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reading-assignment-week-04-adult-cardiac-surgery-ny-2011-20132.pdf

reading-assignment-week-04-adult-cardiac-surgery-ny-2011-20132.pdf

ADULT CARDIAC SURGERYin New York State2011-2013

Departmentof Health

September 2016

Members of the New York State Cardiac Advisory Committee

ChairSpencer King III, M.D. Professor of Medicine, Emeritus Emory University School of Medicine Atlanta, GA

Vice ChairGary Walford, M.D. Associate Professor of Medicine Johns Hopkins Medical Center Baltimore, MD

MembersM. Hashmat Ashraf, M.D., FRCS Chief, Department of Cardiothoracic Surgery Kaleida Health Buffalo, NY

Peter B. Berger, M.D. Senior Vice President of Clinical Research and Interventional Cardiologist Professor of Cardiology and Medicine Northwell Health Hofstra – Northwell School of Medicine New Hyde Park, NY

Frederick Bierman, M.D. Director of Graduate Medical Education Westchester Medical Center Valhalla, NY

Jeptha Curtis, M.D. Asst. Professor, Dept. of Internal Medicine Director, Center for Outcomes Research & Evaluation Data Analytic Center Yale University School of Medicine New Haven, CT

Jeffrey P. Gold, M.D. Chancellor University of Nebraska Medical Center Omaha, NE

Alice Jacobs, M.D. Director, Cardiac Catheterization Laboratory & Interventional Cardiology Boston Medical Center Boston, MA

Desmond Jordan, M.D. Associate Professor of Clinical Anesthesiology in Biomedical Informatics NY Presbyterian Hospital – Columbia New York, NY

Thomas Kulik, M.D. Director, Pulmonary Hypertension Program Children’s Hospital Boston Boston, MA

Stephen Lahey, M.D. Chief, Division of Cardiothoracic Surgery University of Connecticut Health Center Farmington, CT

Frederick S. Ling, MD Professor in Medicine (Cardiology) University of Rochester Medical Center Rochester, NY

Ralph Mosca, M.D. Vice Chairman, Department of Cardiac Surgery Director, Congenital Cardiac Surgery NYU Medical Center

New York, NY

Carlos E. Ruiz, M.D., Ph.D. Professor of Cardiology in Pediatrics and Medicine Director, Structural and Congenital Heart Disease Hackensack University Medical Center Heart and Vascular Hospital The Joseph M. Sanzari Children’s Hospital Hackensack, NJ

Samin K. Sharma, M.D. Director, Cardiac Catheterization Laboratory Mount Sinai Medical Center New York, NY

Craig Smith, M.D. Chairman, Department of Surgery NY Presbyterian Hospital – Columbia New York, NY

Nicholas Stamato, M.D. Co-Director, Cardiology Campbell County Memorial Hospital Gilette, WY

Thoralf Sundt, III, M.D. Chief, Cardiac Surgical Division Co-Director, Heart Center and Institute for Heart, Vascular and Stroke Massachusetts General Hospital Boston, MA

James Tweddell, M.D. Surgical Director and Executive Co-Director The Heart Institute Professor of Surgery Cincinnati Children’s Hospital Medical Center Cincinnati, OH

Ferdinand Venditti, Jr., M.D. Executive Vice President for System Care Delivery Hospital General Director Vice Dean for Clinical Affairs Professor of Medicine Albany Medical Center Albany, NY

Andrew S. Wechsler, M.D. Professor and Chair, Department of Cardiothoracic Surgery Drexel University College of Medicine Philadelphia, PA

ConsultantEdward L. Hannan, Ph.D. Distinguished Professor Emeritus Department of Health Policy, Management & Behavior Associate Dean Emeritus University at Albany, School of Public Health Rensselaer, NY

Cardiac Surgery Reporting System Subcommittee

Members & ConsultantsCraig Smith, M.D. (Chair) Chairman, Department of Surgery NY Presbyterian Hospital – Columbia

M. Hashmat Ashraf, M.D., FRCS Chief, Department of Cardiothoracic Surgery Kaleida Health

Jeffrey P. Gold, M.D. Chancellor University of Nebraska Medical Center

Edward L. Hannan, Ph.D. Distinguished Professor Emeritus Department of Health Policy, Management & Behavior Associate Dean Emeritus University at Albany, School of Public Health

Desmond Jordan, M.D. Associate Professor of Clinical Anesthesiology in Biomedical Informatics NY Presbyterian Hospital – Columbia

Stephen Lahey, M.D. Chief, Division of Cardiothoracic Surgery University of Connecticut Health Center

Ralph Mosca, M.D. Vice Chairman, Department of Cardiac Surgery Director, Congenital Cardiac Surgery NYU Medical Center

Carlos E. Ruiz, M.D., Ph.D. Professor of Cardiology in Pediatrics and Medicine Director, Structural and Congenital Heart Disease Hackensack University Medical Center Heart and Vascular Hospital The Joseph M. Sanzari Children’s Hospital

Nicholas J. Stamato, M.D. Co-Director, Cardiology Campbell County Memorial Hospital

Thoralf Sundt, III, M.D. Chief, Cardiac Surgical Division Co-Director, Heart Center and Institute for Heart, Vascular and Stroke Massachusetts General Hospital

James Tweddell, M.D. Surgical Director and Executive Co-Director The Heart Institute Professor of Surgery Cincinnati Children’s Hospital Medical Center

Andrew S. Wechsler, M.D. Professor and Chair, Department of Cardiothoracic Surgery Drexel University College of Medicine

Staff to CSRS Analysis Workgroup – New York State Department of HealthFoster C. Gesten, MD Chief Medical Officer Office of Quality and Patient Safety, NYSDOH

Kimberly S. Cozzens, M.A. Program Manager Cardiac Services Program

Ashraf Al-Hamadani, MD, MPH Clinical Record Reviewer Cardiac Services Program

Lori Frazier Project Assistant Cardiac Services Program

Jessica Kincaid Quality Improvement Project Coordinator Cardiac Services Program

Rosemary Lombardo, M.S. CSRS Coordinator Cardiac Services Program

Leahruth Saavedra, MS Clinical Data Coordinator Cardiac Services Program

Zaza Samadashvili, M.D., M.P.H. Research Scientist Cardiac Services Program

TABLE OF CONTENTS

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

CORONARY ARTERY BYPASS GRAFT SURGERY (CABG) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

CARDIAC VALVE PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

THE DEPARTMENT OF HEALTH PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

PATIENT POPULATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

RISK ADJUSTMENT FOR ASSESSING PROVIDER PERFORMANCE . . . . . . . . . . . . . . . . . . . . . . 11

Data Collection, Data Validation and Identifying In-Hospital/30-Day Deaths and 30-Day Readmission . . 11

Assessing Patient Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Predicting Patient Mortality Rates for Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Computing the Risk-Adjusted Mortality Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Interpreting the Risk-Adjusted Mortality Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Predicting Patient Readmission and Computing and Interpreting Risk-Adjusted Readmission Rates . . 13

How This Initiative Contributes to Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

DEFINITIONS OF KEY TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

2013 HOSPITAL OUTCOMES FOR CABG SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Table 1 In-Hospital/30-Day Observed, Expected and Risk-Adjusted Mortality Rates for Isolated CABG Surgery in New York State, 2013 Discharges. . . . . . . . . . . . . . 16

Figure 1 In-Hospital / 30-Day Risk-Adjusted Mortality Rates for Isolated CABG in New York State, 2013 Discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Table 2 30-Day Risk-Adjusted Readmission Rates for Isolated CABG in New York State, 2013 Discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 2 30-Day Risk-Adjusted Readmission Rates for Isolated CABG in New York State, 2013 Discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

2011-2013 HOSPITAL OUTCOMES FOR VALVE SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Table 3 In-Hospital/30-Day Observed, Expected and Risk-Adjusted Mortality Rates for Valve or Valve/CABG Surgery in New York State, 2011-2013 Discharges . . . . . . . . . . . . 21

Figure 3 In-Hospital/30-Day Risk-Adjusted Mortality Rates for Valve or Valve/CABG Surgery in New York State, 2011-2013 Discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Table 4 Hospital Volume for Valve Surgery in New York State, 2011-2013 Discharges. . . . . . . . . 23

Table 5 Hospital Volume for Transcatheter Aortic Valve Replacement in New York State, 2013 Discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

2011-2013 HOSPITAL AND SURGEON OUTCOMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Table 6 In-Hospital/30-Day Observed, Expected and Risk-Adjusted Mortality Rates by Surgeon for Isolated CABG and Valve Surgery (done in combination with or without CABG) in New York State, 2011-2013 Discharges . . . . . . . . . . . . . . . . 25

Table 7 Summary Information for Surgeons Practicing at More Than One Hospital, 2011-2013. . . . 33

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SURGEON AND HOSPITAL VOLUMES FOR TOTAL ADULT CARDIAC SURGERY, 2011-2013 . . . . . . . 36

Table 8 Surgeon and Hospital Volume for Isolated CABG, Valve or Valve/CABG, Other Cardiac Surgery and Total Adult Cardiac Surgery, 2011-2013 . . . . . . . . . . . . . . 36

CRITERIA USED IN REPORTING SIGNIFICANT RISK FACTORS (2013) . . . . . . . . . . . . . . . . . . . 43

MEDICAL TERMINOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

APPENDIX 1 Risk Factors for CABG In-Hospital / 30-Day Deaths in New York State in 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

APPENDIX 2 Risk Factors for CABG 30-Day Readmissions in New York State in 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

APPENDIX 3 Risk Factors for Valve Surgery In-Hospital/30-Day Mortality in New York State in 2011-2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

APPENDIX 4 Risk Factors for Valve and CABG Surgery In-Hospital/30-Day Mortality in New York State in 2011-2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

APPENDIX 5 Risk Factors for Isolated CABG In-Hospital/30-Day Mortality in New York State 2011-2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

NEW YORK STATE CARDIAC SURGERY CENTERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

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INTRODUCTIONFor over twenty years, the NYS Cardiac Data Reporting System has been a powerful resource for quality improvement in the areas of cardiac surgery and percutaneous coronary interventions (PCI). Building on this strong foundation, we are pleased to include in one report information on mortality after coronary artery bypass graft (CABG) surgery and valve repair or replacement surgery, readmissions after CABG, and preliminary information on transcatheter aortic valve replacement (TAVR) in NYS.

New York State (NYS) has taken a leadership role in setting standards for cardiac services, monitoring outcomes and sharing performance data with patients, hospitals and physicians. Hospitals and doctors involved in cardiac care have worked in cooperation with the NYS Department of Health (Department of Health) and the NYS Cardiac Advisory Committee (Cardiac Advisory Committee) to compile accurate and meaningful data that can and have been used to enhance quality of care. We believe that this process has been instrumental in achieving the excellent outcomes that are evidenced in this report for centers across NYS.

The information contained in this report is intended for health care providers, patients and families of patients who are considering cardiac surgery. It includes:

• Mortality rates, adjusted for patient severity of illness, for CABG surgery and valve repair or replacement surgery at NYS hospitals.

• Readmission rates, adjusted for patient severity of illness, following CABG at NYS hospitals.• Mortality rates, adjusted for patient severity of illness, following CABG for surgeons performing

the procedure.• Volume (number of cases) of all cardiac surgery for NYS hospitals and surgeons.• Volume (number of cases) of TAVR at NYS hospitals.• Description of the patient risk factors associated with mortality for CABG and valve surgery and those

associated with readmissions after CABG surgery.

The data that serve as the basis for this report are collected by the NYS Department of Health cooperatively with hospitals throughout the state. Careful auditing and rigorous analysis assure that these reports represent meaningful outcome assessments. The report was developed with clinical guidance from the NYS Cardiac Advisory Committee, an advisory body to the Commissioner of Health consisting of nationally recognized cardiac surgeons, cardiologists and others from related disciplines working both in New York State and elsewhere. The Cardiac Advisory Committee is to be commended for sustained leadership in these efforts.

As they develop treatment plans, we encourage doctors to discuss this information with their patients and colleagues. While these statistics are an important tool in making informed health care choices, individual treatment plans must be made by doctors and patients together after careful consideration of all pertinent factors. It is important to recognize that many factors can influence the outcome of cardiac surgery. These include the patient’s health before the procedure, the skill of the operating team and general after-care. In addition, keep in mind that the information in this booklet does not include data after 2013. Important changes may have taken place in hospitals during that time period.

It is important that patients and physicians alike give careful consideration to the importance of healthy lifestyles for all those affected by heart disease. While some risk factors, such as heredity, gender and age cannot be controlled, others certainly can. Controllable risk factors that contribute to a higher likelihood of developing coronary artery disease are high cholesterol levels, cigarette smoking, high blood pressure, obesity and sedentary lifestyle. Careful attention to these risk factors after surgery will continue to be important in promoting good health and preventing recurrence of disease.

Hospitals and physicians in NYS can take pride in the excellent patient care provided and in their role in contributing to this unique collaborative quality improvement system. The Department of Health will continue to work in partnership with hospitals and physicians to ensure that continued high-quality cardiac surgery is available to NYS residents.

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CORONARY ARTERY BYPASS GRAFT SURGERY (CABG)Heart disease is the leading cause of death in NYS, and the most common form of heart disease is atherosclerotic coronary artery disease. Different treatments are recommended for patients with coronary artery disease. For some people, changes in lifestyle, such as dietary changes, not smoking and regular exercise, can result in great improvements in health. In other cases, medication prescribed for high blood pressure or other conditions can make a significant difference.

