmouth Medical School, Hanover, New Hampshire
I
n this issue of The Annals of Thoracic Surgery, DeFoe and colleagues from the Northern New England Cardiovascular Disease Study Group (NNE) report on the relationship between lowest hematocrit during cardiopulmonary bypass and clinical outcome after coronary artery bypass grafting (CABG) [1]. Of 6,980 consecutive patients who underwent CABG at six medical centers in Maine, New Hampshire, and Vermont and at the BethIsrael Deaconess Hospital between July 1996 and December 1998, those whose hematocrit while on cardiopulmonary bypass was allowed to fall below 19% had higher in-hospital mortality rates, higher intraoperative use of balloon support, and more frequent return to cardiopulmonary bypass after initial attempt at separation. Women, individuals with small body surface areas, and patients who were anemic before operation were most likely to be severely anemic on bypass. See also page 769
This article is important for what it tells us about the consequences of levels of anemia which we previously accepted as harmless. It is equally important for what it tells us about how regional collaboration can help clinicians to improve the care of the patients who trust them with their lives. I was present at the meeting in Portland, Maine, in May 1989, when the NNE reported to its membership that there was a more than twofold difference in mortality rates among member institutions performing CABG operations. Although I feared that releasing such sensitive information would incite witch-hunts and gaming strategies that would destroy the consortium, I reluctantly agreed with the rest of the organization to publish our data [2] only after we promised one another that we would use it solely to improve care. Ten years later, this article represents another fulfillment of that promise. During the 2 years after the NNE’s initial report, site visits among member institutions made us aware of how differently we were practicing cardiac surgery [3]. Retrospective review of charts of patients who died after CABG revealed that postoperative low cardiac output syndrome (LOS), mostly among patients who had normal ventricular function before operation, was the most common initiating event leading to death. Differing incidence of LOS explained 80% of the differences in mortality between surgeons with high mortality rates and surgeons with low mortality rates [4]. Studying differences in blood Address reprint requests to Dr Nugent, Section of Cardiothoracic Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756-0001; e-mail: william.c.nugenthitchcock.org.
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
utilization, suggested by our perfusionists, is part of our effort to better understand LOS within the region. There is a tradeoff between optimizing oxygen delivery and avoiding the hemodynamic and infectious risks of transfusion. Whether, when, and how much blood to transfuse in patients undergoing CABG is a complex decision. Among Northern New England hospitals this clinical uncertainty is reflected in institutional transfusion rates for CABG patients that vary between 28% and 78%. Finding no differences in patient characteristics that would explain this variation, we now recognize that the decision to transfuse has been driven mostly by clinician preference and habit. This study also suggests that the negative impact of anemia has already been incurred by the time the decision to transfuse is made. I anticipate that variation in transfusion rates will narrow while strategies to avoid anemia on bypass replace our traditional processes. These actions will likely save more lives. At its May 2000 meeting in Manchester, New Hampshire, the NNE reported to its membership that last year’s adjusted regional mortality rate for isolated CABG was 2.1%. It also reported that there has been no statistical difference in mortality rates among participating institutions for the last 5 years. Working together, we have made it possible to undergo CABG at any institution in Northern New England at the same high likelihood of survival. Avoiding excessive anemia on bypass is one of many examples of how we have learned to improve the results of our care, findings we could not have made by working alone or only within our own institutions. In Northern New England, collegial trust remains strong, based on our original promise: we collect and share data solely to improve care. Our regional performance has become as important as our individual or institutional performance. The skepticism and paranoia that I felt in 1990 have been replaced by pride in the clinicians who I am privileged to collaborate with and in the work that we have done together.
References 1. DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Ann Thorac Surg 2001;71:769 –76. 2. O’Connor GT, Plume SK, Olmstead EM, et al. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. JAMA 1991;266:803–9. 3. O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA 1996; 275:841– 6. 4. O’Connor GT, Birkmeyer JD, Dacey LJD, et al. Results of a regional study of modes of death associated with coronary artery bypass grafting. Ann Thorac Surg 1998;66:1323–9. Ann Thorac Surg 2001;71:765
• 0003-4975/01/$20.00 PII S0003-4975(00)02461-9