Abstract
Objectives: Coronary artery disease and valvular heart disease are leading causes of mortality globally. This study aimed to investigate the correlation between expected mortality rates (EMRs) and observed mortality rates (OMRs) for common cardiac interventions using recent national data on percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and cardiac valve surgeries. Methods: This multi-institutional, retrospective observational study analyzed in-hospital/30-day mortality outcomes for 106,836 patients who underwent PCI, CABG, or cardiac valve procedures across 64 non-federal hospitals in New York State between December 2012 and November 2015. The procedures included emergency and non-emergency PCI, CABG, valve or valve-CABG surgeries, and transcatheter aortic valve replacement (TAVR). Results: Among the 106,836 patients, a 3.21% 30-day mortality rate was observed (n=3,436). To assess the disparity between OMR and EMR, a one-sample t-test was performed. Effect sizes were determined using Cohen’s d and Hedges’ correction. With a 95% confidence interval, the t-value for the OMR (mean difference =2.037±1.728, CI: 1.95-2.12) was 47.270, whereas the EMR (mean difference =1.930±1.284, CI: 1.86-1.99) yielded a t-value of 60.279. The OMR was significantly greater than the EMR (P<0.001). Conclusion: The OMR was significantly greater than the EMR across all cardiac procedures, suggesting potential influences from patient demographics, comorbidities, and variations in hospital practices. Further research is needed to understand these factors and improve the quality of cardiac care.
Keywords: Percutaneous coronary intervention, coronary artery bypass graft, valve surgery, coronary artery disease, transcatheter aortic valve replacement, expected mortality rate, observed mortality rate, coronary artery disease, myocardial infarction, risk-adjusted mortality rate, left main coronary artery
Introduction
Coronary artery disease (CAD) and valvular heart disease continue to be the leading causes of mortality worldwide. In the United States, CAD is responsible for one in every six deaths, with an American suffering a coronary event every 25 seconds and dying from it every minute on average [1].
The Coronary Artery Bypass Grafting (CABG) program refers to a structured clinical approach involving preoperative risk assessment, surgical intervention, and postoperative management to optimize patient outcomes. It integrates standardized protocols for patient selection, perioperative care, and long-term follow-up to enhance surgical success and reduce complications.
Coronary revascularization is the primary treatment for unprotected left main coronary artery (ULMCA) disease, with coronary artery bypass grafting (CABG) surgery traditionally being the standard approach. However, recent evidence indicates that percutaneous coronary intervention (PCI) can be a noninferior option for certain patient populations [2,3].
CABG and PCI differ significantly in their potential to reduce the incidence of myocardial infarctions (MIs). With its focus on flow-limiting lesions, most MIs occur at sites of non-flow-limiting stenosis, suggesting that the incidence of new MIs will not be greatly reduced with PCI. In contrast, CABG may offer “collateralization” through the bypass of multiple coronary lesions that can prevent MIs caused by plaque rupture or rapid progression of plaques that are not flow-limiting at the outset [4,5].
There is also a need to evaluate outcomes for emergency PCI and PCI. These subcategories represent differing clinical scenarios with unique challenges and risk profiles [6]. Emergency PCI is typically performed in acute settings, such as during a myocardial infarction [7], whereas non-emergency PCI is planned and executed under more controlled circumstances [8].
Furthermore, combined valve/CABG surgeries and transcatheter aortic valve replacement (TAVR) procedures are integral components of contemporary cardiac care. Combined valve/CABG surgeries address both coronary artery disease and valvular dysfunction in a single procedure, presenting unique complexities and risks [9]. TAVR, an innovative minimally invasive procedure, has emerged as a crucial alternative for high-risk patients ineligible for traditional valve surgery [10].
While combined valve/CABG surgery allows the simultaneous correction of both coronary and valvular disorders, it is associated with greater procedural complexity, extended surgical durations, and an increased risk of perioperative complications, including acute kidney injury and atrial fibrillation. However, the procedure might lead to long-term advantages, such as sustained hemodynamic improvement and a reduced need for reintervention [10]. On the other hand, TAVR provides a less invasive option, which is especially beneficial for individuals with severe aortic stenosis who are at high or prohibitive surgical risk [11]. Studies have shown its noninferiority to surgery in intermediate-risk patients, with advantages such as lower transfusion requirements and a reduced incidence of acute kidney injury [12,13]. Nevertheless, TAVR has been associated with higher rates of residual aortic regurgitation and the need for pacemaker implantation, potentially affecting long-term outcomes [12].
Whereas there are many investigations into individual procedural outcomes, there is a great need for comprehensive studies comparing mortality rates across cardiac intervention modalities using more nuanced risk-adjustment methodologies.
This study aims to conduct a rigorous, multi-institutional analysis of cardiac intervention outcomes, providing unprecedented insights into mortality risk stratification and procedural performance across diverse cardiac intervention modalities.
Methods
Study population and ethical considerations
The State of New York provides a variety of data, datasets, information, content, files, documents, and materials on the OPEN-NY website (https://data.ny.gov/). This platform promotes the sharing, utilization, and reuse of Open Data (https://data.ny.gov/download/77gx-ii52/application/pdf). Data files are available for download in aggregated form at the hospital and operator levels on the institutional website (https://health.data.ny.gov/). We obtained datasets for “Adult Cardiac Surgery” and “Percutaneous Coronary Interventions (PCIs)” in New York State from 2013-2015 from this website.
This multicenter, retrospective observational study was conducted at 64 non-federal hospitals in New York State, with comprehensive institutional review board approval. The strong methodological approach was strictly followed to ensure adherence to ethical research standards and the maintenance of patient confidentiality.
Study population
The study cohort comprised 106,836 patients who underwent comprehensive cardiac interventions between December 1, 2012, and November 30, 2015. The inclusion criteria were meticulously defined to capture a representative patient population, as follows: (1) Patients who underwent percutaneous coronary interventions (emergency and non-emergency); (2) CABG procedures; (3) Cardiac valve surgeries (isolated and combined); (4) TAVR.
Exclusion criteria: (1) Patients residing outside the United States; (2) Patients with multiple concurrent cardiac procedures within 30-day periods; (3) Patients experiencing cardiogenic shock.