Sometimes, however, an interventional procedure is recommended. The two common procedures performed on patients with coronary artery disease are CABG surgery and percutaneous coronary intervention (PCI).

CABG surgery is an operation in which a vein or artery from another part of the body is used to create an alternate path for blood to flow to the heart muscle, bypassing the arterial blockage. Typically, a section of one of the large (saphenous) veins in the leg, the radial artery

in the arm or the mammary artery in the chest is used to construct the bypass. One or more bypasses may be performed during a single operation, since providing several routes for the blood supply to travel is believed to improve long-term success for the procedure. CABG surgery is one of the most common, successful major operations currently performed in the United States.

As is true of all major surgery, risks must be considered. The patient is totally anesthetized and there is generally a substantial recovery period in the hospital followed by several weeks of recuperation at home. Even in successful cases, there is a risk of relapse causing the need for another operation.

Those who have CABG surgery are not cured of coronary artery disease; the disease can still occur in the grafted blood vessels or other coronary arteries. In order to minimize new blockages, patients should continue to reduce their risk factors for heart disease.

CARDIAC VALVE PROCEDURESHeart valves control the flow of blood as it enters the heart and is pumped from the chambers of the heart to the lungs for oxygenation and back to the body. There are four valves: the tricuspid, mitral, pulmonary and aortic valves. Heart valve disease occurs when a valve cannot open all the way because of disease or injury, thus causing a decrease in blood flow to the next heart chamber. Another type of valve problem occurs when the valve does not close completely, which leads to blood leaking backward into the previous chamber. Either of these problems causes the heart to work harder to pump blood or causes blood to back up in the lungs or lower body.

When a valve is stenotic (too narrow to allow enough blood to flow through the valve opening) or incompetent (cannot close tightly enough to prevent the backflow of blood), one of the treatment options is to repair the valve. Repair of a stenotic valve typically involves widening the valve opening, whereas repair

of an incompetent valve is typically achieved by narrowing or tightening the supporting structures of the valve. The mitral valve is particularly amenable to valve repairs because its parts can frequently be repaired without having to be replaced.

In many cases, defective valves are replaced rather than repaired, using either a mechanical or biological valve. Mechanical valves are built using durable materials that generally last a lifetime. Biological valves are made from tissue taken from pigs, cows or humans. Mechanical and biological valves each have advantages and disadvantages that can be discussed with referring physicians.

The most common heart valve surgeries involve the aortic and mitral valves. Patients undergoing heart surgery are totally anesthetized and are usually placed on a heart-lung machine, whereby the heart is stopped for a short period of time using special drugs. As is the case for CABG surgery, there is a recovery period of

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several weeks at home after being discharged from the hospital. Some patients require replacement of more than one valve and some patients with both coronary artery disease and valve disease require valve replacement and CABG surgery. This report contains outcomes for the following valve surgeries when done alone or in combination with CABG: Aortic Valve Replacement, Mitral Valve Repair, Mitral Valve Replacement and Multiple Valve Surgery.

In recent years, a new technique for replacement of the aortic valve has been tested and approved for use in the United States under certain circumstances. This procedure, known as Transcatheter Aortic Valve Replacement (TAVR, also sometimes called Transcatheter Aortic Valve Implantation or TAVI), differs from traditional surgical valve replacement in that the replacement valve is delivered to the

heart through a catheter rather than through a standard surgical incision. The procedure is performed collaboratively by cardiologists and cardiac surgeons.

During the time-period included in this report (2011-2013), the procedure was performed relatively infrequently at a limited number of hospitals. The volume of cases in this time period is not large enough to adequately risk-adjust outcomes at the hospital or physician level. In the interest of providing some information about this emerging procedure while avoiding the risk of drawing invalid conclusions based on limited data, this report contains the volume of TAVR cases in 2013 for each hospital as well as the volume of cases for NYS and in-hospital / 30-Day mortality rate for all TAVR procedures performed in NYS in Table 5.

THE DEPARTMENT OF HEALTH PROGRAMFor many years, the Department of Health has been studying the effects of patient and treatment characteristics (called risk factors) on outcomes for patients with heart disease. Detailed statistical analyses of the information received from the study have been conducted under the guidance of the Cardiac Advisory Committee, a group of independent practicing cardiac surgeons, cardiologists and other professionals in related fields.

The results have been used to create a cardiac profile system which assesses the performance of hospitals and surgeons over time,

independent of the severity of each individual patient’s pre-operative conditions.

Designed to improve health in people with heart disease, this program is aimed at:

• understanding the health risks of patients that adversely affect how they will fare in coronary artery bypass surgery and/or valve surgery;

• improving the results of different treatments of heart disease;

• improving cardiac care; and

• providing information to help patients make better decisions about their own care.

PATIENT POPULATIONThis report is based on data for patients discharged between December 1, 2010, and November 30, 2013, provided by all non-federal hospitals in NYS where cardiac surgery is performed. The analysis period for this report includes patients discharged in December 2010 but not those discharged in December 2013. This strategy allows for more timely report publication by eliminating the need to track patients for 30-day mortality into the following calendar year. Inclusion of cases from

the previous December allows for meaningful comparison of 12-month volume as found in previous reports. The single year analysis for 2013 cases includes patients discharged from December 1, 2012 through November 30, 2013. In total there were 57,623 cardiac surgical procedures performed during this time period.

For various reasons, some of these cases are excluded from analysis in this report. The reasons for exclusion and number of cases affected are described below.

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Records for 118 patients residing outside the United States were excluded because these patients could not be followed after hospital discharge. There were 12 cases excluded from analysis because each 30-day mortality can only be associated with a single cardiac surgery.

Beginning with patients discharged in 2006, the Department of Health, with the advice of the Cardiac Advisory Committee, began a trial period of excluding from publicly released reports any patients meeting the Cardiac Data System definition of pre-operative cardiogenic shock. Cardiogenic shock is a condition associated with severe hypotension (very low blood pressure). [The technical definition used in this report can be found on page 43.] Patients in cardiogenic shock are extremely high-risk, but for some, cardiac surgery may be their best chance for survival. Furthermore, the magnitude of the risk is not always easily determined using registry data. These cases were excluded after careful deliberation and input from NYS providers and others in an effort to ensure that physicians could accept these cases where appropriate without concern over a detrimental impact on their reported outcomes. In total, 569 cases with cardiogenic shock were removed from the data. This accounts for 0.99 percent of all cardiac surgeries (CABG, valve surgery and other cardiac surgery reported in this data system) in the three years.

After all of the above exclusions, there were 56,924 cardiac surgeries analyzed in this report. Isolated CABG surgery represented 43.81

percent of all adult cardiac surgery included in this report. Valve or combined valve/CABG surgery represented 39.02 percent of all adult cardiac surgery for the same period. TAVR represented 2.37 percent of all cardiac surgeries reported. Total cardiac surgery, isolated CABG, valve surgery and other cardiac surgery volumes are tabulated in Table 8 by hospital and surgeon for the period 2011 through 2013.

While there were 8,168 CABG cases included in the mortality analysis for 2013 discharges, some additional exclusions were required for the readmission analysis. Records belonging to patients residing outside NYS were excluded because there is no reliable way to track out-of state readmissions. This accounted for 287 cases. Another 127 patients were excluded because they died in the same admission as their index CABG, so readmission was impossible. Two patients were transferred after CABG and discharged from the second hospital in December, making them ineligible for 30-day follow-up.

In total, the number of exclusions was 416, leaving 7,755 cases to be examined for 30-day readmission rates.

Note on Hospitals Not Performing Cardiac Surgery During Entire 2011 – 2013 Period

Southside Hospital began performing cardiac surgery in February 2011. Millard Fillmore Hospital closed in 2013 and performed the last cardiac surgery in March of that year.

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RISK ADJUSTMENT FOR ASSESSING PROVIDER PERFORMANCEProvider performance is directly related to patient outcomes. Whether patients recover quickly, experience complications, require another hospitalization, or die following a procedure is, in part, a result of the kind of medical care they receive. It is difficult, however, to compare outcomes across hospitals when assessing provider performance because different hospitals treat different types of patients. Hospitals with sicker patients may have higher rates of death and readmission than other hospitals in the state. The following describes how the Department of Health adjusts for patient risk in assessing provider outcomes.

Data Collection, Data Validation and Identifying In-Hospital/30-Day Deaths and 30-Day Readmission

As part of the risk-adjustment process, NYS hospitals where cardiac surgery is performed provide information to the Department of Health for each patient undergoing that procedure. Cardiac surgery departments collect data concerning patients’ demographic and clinical characteristics. Approximately 40 of these characteristics (called risk factors) are collected for each patient. Along with information about the procedure, physician and the patient’s status at discharge, these data are entered into a computer and sent to the Department of Health for analysis.

Data are verified through review of unusual reporting frequencies, cross-matching of cardiac surgery data with other Department of Health databases and a review of medical records for a selected sample of cases. These activities are extremely helpful in ensuring consistent interpretation of data elements across hospitals.

The analyses in this report base mortality on deaths occurring during the same hospital stay in which a patient underwent cardiac surgery and on deaths that occur after discharge but within 30 days of surgery.

An in-hospital death is defined as a patient who died subsequent to CABG or valve surgery during the same admission or was discharged to hospice care and expired within 30 days.

Deaths that occur after hospital discharge but within 30 days of surgery are also counted in the risk-adjusted mortality analyses. This is done because hospital length of stay has been decreasing and, in the opinion of the Cardiac Advisory Committee, most deaths that occur after hospital discharge but within 30 days of surgery are related to complications of surgery.

Data on deaths occurring after discharge from the hospital are obtained from the Department of Health, the New York City Department of Health and Mental Hygiene Bureau of Vital Statistics, and the National Death Index.

Data on readmissions are obtained from the Department of Health’s acute care hospital dataset, the Statewide Planning and Research Cooperative System (SPARCS), which contains data pertaining to all acute care hospital discharges in the state.

Thirty-day readmission is defined as admission to a NYS non-Federal hospital within 30 days of discharge from the index hospitalization. For patients whose index hospitalization ends in transfer to another acute care facility, the 30 day period begins upon discharge from the second hospital.

Assessing Patient Risk

Each person who develops heart disease has a unique health history. A cardiac profile system has been developed to evaluate the risk of treatment for each individual patient based on his or her history, weighing the important health factors for that person based on the experiences of thousands of patients who have undergone the same procedures in recent years. All important risk factors for each patient are combined to create a risk profile. For example, an 80-year-old patient with renal failure requiring dialysis has a very different risk profile than a 40-year-old with no renal failure.

The statistical analyses conducted by the Department of Health consist of determining which of the risk factors collected are significantly related to death or readmission following CABG and/or valve surgery and

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determining how to weigh the significant risk factors to predict the chance each patient will have of dying or being readmitted, given his or her specific characteristics.

Doctors and patients should review individual risk profiles together. Treatment decisions must be made by doctors and patients together after consideration of all the information.

Predicting Patient Mortality Rates for Providers

The statistical methods used to predict mortality on the basis of the significant risk factors are tested to determine whether they are sufficiently accurate in predicting mortality for patients who are extremely ill prior to undergoing the procedure as well as for patients who are relatively healthy. These tests have confirmed that the models are reasonably accurate in predicting how patients of all different risk levels will fare when undergoing cardiac surgery.

The mortality rate for each hospital and surgeon is also predicted using the relevant statistical models. This is accomplished by summing the predicted probabilities of death for each of the provider’s patients and dividing by the number of patients. The resulting rate is an estimate of what the provider’s mortality rate would have been if the provider’s performance were identical to the state performance. The percentage is called the predicted or expected mortality rate (EMR). A hospital’s EMR is contrasted with its observed mortality rate (OMR), which is the number of patients who died divided by the total number of patients.

Computing the Risk-Adjusted Mortality Rate

The risk-adjusted mortality rate (RAMR) represents the best estimate, based on the associated statistical model, of what the provider’s mortality rate would have been if the provider had a mix of patients identical to the statewide mix. Thus, the RAMR has, to the extent possible, ironed out differences among providers in patient severity of illness, since it arrives at a mortality rate for each provider for an identical group of patients. To calculate the RAMR, the OMR is first divided by the provider’s EMR. If the resulting ratio is larger than one, the provider has a higher mortality rate than expected on the basis of its patient

mix; if it is smaller than one, the provider has a lower mortality rate than expected from its patient mix. For isolated CABG patients the ratio is then multiplied by the overall statewide mortality rate of 1.84 percent (in-hospital/30-day mortality in 2013) to obtain the provider’s RAMR. For the three-year period 2011-2013, the ratio is multiplied by 1.51 percent (in-hospital/30-day mortality rate) for isolated CABG patients or 3.45 percent (in-hospital/30-day mortality rate) for valve or valve/CABG patients.

There is no Statewide EMR or RAMR, because the statewide data is not risk-adjusted. The Statewide OMR (number of total cases divided by number of total deaths) serves as the basis for comparison for each hospital’s EMR and RAMR.

Interpreting the Risk-Adjusted Mortality Rate

If the RAMR is significantly lower than the statewide mortality rate, the provider has a significantly better performance than the state as a whole; if the RAMR is significantly higher than the statewide mortality rate, the provider has a significantly worse performance than the state as a whole.

