Outcomes analysis, quality improvement, and patient safety
“What’s the Risk?” Assessing and Mitigating Risk in Cardiothoracic Surgery

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Burden of Cardiac and Thoracic Disorders

Acquired heart disease affects 27.6 million adults in the United States, is the leading cause of death (611,106 estimated for 2016), and is projected to result in 3.7 million hospitalizations annually [5]. Approximately 600,000 adult cardiac surgical procedures are expected to be performed in 2016 [6]. In addition, congenital heart disease affects approximately 1% of live births (40,000 per year in the United States), and approximately 25% of those require surgery in their first year of life [7]

Host Factors

Surgical risk should be assessed and mitigated where possible across all phases of patient care. Risk is increased when a mismatch exists between the physiologic demand of the procedure and the patient’s functional reserve. Age is consistently an important risk factor, and elderly patients incur added risk associated with the potential for frailty, falls, infection, and pulmonary complications 16, 17. At the other end of the spectrum, prematurity also confers risk, with one study reporting 43%

Non–Host Factors

In delivering the best possible care, surgeons must choose the appropriate procedure for each individual patient and intervene in a timely fashion. Each patient’s values and constraints, pathologic anatomy, and physiology will challenge surgical decision making and the system of health care delivery. In cardiac surgery, for example, procedural considerations tailored to risk profiles include on-pump CABG versus off-pump CABG, CABG versus minimally invasive CABG, total arterial revascularization

Systems of Care

Important in the discussion of optimizing the delivery of surgical care has been the influence of the health care facility and the relationship between surgical volume and clinical outcomes [78]. Market concentration and individual hospital volumes contribute to declining mortality associated with esophagectomy and pulmonary lobectomy [79]. Reductions in mortality rates with cardiovascular procedures have been associated with factors not related to volume, although increased institutional

Conclusion

The considerable global burden of surgery, combined with evidence of considerable variability in cardiothoracic surgical outcomes, and its associated costs create a “burning platform” to improve the delivery of health care. An important component of this effort involves a systematic, prioritized approach to risk assessment and management to improve safety, quality, and value in all aspects of surgical care. Each facility, health system, and individual practitioner has unique and important

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