Data collection and management
This study analyzed 40 predefined clinical risk factors, including patient demographics (age, sex, BMI), comorbidities (diabetes, hypertension, renal disease, prior stroke), procedural characteristics (emergency status, surgical complexity), and laboratory values (creatinine, hemoglobin levels). These factors were collected from cardiac catheterization laboratories and validated using multi-source cross-referencing with hospital records.
Data collection involved a comprehensive, standardized approach: 1. Demographic and clinical data acquisition: (1) Approximately 40 detailed risk factors collected for each patient; (2) Information sourced from cardiac catheterization laboratories; (3) Comprehensive patient characterization, including hospital, physician, and discharge status details. 2. Data validation protocols: (1) Cross-verification through multiple departments of health databases; (2) Detailed medical record reviews for a selected case sample; (3) Rigorous validation processes ensuring consistent data interpretation across participating institutions.
Statistical analysis
Data analysis was carried out in SPSS, STATA, and Python 3 environments to explore the relationships among variables, including estimation of pooled risk ratios and visualizations of the data. For the results to be reported, one-sample t-tests shall be in the form of means ± SDs [SD: standard deviation] at 95% confidence intervals, whereas the effect sizes were derived by Cohen’s d with Hedges’ correction. A P-value <0.05 was considered statistically significant.
Ethical and regulatory compliance
To enhance quality of cardiac interventions, the New York State Department of Health annually publishes aggregated public data on mortality following PCI and cardiac surgery procedures. This research, which relies on data reported at the provider and operator levels, did not require informed consent or approval from a local ethics committee.
Results
A total of 106,836 patients from 64 hospitals in New York State were included in this study based on the defined inclusion criteria. The study examined six types of cardiac procedures (all PCI, CABG, emergency PCI, non-emergency PCI, combined Valve/CABG, and TAVR).
Participant demographics
A total of 106,836 patients from 64 hospitals in New York State met the inclusion criteria and were included in the analysis. The cohort included 49,035 PCI cases (25,735 emergency PCI, 40,412 non-emergency PCI), 8,356 isolated CABG procedures, 22,129 valve or valve/CABG surgeries, and 5,554 TAVR procedures (Figure 1).
Figure 1.
Number of cases for each procedure.
General findings
Overall mortality rate: Across all procedures, the 30-day mortality rate was 3.21%, corresponding to 3,436 deaths.
PCI analysis (2015)
Table 1 and Figure 2 present the PCI mortality results for 62 hospitals: (1) The observed mortality rate (OMR) was 1.14% for 49,035 PCI patients. (2) Range: 0.00% to 3.65%. (3) Expected mortality rate (EMR): 0.74% to 2.52%. (4) Risk-Adjusted Mortality Rates (RAMRs): 0.00% to 2.78%.
Table 1.
In-hospital and 30-day observed, expected, and risk-adjusted mortality rates for PCI in New York State, 2015
| Hospitals | Cases | Deaths | All Cases | 95% CI for RAMR | Non-Emergency | |||
|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
| OMR | EMR | RAMR | Cases | RAMR | ||||
| Albany Med. Ctr | 695 | 18 | 2.59 | 1.35 | 2.18* | (1.29, 3.45) | 516 | 1.52 |
| Arnot Ogden Med Ctr | 336 | 1 | 0.30 | 0.93 | 0.37 | (0.00, 2.03) | 249 | 0.53 |
| Bassett Medical Center | 538 | 5 | 0.93 | 1.11 | 0.95 | (0.31, 2.22) | 442 | 0.24 |
| Bellevue Hospital Ctr | 415 | 7 | 1.69 | 1.88 | 1.02 | (0.41, 2.10) | 313 | 0.52 |
| Bronx-Lebanon-Concourse | 137 | 5 | 3.65 | 2.52 | 1.65 | (0.53, 3.84) | 70 | 0.00 |
| Brookdale Univ Hosp Med Ctr | 183 | 2 | 1.09 | 1.55 | 0.80 | (0.09, 2.90) | 112 | 0.55 |
| Brookhaven Memorial | 352 | 5 | 1.42 | 1.04 | 1.56 | (0.50, 3.63) | 272 | 1.95 |
| Buffalo General Hosp | 1522 | 22 | 1.45 | 1.17 | 1.40 | (0.88, 2.12) | 1087 | 0.82 |
| Cayuga Med Ctr Ithaca | 160 | 2 | 1.25 | 1.93 | 0.74 | (0.08, 2.66) | 81 | 0.00 |
| Champ-Valley Phys Hosp | 572 | 8 | 1.40 | 0.93 | 1.71 | (0.74, 3.37) | 437 | 1.37 |
| Crouse Hospital | 311 | 6 | 1.93 | 1.20 | 1.84 | (0.67, 4.00) | 220 | 1.18 |
| Ellis Hospital | 470 | 9 | 1.91 | 1.22 | 1.78 | (0.81, 3.39) | 278 | 1.85 |
