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Gerald T. O'Connor, PhD, DSc; Stephen K. Plume, MD; Elaine M. Olmstead; Laurence H. Coffin, MD; Jeremy R. Morton, MD; Christopher T. Maloney, MD; Edward R. Nowicki, MD; Joan F. Tryzelaar, MD; Felix Hernandez, MD; Lawrence Adrian, PA-C; Kevin J. Casey; David N. Soule; Charles A. S. Marrin, MB,BS; William C. Nugent, MD; David C. Charlesworth, MD; Robert Clough, MD; Saul Katz, MD; Bruce J. Leavitt, MD; John E. Wennberg, MD, MPH

JAMA. 1991;266(6):803-809.

Abstract
Objective.
—A prospective regional study was conducted to determine if the observed differences in in-hospital mortality rates associated with coronary artery bypass grafting (CABG) are solely the result of differences in patient case mix.

Design.
—Regional prospective cohort study. Data including patient demographic and historical data, body surface area, cardiac catheterization results, priority of surgery, comorbidity, and status at hospital discharge were collected. This study presents data for 3055 CABG patients between July 1,1987, and April 15, 1989.

Setting.
—This study includes data from all surgeons performing cardiothoracic surgery in Maine, New Hampshire, and Vermont; the data were collected from five regional medical centers.

Patients.
—Data were collected from all consecutive isolated CABG surgery patients during the study period.

Main Outcome Measures.
—Crude and adjusted in-hospital mortality rates associated with CABG.

Main Results.
—The overall crude in-hospital mortality rate for isolated CABG was 4.3%. The rate varied among centers (range, 3.1% to 6.3%) and among surgeons (range, 1.9% to 9.2%). Predictors of in-hospital mortality included increased age, female gender, small body surface area, greater comorbidity, reoperation, poorer cardiac function as indicated by a lower ejection fraction, increased left ventricular end diastolic pressure, and emergent or urgent surgery. After adjusting for the effects of potentially confounding variables, substantial and statistically significant variability was observed among medical centers (P =.021) and among surgeons (P =.025).

Conclusion.
—We conclude that the observed differences in in-hospital mortality rates among institutions and among surgeons in northern New England are not solely the result of differences in case mix as described by these variables and may reflect differences in currently unknown aspects of patient care. Understanding this variation requires a detailed understanding of the processes of care.

(JAMA. 1991;266:803-809)

Author Affiliations
PA, RN; for the Northern New England Cardiovascular Disease Study Group

From the Departments of Medicine (Dr O'Connor and Ms Olmstead), Surgery (Drs Plume, Marrin, and Nugent), and Community and Family Medicine (Drs O'Connor and Wennberg) and The Center for Evaluative Clinical Sciences (Drs O'Connor, Plume, and Wennberg), Dartmouth-Hitchcock Medical Center, Hanover, NH; Department of Surgery, Medical Center Hospital of Vermont, Burlington (Drs Coffin and Leavitt and Mr Casey); Department of Surgery, Maine Medical Center, Portland (Drs Morton, Nowicki, Tryzelaar, and Katz and Mr Adrian); Department of Surgery, Catholic Medical Center, Manchester, NH (Drs Maloney and Charlesworth); Department of Surgery, Eastern Maine Medical Center, Bangor (Drs Hernandez and Clough); and Maine Medical Assessment Program, Augusta (Mr Soule).

Footnotes
Reprint requests to Clinical Research Section, Department of Medicine, Dartmouth-Hitchcock Medical Center, 2 Maynard St, Hanover, NH 03756 (Dr O'Connor).

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