The RAMR is used in this report as a measure of quality of care provided by hospitals and surgeons. However, there are reasons that a provider’s RAMR may not be indicative of its true quality. For example, extreme outcome rates may occur due to chance alone. This is particularly true for low-volume providers, for whom very high or very low mortality rates are more likely to occur than for high-volume providers. To prevent misinterpretation of differences caused by chance variation, confidence intervals are reported in the results. The interpretations of those terms are provided later when the data are presented.

Differences in hospital coding of risk factors could be an additional reason that a provider’s RAMR may not be reflective of quality of care. The Department of Health monitors the quality of coded data by reviewing samples of patients’ medical records to ascertain the presence of key risk factors. When significant coding problems are discovered, hospitals are required to correct these data and are subjected to subsequent monitoring.

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Although there are reasons that RAMRs presented here may not be a perfect reflection of quality of care, the Department of Health feels that this information is a valuable aid in choosing providers for cardiac surgery.

Predicting Patient Readmission and Computing and Interpreting Risk-Adjusted Readmission Rates

Patient risk of 30-day readmission is assessed using the same methods used for assessing mortality risk as described above. All potential risk factors are considered and those that are independently related to readmission are identified and given weights so as to best predict the risk of 30-day readmission for each patient. Observed readmission rates (ORR), expected readmission rates (ERR) and risk-adjusted readmission rates (RARR) are calculated in the same way that OMR, EMR and RAMR are calculated. ERR and RARR are compared to the statewide observed readmission rate (13.72 percent in 2013).

This analysis is based on all-cause readmission, not just readmission directly related to the CABG procedure. Not all readmissions represent a poor patient outcome or reflect poor patient care. However, by risk-adjusting and comparing the results across the many hospitals that perform this procedure we are able to look for meaningful differences from the overall statewide experience. If the RARR is significantly lower than the statewide readmission rate, the hospital has a better performance than the state as a whole; if the RARR is significantly higher than the statewide readmission rate, the hospital has a worse performance than the state as a whole.

As described above for mortality, there are reasons that a provider’s RARR may not be indicative of its true quality. Confidence intervals and careful attention to data quality are used in the same way for readmission as they are for mortality.

How This Initiative Contributes to Quality Improvement

One goal of the Department of Health and the Cardiac Advisory Committee is to improve the quality of care related to cardiac surgery in NYS. Providing the hospitals and cardiac surgeons in NYS with data about their own outcomes for these procedures allows them to examine the quality of the care they provide and to identify areas that need improvement.

The data collected and analyzed in this program are reviewed by the Cardiac Advisory Committee. Committee members assist with interpretation and advise the Department of Health regarding hospitals and surgeons that may need special attention. Committee members have also conducted site visits to particular hospitals and have recommended that some hospitals obtain the expertise of outside consultants to design improvements for their programs.

The overall results of this program of ongoing review show that significant progress is being made. In response to the program’s results for surgery, facilities have refined patient criteria, evaluated patients more closely for pre-operative risks and directed them to the appropriate surgeon. More importantly, many hospitals have identified medical care processes that have led to less than optimal outcomes, and have altered those processes to achieve improved results

14

DEFINITIONS OF KEY TERMSThe observed mortality rate (OMR) is the observed number of deaths divided by the total number of cases.

The expected mortality rate (EMR) is the sum of the predicted probabilities of death for all patients divided by the total number of patients.

The risk-adjusted mortality rate (RAMR) is the best estimate, based on the statistical model, of what the provider’s mortality rate would have been if the provider had a mix of patients identical to the statewide mix. It is obtained by first dividing the OMR by the EMR, and then multiplying by the relevant statewide mortality rate (for example, 1.84 percent for Isolated CABG patients in 2013 or 3.45 percent for Valve or Valve/CABG patients in 2011-2013).

The observed readmission rate (ORR) is the observed number of 30-day readmissions divided by the total number of analyzed cases.

The expected readmission rate (ERR) is the sum of the predicted probabilities of readmission for all patients divided by the total number of analyzed cases.

The risk-adjusted readmission rate (RARR) is the best estimate, based on the statistical model, of what the provider’s readmission rate would have been if the provider had a mix of patients similar to the statewide mix. It is obtained by first dividing the ORR by the ERR, and then multiplying that quotient by the statewide readmission rate (13.72 percent 30-day readmission rate for all CABG patients discharged in 2013).

Confidence Intervals are used to identify which hospitals had significantly more or fewer deaths or readmissions than expected given the risk factors of their patients. The confidence interval identifies the range in which the risk-adjusted rate may fall. Hospitals with significantly higher rates than expected after adjusting for risk are those where the confidence interval range falls entirely above the statewide mortality rate. Hospitals with significantly lower rates than expected, given the severity of illness of their patients before surgery, have confidence intervals entirely below the statewide mortality rate. The more cases a provider performs, the narrower their confidence interval will be. This is because as a provider performs more cases, the likelihood of chance variation in the risk-adjusted rate decreases.

15

2013 HOSPITAL OUTCOMES FOR CABG SURGERYTable 1 and Figure 1 present the CABG surgery results for the 39 hospitals performing this operation in NYS in 2013. The table contains, for each hospital, the number of isolated CABG operations (CABG operations with no other major heart surgery earlier in the hospital stay) for patients discharged in 2013, the number of in-hospital/30-day deaths, the OMR, the EMR based on the statistical model presented in Appendix 1, the RAMR and a 95 percent confidence interval for the RAMR.

As indicated in Table 1, the overall in-hospital/ 30-day mortality rate for the 8,168 CABG surgeries was 1.84 percent. In-hospital/30-day OMRs ranged from 0.00 percent to 4.03 percent. The range of EMRs, which measure patient severity of illness, was 0.98 percent to 2.68 percent.

The RAMRs, which are used to measure performance, ranged from 0.00 percent to 5.09 percent. No hospitals had RAMRs that were significantly lower than the statewide rate. One hospital (Buffalo General Hospital) had a mortality rate that was significantly higher than the statewide rate.

The 2013 in-hospital/30-day mortality rate of 1.84 percent for Isolated CABG is higher than the 1.46 percent observed in 2012.

The in-hospital OMR for 2013 Isolated CABG discharges (not shown in Table 1) was 1.42 percent for all 8,168 patients included in the analysis.

Figure 1 provides a visual representation of the data displayed in Tables 1. For each hospital, the black dot represents the RAMR and the gray bar represents the confidence interval, or potential statistical error, for the RAMR. The black vertical line is the NYS in-hospital/30-day mortality rate. A gray bar that extends far above and/or below the statewide average indicates that a hospital has a wide confidence interval. This

is common when the hospital has a very small number of cases. It does not necessarily mean that the risk-adjusted mortality rate is very high or very low. For any hospital where the gray bar crosses the state average line, the RAMR is not statistically different from the state as a whole. Hospitals that are statistical outliers will have gray bars (confidence intervals) that are either entirely above or entirely below the line for the statewide rate.

Table 2 presents the 30-day readmission results for the 39 hospitals performing CABG in NYS in 2013 for which data could be analyzed. The table contains, for each hospital, the number of CABGs resulting in 2013 discharges, the number of 30-Day readmissions, the ORR, the ERR based on the statistical model presented in Appendix 2, the RARR and a 95 percent confidence interval for the RARR.

The overall ORR for the 7755 CABGs included in this 2013 analysis was 13.72 percent. Observed readmission rates ranged from 7.56 percent to 26.60 percent. The range in ERRs, which measure patient severity of illness, was between 11.30 percent and 15.68 percent. The RARRs, which measure hospital performance, range from 7.65 percent to 28.11 percent.

Based on confidence intervals for RARRs, three hospitals (Good Samaritan in Suffern, New York Methodist in Brooklyn, and New York Presbyterian – Queens) had RARRs that were significantly higher than the statewide average. Two hospitals (New York Presbyterian – Columbia in Manhattan and St. Peter’s Hospital in Albany) had RARRs that were significantly lower than the statewide average.

Figure 2 provides a visual representation of the data displayed in Table 2. It is interpreted in the same way as Figure 1 described above.

16

Table 1

In-Hospital/30-Day Observed, Expected and Risk-Adjusted Mortality Rates for Isolated CABG Surgery in New York State, 2013 Discharges (Listed Alphabetically by Hospital)

Hospital Cases Deaths OMR EMR RAMR 95% CI for RAMR

Albany Med. Ctr 205 3 1.46 1.80 1.50 (0.30, 4.37)Arnot Ogden Med Ctr 69 2 2.90 1.69 3.15 (0.35,11.36)Bellevue Hospital Ctr 84 0 0.00 1.29 0.00 (0.00, 6.20)Buffalo General Hosp 448 16 3.57 1.78 3.68 * (2.10, 5.97)Champ. Valley Phys Hosp 67 2 2.99 1.22 4.51 (0.51,16.28)Ellis Hospital 177 2 1.13 1.50 1.38 (0.16, 4.99)Erie County Med Ctr 22 0 0.00 1.49 0.00 (0.00,20.62)Good Sam – Suffern 108 3 2.78 1.79 2.86 (0.57, 8.34)Lenox Hill Hospital 256 5 1.95 1.61 2.23 (0.72, 5.19)Long Island Jewish MC 173 3 1.73 2.68 1.19 (0.24, 3.47)M I Bassett Hospital 79 0 0.00 2.16 0.00 (0.00, 3.94)Maimonides Medical Ctr 267 3 1.12 2.26 0.91 (0.18, 2.67)Mercy Hospital 326 7 2.15 1.66 2.37 (0.95, 4.89)Montefiore – Moses 190 3 1.58 1.79 1.62 (0.33, 4.73)Montefiore – Weiler 174 2 1.15 1.54 1.37 (0.15, 4.96)Mount Sinai Beth Israel 174 3 1.72 1.50 2.11 (0.42, 6.17)Mount Sinai Hospital 385 5 1.30 1.33 1.80 (0.58, 4.19)Mount Sinai St. Lukes 116 2 1.72 2.07 1.53 (0.17, 5.51)NY Methodist Hospital 97 2 2.06 1.34 2.82 (0.32,10.19)NYP-Columbia Presby. 419 5 1.19 1.99 1.10 (0.36, 2.57)NYP-Queens 90 1 1.11 1.42 1.44 (0.02, 7.99)NYP-Weill Cornell 176 2 1.14 1.20 1.74 (0.20, 6.28)NYU Hospitals Center 135 1 0.74 0.98 1.38 (0.02, 7.70)North Shore Univ Hosp 290 8 2.76 1.98 2.55 (1.10, 5.03)Rochester General Hosp 306 5 1.63 1.81 1.65 (0.53, 3.86)Southside Hospital 163 5 3.07 2.65 2.12 (0.68, 4.95)St. Elizabeth Med Ctr 211 7 3.32 2.12 2.88 (1.15, 5.93)St. Francis Hospital 658 11 1.67 2.00 1.54 (0.77, 2.75)St. Josephs Hospital 391 6 1.53 2.57 1.10 (0.40, 2.38)St. Peters Hospital 302 7 2.32 2.27 1.87 (0.75, 3.86)Staten Island Univ Hosp 238 4 1.68 1.76 1.75 (0.47, 4.48)Strong Memorial Hosp 232 7 3.02 1.88 2.95 (1.18, 6.08)UHS-Wilson Med Ctr 149 6 4.03 1.98 3.74 (1.37, 8.14)Univ. Hosp-Brooklyn 51 2 3.92 1.41 5.09 (0.57,18.39)Univ. Hosp-Stony Brook 243 4 1.65 1.79 1.69 (0.46, 4.33)Univ. Hosp-Upstate 70 2 2.86 2.11 2.49 (0.28, 8.98)Vassar Bros. Med Ctr 166 1 0.60 1.48 0.75 (0.01, 4.15)Westchester Med Ctr 231 2 0.87 1.60 0.99 (0.11, 3.58)Winthrop-Univ. Hosp 230 1 0.43 1.52 0.52 (0.01, 2.91)

STATEWIDE TOTAL 8168 150 1.84

* Risk-adjusted mortality rate significantly higher than the statewide rate based on 95 percent confidence interval.

17

Figure 1

In-Hospital/30-Day Risk-Adjusted Mortality Rates for Isolated CABG in New York State, 2013 Discharges

Albany Med. CtrArnot Ogden Med CtrBellevue Hospital Ctr

Buffalo General Hosp*Champ.Valley Phys Hosp

Ellis HospitalErie County Med CtrGood Sam – SuffernLenox Hill Hospital

Long Island Jewish MCM I Bassett Hospital

Maimonides Medical CtrMercy Hospital

Montefiore – MosesMontefiore – Weiler

Mount Sinai Beth IsraelMount Sinai HospitalMount Sinai St. Lukes

NY Methodist HospitalNYP-Columbia Presby.

NYP-QueensNYP-Weill Cornell

NYU Hospitals CenterNorth Shore Univ Hosp

Rochester General HospSouthside Hospital

St. Elizabeth Med CtrSt. Francis Hospital

St. Josephs HospitalSt. Peters Hosp.

Staten Island Univ HospStrong Memorial Hosp

UHS-Wilson Med CtrUniv. Hosp-Brooklyn

Univ. Hosp-Stony BrookUniv. Hosp-Upstate

Vassar Bros. Med CtrWestchester Med CtrWinthrop-Univ. Hosp

0 2 4 6 8 10 25

11.36

16.28

20.62

10.19

18.39

KeyRAMRPotential margin of statistical error

1.84New York State Average

* Risk-adjusted mortality rate significantly higher than the statewide rate based on 95 percent confidence interval.