| Elmhurst Hospital Ctr | 427 | 2 | 0.47 | 0.89 | 0.60 | (0.07, 2.16) | 305 | 0.00 |
| Faxton - St. Luke’s | 157 | 3 | 1.91 | 1.22 | 1.78 | (0.36, 5.19) | 131 | 0.89 |
| Glens Falls Hospital | 180 | 0 | 0.00 | 1.19 | 0.00 | (0.00, 1.94) | 108 | 0.00 |
| Good Sam - Suffern | 575 | 10 | 1.74 | 1.80 | 1.10 | (0.53, 2.02) | 399 | 0.59 |
| Good Sam - West Islip | 1059 | 3 | 0.28 | 0.79 | 0.41 | (0.08, 1.19) | 969 | 0.42 |
| Huntington Hospital | 502 | 4 | 0.80 | 1.07 | 0.85 | (0.23, 2.17) | 395 | 0.24 |
| Jamaica Hosp Med Ctr | 302 | 1 | 0.33 | 1.50 | 0.25 | (0.00, 1.40) | 157 | 0.00 |
| Lenox Hill Hospital | 1856 | 15 | 0.81 | 0.80 | 1.15 | (0.65, 1.90) | 1741 | 0.81 |
| Long Island Jewish MC | 1039 | 12 | 1.15 | 0.94 | 1.40 | (0.72, 2.44) | 903 | 1.28 |
| Lutheran Medical Ctr | 187 | 2 | 1.07 | 2.04 | 0.60 | (0.07, 2.15) | 144 | 0.35 |
| Maimonides Medical Ctr | 1056 | 8 | 0.76 | 1.89 | 0.46** | (0.20, 0.90) | 832 | 0.40 |
| Mercy Hospital | 1108 | 18 | 1.62 | 1.11 | 1.66 | (0.98, 2.62) | 860 | 1.12 |
| Montefiore - Moses | 944 | 7 | 0.74 | 1.1 | 0.76 | (0.31, 1.57) | 799 | 0.40 |
| Montefiore - Weiler | 584 | 8 | 1.37 | 1.3 | 1.2 | (0.52, 2.36) | 442 | 0.00** |
| Mount Sinai Beth Israel | 1721 | 12 | 0.7 | 1.01 | 0.79 | (0.41, 1.37) | 1591 | 0.43 |
| Mount Sinai Hospital | 3610 | 14 | 0.39 | 0.74 | 0.6** | (0.33, 1.00) | 3483 | 0.37** |
| Mount Sinai St. Lukes | 489 | 12 | 2.45 | 1.61 | 1.74 | (0.90, 3.03) | 413 | 1.15 |
| NYP-Brooklyn Methodist | 1251 | 23 | 1.84 | 0.95 | 2.19* | (1.39, 3.29) | 1130 | 1.08 |
| NYP-Columbia Presby | 2360 | 17 | 0.72 | 0.9 | 0.91 | (0.53, 1.45) | 2227 | 0.65 |
| NYP-Lawrence Hospital | 113 | 0 | 0 | 0.95 | 0 | (0.00, 3.90) | 93 | 0.00 |
| NYP-Queens | 778 | 10 | 1.29 | 0.77 | 1.9 | (0.91, 3.49) | 623 | 1.17 |
| NYP-Weill Cornell | 1056 | 11 | 1.04 | 1.23 | 0.96 | (0.48, 1.72) | 946 | 0.48 |
| NYU Hospitals Center | 1634 | 6 | 0.37 | 0.75 | 0.55 | (0.20, 1.20) | 1539 | 0.42 |
| NYU Winthrop Hospital | 1041 | 9 | 0.86 | 1.41 | 0.7 | (0.32, 1.32) | 887 | 0.49 |
| North Shore Univ Hosp | 2370 | 23 | 0.97 | 1.19 | 0.93 | (0.59, 1.39) | 2034 | 0.72 |
| Olean General Hosp | 149 | 3 | 2.01 | 1.54 | 1.48 | (0.30, 4.34) | 71 | 0.00 |
| Orange Regional Med Ctr | 508 | 4 | 0.79 | 1.09 | 0.82 | (0.22, 2.11) | 350 | 0.84 |
| Richmond Univ Med Ctr | 119 | 1 | 0.84 | 0.96 | 0.99 | (0.01, 5.53) | 89 | 2.20 |
| Rochester General Hosp | 1625 | 21 | 1.29 | 1.15 | 1.28 | (0.79, 1.95) | 1301 | 0.77 |
| Samaritan Hospital | 215 | 2 | 0.93 | 1.09 | 0.97 | (0.11, 3.51) | 119 | 1.41 |
| Saratoga Hospital | 87 | 3 | 3.45 | 1.41 | 2.78 | (0.56, 8.11) | 71 | 2.21 |
| South Nassau Com. Hosp | 420 | 10 | 2.38 | 1.1 | 2.46* | (1.18, 4.52) | 300 | 2.28* |
| Southside Hospital | 703 | 6 | 0.85 | 0.96 | 1.01 | (0.37, 2.21) | 604 | 0.99 |
| St. Barnabas Hospital | 164 | 4 | 2.44 | 1.03 | 2.69 | (0.72, 6.90) | 129 | 0.96 |
| St. Catherine of Siena | 299 | 3 | 1 | 1.33 | 0.86 | (0.17, 2.50) | 234 | 0.42 |
| St. Elizabeth Med Ctr | 763 | 14 | 1.83 | 1.27 | 1.64 | (0.90, 2.75) | 616 | 1.14 |
| St. Francis Hospital | 2768 | 37 | 1.34 | 1.04 | 1.46 | (1.03, 2.01) | 2592 | 0.94 |
| St. Joseph’s Hospital | 1960 | 26 | 1.33 | 1.35 | 1.11 | (0.73, 1.63) | 1505 | 0.96 |
| St. Lukes Cornwall Hosp | 259 | 3 | 1.16 | 1.31 | 1 | (0.20, 2.93) | 173 | 0.56 |
| St. Peters Hospital | 856 | 11 | 1.29 | 0.92 | 1.59 | (0.79, 2.84) | 659 | 1.15 |
| Staten Island Univ Hosp | 710 | 5 | 0.7 | 0.77 | 1.04 | (0.34, 2.44) | 583 | 0.84 |
| Strong Memorial Hosp | 910 | 14 | 1.54 | 1.21 | 1.45 | (0.79, 2.43) | 612 | 1.21 |
| UHS-Wilson Med Ctr | 747 | 11 | 1.47 | 1.29 | 1.3 | (0.65, 2.33) | 556 | 0.90 |
| Unity Hospital | 282 | 2 | 0.71 | 1.71 | 0.47 | (0.05, 1.70) | 207 | 0.00 |
| Univ. Hosp-Brooklyn | 280 | 5 | 1.79 | 2.25 | 0.9 | (0.29, 2.11) | 185 | 0.25 |
| Univ. Hosp-Stony Brook | 1431 | 24 | 1.68 | 1.48 | 1.29 | (0.82, 1.92) | 1074 | 0.93 |
| Univ. Hosp-Upstate | 186 | 6 | 3.23 | 1.8 | 2.04 | (0.75, 4.44) | 106 | 3.23 |
| Vassar Bros Med Ctr | 683 | 12 | 1.76 | 1.62 | 1.24 | (0.64, 2.16) | 478 | 0.62 |
| Westchester Med Ctr | 393 | 7 | 1.78 | 1.91 | 1.06 | (0.43, 2.19) | 232 | 0.55 |
| White Plains Hospital | 419 | 4 | 0.95 | 1.27 | 0.86 | (0.23, 2.19) | 338 | 0.34 |
| Statewide Total | 49035 | 558 | 1.14 | 40412 | 0.74 | |||
Risk adjusted mortality rate significantly higher than statewide rate based on 95 percent confidence interval.
