Surg 1996;5(1) I I th Inter
ADVANCES IN QUALITY OF CARE AND EFFICIENCY M THE MANAGEMENT OF CARDIAC SURGERY PATIENTS J. Tatoulis, J Peirce, I. Wayland Department of Cardmthoracic Surgery, Royal Melbourne Hospital, Vie., Australia
Systolic anterior motion of the mitral valve after mitral valve repair for mitral regurgitation R.B Garlick, M A.H.Gardner, P.J.Tesar The Prince Charles Hospital, Brisbane Systohc anterior motion (SAM) of the mitral valve causing I& ventricular outflow tract obstructmn (LVOTO) or mitral regurgitatmn (MR) may complicate an otherwise successful maal valve repair. It 1s thought that excess posterior mitral leaflet tissue remaining after repair is responsible by pushing the anterior leaflet mto the left ventricular outflow tract. Added factors include a narrow mdro-aortx angle. a small left ventricle and a hyperd\namx post-byTpass haemcdpnamic state. Smce 1991 when transcesophageal echo was mtroduced to assess mitral valve repair intraoperatively, six cases of systohc anterior motion have occurred (for an incidence of 19%). All patients had moderate to severe m&al regurgitation due to prolapse of the posterior mitral leaflet secondary to m:romatous degeneratmn preoperatively All patients undcnvent quadrantic resectmn of the posterior mitral leaflet and four patients had an annuloplasty with a stnp of pericardium. SAM was marked m all patients wth significant LVOTO in five and moderate m&al regurgitatmn m four One patient with no LVOTO or MR reqmred no further treatment, wth resolution of the SAM postoperatively and one patient responded to cessation of ionotroplc therapy, mtravencms verapunal and tlmd loading. Four patients underwent a second pump run with further resection of the posterior mitral lea&t or opening up of the mmuloplasty Of these four, MR w,orsened in two requnng valve replacement whilst in another recurrence of MR 15 months later due scarring and retraction of the postermr n&al leaflet necessitated reaperatmn and replacement. Further measures are required If systolic anterior motion after mitral valve repmr causes left ventricular outflow tract obstructmn or mdral regurgitation This may be medical therapy to correct a post-bypass hyperdlnamic haem&namic state or further surgery to reduce the postermr mitral leaflet. Only If these measures are unsuccessful is mitral valve replacement necessary
Cardiothoracic Annual Scientific
There is increasing emphasison measurementand improvement, of standards of care, length of stay (LOS) and effuency in the hospital managementof patients undergomg cardiac surgery. The aim of this study was to evaluate2 specific initiatives to addressthese issues. The first was the introduction of specific Clinical ManagementPlan (CMP) for cardiac surgery. This was followed by the introduction of a Hospital In The Home (Iw) early discharge programme. The methods involved developmentof standardized CMP’s for similar groups of patients, Coronary Artery Grafts (CAG), Valve Surgery (VR), Coronary Grafts and Valves (CAG & VR), etc. AU obsewations, clinical tests and parameters to be achievedby pauents on each day were defined and data was collected prospectively. From July 1993to June 1995,all patients (1367) were managedin this way. From March 1995,the HIH programme was commenced All patients (232) were enrolled. Exclusions were patients > 75 years, home > 30 km away, emergency patients in cardiogenic shock, and patients undergoing multiple procedures. The HIH programme study was controlled, initially by randomizatxonand subsequently by usmg the > 30 km group as the control group (C). The HIH group war discharged on the 6th post-op day unless there was a medical contra-indication. The HIH patients were visited by a Cardiac Surgery Nurse, at home for 1 or 2 days. All datawas collected prospectively includmg unplanned re-admxssions, attendancesto casuals, and comphcations including infechon, elisions, pleural and pericardial, myocardral infarction Patient satisfaction surveys were conducted and data reviewed monthly. Results: The introduction of CMP reduced the total hospital LOS from a mean of 11.8 days to 8.8 days for the entire group, and CAG, from I I. I days to 8.4 days The incidence of major events was simdar to 92/93. Peri-op mortal 93/94 2.1% Y2.9%, pen-op AM1 2.5% -v- 2.5%, sternal infection 931941.S%-v- 1.I%, re-op for bleeding 93/94 2.2% -v- 3.5%. The HIH programme resulted m further reduction of LOS by 0.7 days. Of the 80 HIH patients, 60 were discharged as planned (p.o day 6). There were no readmissions (30 days). 2 (3.3%) returned to casualty (palpitations), 1 (1.6%) developeda leg wound infection treatedat home. There were no deaths. Conclusion: Introduction of CMP resulted in a marked reduction ofLOS (up to 30%) without compromise in quality of care and outcome. These results were further enhancedby early discharge of well selectedpatients.
