Benchmarking the provision of coronary artery bypass grafting surgery in Newfoundland and Labrador

Power, Lorena (2003) Benchmarking the provision of coronary artery bypass grafting surgery in Newfoundland and Labrador. Masters thesis, Memorial University of Newfoundland.

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Abstract

Governmental concern for the effective utilization of limited health care resources has necessitated the development of standardized, objective tools to measure and document changes within the health care system. The use of coronary artery bypass grafting surgery (CABGS), like all other health procedures, has high public cost and must be perfom1ed appropriately, when necessary, efficiently, and with high quality of care. Establishing the required frequency of a procedure, CABGS, in a population (benchmarking) is vital to ensure adequate allocation of resources. In 1995 researchers found that CABG surgery in Newfoundland and Labrador (NL) was being appropriately applied but that access to the service was far less than ideal. The authors benchmarked the need for CABGS. The current investigation was designed to reassess the need for CABGS in this province and to provide revised benchmarks. The analysis compared data between study periods and addressed the following areas: the current need for CABGS in NL, the appropriateness of utilization, the necessity of utilization, the waiting times, the quality of care delivered with this service, and the future need of CABGS in NL. -- All patients identified with critical coronary artery disease (CAD) through coronary angiography (CA) between August 18, 1998 and August 13, 1999 were included in the study. In addition, all patients who received CABGS during the same study period were followed for quality of care. Findings were then compared with a previous study (1994/95). -- In 1998/99, 1625 patients had critical coronary artery disease and were characterized by late stage angina symptoms and multi-vessel disease. The average age was 62 years and 75% were male. Four hundred thirty-four patients (434) underwent CABGS during the study period while 517 patients were referred for surgery. Thus, the waitlist increased by ~ 30% throughout the year. Only 40% of patients received surgery within the recommended waiting time. Over 94% of the referrals were deemed necessary. There was an excellent correlation between the cardiovascular team and the objective RA D criterion in decision-making (Kappa=0.86). We identified an additional 91 patients for whom surgery was recommended, according to RAND criteria, but who did not receive a referral. Eighty-six percent (86%; n=78) of this group were actually treated with percutaneous transluminal coronary angioplasty (PTCA). -- Since 1994/95, the number of diagnostic catheterizations has increased by 37%. In addition, there was a 50% increase in critical coronary artery disease diagnosis (1 082-1625). In both studies, the proportion of patients with critical CAD diagnosed by angiography was similar. Although age and gender remained stable throughout the study periods, the latter (1999) cohort was characterized by a higher proportion of Class III angina, a lower proportion of positive exercise stress testing results, and less patients with a very low ejection fraction. Yet, the proportion of patients with critical CAD referred for CABGS remained stable (36%). Whilst there has been a dramatic increase in referrals for angioplasty (137%), there has been a relative decline in medical therapy as a means of treatment for these patients (-18%). Compared to 1995, increased utilization of CABGS was related to the diagnosis of patients at an earlier symptomatic phase of coronary artery disease (CAD) and to increased access to coronary catheterization. In addition, increased use of PTCA and changes in health care altered demand. -- We concluded that physician clinical decision-making was an appropriate way by which to measure need for CABGS. The authors have noted an increase in utilization of cardiac catheterization, which resulted in an increase in referrals for CABGS (8% per annum). Thus, allowing for growth in access to coronary angiography, and change in case mix as well as the need to reduce the waiting list, we estimated annual need to be 1.72 surgeries/ 1,000 population > 20 yrs of age in 200112002. However, predictions proved unreliable and need was underestimated. -- In times of continual fluctuation in rate and changing assumptions between 1994 and 1999, it is difficult to provide a confident estimation of future need. Research should instead aim to identify stability. Persistent monitoring should recognize this period of stability and researchers will be better able to estimate future trends at that time.

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