Risk adjusted mortality rate significantly lower than statewide rate based on 95 percent confidence interval.
Figure 2.
RAMR with 95% confidence intervals for PCI-all cases (year 2015).
Three hospitals (Albany Medical Center, NYP-Brooklyn Methodist, and South Nassau Community Hospital) had RAMRs that were significantly higher than the statewide average, whereas two hospitals (Maimonides Medical Center in Brooklyn and Mount Sinai Hospital) had RAMRs that were significantly lower.
Non-emergency PCI analysis (2015)
Figure 3 shows the results for non-emergency PCI procedures: (1) OMR: The statewide in-hospital/30-day mortality rate for non-emergency cases is 0.74%. (2) Range: 0.00% to 3.23%.
Figure 3.
RISK-ADJUSTED MORTALITY RATES with 95% confidence for Non- emergency PCI (year 2015).
One hospital (South Nassau Community Hospital) had a RAMR that was significantly higher than the statewide average. Two hospitals (Montefiore Medical Center - Weiler Division in Bronx and Mount Sinai Medical Center in Manhattan) had RAMRs that were significantly lower than the statewide rate.
CABG analysis (2015)
Table 2 and Figure 4 present the CABG surgery results for 38 hospitals: (1) OMR: 1.56% for 8,356 CABG surgeries. (2) Range: 0.00% to 16.67%. (3) EMR: 0.82% to 2.28%. (4) RAMR: 0.00% to 12.60%.
Table 2.
In-hospital and 30-day observed, expected, and risk-adjusted mortality rates for isolated CABG surgery in New York State, 2015 discharges
| Hospital | Cases | Deaths | OMR | EMR | RAMR | 95% CI for RAMR |
|---|---|---|---|---|---|---|
| Albany Med. Ctr | 260 | 3 | 1.15 | 1.66 | 1.08 | (0.22, 3.16) |
| Arnot Ogden Med Ctr | 80 | 1 | 1.25 | 0.82 | 2.37 | (0.03, 13.16) |
| Bassett Medical Center | 74 | 2 | 2.70 | 1.02 | 4.13 | (0.46, 14.91) |
| Bellevue Hospital Ctr | 113 | 2 | 1.77 | 0.95 | 2.89 | (0.32, 10.42) |
| Buffalo General Hosp | 474 | 10 | 2.11 | 1.25 | 2.62 | (1.26, 4.82) |
| Ellis Hospital | 185 | 4 | 2.16 | 1.58 | 2.12 | (0.57, 5.44) |
| Good Sam - Suffern | 108 | 2 | 1.85 | 1.10 | 2.63 | (0.29, 9.48) |
| Good Sam-West Islip | 199 | 2 | 1.01 | 1.39 | 1.12 | (0.13, 4.05) |
| Lenox Hill Hospital | 259 | 8 | 3.09 | 1.84 | 2.61 | (1.12, 5.14) |
| Long Island Jewish MC | 97 | 0 | 0.00 | 1.48 | 0.00 | (0.00, 3.98) |
| Maimonides Medical Ctr | 255 | 8 | 3.14 | 2.28 | 2.14 | (0.92, 4.22) |
| Mercy Hospital | 391 | 5 | 1.28 | 1.42 | 1.40 | (0.45, 3.27) |
| Montefiore - Moses | 176 | 0 | 0.00 | 1.24 | 0.00 | (0.00, 2.61) |
| Montefiore - Weiler | 194 | 4 | 2.06 | 1.41 | 2.28 | (0.61, 5.84) |
| Mount Sinal Beth Israel | 210 | 1 | 0.48 | 1.26 | 0.59 | (0.01, 3.28) |
| Mount Sinal Hospital | 398 | 5 | 1.26 | 1.69 | 1.16 | (0.37, 2.70) |
| Mount Sinal St. Lukes | 146 | 1 | 0.68 | 1.57 | 0.68 | (0.01, 3.78) |
| NYP-Brooklyn Methodist | 110 | 1 | 0.91 | 1.91 | 0.74 | (0.01, 4.12) |
| NYP-Columbia Presby. | 387 | 8 | 2.07 | 2.06 | 1.56 | (0.67, 3.08) |
| NYP-Queens | 117 | 0 | 0.00 | 0.83 | 0.00 | (0.00, 5.88) |
| NYP-Weill Cornell | 196 | 2 | 1.02 | 1.56 | 1.02 | (0.11, 3.69) |
| NYU Hospitals Center | 183 | 2 | 1.09 | 1.18 | 1.45 | (0.16, 5.22) |
| NYU Winthrop Hospital | 208 | 1 | 0.48 | 1.32 | 0.57 | (0.01, 3.15) |
| North Shore Univ Hosp | 421 | 4 | 0.95 | 1.70 | 0.87 | (0.23, 2.23) |
| Rochester General Hosp | 355 | 8 | 2.25 | 1.60 | 2.19 | (0.94, 4.31) |
| Southside Hospital | 170 | 1 | 0.59 | 0.97 | 0.95 | (0.01, 5.27) |
| St. Elizabeth Med Ct | 166 | 5 | 3.01 | 1.57 | 2.98 | (0.96, 6.94) |
| St. Francis Hospital | 481 | 9 | 1.87 | 1.88 | 1.54 | (0.70, 2.93) |
| St. Josephs Hospital | 382 | 6 | 1.57 | 1.59 | 1.54 | (0.56, 3.36) |
| St. Peters Hospital | 344 | 1 | 0.29 | 1.05 | 0.43 | (0.01, 2.39) |
| Staten Island Univ Hosp | 185 | 4 | 2.16 | 1.83 | 1.84 | (0.49, 4.70) |
| Strong Memorial Hosp | 203 | 2 | 0.99 | 1.75 | 0.88 | (0.10, 3.17) |
| UHS-Wilson Med Ctr | 142 | 2 | 1.41 | 1.34 | 1.63 | (0.18, 5.90) |
| Univ. Hosp-Brooklyn | 36 | 6 | 16.67 | 2.06 | 12.6* | (4.60, 27.43) |
| Univ. Hosp-Stony Brook | 297 | 3 | 1.01 | 1.88 | 0.84 | (0.17, 2.45) |
| Univ. Hosp-Upstate | 31 | 1 | 3.23 | 1.06 | 4.75 | (0.06, 26.44) |
| Vassar Bros. Med Ctr | 174 | 2 | 1.15 | 1.57 | 1.14 | (0.13, 4.10) |
| Westchester Med Ctr | 149 | 4 | 2.68 | 2.15 | 1.94 | (0.52, 4.97) |
| Statewide Total | 8356 | 130 | 1.56 |
Figure 4.