IN COST CONTAINMENT
AORTIC AND PULMONARY HOMOGRAFT AORTIC VALVE REPLACEMENT AT ROYAL PERTH HOSPITAL: ANALYSIS OF THE FIRST 61 CASES. J.M. Rankin’, J. Tan’, A.J. Hedge’ Department of Cardiology’ and Cardiothoracic Surgery’, Royal Perth Hospital, Perth, Western Australia. Sixty one homograff aotic valve replacements were performed at cur institution Setmen 13/3/90 and X/9/94 by four surgeons. Patients ranged from 18 to 82 years of age (mean 53.9) and the majority (47.5%) were in NYHA functional class 2, with four patients (6.5%) in dass 4. Aortic homogmtb were prefelTed although pulmonary hamqrafts were used in 15 cases (24.6%) because of the lack of an appropriately sized aortic homogrt&. A subcoronary technique was used in 43 cases (70%), other techniques included 14 (23%) inclusion cylinders and 2 root replacements (3.3%). There was one periaperative death (1.6%) from cardiogenic shock, sepsis and multi-xgan failure. Mean follow-up was 24 months (range 0 - 64 months). FolIow-up data wre available for 55 (90.1%) of the cases. The prosthesis was assessed by echocardiomphy prior to discharge in 56 cases (91.8%) and longterm echocardiog,aphic assessmentavailable for 38 cases (62.3%). There were two deaths at 2 and 8 months (Pulmonary sepsis C CVA respectively) gitig a 2 year momlity of 4.9%. There was no definite evidence of an embolic event related to the prosthesis and no case of endocarditis. Severe ostial I.& Main stenosis requiring bypass grafting developed 12 months after an inclusion cylinder amtic homogmft was implanted in one patient with previousIy mxmal coronary arteries. Sign&ant (zmoderate) incompetence was detected in 8 cases (13.1%). The only factor predictive of valve failure was the fmlctimlal class with 75% of the patients in class 4 developing significant incompetence (p=al.oOOS).Despite the relatively small number of pulmonary homogra&, there was a strong trend to higher rates of significant incompetence in pulmonary (28.6%) compared to aortic (9.7%) homografts @=O.OB).There was also a trend to increasing incmnpetence for valves inverted during insertion &0.07). Four cases (6.5%) required redo valve replacement. This was significantly more common for pulmomuy (21.4%) than amtic (2.4%) homogmfts (p==O.OZ). Redo valve replacement was s&fmanUy more cmmmcmin those valves inverted during insertion @=x1.02).Amongst survivors, t?eedom from significant incompetencewas 90.9% at 2 years (95.1% for aortic and 78.6% for pulmonary homogr&ts).
Brian Buxton Victoria1Heart Centre, Epworth Hospital, Melbourne Capitatian is a system by which payments to professionals are made in a smgle paymentper caprro, irrespective of the services provided. The syfem has been tried in the United Kingdom by government and recently by health mamtenance organizations in the US. Capitation results in the reversal of the economic incentives and is hkely to create a surplus of cardiac specialists and facilities. As practiced in California. capltated cardiac prowders reduce costs by about one third. The cardiac surgeonshave been identified as the single largest potential pool for cardiac cost reductions in the US. At present relatively few insurers use capitation as the method of payment (cardiology only 2 1%). By capitating primary care physicians, the demand for specialist services drops dramatically Capitation of specialists 1s expected to further reduce prowder spending. This process results in no new practices of cardiac care where the primary care physician becomes more important, resulting in the cardiologist or cardiac surgeon being reduced to little more than a technician. The process is likely to result in a dramatic reduction in professional income by as much as 50% and this is likely to be combinedwith a surplus of cardmc specialists. Relatively few health insurance companies use capltation as a method of payment for cardiac surgeons but in most companies the mtionale for capitating cardiac surgeons’ fees rather than paying case fees is based primarily on administrative convenience. The disheartenmgeffects of cap&ion are that the procedural rates may drop by as much as two thirds, wth enormous cost savings to insurance companies and hospitals. The questlooof quality of service and the availabihty of services are the main concerns. This may ultimately place in Jeopardy patients from the high cost centres such as academic and hospitals with research and teaching interests. In Australia we are at present protected to some extent from this process becauseof the dramatic fall in private health insurance.