18

Table 2

In-Hospital/30-Day Observed, Expected and Risk-Adjusted Readmission Rates for Isolated CABG Surgery in New York State, 2013 Discharges (Listed Alphabetically by Hospital)

Hospital Cases Readmits ORR ERR RARR 95% CI for RARR

Albany Med. Ctr 186 29 15.59 14.11 15.16 (10.15,21.77)Arnot Ogden Med Ctr 59 5 8.47 12.34 9.42 ( 3.04,21.98)Bellevue Hospital Ctr 83 16 19.28 13.77 19.21 (10.97,31.19)Buffalo General Hosp 430 61 14.19 12.89 15.10 (11.55,19.40)Champ.Valley Phys Hosp 65 6 9.23 12.23 10.35 ( 3.78,22.54)Ellis Hospital 173 14 8.09 13.35 8.32 ( 4.54,13.95)Erie County Med Ctr 22 5 22.73 14.57 21.40 ( 6.90,49.93)Good Sam – Suffern 93 21 22.58 13.92 22.26* (13.77,34.03)Lenox Hill Hospital 241 46 19.09 14.22 18.42 (13.48,24.57)Long Island Jewish MC 170 22 12.94 15.36 11.56 ( 7.24,17.50)M I Bassett Hospital 79 11 13.92 13.01 14.68 ( 7.32,26.27)Maimonides Medical Ctr 260 36 13.85 14.75 12.88 ( 9.02,17.83)Mercy Hospital 317 46 14.51 13.07 15.24 (11.15,20.32)Montefiore – Moses 182 23 12.64 15.29 11.34 ( 7.18,17.01)Montefiore – Weiler 172 28 16.28 15.02 14.87 ( 9.88,21.50)Mount Sinai Beth Israel 166 26 15.66 12.59 17.07 (11.15,25.02)Mount Sinai Hospital 358 54 15.08 14.08 14.70 (11.04,19.18)Mount Sinai St. Lukes 105 16 15.24 15.10 13.84 ( 7.91,22.48)NY Methodist Hospital 94 25 26.60 12.98 28.11* (18.18,41.49)NYP-Columbia Presby. 352 35 9.94 14.34 9.51** ( 6.63,13.23)NYP-Queens 88 20 22.73 12.12 25.72* (15.70,39.72)NYP-Weill Cornell 142 19 13.38 12.29 14.94 ( 8.99,23.33)NYU Hospitals Center 119 12 10.08 11.30 12.24 ( 6.32,21.39)North Shore Univ Hosp 281 43 15.30 13.51 15.54 (11.25,20.94)Rochester General Hosp 299 40 13.38 13.22 13.89 ( 9.92,18.91)Southside Hospital 156 25 16.03 14.38 15.29 ( 9.89,22.57)St. Elizabeth Med Ctr 205 26 12.68 13.79 12.62 ( 8.24,18.49)St. Francis Hospital 633 90 14.22 13.94 13.99 (11.25,17.20)St. Josephs Hospital 384 44 11.46 14.24 11.04 ( 8.02,14.83)St. Peters Hospital 291 22 7.56 13.55 7.65** ( 4.79,11.59)Staten Island Univ Hosp 223 26 11.66 13.48 11.87 ( 7.75,17.39)Strong Memorial Hosp 223 28 12.56 13.76 12.52 ( 8.31,18.09)UHS-Wilson Med Ctr 137 16 11.68 14.11 11.35 ( 6.48,18.44)Univ. Hosp-Brooklyn 49 8 16.33 15.68 14.28 ( 6.15,28.15)Univ. Hosp-Stony Brook 237 38 16.03 13.73 16.02 (11.33,21.99)Univ. Hosp-Upstate 68 6 8.82 14.74 8.21 ( 3.00,17.88)Vassar Bros. Med Ctr 165 16 9.70 12.60 10.56 ( 6.03,17.15)Westchester Med Ctr 221 28 12.67 13.76 12.63 ( 8.39,18.25)Winthrop-Univ. Hosp 227 32 14.10 12.72 15.20 (10.40,21.47

STATEWIDE TOTAL 7755 1064 13.72

* Risk-adjusted readmission rate significantly higher than the statewide rate based on 95 percent confidence interval. ** Risk-adjusted readmission rate significantly lower than the statewide rate based on 95 percent confidence interval.

19

Figure 2

30-Day Risk-Adjusted Readmission Rates for Isolated CABG in New York State, 2013 Discharges

Winthrop-Univ. HospWestchester Med CtrVassar Bros. Med Ctr

Univ. Hosp-UpstateUniv. Hosp-Stony Brook

Univ. Hosp-BrooklynUHS-Wilson Med Ctr

Strong Memorial HospStaten Island Univ Hosp

St. Peters Hosp.**St. Josephs HospitalSt. Francis Hospital

St. Elizabeth Med CtrSouthside Hospital

Rochester General HospNorth Shore Univ Hosp

NYU Hospitals CenterNYP-Weill Cornell

NYP-Queens*NYP-Columbia Presby.**NY Methodist Hospital*

Mount Sinai St. LukesMount Sinai Hospital

Mount Sinai Beth IsraelMontefiore – WeilerMontefiore – Moses

Mercy HospitalMaimonides Medical Ctr

M I Bassett HospitalLong Island Jewish MC

Lenox Hill HospitalGood Sam – Suffern*Erie County Med Ctr

Ellis HospitalChamp.Valley Phys Hosp

Buffalo General HospBellevue Hospital CtrArnot Ogden Med Ctr

Albany Med. Ctr

0 5 10 15 20 25 30

31.19

50

49.9334.03

41.49

39.72

13.72New York State Average

KeyRAMRPotential margin of statistical error

* Risk-adjusted readmission rate significantly higher than the statewide rate based on 95 percent confidence interval.** Risk-adjusted readmission rate significantly lower than the statewide rate based on 95 percent confidence interval.

20

2011-2013 HOSPITAL OUTCOMES FOR VALVE SURGERYTable 3 and Figure 3 present the combined Valve Only and Valve/CABG surgery results for the 40 hospitals performing these operations in NYS during the years 2011-2013. The table contains, for each hospital, the combined number of Valve Only and Valve/CABG operations resulting in 2011-2013 discharges, the number of in-hospital/30-day deaths, the OMR, the EMR based on the statistical models presented in Appendices 3-4, the RAMR and a 95 percent confidence interval for the RAMR.

As indicated in Table 3, the overall in-hospital/30-day mortality rate for the 22,213 combined Valve Only and Valve/CABG procedures performed at the 40 hospitals was 3.45 percent. The OMRs ranged from 0.00 percent to 8.25 percent. The range of EMRs, which measure patient severity of illness, was 1.56 percent to 4.55 percent.

The RAMRs, which are used to measure performance, ranged from 0.00 percent to 14.37 percent. Three hospitals (Arnot Ogden Medical Center in Elmira, Rochester General Hosptial, and Strong Memorial Hospital in Rochester) had RAMRs that were significantly higher than the statewide rate. One hospital (St. Joseph’s Hospital in Syracuse) had a RAMR that was significantly lower than the statewide rate.

Figure 3 provides a visual representation of the data displayed in Table 3. It is interpreted in the same way as Figure 1 described above.

Table 4 presents valve procedures performed at the 40 cardiac surgery hospitals in NYS during 2011-2013. The table contains, for each hospital, the number of valve operations (as

defined by eight separate groups: Aortic Valve Replacements, Aortic Valve Repair or Replacements plus CABG, Mitral Valve Replacement, Mitral Valve Replacement plus CABG, Mitral Valve Repair, Mitral Valve Repair plus CABG, Multiple Valve Surgery and Multiple Valve Surgery plus CABG) resulting in 2011-2013 discharges. In addition to the hospital volumes, the rate of in-hospital/30-day death for the state (Statewide Mortality Rate) is given for each group. Unless otherwise specified, when the report refers to Valve or Valve/CABG procedures it is referring to the last column of Table 4.

The 2011-2013 in-hospital/30-day OMR of 3.45 percent for Valve and Valve/CABG surgeries is lower than the 3.74 percent observed for 2010-2012. The in-hospital OMR for 2011-2013 valve surgeries (not shown in Table 3) is 2.90 percent for the 22,213 patients included in this analysis.

Table 5 presents the number of transcatheter aortic valve replacement (TAVR) procedures performed at the 20 hospitals performing TAVR during the 2013 discharge period. Table 5 also presents the statewide in-hospital / 30-day mortality rate of 6.37 percent for the 1350 TAVR discharges during that time period. It is important to note that TAVR was a relatively new procedure during the time period in question and the number of cases performed in 2013 may be very different from current program volume. Some hospitals listed in Table 5 began performing the procedure during 2013 and the number of cases listed does not represent a full year’s program activity. Other hospitals have begun performing the procedure more recently.

21

Table 3

In-Hospital/30-Day Observed, Expected, and Risk-Adjusted Mortality Rates for Valve or Valve/CABG Surgery in New York State, 2011-2013 Discharges.

Hospital Cases Deaths OMR EMR RAMR 95% CI for RAMR

Albany Med. Ctr 623 16 2.57 3.42 2.59 (1.48, 4.21)Arnot Ogden Med Ctr 99 8 8.08 1.94 14.37 * (6.19,28.31)Bellevue Hospital Ctr 226 7 3.10 2.33 4.59 (1.84, 9.46)Buffalo General Hosp 631 18 2.85 2.79 3.53 (2.09, 5.58)Champ.Valley Phys Hosp 75 3 4.00 1.56 8.83 (1.78,25.81)Ellis Hospital 299 14 4.68 3.07 5.27 (2.88, 8.84)Erie County Med Ctr 30 1 3.33 3.87 2.98 (0.04,16.56)Good Sam – Suffern 129 2 1.55 2.44 2.19 (0.25, 7.92)Lenox Hill Hospital 479 16 3.34 3.50 3.30 (1.88, 5.36)Long Island Jewish MC 534 11 2.06 3.44 2.07 (1.03, 3.70)M I Bassett Hospital 102 0 0.00 3.05 0.00 (0.00, 4.07)Maimonides Medical Ctr 490 16 3.27 3.81 2.96 (1.69, 4.81)Mercy Hospital 481 14 2.91 2.58 3.89 (2.13, 6.53)Millard Fillmore Hosp 98 2 2.04 2.11 3.34 (0.38,12.07)Montefiore – Moses 426 17 3.99 4.02 3.42 (1.99, 5.48)Montefiore – Weiler 328 14 4.27 4.55 3.24 (1.77, 5.44)Mount Sinai Beth Israel 244 12 4.92 3.22 5.27 (2.72, 9.21)Mount Sinai Hospital 1820 55 3.02 3.36 3.10 (2.34, 4.04)Mount Sinai St. Lukes 271 13 4.80 3.20 5.18 (2.76, 8.86)NY Methodist Hospital 182 6 3.30 3.04 3.74 (1.37, 8.15)NYP-Columbia Presby. 2228 71 3.19 3.82 2.88 (2.25, 3.63)NYP-Queens 117 0 0.00 2.68 0.00 (0.00, 4.04)NYP-Weill Cornell 1303 32 2.46 3.22 2.63 (1.80, 3.72)NYU Hospitals Center 1308 41 3.13 2.69 4.03 (2.89, 5.47)North Shore Univ Hosp 932 34 3.65 3.47 3.63 (2.51, 5.07)Rochester General Hosp 1025 55 5.37 3.77 4.91 * (3.70, 6.39)Southside Hospital 344 10 2.91 3.75 2.68 (1.28, 4.92)St. Elizabeth Med Ctr 324 14 4.32 3.07 4.86 (2.65, 8.15)St. Francis Hospital 1831 67 3.66 3.86 3.28 (2.54, 4.16)St. Josephs Hospital 1104 26 2.36 3.95 2.06 ** (1.34, 3.01)St. Peters Hospital 717 27 3.77 3.64 3.57 (2.35, 5.19)Staten Island Univ Hosp 275 13 4.73 3.18 5.13 (2.73, 8.78)Strong Memorial Hosp 642 35 5.45 3.37 5.58 * (3.89, 7.76)UHS-Wilson Med Ctr 249 11 4.42 2.53 6.04 (3.01,10.80)Univ. Hosp-Brooklyn 97 8 8.25 4.31 6.60 (2.84,13.01)Univ. Hosp-Stony Brook 476 19 3.99 4.03 3.42 (2.06, 5.35)Univ. Hosp-Upstate 211 6 2.84 3.12 3.15 (1.15, 6.85)Vassar Bros. Med Ctr 468 13 2.78 3.44 2.79 (1.48, 4.77)Westchester Med Ctr 381 14 3.67 4.07 3.12 (1.70, 5.23)Winthrop-Univ. Hosp 614 26 4.23 3.53 4.15 (2.71, 6.08)

STATEWIDE TOTAL 22213 767 3.45

* Risk-adjusted mortality rate significantly higher than the statewide rate based on 95 percent confidence interval. ** Risk-adjusted mortality rate significantly lower than the statewide rate based on 95 percent confidence interval.