RISK-ADJUSTED MORTALITY RATES with 95 percent confidence interval for CABG (year 2015).
University Hospital - Brooklyn had a significantly higher RAMR compared to the statewide average.
TAVR analysis (2013-2015)
Table 3 and Figure 5 present the TAVR results for 24 hospitals from 2013 to 2015: (1) OMR: 4.75% for 5,554 TAVR procedures. (2) Range: 0.00% to 8.41%. (3) EMR: 3.44% to 7.45%. (4) RAMR: 0.00% to 8.07%.
Table 3.
In-hospital/30-day observed, expected, and risk-adjusted mortality rates for TAVR in New York State, 2013-2015 (Alphabetically by Hospital)
| Hospital | Cases | Deaths | OMR | EMR | RAMR | 95% CI for RAMR |
|---|---|---|---|---|---|---|
| Albany Med. Ctr | 339 | 13 | 3.83 | 4.19 | 4.35 | (2.31, 7.44) |
| Buffalo General Hosp | 238 | 9 | 3.78 | 4.52 | 3.97 | (1.81, 7.55) |
| Lenox Hill Hospital | 128 | 8 | 6.25 | 4.91 | 6.05 | (2.60, 11.92) |
| Long Island Jewish MC | 141 | 5 | 3.55 | 4.94 | 3.41 | (1.10, 7.96) |
| Maimonides Medical Ctr | 151 | 7 | 4.64 | 4.16 | 5.29 | (2.12, 10.90) |
| Mercy Hospital | 7 | 0 | 0.00 | 5.40 | 0.00 | (0.00, 46.14) |
| Montefiore - Moses | 115 | 7 | 6.09 | 5.24 | 5.52 | (2.21, 11.38) |
| Montefiore - Weiler | 17 | 1 | 5.88 | 3.47 | 8.07 | (0.11, 44.88) |
| Mount Sinai Hospital | 452 | 33 | 7.30 | 4.78 | 7.26* | (4.99, 10.19) |
| NYP-Brooklyn Methodist | 40 | 3 | 7.50 | 4.73 | 7.54 | (1.52, 22.04) |
| NYP-Columbia Presby. | 959 | 34 | 3.55 | 5.63 | 2.99** | (2.07, 4.18) |
| NYP-Weill Cornell | 329 | 16 | 4.86 | 4.31 | 5.37 | (3.06, 8.71) |
| NYU Hospitals Center | 322 | 12 | 3.73 | 3.44 | 5.15 | (2.66, 8.99) |
| NYU Winthrop Hospital | 537 | 20 | 3.72 | 4.45 | 3.97 | (2.43, 6.14) |
| North Shore Univ Hosp | 323 | 16 | 4.95 | 4.77 | 4.94 | (2.82, 8.02) |
| Rochester General Hosp | 4 | 0 | 0.00 | 7.45 | 0.00 | (0.00, 58.52) |
| Southside Hospital | 116 | 4 | 3.45 | 3.79 | 4.33 | (1.16, 11.08) |
| St. Francis Hospital | 542 | 26 | 4.80 | 4.87 | 4.68 | (3.06, 6.86) |
| St. Josephs Hospital | 278 | 18 | 6.47 | 4.74 | 6.50 | (3.85, 10.27) |
| St. Peters Hospital | 68 | 5 | 7.35 | 4.33 | 8.07 | (2.60, 18.84) |
| Strong Memorial Hosp | 159 | 13 | 8.18 | 5.20 | 7.47 | (3.97, 12.78) |
| UHS-Wilson Med Ctr | 38 | 0 | 0.00 | 4.19 | 0.00 | (0.00, 10.94) |
| Univ. Hosp-Stony Brook | 107 | 9 | 8.41 | 4.99 | 8.01 | (3.66, 15.21) |
| Westchester Med Ctr | 144 | 5 | 3.47 | 5.55 | 2.97 | (0.96, 6.94) |
| Statewide Total | 5554 | 264 | 4.75 |
Risk adjusted mortality rate significantly higher than statewide rate based on 95 percent confidence interval.
Risk adjusted mortality rate significantly lower than statewide rate based on 95 percent confidence interval.
Figure 5.
RISK-ADJUSTED MORTALITY RATES with 95 percent confidence interval for TAVR (years 2013-2015).
One hospital (Mount Sinai Hospital in Manhattan) had a RAMR that was statistically higher than the statewide rate, whereas one hospital (NY Presbyterian at Columbia in Manhattan) had a RAMR that was statistically lower.
The provided image, a forest plot, shows the effect sizes and 95% confidence intervals for different hospitals performing TAVR between 2013 and 2015. Hospitals such as Albany Medical Center, Buffalo General Medical Center, and others are included, demonstrating the overall effect size and variation among institutions.
Emergency PCI analysis (2013-2015)
Figure 6 shows the results for emergency PCI procedures between 2013 and 2015: (1) OMR: The statewide in-hospital/30-day mortality rate for emergency PCI cases during this period was 3.04%. (2) Range: 0.00% to 7.20%. (3) RAMR: 0.00% to 6.70%.
Figure 6.
RISK-ADJUSTED MORTALITY RATES with 95 percent confidence interval for emergency (years 2013-2015).
