Collaborative Quality Improvement Reduces Postoperative Pneumonia After Isolated Coronary Artery Bypass Grafting Surgery

Abstract

Background: To date, studies evaluating outcome improvements associated with participation in physician-led collaboratives have been limited by the absence of a contemporaneous control group. We examined post cardiac surgery pneumonia rates associated with participation in a statewide, quality improvement collaborative relative to a national physician reporting program.

Methods and results: We evaluated 911 754 coronary artery bypass operations (July 1, 2011, to June 30, 2017) performed across 1198 hospitals participating in a voluntary national physician reporting program (Society of Thoracic Surgeons [STS]), including 33 that participated in a Michigan-based collaborative (MI-Collaborative). Unlike STS hospitals not participating in the MI-Collaborative (i.e., STSnonMI) that solely received blinded reports, MI-Collaborative hospitals received a multi-faceted intervention starting November 2012 (quarterly in-person meetings showcasing unblinded data, webinars, site visits). Eighteen of the MI-Collaborative hospitals received additional support to implement recommended pneumonia prevention practices ("MI-CollaborativePlus"), whereas 15 did not ("MI-CollaborativeOnly"). We evaluated rates of postoperative pneumonia, adjusting for patient mix and hospital effects. Baseline patient characteristics were qualitatively similar between groups and time. During the preintervention period (Q3/2011 through Q3/2012), there was no statistically significant difference in the adjusted odds of pneumonia for STS hospitals participating in the MI-Collaborative compared to the STS non-MI hospitals. However, during the intervention period (Q4/2012 through Q2/2017), there was a significant 2% reduction per quarter in the adjusted odds of pneumonia for MI-Collaborative hospitals (n=33) relative to the STS-nonMI hospitals. There was a significant 3% per quarter reduction in the adjusted odds of pneumonia for the MI-CollaborativeOnly (n=15) hospitals relative to the STS-nonMI hospitals. Over the course of the overall study period, the STS-nonMI hospitals had a 1.96% reduction in risk-adjusted pneumonia (pre- vs. intervention periods), which was less than the MI-Collaborative (3.23%, P=0.011). Over the same time period, the MI-CollaborativePlus (n=18) reduced adjusted pneumonia rates by 10.29%, P=0.001.

Conclusions: Participation in a physician-led collaborative was associated with significant reductions in pneumonia relative to a national quality reporting program. Interventions including collaborative learning may yield superior outcomes relative to solely using physician feedback reporting.

Clinical trial registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02068716.

Keywords: Cardiopulmonary bypass; infection; thoracic surgery.

Figure 1:

Selection criteria schema for CABG patients from STS. STS (Society of Thoracic Surgeons Adult Cardiac Surgery Database); CABG (coronary artery bypass grafting); STS-nonMI: 1,164 Hospitals (other than those located in Michigan) that participated in the Society of Thoracic Surgeons Adult Cardiac Surgical Database; MI-Collaborative: 33 Michigan hospitals that participated a physician-led collaborative

Figure 2:

Adjusted Postoperative Pneumonia Rates by Group and Calendar Quarter. STS: Society of Thoracic Surgeons; MI: Michigan. STS-nonMI: 1,164 Hospitals (other than those located in Michigan) that participated in the Society of Thoracic Surgeons Adult Cardiac Surgical Database; MI-Collaborative: 33 Michigan hospitals that participated a physician-led collaborative.