22

Figure 3

In-Hospital/30-Day Risk-Adjusted Mortality Rates for Valve or Valve/ CABG Surgery in New York State, 2011-2013 Discharges

Winthrop-Univ. HospWestchester Med CtrVassar Bros. Med Ctr

Univ. Hosp-UpstateUniv. Hosp-Stony Brook

Univ. Hosp-BrooklynUHS-Wilson Med Ctr

Strong Memorial Hosp*Staten Island Univ Hosp

St. Peters Hosp.St. Josephs Hospital**

St. Francis HospitalSt. Elizabeth Med Ctr

Southside HospitalRochester General Hosp*

North Shore Univ HospNYU Hospitals Center

NYP-Weill CornellNYP-Queens

NYP-Columbia Presby.NY Methodist Hospital

Mount Sinai St. LukesMount Sinai Hospital

Mount Sinai Beth IsraelMontefiore – WeilerMontefiore – Moses

Millard Fillmore HospMercy Hospital

Maimonides Medical CtrM I Bassett Hospital

Long Island Jewish MCLenox Hill Hospital

Good Sam – SuffernErie County Med Ctr

Ellis HospitalChamp.Valley Phys Hosp

Buffalo General HospBellevue Hospital Ctr

Arnot Ogden Med Ctr*Albany Med. Ctr

0 2 4 6 8 10 12 141 3 5 7 9 11 13 15 30

16.56

25.81

28.31

3.45New York State Average

KeyRAMRPotential margin of statistical error

* Risk-adjusted mortality rate significantly higher than the statewide rate based on 95 percent confidence interval.** Risk-adjusted mortality rate significantly lower than the statewide rate based on 95 percent confidence interval.

23

Table 4

Hospital Volume for Valve Surgery in New York State, 2011-2013 Discharges

Hospital Aortic Aortic Mitral Mitral Mitral Mitral Multiple Multiple Total Valve Valve Valve Replace Valve Repair Valve Valve Valve or Replace and Replace and Repair and Surgery and Valve/ Surgery CABG Surgery CABG Surgery CABG CABG CABG

Albany Med. Ctr 232 168 30 16 78 32 45 22 623Arnot Ogden Med Ctr 44 37 7 0 5 3 3 0 99Bellevue Hospital Ctr 80 14 41 8 21 6 52 4 226Buffalo General Hosp 238 218 46 17 54 29 22 7 631Champ.Valley Phys Hosp 45 28 2 0 0 0 0 0 75Ellis Hospital 114 96 24 12 22 10 13 8 299Erie County Med Ctr 9 8 4 4 1 0 2 2 30Good Sam – Suffern 45 32 5 10 23 6 6 2 129Lenox Hill Hospital 163 65 50 8 85 22 72 14 479Long Island Jewish MC 143 103 73 32 68 44 52 19 534M I Bassett Hospital 38 44 5 3 2 2 3 5 102Maimonides Medical Ctr 157 96 101 26 30 14 60 6 490Mercy Hospital 168 134 32 17 77 20 21 12 481Millard Fillmore Hosp 33 37 6 0 13 2 6 1 98Montefiore – Moses 119 47 78 28 42 45 52 15 426Montefiore – Weiler 86 55 56 17 23 38 38 15 328Mount Sinai Beth Israel 66 53 34 18 30 17 21 5 244Mount Sinai Hospital 311 148 24 8 214 65 891 159 1820Mount Sinai St. Lukes 52 49 26 13 66 30 29 6 271NY Methodist Hospital 73 33 26 10 7 4 27 2 182NYP-Columbia Presby. 939 404 201 59 253 74 244 54 2228NYP-Queens 49 20 14 6 9 6 12 1 117NYP-Weill Cornell 541 220 130 37 150 23 161 41 1303NYU Hospitals Center 512 110 100 18 342 40 167 19 1308North Shore Univ Hosp 345 226 114 48 50 27 91 31 932Rochester General Hosp 370 236 66 26 128 72 80 47 1025Southside Hospital 104 73 30 12 33 33 41 18 344St. Elizabeth Med Ctr 100 84 16 17 30 30 30 17 324St. Francis Hospital 695 385 95 32 185 123 216 100 1831St. Josephs Hospital 330 257 76 47 130 81 115 68 1104St. Peters Hospital 227 221 27 20 38 50 77 57 717Staten Island Univ Hosp 104 54 39 22 26 10 14 6 275Strong Memorial Hosp 297 158 41 9 69 12 37 19 642UHS-Wilson Med Ctr 104 103 12 9 4 3 8 6 249Univ. Hosp-Brooklyn 25 13 16 1 11 9 16 6 97Univ. Hosp-Stony Brook 165 119 35 20 32 28 42 35 476Univ. Hosp-Upstate 73 37 19 3 47 7 22 3 211Vassar Bros. Med Ctr 152 153 48 25 29 16 24 21 468Westchester Med Ctr 131 101 29 12 38 27 28 15 381Winthrop-Univ. Hosp 212 169 71 36 43 45 28 10 614

Total 7691 4608 1849 706 2508 1105 2868 878 22213

STATEWIDE MORTALITY RATE (%) 2.35 3.58 4.54 5.10 1.28 4.07 5.02 9.11 3.45

24

Table 5

Hospital Volume for Transcatheter Aortic Valve Replacement in New York State, 2013 Discharges (Listed Alphabetically by Hospital)

Hospital Cases

Albany Med. Ctr 67Buffalo General Hosp 42Lenox Hill Hospital 38Long Island Jewish MC 86Maimonides Medical Ctr 35Montefiore – Moses 31Mount Sinai Hospital 107NY Methodist Hospital 4NYP-Columbia Presby. 298NYP-Weill Cornell 103NYU Hospitals Center 27North Shore Univ Hosp 69Southside Hospital 39St. Francis Hospital 106St. Josephs Hospital 51St. Peters Hospital 6Strong Memorial Hosp 42Univ. Hosp-Stony Brook 27Westchester Med Ctr 26Winthrop-Univ. Hosp 146

STATEWIDE TOTAL 1350

STATEWIDE MORTALITY RATE (%) 6.37

25

Table 6

In-Hospital / 30-Day Observed, Expected and Risk-Adjusted Mortality Rates by Surgeon for Isolated CABG and Valve Surgery (done in combination with or without CABG) in New York State, 2011-2013 Discharges

Isolated CABG Isolated CABG, or Valve or Valve/CABG No of 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

STATEWIDE TOTAL 24937 376 1.51 47150 2.42

Albany Med. Ctr #Akujuo A C 46 0 0.00 2.25 0.00 (0.00, 5.34) 72 0.00 #Bennett E 65 0 0.00 1.33 0.00 (0.00, 6.39) 239 2.80 Britton L 162 1 0.62 1.94 0.48 (0.01, 2.67) 319 0.96 Depan H 241 2 0.83 2.17 0.58 (0.06, 2.08) 392 1.49 Devejian N . . . . . ( . , . ) 1 0.00 Miller S 177 4 2.26 1.82 1.88 (0.50, 4.80) 291 1.79 Total 691 7 1.01 1.95 0.78 (0.31, 1.61) 1314 1.60 **

Arnot Ogden Med Ctr Nast E 127 1 0.79 1.45 0.82 (0.01, 4.56) 188 4.15 Raudat C W 96 3 3.13 1.58 2.98 (0.60, 8.72) 131 6.40 All Others 12 0 0.00 0.67 0.00 (0.00,68.54) 15 15.03 Total 235 4 1.70 1.46 1.76 (0.47, 4.49) 334 5.43 *

2011-2013 HOSPITAL AND SURGEON OUTCOMESTable 6 provides the number of Isolated CABG operations, number of CABG patients who died in the hospital or after discharge but within 30 days of surgery, OMR, EMR, RAMR and the 95 percent confidence interval for the RAMR for Isolated CABG patients in 2011-2013. In addition, the final two columns provide the number of Isolated CABG, Valve and Valve/CABG procedures and the RAMR for these patients in 2011-2013 for each of the 40 hospitals performing these operations during the time period. Surgeons and hospitals with RAMRs that are significantly lower or higher than the statewide mortality rate (as judged by the 95 percent confidence interval) are also noted.

The hospital information is presented for each surgeon who met at least one of the following criteria: (a) performed 200 or more cardiac operations during 2011-2013, (b) performed at least one cardiac operation in each of the years, 2011-2013. A cardiac operation is defined as any reportable adult cardiac operation and may include cases not listed in Tables 6 or 7.

The results for surgeons not meeting either of the above criteria are grouped together and reported as “All Others” in the hospital in which the operations were performed. Surgeons who met the above criteria and who performed operations in more than one hospital during 2011-2013 are noted in Table 6 and listed under all hospitals in which they performed these operations. Also, surgeons who met either criterion (a) or (b) above and have performed Isolated CABG, Valve or operations in two or more NYS hospitals are listed separately in Table 7. This table contains the same information as Table 6 across all hospitals in which the surgeon performed operations.

26

Table 6 continued Isolated CABG Isolated CABG, or Valve or Valve/CABG No of 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

Bellevue Hospital Ctr #Balsam L B 129 1 0.78 0.94 1.24 (0.02, 6.89) 246 1.31 ##Culliford A 1 0 0.00 2.93 0.00 (0.00,100.0) 1 0.00 ##Deanda A 112 3 2.68 0.81 4.97 (1.00,14.51) 187 4.89 #Grossi E 1 0 0.00 0.45 0.00 (0.00,100.0) 1 0.00 ##Loulmet D F 24 1 4.17 1.04 6.05 (0.08,33.65) 58 9.98 * ##Zias E 2 0 0.00 2.55 0.00 (0.00,100.0) 2 0.00 Total 269 5 1.86 0.92 3.06 (0.99, 7.15) 495 3.76

Buffalo General Hosp ##Aldridge J 109 6 5.50 1.45 5.71 * (2.08,12.43) 119 9.40 * #Ashraf M 325 6 1.85 1.31 2.13 (0.78, 4.63) 420 2.99 ##Downing S W 8 1 12.50 0.99 18.99 (0.25,100.0) 11 11.36 Grosner G 659 10 1.52 1.40 1.64 (0.78, 3.01) 1175 2.44 All Others 22 1 4.55 1.56 4.40 (0.06,24.46) 29 5.05 Total 1123 24 2.14 1.38 2.34 (1.50, 3.48) 1754 3.08

Champ.Valley Phys Hosp Cahill A T 173 3 1.73 1.16 2.25 (0.45, 6.58) 244 4.67 #El Amir N 14 0 0.00 0.78 0.00 (0.00,50.48) 17 0.00 All Others 42 1 2.38 1.07 3.37 (0.04,18.74) 43 5.34 Total 229 4 1.75 1.12 2.35 (0.63, 6.02) 304 4.54

Ellis Hospital Choumarov K 224 2 0.89 1.26 1.07 (0.12, 3.87) 287 3.78 #Reich H 110 2 1.82 1.37 2.00 (0.22, 7.21) 259 2.40 Singh C 193 1 0.52 1.44 0.54 (0.01, 3.03) 280 2.39 Total 527 5 0.95 1.35 1.06 (0.34, 2.48) 826 2.83

Erie County Med Ctr #Bell-Thomson J 1 0 0.00 0.57 0.00 (0.00,100.0) 1 0.00 ##Downing S W 154 0 0.00 1.29 0.00 (0.00, 2.77) 180 0.79 All Others 18 0 0.00 0.81 0.00 (0.00,37.91) 22 0.00 Total 173 0 0.00 1.24 0.00 (0.00, 2.58) 203 0.73

Good Sam – Suffern #Lundy E F 144 1 0.69 1.62 0.65 (0.01, 3.60) 215 1.12 Salenger R 160 2 1.25 1.29 1.46 (0.16, 5.29) 210 2.46 All Others 49 1 2.04 1.80 1.71 (0.02, 9.51) 57 2.15 Total 353 4 1.13 1.49 1.14 (0.31, 2.93) 482 1.73

Lenox Hill Hospital ##Galloway A 4 0 0.00 1.16 0.00 (0.00,100.0) 15 0.00 ##Loulmet D F 4 0 0.00 1.52 0.00 (0.00,90.78) 9 0.00 Patel N C 556 4 0.72 1.22 0.89 (0.24, 2.28) 772 1.89 Plestis K A 67 3 4.48 1.34 5.05 (1.02,14.76) 192 2.43 Subramanian V 95 2 2.11 2.38 1.34 (0.15, 4.82) 144 3.05 ##Zias E 1 0 0.00 0.62 0.00 (0.00,100.0) 4 0.00 All Others 43 1 2.33 1.11 3.16 (0.04,17.59) 113 3.93 Total 770 10 1.30 1.36 1.44 (0.69, 2.64) 1249 2.31

27

Table 6 continued Isolated CABG Isolated CABG, or Valve or Valve/CABG No of 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

Long Island Jewish MC Graver L 186 3 1.61 1.76 1.38 (0.28, 4.04) 439 1.93 #Manetta F 4 1 25.00 0.56 67.54 (0.88,100.0) 6 79.95 Meyer D B 1 0 0.00 0.69 0.00 (0.00,100.0) 2 0.00 Palazzo R 167 0 0.00 1.28 0.00 (0.00, 2.58) 265 1.24 Parnell V . . . . . ( . , . ) 1 0.00 Scheinerman S J 135 1 0.74 2.02 0.55 (0.01, 3.08) 313 0.60 ** ##Singh V A 2 0 0.00 2.86 0.00 (0.00,96.84) 3 0.00 Total 495 5 1.01 1.66 0.92 (0.30, 2.14) 1029 1.46 **

M I Bassett Hospital Kelley J 131 2 1.53 1.45 1.59 (0.18, 5.73) 196 1.29 Lancey R A 92 0 0.00 1.61 0.00 (0.00, 3.73) 129 0.00 Total 223 2 0.90 1.52 0.89 (0.10, 3.22) 325 0.75

