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The Relation Between Surgeon Volume and Outcome Following Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery^*

^* From the University of Rochester School of Medicine and Dentistry (Drs. Glance and Dick), Rochester, NY; the University of Vermont Medical College (Dr. Osler), Burlington, VT; and the University of California, Irvine (Dr. Mukamel), Irvine, CA.

Correspondence to: Laurent G. Glance, MD, Department of Anesthesiology, University of Rochester Medical Center, 601 Elmwood Ave, Box 604, Rochester, NY 14642; e-mail: Laurent_Glance{at}urmc.rochester.edu

Study objective: Off-pump coronary artery bypass graft (CABG) surgery has been recently reintroduced into clinical practice. In light of the relatively low level of experience of most cardiac surgeons with off-pump CABG surgery, and the exceptional technical challenge of working on a "beating heart," off-pump CABG surgery presents a unique opportunity to explore the effect of surgeon case volume on surgical outcome after controlling for the effects of patient case mix and hospital volume.

Design: A retrospective cohort study analyzing the association between surgeon volume and in-hospital mortality rate for off-pump and on-pump CABG surgery using random-effects logistic regression modeling.

Setting and patients: The analyses were based on the New York State clinical CABG surgery registry. The study sample consisted of 36,930 patients undergoing isolated CABG surgery between 1998 and 1999 that was performed by 181 surgeons at 33 hospitals.

Interventions: None.

Results: There is no association between the number of CABG procedures performed off-pump by an individual surgeon and in-hospital mortality rates (p = 0.93) after controlling for hospital CABG surgery volume and patient-level risk factors. There is also no association between the off-pump CABG surgery mortality rate and the total number of both off-pump and on-pump CABG surgery cases (p = 0.78). In the on-pump CABG surgery cohort, surgeons performing a high volume of CABG procedures had significantly lower risk-adjusted mortality rates among their patients compared to those performing a very low volume, a low-volume, and a medium volume of CABG procedures (p < 0.006).

Conclusion: For off-pump CABG surgery, surgeons performing a high volume of procedures do not have better mortality outcomes than those performing a low volume of procedures. However, higher surgeon case volumes are associated with lower mortality rates for on-pump CABG surgery. The absence of a volume-outcome association for off-pump CABG surgery is especially surprising in light of the more technically demanding nature of off-pump CABG surgery compared to on-pump CABG surgery.

Key Words: coronary artery bypass graft • off pump • quality • report cards • risk adjustment • volume outcome

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