Two hospitals (Buffalo General Hospital and NYP-Brooklyn Methodist Hospital) had RAMRs significantly above the statewide average for emergency cases. Two hospitals (Maimonides Medical Center in Brooklyn and NYU-Winthrop Hospital in Mineola) had RAMRs significantly below the statewide average for emergency cases.
Combined valve/CABG analysis (2013-2015)
Table 4 and Figure 7 present the results for combined valve-only and valve/CABG surgeries performed at 40 hospitals from 2013 to 2015: (1) OMR: 3.03% for 22,129 combined procedures. (2) Range: 0.00% to 11.11%. (3) EMR: 1.33% to 4.41%. (4) RAMR: 0.00% to 10.88%.
Table 4.
In-hospital and 30-day observed, expected, and risk-adjusted mortality rates for valve or Valve/CABG surgery in New York State, 2013-2015 discharges
| Hospital | Cases | Deaths | OMR | EMR | RAMR | 95% CI for RAMR |
|---|---|---|---|---|---|---|
| Albany Med. Ctr | 668 | 27 | 4.04 | 2.89 | 4.25 | (2.80, 6.18) |
| Arnot Ogden Med Ctr | 66 | 2 | 3.03 | 1.8 | 5.12 | (0.57, 18.47) |
| Bassett Medical Center | 137 | 4 | 2.92 | 2.23 | 3.97 | (1.07, 10.16) |
| Bellevue Hospital Ctr | 244 | 3 | 1.23 | 2.08 | 1.79 | (0.36, 5.24) |
| Buffalo General Hosp | 779 | 21 | 2.70 | 2.46 | 3.32 | (2.05, 5.08) |
| Champ.Valley Phys Hosp | 21 | 1 | 4.76 | 1.33 | 10.88 | (0.14, 60.52) |
| Ellis Hospital | 284 | 9 | 3.17 | 2.61 | 3.68 | (1.68, 6.99) |
| Erie County Med Ctr | 4 | 0 | 0.00 | 1.89 | 0.00 | (0.00, 100.0) |
| Good Sam - Suffern | 132 | 6 | 4.55 | 2.68 | 5.15 | (1.88, 11.20) |
| Good Sam-West Islip | 147 | 4 | 2.72 | 2.75 | 3.01 | (0.81, 7.69) |
| Lenox Hill Hospital | 444 | 12 | 2.70 | 2.5 | 3.28 | (1.69, 5.74) |
| Long Island Jewish MC | 416 | 6 | 1.44 | 3.75 | 1.16** | (0.43, 2.54) |
| Maimonides Medical Ctr | 461 | 11 | 2.39 | 4.41 | 1.64** | (0.82, 2.93) |
| Mercy Hospital | 538 | 25 | 4.65 | 2.27 | 6.21* | (4.02, 9.17) |
| Montefiore - Moses | 448 | 21 | 4.69 | 3.6 | 3.95 | (2.44, 6.04) |
| Montefiore - Weiler | 340 | 12 | 3.53 | 4.09 | 2.62 | (1.35, 4.57) |
| Mount Sinai Beth Israel | 229 | 13 | 5.68 | 3.06 | 5.63 | (3.00, 9.63) |
| Mount Sinai Hospital | 2151 | 51 | 2.37 | 3.09 | 2.33 | (1.73, 3.06) |
| Mount Sinai St. Lukes | 275 | 6 | 2.18 | 2.67 | 2.48 | (0.91, 5.40) |
| NYP-Brooklyn Methodist | 180 | 2 | 1.11 | 3.68 | 0.92 | (0.10, 3.30) |
| NYP-Columbia Presby. | 2103 | 55 | 2.62 | 3.17 | 2.50 | (1.88, 3.25) |
| NYP-Queens | 101 | 3 | 2.97 | 2.38 | 3.79 | (0.76, 11.07) |
| NYP-Weill Cornell | 1200 | 28 | 2.33 | 3.08 | 2.30 | (1.53, 3.32) |
| NYU Hospitals Center | 1330 | 25 | 1.88 | 1.86 | 3.07 | (1.99, 4.53) |
| NYU Winthrop Hospital | 517 | 12 | 2.32 | 3.05 | 2.30 | (1.19, 4.02) |
| North Shore Univ Hosp | 879 | 26 | 2.96 | 3.53 | 2.54 | (1.66, 3.72) |
| Rochester General Hosp | 1081 | 39 | 3.61 | 3.28 | 3.33 | (2.37, 4.55) |
| Southside Hospital | 362 | 12 | 3.31 | 3.64 | 2.76 | (1.43, 4.83) |
| St. Elizabeth Med Ctr | 288 | 15 | 5.21 | 2.31 | 6.82* | (3.82, 11.25) |
| St. Francis Hospital | 1474 | 52 | 3.53 | 3.18 | 3.36 | (2.51, 4.41) |
| St. Josephs Hospital | 1356 | 35 | 2.58 | 3.61 | 2.17** | (1.51, 3.02) |
| St. Peters Hospital | 869 | 33 | 3.80 | 3.09 | 3.73 | (2.57, 5.24) |
| Staten Island Univ Hosp | 171 | 4 | 2.34 | 2.78 | 2.55 | (0.69, 6.53) |
| Strong Memorial Hosp | 629 | 30 | 4.77 | 2.54 | 5.69* | (3.84, 8.12) |
| UHS-Wilson Med Ctr | 230 | 14 | 6.09 | 2.06 | 8.96* | (4.89, 15.03) |
| Univ. Hosp-Brooklyn | 90 | 10 | 11.11 | 3.24 | 10.41* | (4.98, 19.14) |
| Univ. Hosp-Stony Brook | 669 | 25 | 3.74 | 3.33 | 3.40 | (2.20, 5.02) |
| Univ. Hosp-Upstate | 71 | 3 | 4.23 | 2.43 | 5.27 | (1.06, 15.40) |
| Vassar Bros. Med Ctr | 436 | 5 | 1.15 | 2.76 | 1.26** | (0.41, 2.94) |
| Westchester Med Ctr | 309 | 9 | 2.91 | 3.64 | 2.43 | (1.11, 4.61) |
| Statewide Total | 22129 | 671 | 3.03 |
Risk adjusted mortality rate significantly higher than statewide rate based on 95 percent confidence interval.