Maimonides Medical Ctr Abrol S 131 1 0.76 2.00 0.58 (0.01, 3.21) 207 2.12 Crooke G 86 2 2.33 1.81 1.94 (0.22, 7.01) 143 2.01 Jacobowitz I 269 2 0.74 2.06 0.54 (0.06, 1.96) 390 0.89 ** Ribakove G 84 2 2.38 2.24 1.60 (0.18, 5.78) 198 2.62 #Saunders P 50 1 2.00 1.46 2.07 (0.03,11.53) 58 2.73 Stephens G A 37 0 0.00 1.38 0.00 (0.00,10.86) 68 5.82 Vaynblat M 135 1 0.74 1.52 0.73 (0.01, 4.08) 218 1.29 All Others 2 0 0.00 0.70 0.00 (0.00,100.0) 2 0.00 Total 794 9 1.13 1.88 0.91 (0.42, 1.73) 1284 1.81

Mercy Hospital ##Aldridge J 7 0 0.00 1.14 0.00 (0.00,69.45) 9 0.00 #Bell-Thomson J 394 7 1.78 1.37 1.95 (0.78, 4.03) 732 3.00 ##Downing S W 250 5 2.00 1.50 2.01 (0.65, 4.69) 305 3.18 Lico S 342 4 1.17 1.33 1.32 (0.36, 3.38) 428 2.26 Total 993 16 1.61 1.39 1.75 (1.00, 2.84) 1474 2.77

Millard Fillmore Hosp ##Aldridge J 17 0 0.00 1.15 0.00 (0.00,28.21) 27 0.00 #Ashraf M 250 2 0.80 1.46 0.83 (0.09, 2.99) 332 1.82 All Others 3 0 0.00 0.84 0.00 (0.00,100.0) 9 0.00 Total 270 2 0.74 1.43 0.78 (0.09, 2.81) 368 1.63

Montefiore – Moses #Bello R A 10 0 0.00 2.36 0.00 (0.00,23.42) 12 0.00 #D Alessandro D A 216 2 0.93 1.29 1.08 (0.12, 3.90) 333 3.02 #Derose J J 26 0 0.00 2.06 0.00 (0.00,10.34) 28 0.00 #Goldstein D J 124 2 1.61 1.29 1.89 (0.21, 6.81) 234 1.51 #Jakobleff W A 105 3 2.86 1.28 3.38 (0.68, 9.87) 128 5.11 #Michler R E 83 0 0.00 1.10 0.00 (0.00, 6.07) 254 1.90 Weinstein S . . . . . ( . , . ) 1 0.00 Total 564 7 1.24 1.31 1.42 (0.57, 2.94) 990 2.37

28

Table 6 continued Isolated CABG Isolated CABG, or Valve or Valve/CABG No of 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

Montefiore – Weiler #Bello R A 183 0 0.00 1.40 0.00 (0.00, 2.16) 271 1.43 #D Alessandro D A 1 0 0.00 10.47 0.00 (0.00,52.82) 3 0.00 #Derose J J 292 3 1.03 1.17 1.33 (0.27, 3.88) 460 2.78 #Goldstein D J 51 0 0.00 1.34 0.00 (0.00, 8.10) 95 0.74 #Jakobleff W A 2 0 0.00 4.76 0.00 (0.00,58.11) 3 0.00 #Michler R E 3 0 0.00 1.00 0.00 (0.00,100.0) 28 0.00 Total 532 3 0.56 1.29 0.66 (0.13, 1.92) 860 1.89

Mount Sinai Beth Israel ##Culliford A . . . . . ( . , . ) 3 51.81 ##Deanda A . . . . . ( . , . ) 1 0.00 Dimitrova K R 3 0 0.00 1.21 0.00 (0.00,100.0) 6 0.00 ##Galloway A . . . . . ( . , . ) 1 0.00 Geller C M 56 0 0.00 1.73 0.00 (0.00, 5.72) 86 2.06 Hoffman D 149 2 1.34 1.04 1.94 (0.22, 7.01) 187 3.33 ##Loulmet D F . . . . . ( . , . ) 1 0.00 Tranbaugh R 250 2 0.80 0.96 1.25 (0.14, 4.52) 373 3.05 ##Zias E 2 0 0.00 1.00 0.00 (0.00,100.0) 6 0.00 All Others 21 1 4.76 2.40 2.99 (0.04,16.64) 61 3.46 Total 481 5 1.04 1.14 1.37 (0.44, 3.20) 725 3.09

Mount Sinai Hospital Adams D H 17 0 0.00 0.82 0.00 (0.00,39.52) 994 1.51 ** Anyanwu A C 48 2 4.17 1.34 4.70 (0.53,16.95) 145 5.96 * Chikwe J Y 154 2 1.30 1.08 1.81 (0.20, 6.55) 258 1.83 DiLuozzo G 3 0 0.00 0.62 0.00 (0.00,100.0) 15 13.78 Filsoufi F 269 3 1.12 1.03 1.63 (0.33, 4.75) 409 3.06 Milla F 58 0 0.00 1.04 0.00 (0.00, 9.14) 117 1.00 Reddy R C 306 7 2.29 1.30 2.65 (1.06, 5.47) 407 3.36 Stelzer P 44 1 2.27 0.88 3.91 (0.05,21.76) 315 1.80 #Stewart A S 2 0 0.00 0.70 0.00 (0.00,100.0) 3 0.00 Tannous H J 56 0 0.00 0.89 0.00 (0.00,11.08) 96 0.00 Varghese R 46 0 0.00 0.57 0.00 (0.00,20.97) 62 0.00 All Others 5 0 0.00 0.45 0.00 (0.00,100.0) 7 0.00 Total 1008 15 1.49 1.09 2.05 (1.15, 3.39) 2828 2.35

Mount Sinai St. Lukes Balaram S K 80 1 1.25 2.07 0.91 (0.01, 5.06) 138 3.15 Swistel D 258 4 1.55 1.82 1.28 (0.35, 3.28) 471 2.82 Total 338 5 1.48 1.88 1.19 (0.38, 2.77) 609 2.90

NY Methodist Hospital #Gulkarov I M 80 0 0.00 1.21 0.00 (0.00, 5.71) 142 0.00 #Tortolani A 135 3 2.22 1.13 2.97 (0.60, 8.68) 217 5.47 * All Others 60 0 0.00 1.63 0.00 (0.00, 5.66) 98 0.00 Total 275 3 1.09 1.26 1.30 (0.26, 3.81) 457 2.42

29

Table 6 continued Isolated CABG Isolated CABG, or Valve or Valve/CABG No of 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

NYP-Columbia Presby. Argenziano M 185 2 1.08 0.93 1.75 (0.20, 6.32) 467 2.26 #Bacha E . . . . . ( . , . ) 13 0.00 #Chen J M . . . . . ( . , . ) 1 0.00 Naka Y 242 2 0.83 1.27 0.98 (0.11, 3.55) 479 2.79 Quaegebeur J . . . . . ( . , . ) 1 0.00 Smith C 136 1 0.74 1.01 1.10 (0.01, 6.13) 729 1.46 #Stewart A S 193 6 3.11 1.93 2.43 (0.89, 5.28) 590 2.37 Takayama H 304 7 2.30 1.87 1.86 (0.75, 3.83) 507 2.85 Williams M R 86 1 1.16 1.54 1.14 (0.01, 6.33) 547 1.63 All Others 57 1 1.75 1.97 1.34 (0.02, 7.46) 97 2.09 Total 1203 20 1.66 1.50 1.67 (1.02, 2.59) 3431 2.14

NYP-Queens #Lang S 286 3 1.05 1.18 1.34 (0.27, 3.93) 403 1.12 Total 286 3 1.05 1.18 1.34 (0.27, 3.93) 403 1.12

NYP-Weill Cornell #Bacha E . . . . . ( . , . ) 1 0.00 #Chen J M . . . . . ( . , . ) 3 0.00 Girardi L 231 0 0.00 1.34 0.00 (0.00, 1.79) 955 1.51 #Gulkarov I M 3 0 0.00 0.95 0.00 (0.00,100.0) 5 0.00 Isom O 12 0 0.00 0.69 0.00 (0.00,66.67) 51 0.00 Krieger K 166 3 1.81 1.13 2.40 (0.48, 7.02) 577 2.64 #Lang S 4 0 0.00 0.78 0.00 (0.00,100.0) 11 0.00 Salemi A 104 2 1.92 1.03 2.83 (0.32,10.20) 215 1.61 #Tortolani A 1 1 100.00 0.93 100.00 (2.12,100.0) 1 100.00 All Others 1 0 0.00 1.06 0.00 (0.00,100.0) 6 0.00 Total 522 6 1.15 1.19 1.46 (0.53, 3.17) 1825 1.91

NYU Hospitals Center #Balsam L B 1 0 0.00 0.36 0.00 (0.00,100.0) 8 3.56 ##Culliford A 60 1 1.67 0.86 2.93 (0.04,16.33) 139 1.48 ##Deanda A 4 0 0.00 0.64 0.00 (0.00,100.0) 15 0.00 ##Galloway A 58 1 1.72 1.02 2.54 (0.03,14.12) 584 2.99 #Grossi E 6 0 0.00 0.91 0.00 (0.00,100.0) 14 7.20 ##Loulmet D F 62 0 0.00 0.73 0.00 (0.00,12.21) 365 2.66 Mosca R S . . . . . ( . , . ) 1 0.00 ##Zias E 149 4 2.68 0.82 4.93 (1.33,12.62) 440 2.82 All Others 60 1 1.67 1.00 2.52 (0.03,14.04) 142 5.99 Total 400 7 1.75 0.87 3.05 (1.22, 6.28) 1708 3.01

North Shore Univ Hosp Esposito R 267 1 0.37 1.45 0.39 (0.01, 2.17) 496 3.08 Hall M 189 2 1.06 1.74 0.92 (0.10, 3.31) 349 2.18 #Hartman A 34 0 0.00 1.33 0.00 (0.00,12.27) 198 1.28 #Kalimi R 78 2 2.56 1.66 2.32 (0.26, 8.39) 171 2.76 Pogo G 162 5 3.09 1.81 2.58 (0.83, 6.01) 276 3.56 Vatsia S 192 5 2.60 1.55 2.53 (0.82, 5.91) 352 1.73 All Others 10 0 0.00 1.80 0.00 (0.00,30.80) 22 4.24 Total 932 15 1.61 1.61 1.51 (0.84, 2.49) 1864 2.51

30

Table 6 continued Isolated CABG Isolated CABG, or Valve or Valve/CABG No of 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

Rochester General Hosp Cheeran D 484 11 2.27 1.72 1.99 (0.99, 3.56) 866 2.92 Kirshner R 428 12 2.80 1.63 2.60 (1.34, 4.54) 1050 3.85 * All Others 52 2 3.85 1.91 3.04 (0.34,10.96) 73 6.29 Total 964 25 2.59 1.69 2.31 (1.50, 3.42) 1989 3.53 *

Southside Hospital #Hartman A 53 1 1.89 2.06 1.38 (0.02, 7.68) 222 1.59 #Kalimi R 197 4 2.03 1.95 1.57 (0.42, 4.03) 323 1.96 #Manetta F 133 3 2.26 1.96 1.73 (0.35, 5.06) 177 3.06 ##Singh V A 16 1 6.25 1.67 5.65 (0.07,31.42) 21 10.32 Total 399 9 2.26 1.96 1.74 (0.79, 3.30) 743 2.22

St. Elizabeth Med Ctr #Akujuo A C 131 2 1.53 1.20 1.92 (0.22, 6.93) 204 3.97 #El Amir N 214 3 1.40 1.53 1.38 (0.28, 4.03) 321 3.20 Joyce F 265 7 2.64 1.72 2.32 (0.93, 4.78) 409 3.00 Total 610 12 1.97 1.54 1.92 (0.99, 3.36) 934 3.26

St. Francis Hospital Bercow N 381 8 2.10 1.68 1.88 (0.81, 3.70) 628 2.97 Colangelo R 662 9 1.36 1.53 1.34 (0.61, 2.55) 1166 1.71 #Fernandez H A 197 0 0.00 2.22 0.00 ** (0.00, 1.26) 283 1.15 Lamendola C 285 5 1.75 1.73 1.53 (0.49, 3.57) 514 3.31 #Lundy E F 24 1 4.17 1.97 3.18 (0.04,17.70) 27 4.03 Robinson N 292 1 0.34 1.53 0.34 (0.00, 1.87) 747 2.19 #Taylor J 186 1 0.54 1.46 0.55 (0.01, 3.09) 487 1.54 All Others 21 0 0.00 2.25 0.00 (0.00,11.71) 27 0.00 Total 2048 25 1.22 1.66 1.11 (0.72, 1.64) 3879 2.13

St. Josephs Hospital Green G R 230 4 1.74 1.64 1.59 (0.43, 4.08) 490 1.42 #Lutz C J 107 1 0.93 1.77 0.80 (0.01, 4.42) 223 0.91 Marvasti M 172 3 1.74 1.80 1.46 (0.29, 4.26) 398 1.21 Nazem A 312 4 1.28 2.02 0.95 (0.26, 2.44) 516 1.33 Zhou Z 323 5 1.55 1.84 1.27 (0.41, 2.97) 604 2.00 All Others 25 1 4.00 1.82 3.32 (0.04,18.46) 42 8.81 * Total 1169 18 1.54 1.84 1.26 (0.75, 2.00) 2273 1.64 **