Risk adjusted mortality rate significantly lower than statewide rate based on 95 percent confidence interval.
Figure 7.
RISK-ADJUSTED MORTALITY RATES with 95 percent confidence interval for Valve or Valve/CABG surgery (years 2013-2015).
Five hospitals (Mercy Hospital in Buffalo, St. Elizabeth Medical Center in Utica, Strong Memorial Hospital in Rochester, United Health Services - Wilson in Johnson City, and University Hospital - Brooklyn) had RAMRs that were significantly higher than the statewide rate. Four hospitals (Long Island Jewish in New Hyde Park, Maimonides Medical Center in Brooklyn, St. Joseph’s Hospital in Syracuse, and Vassar Brothers Medical Center in Poughkeepsie) had significantly lower RAMRs.
Statistical analysis
To assess the difference between OMR and EMR, a one-sample t-test was conducted (Table 5 and Figure 8): (1) OMR: Mean difference =2.037±1.728 (95% CI: 1.95-2.12), t=47.270. (2) EMR: Mean difference =1.930±1.284 (95% CI: 1.86-1.99), t=60.279. (3) Significance: P<0.001 for both OMR and EMR, indicating a significant difference between the observed and expected mortality rates.
Table 5.
Comparative analysis of the difference between the observed mortality rate (OMR) and the expected mortality rate (EMR) for PCI and cardiac surgery procedures
| A. | ||||||
|
| ||||||
| N | Mean | Std. Deviation | Std. Error Mean | |||
|
| ||||||
| Observed Mortality Rate | 1609 | 2.307 | 1.72854 | 0.04309 | ||
| Expected Moratality Rate | 1609 | 1.9301 | 1.2844 | 0.03202 | ||
|
| ||||||
| B. | ||||||
|
| ||||||
| t | df | Sig. (2-tailed) | Mean Difference | 95% Confidence Interval of the Differences | ||
|
| ||||||
| Lower | Upper | |||||
|
| ||||||
| Observed Mortality Rate | 47.27 | 1608 | <.001 | 2.03698 | 1.9525 | 2.1215 |
| Expected Mortality Rate | 60.28 | 1608 | .000 | 1.93014 | 1.8673 | 1.9929 |
| Test Value = 0 | ||||||
|
| ||||||
| C. | ||||||
|
| ||||||
| Standardizer* | Point Estimate | 95% Confidence Interval | ||||
|
| ||||||
| Lower | Upper | |||||
|
| ||||||
| Observed Mortality Rate | Cohen’s d | 1.72854 | 1.178 | 1.115 | 1.242 | |
| Hedges’ correction | 1.72935 | 1.178 | 1.114 | 1.241 | ||
| Expected Mortality Rate | Cohen’s d | 1.28440 | 1.503 | 1.431 | 1.574 | |
| Hedges’ correction | 1.28500 | 1.502 | 1.431 | 1.573 | ||
The denominator used in estimating the effect sizes. Cohen’s d uses the sample standard deviation. Hedges’ correction uses the sample standard deviation, plus a correction factor.
Figure 8.
Expected mortality rate vs. risk adjusted mortality rate.
Effect sizes: 1. OMR: (1) Cohen’s d: 1.178 (95% CI: 1.115-1.242). (2) Hedges’ correction: 1.178 (95% CI: 1.114-1.241). 2. EMR: (1) Cohen’s d: 1.503 (95% CI: 1.431-1.574). (2) Hedges’ correction: 1.502 (95% CI: 1.431-1.573).
These analyses demonstrate that the OMR is significantly greater than the EMR, highlighting the need for further investigations into the factors influencing these rates.
Discussion
Summary of findings
Modern cardiac interventions create a clinical quagmire, as the confluence of factors is determined to influence patient outcomes and mortality. A landmark comprehensive study of 106,836 patients at 64 non-federal hospitals across New York State provides an unprecedented glimpse into the complex dynamics of risk-adjusted mortality in different cardiac procedures. This study is unique in that all cardiac interventions were studied simultaneously, including all PCI, CABG, valve surgeries and TAVR.
Mortality rate discrepancies and systemic insights
The findings suggest that institutional factors, procedural complexity, and patient-specific variables play a critical role in determining mortality rates. In our view, optimizing patient selection criteria and developing standardized perioperative protocols could mitigate some of the observed disparities. Further, targeted quality improvement initiatives at hospitals with high risk-adjusted mortality rates may help enhance overall patient outcomes.
The statistically significant difference in mortality rates, particularly for Emergency PCI, is a scientifically important finding that contradicts current medical knowledge. A growing body of research demonstrates that the intricate physiological mechanisms involved in emergency cardiac interventions give rise to a distinctive risk profile that is fundamentally different from planned procedures [14]. The increased mortality rates cannot be explained by a single factor but arise from the complex interplay of acute cardiovascular stress, inadequate pre-procedural stabilization, and inherent patient vulnerability [15].
Numerous studies have underscored the importance of risk-adjusted mortality rates as a benchmark for evaluating hospital performance in cardiac surgeries. For example, an article declared that hospitals with higher volumes of cardiac procedures tend to have lower mortality rates, suggesting a volume-outcome relationship [16]. Despite advancements in surgical techniques and postoperative care, our findings indicate that the observed mortality rates remain higher than expected. This discrepancy could be due to various factors, including patient demographics, comorbidities, and differences in hospital practices.
Institutional performance variations
Our findings dramatically highlight the important impact of institutional practices on surgical outcomes and show that hospital-specific factors can influence patient survival to a great extent. Whereas traditionally, medical performance was assumed to be homogeneous, this research shows considerable variation in risk-adjusted mortality rates among different healthcare institutions. The differences likely stem from differences in the experience of the surgical team, technological capabilities, postoperative care protocols, and quality improvement mechanisms at the institutional level [17,18].
Adelborg et al. (2017) examined long-term mortality after CABG surgery and reported that patients had a higher mortality rate compared to the general population, particularly within the first 30 days post-surgery [19]. This aligns with our findings, suggesting that immediate postoperative care is crucial in reducing mortality.