St. Peters Hosp. #Bennett E 11 0 0.00 1.07 0.00 (0.00,47.08) 42 0.00 Canavan T 174 2 1.15 1.62 1.07 (0.12, 3.87) 205 1.38 Edwards N 146 1 0.68 1.12 0.92 (0.01, 5.12) 316 2.02 #Reich H 5 0 0.00 2.32 0.00 (0.00,47.67) 5 0.00 Saifi J 199 1 0.50 1.49 0.51 (0.01, 2.83) 579 2.78 Terrien C M 290 6 2.07 1.39 2.25 (0.82, 4.89) 392 2.29 All Others 80 2 2.50 1.55 2.43 (0.27, 8.78) 83 5.40 Total 905 12 1.33 1.43 1.40 (0.72, 2.45) 1622 2.42

31

Table 6 continued Isolated CABG Isolated CABG, or Valve or Valve/CABG No of 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

Staten Island Univ Hosp Asgarian K T 129 1 0.78 0.99 1.18 (0.02, 6.55) 208 3.86 McGinn J 308 6 1.95 1.34 2.19 (0.80, 4.76) 452 3.86 Rosell F M 272 2 0.74 1.59 0.70 (0.08, 2.52) 324 0.82 ##Singh V A 10 1 10.00 1.21 12.46 (0.16,69.32) 10 20.03 All Others 8 1 12.50 1.06 17.72 (0.23,98.57) 8 28.48 Total 727 11 1.51 1.37 1.67 (0.83, 2.98) 1002 3.11

Strong Memorial Hosp Alfieris G . . . . . ( . , . ) 1 0.00 Gensini P F . . . . . ( . , . ) 2 0.00 Hicks G 208 5 2.40 1.45 2.51 (0.81, 5.85) 313 4.35 Knight P 468 14 2.99 1.46 3.09 * (1.69, 5.18) 944 3.99 * Massey H 88 2 2.27 2.01 1.71 (0.19, 6.17) 146 4.12 Total 764 21 2.75 1.52 2.73 * (1.69, 4.17) 1406 4.08 *

UHS-Wilson Med Ctr Wong K 225 9 4.00 1.77 3.42 * (1.56, 6.48) 359 4.11 Yousuf M 233 7 3.00 1.64 2.77 (1.11, 5.70) 348 5.20 * Total 458 16 3.49 1.70 3.10 * (1.77, 5.03) 707 4.65 *

Univ. Hosp-Brooklyn Burack J H 11 0 0.00 1.07 0.00 (0.00,46.96) 15 0.00 Lee D C 32 1 3.13 2.68 1.76 (0.02, 9.80) 44 1.90 Tak V M 123 4 3.25 1.93 2.54 (0.68, 6.49) 204 4.83 * Total 166 5 3.01 2.02 2.25 (0.72, 5.25) 263 4.18

Univ. Hosp-Stony Brook Bilfinger T 38 3 7.89 1.85 6.45 (1.30,18.83) 54 8.42 * #Fernandez H A 95 1 1.05 1.44 1.10 (0.01, 6.12) 169 1.59 Gupta S 147 2 1.36 1.70 1.21 (0.14, 4.36) 273 0.74 McLarty A 7 0 0.00 1.61 0.00 (0.00,49.05) 11 10.69 Seifert F 214 3 1.40 1.59 1.33 (0.27, 3.88) 281 2.75 #Taylor J 111 0 0.00 1.54 0.00 (0.00, 3.25) 236 1.07 All Others 71 2 2.82 2.05 2.08 (0.23, 7.50) 135 4.39 Total 683 11 1.61 1.65 1.47 (0.74, 2.64) 1159 2.39

Univ. Hosp-Upstate Fink G W 191 3 1.57 1.42 1.67 (0.34, 4.88) 287 2.45 #Lutz C J 157 2 1.27 1.57 1.22 (0.14, 4.42) 266 2.15 All Others 28 2 7.14 2.19 4.91 (0.55,17.73) 34 6.11 Total 376 7 1.86 1.54 1.82 (0.73, 3.76) 587 2.55

Vassar Bros. Med Ctr Bhutani A K 66 1 1.52 1.26 1.82 (0.02,10.13) 74 2.42 Sarabu M 148 0 0.00 1.41 0.00 (0.00, 2.66) 385 1.08 Shahani R B 147 2 1.36 1.76 1.17 (0.13, 4.21) 236 2.46 Zakow P 201 3 1.49 1.50 1.50 (0.30, 4.38) 335 2.61 Total 562 6 1.07 1.51 1.06 (0.39, 2.31) 1030 1.87

32

Table 6 continued Isolated CABG Isolated CABG, or Valve or Valve/CABG No of 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

Westchester Med Ctr Lafaro R 112 0 0.00 1.46 0.00 (0.00, 3.38) 166 1.98 Lansman S 62 0 0.00 1.49 0.00 (0.00, 5.97) 106 2.40 Malekan R 200 3 1.50 1.89 1.19 (0.24, 3.49) 263 2.57 #Saunders P 1 0 0.00 1.37 0.00 (0.00,100.0) 1 0.00 Sett S S . . . . . ( . , . ) 1 0.00 Spielvogel D 246 3 1.22 1.61 1.14 (0.23, 3.35) 429 1.50 All Others 59 0 0.00 2.23 0.00 (0.00, 4.20) 95 0.00 Total 680 6 0.88 1.71 0.78 (0.28, 1.69) 1061 1.79

Winthrop-Univ. Hosp Goncalves J A 203 3 1.48 1.37 1.62 (0.33, 4.74) 450 2.38 Kokotos W J 210 3 1.43 1.67 1.29 (0.26, 3.76) 387 2.79 Lee W W 147 0 0.00 1.73 0.00 (0.00, 2.18) 186 1.28 Schubach S 176 0 0.00 1.21 0.00 (0.00, 2.60) 327 2.35 All Others 4 0 0.00 0.50 0.00 (0.00,100.0) 4 0.00 Total 740 6 0.81 1.49 0.82 (0.30, 1.79) 1354 2.38

STATEWIDE TOTAL 24937 376 1.51 47150 2.42

* RAMR significantly higher than statewide rate based on 95 percent confidence interval. ** RAMR significantly lower than statewide rate based on 95 percent confidence interval. # Performed operations in another NYS hospital. ## Performed operations in two or more other NYS hospitals.

33

Table 7

Summary Information for Surgeons Practicing at More Than One Hospital, 2011-2013.

Isolated CABG Isolated CABG, or Valve or Valve/CABG 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

Akujuo A C 177 2 1.13 1.47 1.16 (0.13, 4.18) 276 2.74 Albany Med. Ctr 46 0 0.00 2.25 0.00 (0.00, 5.34) 72 0.00 St. Elizabeth Med Ctr 131 2 1.53 1.20 1.92 (0.22, 6.93) 204 3.97

Aldridge J 133 6 4.51 1.40 4.86 * (1.78, 10.59) 155 6.28 * Buffalo General Hosp 109 6 5.50 1.45 5.71 * (2.08, 12.43) 119 9.40 * Mercy Hospital 7 0 0.00 1.14 0.00 (0.00, 69.45) 9 0.00 Millard Fillmore Hosp 17 0 0.00 1.15 0.00 (0.00,28.21) 27 0.00

Ashraf M 575 8 1.39 1.37 1.53 (0.66, 3.01) 752 2.47 Buffalo General Hosp 325 6 1.85 1.31 2.13 (0.78, 4.63) 420 2.99 Millard Fillmore Hosp 250 2 0.80 1.46 0.83 (0.09, 2.99) 332 1.82

Bacha E . . . . . ( . , . ) 14 0.00 NYP-Columbia Presby. . . . . . ( . , . ) 13 0.00 NYP-Weill Cornell . . . . . ( . , . ) 1 0.00

Balsam L B 130 1 0.77 0.94 1.24 (0.02, 6.87) 254 1.66 Bellevue Hospital Ctr 129 1 0.78 0.94 1.24 (0.02, 6.89) 246 1.31 NYU Hospitals Center 1 0 0.00 0.36 0.00 (0.00, 100.0) 8 3.56

Bell-Thomson J 395 7 1.77 1.37 1.95 (0.78, 4.02) 733 3.00 Erie County Med Ctr 1 0 0.00 0.57 0.00 (0.00,100.0) 1 0.00 Mercy Hospital 394 7 1.78 1.37 1.95 (0.78, 4.03) 732 3.00

Bello R A 193 0 0.00 1.45 0.00 (0.00, 1.98) 283 1.37 Montefiore – Moses 10 0 0.00 2.36 0.00 (0.00, 23.42) 12 0.00 Montefiore – Weiler 183 0 0.00 1.40 0.00 (0.00, 2.16) 271 1.43

Bennett E 76 0 0.00 1.29 0.00 (0.00, 5.63) 281 2.36 Albany Med. Ctr 65 0 0.00 1.33 0.00 (0.00, 6.39) 239 2.80 St. Peters Hosp. 11 0 0.00 1.07 0.00 (0.00, 47.08) 42 0.00

Chen J M . . . . . ( . , . ) 4 0.00 NYP-Columbia Presby. . . . . . ( . , . ) 1 0.00 NYP-Weill Cornell . . . . . ( . , . ) 3 0.00

Culliford A 61 1 1.64 0.89 2.78 (0.04,15.45) 143 2.18 Bellevue Hospital Ctr 1 0 0.00 2.93 0.00 (0.00,100.0) 1 0.00 Mount Sinai Beth Israel . . . . . ( . , . ) 3 51.81 NYU Hospitals Center 60 1 1.67 0.86 2.93 (0.04,16.33) 139 1.48

D Alessandro D A 217 2 0.92 1.33 1.04 (0.12, 3.76) 336 2.92 Montefiore – Moses 216 2 0.93 1.29 1.08 (0.12, 3.90) 333 3.02 Montefiore – Weiler 1 0 0.00 10.47 0.00 (0.00,52.82) 3 0.00

34

Table 7 continued Isolated CABG Isolated CABG, or Valve or Valve/CABG 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

Deanda A 116 3 2.59 0.81 4.83 (0.97,14.11) 203 4.56 Bellevue Hospital Ctr 112 3 2.68 0.81 4.97 (1.00,14.51) 187 4.89 Mount Sinai Beth Israel . . . . . ( . , . ) 1 0.00 NYU Hospitals Center 4 0 0.00 0.64 0.00 (0.00,100.0) 15 0.00

Derose J J 318 3 0.94 1.24 1.15 (0.23, 3.36) 488 2.63 Montefiore – Moses 26 0 0.00 2.06 0.00 (0.00,10.34) 28 0.00 Montefiore – Weiler 292 3 1.03 1.17 1.33 (0.27, 3.88) 460 2.78

Downing S W 412 6 1.46 1.41 1.55 (0.57, 3.38) 496 2.75 Buffalo General Hosp 8 1 12.50 0.99 18.99 (0.25,100.0) 11 11.36 Erie County Med Ctr 154 0 0.00 1.29 0.00 (0.00, 2.77) 180 0.79 Mercy Hospital 250 5 2.00 1.50 2.01 (0.65, 4.69) 305 3.18

El Amir N 228 3 1.32 1.49 1.34 (0.27, 3.90) 338 3.13 Champ.Valley Phys Hosp 14 0 0.00 0.78 0.00 (0.00,50.48) 17 0.00 St. Elizabeth Med Ctr 214 3 1.40 1.53 1.38 (0.28, 4.03) 321 3.20

Fernandez H A 292 1 0.34 1.97 0.26 ** (0.00, 1.46) 452 1.31 St. Francis Hospital 197 0 0.00 2.22 0.00 ** (0.00, 1.26) 283 1.15 Univ. Hosp-Stony Brook 95 1 1.05 1.44 1.10 (0.01, 6.12) 169 1.59

Galloway A 62 1 1.61 1.03 2.36 (0.03,13.10) 600 2.93 Lenox Hill Hospital 4 0 0.00 1.16 0.00 (0.00,100.0) 15 0.00 Mount Sinai Beth Israel . . . . . ( . , . ) 1 0.00 NYU Hospitals Center 58 1 1.72 1.02 2.54 (0.03,14.12) 584 2.99

Goldstein D J 175 2 1.14 1.30 1.32 (0.15, 4.77) 329 1.25 Montefiore – Moses 124 2 1.61 1.29 1.89 (0.21, 6.81) 234 1.51 Montefiore – Weiler 51 0 0.00 1.34 0.00 (0.00, 8.10) 95 0.74

Grossi E 7 0 0.00 0.85 0.00 (0.00,93.39) 15 7.10 Bellevue Hospital Ctr 1 0 0.00 0.45 0.00 (0.00,100.0) 1 0.00 NYU Hospitals Center 6 0 0.00 0.91 0.00 (0.00,100.0) 14 7.20

Gulkarov I M 83 0 0.00 1.20 0.00 (0.00, 5.55) 147 0.00 NY Methodist Hospital 80 0 0.00 1.21 0.00 (0.00, 5.71) 142 0.00 NYP-Weill Cornell 3 0 0.00 0.95 0.00 (0.00,100.0) 5 0.00

Hartman A 87 1 1.15 1.77 0.98 (0.01, 5.44) 420 1.46 North Shore Univ Hosp 34 0 0.00 1.33 0.00 (0.00,12.27) 198 1.28 Southside Hospital 53 1 1.89 2.06 1.38 (0.02, 7.68) 222 1.59

Jakobleff W A 107 3 2.80 1.34 3.15 (0.63, 9.22) 131 4.85 Montefiore – Moses 105 3 2.86 1.28 3.38 (0.68, 9.87) 128 5.11 Montefiore – Weiler 2 0 0.00 4.76 0.00 (0.00,58.11) 3 0.00