Procedural complexity and mortality patterns
Unique mortality rates for the different cardiac procedures, with TAVR at 4.75% and combined valve/CABG at 3.03%, highlight the nuanced complexity of cardiac surgical interventions. Such variations indicate that procedure-specific protocols and specialized expertise are critical in the optimization of patient survival [20]. Subtle differences among interventions further emphasize the need for tailored, precision-based approaches in cardiac surgical care [21].
Conversely, a study published in JAMA Network Open (2023) reported that sex and the presence of postoperative atrial fibrillation significantly influence long-term mortality after cardiac surgery [22]. This study highlighted that specific patient factors could impact outcomes, which may explain some of the variations observed in our study.
Technological and professional development implications
This research compels a fundamental reimagining of cardiac surgical risk assessment and management strategies. Advanced risk prediction models have emerged as promising avenues for enhancing surgical decision-making, requiring sophisticated algorithms that can integrate multiple patient and institutional variables [23]. The future of cardiac care demands continuous investment in technological infrastructure, surgical team training, and a culture of perpetual learning and professional development.
Additionally, a study by Stanford Medicine (2019) reported that invasive procedures like PCI and CABG did not significantly reduce long-term mortality rates compared to medical therapy alone [24]. This finding differs from our results, suggesting that the benefits of invasive procedures might be more nuanced and dependent on patient selection and procedural timing.
Comparative scientific context
Our findings resonate with and simultaneously challenge existing cardiac surgery research. Previous investigations have confirmed elevated mortality risks within the initial 30 days post-surgery [25], while recent studies have highlighted the nuanced impact of patient-specific factors [26-28]. This research provides a rich, multidimensional framework for understanding the complex interplay between patient characteristics, procedural specifics, and institutional practices.
A comprehensive review by Hardiman et al. (2022) revealed numerous factors affecting mortality after CABG surgery, including patient characteristics, disease severity, and preoperative health status [29]. This review supports our findings by emphasizing the importance of patient-related factors in determining surgical outcomes.
Clinical practice and policy implications
Our findings underscore the necessity for a fundamental change in the integration of procedural risks and institutional capabilities into clinical decision-making for cardiac procedures. Although existing guidelines focus mostly on patient-related factors, our results indicate that institutional performance measurements, including risk-adjusted mortality rates (RAMRs), should play a more significant role in determining referral patterns and quality enhancement strategies. The wide range of RAMRs among hospitals, especially for high-risk procedures such as emergency PCI and combined valve/CABG surgeries, highlights the impact of institutional variables beyond patient selection and clinical performance. These variations indicate differences in hospital preparedness for complications, the efficacy of multidisciplinary team collaboration, and the willingness to follow improved surgical protocols. Therefore, we suggest an organized approach to cardiac care that correlates procedural complexity with institutional proficiency, ensuring that high-risk procedures are centralized in hospitals that demonstrate consistently superior outcomes.
These results have significant implications for clinical practice and healthcare policy. Hospitals should use efficient procedures and evidence-based protocols to enhance the quality of treatment for patients undergoing cardiac surgery. Improving preoperative evaluation to identify high-risk patients and optimizing postoperative management can significantly enhance recovery and reduce complications. Furthermore, investing in training as well as recruiting experienced surgical teams and support personnel is essential, as their expertise and quality of care significantly influence patient outcomes. Continuous professional development and keeping up with the latest clinical guidelines will guarantee that healthcare professionals are adequately prepared to manage the complexities of cardiac procedures.
Furthermore, our findings challenge the assumption that technological advancements are the only reason for improved outcomes in cardiac procedures. Instead, they underscore the critical role of continuous quality evaluations and constant protocol refinement in increasing patient survival. Institutions with outlier RAMRs should conduct organized investigations and targeted interventions, including simulation-based training and real-time mortality review committees, to address systemic vulnerabilities. Policymakers and healthcare administrators should use these findings to develop strategies for enhancing cardiac care at both the state and national levels. Investments in evidence-based methods, infrastructure improvement, and inter-institutional collaboration can increase care quality and survival rates.
By focusing on these aspects, healthcare systems can work toward lowering mortality disparities and guarantee that all patients have the highest standard of care in cardiac procedures. The observed mortality rates exceeding the expected values across many modalities (P<0.001) highlight the critical need for fundamental changes to enhance patient outcomes beyond just technical advancements. A dual focus on improving patient-centered medical care and demanding institutional accountability through transparent outcome reporting is crucial for developing significant improvements in cardiac surgical interventions.
Study strengths and limitations
Some of the strengths of this study include a large sample size that enhances generalizability. The inclusion of multiple cardiac procedures provides an overview of comprehensive hospital performance. This is an observational study and, as such, cannot determine causation. Risk-adjusted mortality rates may not be fully accounted for with respect to patient-related factors, including socioeconomic status and access to follow-up care. Additionally, the data are limited to non-federal hospitals in New York State, and this might not be applicable to other areas. Unmeasured confounding variables, such as hospital staffing levels and the availability of advanced technologies, could also influence outcomes.
While the study offers very valuable insight, it equally recognizes these inherent limitations. Future research should overcome these problems by covering a wide range of variables and using sophisticated analytical techniques.
Future research directions
Future studies need to elucidate specific factors that contribute to the observed higher mortality rates. This may involve examining hospital-specific variables, such as staffing levels and adherence to clinical guidelines, and patient-related factors, including comorbidities and access to healthcare services. Longitudinal studies tracking long-term outcomes and the development of comprehensive risk prediction models are critical next steps. Moreover, the assessment of various interventions using randomized controlled trials and other strong study designs would provide high-quality evidence in order to improve patient outcomes.
Conclusion
This comprehensive investigation offers a critical overview of cardiac surgical mortality rates, emphasizing the complex interplay of patient characteristics, institutional practices, and surgical interventions. Shedding light on these complex relationships, this study lays the foundational framework for targeted improvement initiatives in cardiac care delivery for more personalized, more precise, and more effective medical interventions across various cardiac procedures, including all PCI, CABG, emergency PCI, Non-emergency PCI, combined valve/CABG, and TAVR.
Acknowledgements
The authors would like to thank the researchers whose work was included in this study.
Disclosure of conflict of interest
None.
References
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