Kalimi R 275 6 2.18 1.87 1.76 (0.64, 3.84) 494 2.23 North Shore Univ Hosp 78 2 2.56 1.66 2.32 (0.26, 8.39) 171 2.76 Southside Hospital 197 4 2.03 1.95 1.57 (0.42, 4.03) 323 1.96

Lang S 290 3 1.03 1.17 1.33 (0.27, 3.89) 414 1.09 NYP-Queens 286 3 1.05 1.18 1.34 (0.27, 3.93) 403 1.12 NYP-Weill Cornell 4 0 0.00 0.78 0.00 (0.00,100.0) 11 0.00

35

Table 7 continued Isolated CABG Isolated CABG, or Valve or Valve/CABG 95% CI Cases Deaths OMR EMR RAMR for RAMR Cases RAMR

Loulmet D F 90 1 1.11 0.85 1.98 (0.03,10.99) 433 3.56 Bellevue Hospital Ctr 24 1 4.17 1.04 6.05 (0.08,33.65) 58 9.98 * Lenox Hill Hospital 4 0 0.00 1.52 0.00 (0.00,90.78) 9 0.00 Mount Sinai Beth Israel . . . . . ( . , . ) 1 0.00 NYU Hospitals Center 62 0 0.00 0.73 0.00 (0.00,12.21) 365 2.66

Lundy E F 168 2 1.19 1.67 1.08 (0.12, 3.88) 242 1.47 Good Sam – Suffern 144 1 0.69 1.62 0.65 (0.01, 3.60) 215 1.12 St. Francis Hospital 24 1 4.17 1.97 3.18 (0.04,17.70) 27 4.03

Lutz C J 264 3 1.14 1.65 1.04 (0.21, 3.03) 489 1.55 St. Josephs Hospital 107 1 0.93 1.77 0.80 (0.01, 4.42) 223 0.91 Univ. Hosp-Upstate 157 2 1.27 1.57 1.22 (0.14, 4.42) 266 2.15

Manetta F 137 4 2.92 1.92 2.29 (0.62, 5.86) 183 3.64 Long Island Jewish MC 4 1 25.00 0.56 67.54 (0.88,100.0) 6 79.95 Southside Hospital 133 3 2.26 1.96 1.73 (0.35, 5.06) 177 3.06

Michler R E 86 0 0.00 1.09 0.00 (0.00, 5.88) 282 1.71 Montefiore – Moses 83 0 0.00 1.10 0.00 (0.00, 6.07) 254 1.90 Montefiore – Weiler 3 0 0.00 1.00 0.00 (0.00,100.0) 28 0.00

Reich H 115 2 1.74 1.41 1.85 (0.21, 6.69) 264 2.36 Ellis Hospital 110 2 1.82 1.37 2.00 (0.22, 7.21) 259 2.40 St. Peters Hosp. 5 0 0.00 2.32 0.00 (0.00,47.67) 5 0.00

Saunders P 51 1 1.96 1.45 2.03 (0.03,11.31) 59 2.69 Maimonides Medical Ctr 50 1 2.00 1.46 2.07 (0.03,11.53) 58 2.73 Westchester Med Ctr 1 0 0.00 1.37 0.00 (0.00,100.0) 1 0.00

Singh V A 28 2 7.14 1.59 6.77 (0.76,24.46) 34 10.92 Long Island Jewish MC 2 0 0.00 2.86 0.00 (0.00,96.84) 3 0.00 Southside Hospital 16 1 6.25 1.67 5.65 (0.07,31.42) 21 10.32 Staten Island Univ Hosp 10 1 10.00 1.21 12.46 (0.16,69.32) 10 20.03

Stewart A S 195 6 3.08 1.92 2.42 (0.88, 5.26) 593 2.37 Mount Sinai Hospital 2 0 0.00 0.70 0.00 (0.00,100.0) 3 0.00 NYP-Columbia Presby. 193 6 3.11 1.93 2.43 (0.89, 5.28) 590 2.37

Taylor J 297 1 0.34 1.49 0.34 (0.00, 1.90) 723 1.39 ** St. Francis Hospital 186 1 0.54 1.46 0.55 (0.01, 3.09) 487 1.54 Univ. Hosp-Stony Brook 111 0 0.00 1.54 0.00 (0.00, 3.25) 236 1.07

Tortolani A 136 4 2.94 1.13 3.94 (1.06,10.08) 218 6.07 * NY Methodist Hospital 135 3 2.22 1.13 2.97 (0.60, 8.68) 217 5.47 * NYP-Weill Cornell 1 1 100.00 0.93 100.00 (2.12,100.0) 1 100.00

Zias E 154 4 2.60 0.84 4.64 (1.25,11.87) 452 2.74 Bellevue Hospital Ctr 2 0 0.00 2.55 0.00 (0.00,100.0) 2 0.00 Lenox Hill Hospital 1 0 0.00 0.62 0.00 (0.00,100.0) 4 0.00 Mount Sinai Beth Israel 2 0 0.00 1.00 0.00 (0.00,100.0) 6 0.00 NYU Hospitals Center 149 4 2.68 0.82 4.93 (1.33,12.62) 440 2.82

* RAMR significantly higher than statewide rate based on 95 percent confidence interval. ** RAMR significantly lower than statewide rate based on 95 percent confidence interval.

36

SURGEON AND HOSPITAL VOLUMES FOR TOTAL ADULT CARDIAC SURGERY, 2011-2013Table 8 presents, for each hospital and for each surgeon performing at least 200 cardiac operations in any hospital in 2011-2013 and/or performing one or more cardiac operations in each of the years 2011-2013, the total number of Isolated CABG operations, the total number of Valve or Valve/CABG operations, the total number of Other Cardiac operations and Total Cardiac operations. As in Table 6, results for surgeons not meeting the above criteria are grouped together in an “All Others” category.

The Isolated CABG column includes patients who undergo bypass of one or more of the coronary arteries with no other major heart

surgery earlier in the same admission. Valve or Valve/CABG volumes include the total number of cases for the eight Valve or groups that were identified in Table 4. Other Cardiac Surgery refers to cardiac procedures not represented by Isolated CABG, and Valve or Valve/CABG operations and includes, but is not limited to: repairs of congenital conditions, heart transplants, aneurysm repairs, ventricular reconstruction and ventricular assist device insertions. Total Cardiac Surgery is the sum of the previous three columns and includes any surgery on the heart or great vessels.

Table 8

Surgeon and Hospital Volume for Isolated CABG, Valve or Valve/CABG, Other Cardiac Surgery, and Total Adult Cardiac Surgery, 2011-2013

Other Total Isolated Valve or Cardiac Cardiac CABG Valve/CABG Surgery Surgery

Albany Med. Ctr Akujuo A C 46 26 5 77 Bennett E 65 174 112 351 Britton L 162 157 80 399 Depan H 241 151 48 440 Devejian N 0 1 12 13 Miller S 177 114 26 317 Total 691 623 283 1597

Arnot Ogden Med Ctr Nast E 127 61 12 200 Raudat C W 96 35 11 142 All Others 12 3 0 15 Total 235 99 23 357

Bellevue Hospital Ctr Balsam L B 129 117 55 301 Culliford A 1 0 1 2 Deanda A 112 75 97 284 Grossi E 1 0 1 2 Loulmet D F 24 34 3 61 Zias E 2 0 0 2 All Others 0 0 1 1 Total 269 226 158 653

37

Table 8 continued Other Total Isolated Valve or Cardiac Cardiac CABG Valve/CABG Surgery Surgery

Buffalo General Hosp Aldridge J 109 10 38 157 Ashraf M 325 95 54 474 Downing S W 8 3 2 13 Grosner G 659 516 110 1285 All Others 22 7 1 30 Total 1123 631 205 1959

Champ.Valley Phys Hosp Cahill A T 173 71 12 256 El Amir N 14 3 1 18 All Others 42 1 1 44 Total 229 75 14 318

Ellis Hospital Choumarov K 224 63 6 293 Reich H 110 149 24 283 Singh C 193 87 14 294 Total 527 299 44 870

Erie County Med Ctr Bell-Thomson J 1 0 1 2 Downing S W 154 26 25 205 All Others 18 4 7 29 Total 173 30 33 236

Good Sam – Suffern Lundy E F 144 71 6 221 Salenger R 160 50 12 222 All Others 49 8 0 57 Total 353 129 18 500

Lenox Hill Hospital Galloway A 4 11 0 15 Loulmet D F 4 5 1 10 Patel N C 556 216 33 805 Plestis K A 67 125 176 368 Subramanian V 95 49 21 165 Zias E 1 3 0 4 All Others 43 70 88 201 Total 770 479 319 1568

Long Island Jewish MC Graver L 186 253 45 484 Manetta F 4 2 1 7 Meyer D B 1 1 14 16 Palazzo R 167 98 68 333 Parnell V 0 1 21 22 Scheinerman S J 135 178 91 404 Singh V A 2 1 0 3 All Others 0 0 2 2 Total 495 534 242 1271

38

Table 8 continued Other Total Isolated Valve or Cardiac Cardiac CABG Valve/CABG Surgery Surgery

M I Bassett Hospital Kelley J 131 65 14 210 Lancey R A 92 37 6 135 Total 223 102 20 345

Maimonides Medical Ctr Abrol S 131 76 51 258 Crooke G 86 57 52 195 Jacobowitz I 269 121 26 416 Ribakove G 84 114 37 235 Saunders P 50 8 18 76 Stephens G A 37 31 5 73 Vaynblat M 135 83 19 237 All Others 2 0 1 3 Total 794 490 209 1493

Mercy Hospital Aldridge J 7 2 0 9 Bell-Thomson J 394 338 83 815 Downing S W 250 55 17 322 Lico S 342 86 37 465 Total 993 481 137 1611

Millard Fillmore Hosp Aldridge J 17 10 3 30 Ashraf M 250 82 12 344 All Others 3 6 1 10 Total 270 98 16 384

Montefiore – Moses Bello R A 10 2 15 27 D Alessandro D A 216 117 87 420 Derose J J 26 2 45 73 Goldstein D J 124 110 72 306 Jakobleff W A 105 23 14 142 Michler R E 83 171 45 299 Weinstein S 0 1 27 28 All Others 0 0 4 4 Total 564 426 309 1299

Montefiore – Weiler Bello R A 183 88 29 300 D Alessandro D A 1 2 2 5 Derose J J 292 168 67 527 Goldstein D J 51 44 8 103 Jakobleff W A 2 1 2 5 Michler R E 3 25 1 29 Total 532 328 109 969

39

Table 8 continued Other Total Isolated Valve or Cardiac Cardiac CABG Valve/CABG Surgery Surgery

Mount Sinai Beth Israel Culliford A 0 3 0 3 Deanda A 0 1 1 2 Dimitrova K R 3 3 5 11 Galloway A 0 1 0 1 Geller C M 56 30 11 97 Hoffman D 149 38 12 199 Loulmet D F 0 1 0 1 Tranbaugh R 250 123 41 414 Zias E 2 4 0 6 All Others 21 40 16 77 Total 481 244 86 811

Mount Sinai Hospital Adams D H 17 977 141 1135 Anyanwu A C 48 97 215 360 Chikwe J Y 154 104 44 302 DiLuozzo G 3 12 114 129 Filsoufi F 269 140 20 429 Milla F 58 59 28 145 Reddy R C 306 101 66 473 Stelzer P 44 271 220 535 Stewart A S 2 1 5 8 Tannous H J 56 40 6 102 Varghese R 46 16 10 72 All Others 5 2 61 68 Total 1008 1820 930 3758

Mount Sinai St. Lukes Balaram S K 80 58 32 170 Swistel D 258 213 39 510 Total 338 271 71 680

NY Methodist Hospital Gulkarov I M 80 62 28 170 Tortolani A 135 82 4 221 All Others 60 38 15 113 Total 275 182 47 504

NYP-Columbia Presby. Argenziano M 185 282 49 516 Bacha E 0 13 151 164 Chen J M 0 1 15 16 Naka Y 242 237 198 677 Quaegebeur J 0 1 56 57 Smith C 136 593 61 790 Stewart A S 193 397 369 959 Takayama H 304 203 137 644 Williams M R 86 461 682 1229 All Others 57 40 355 452 Total 1203 2228 2073 5504

40

Table 8 continued Other Total Isolated Valve or Cardiac Cardiac CABG Valve/CABG Surgery Surgery

NYP-Queens Lang S 286 117 24 427 Total 286 117 24 427

NYP-Weill Cornell Bacha E 0 1 6 7 Chen J M 0 3 26 29 Girardi L 231 724 676 1631 Gulkarov I M 3 2 1 6 Isom O 12 39 7 58 Krieger K 166 411 23 600 Lang S 4 7 2 13 Salemi A 104 111 282 497 Tortolani A 1 0 0 1 All Others 1 5 0 6 Total 522 1303 1023 2848

NYU Hospitals Center Balsam L B 1 7 20 28 Culliford A 60 79 17 156 Deanda A 4 11 38 53 Galloway A 58 526 44 628 Grossi E 6 8 6 20 Loulmet D F 62 303 80 445 Mosca R S 0 1 31 32 Zias E 149 291 54 494 All Others 60 82 20 162 Total 400 1308 310 2018

North Shore Univ Hosp Esposito R 267 229 84 580 Hall M 189 160 22 371 Hartman A 34 164 61 259 Kalimi R 78 93 19 190 Pogo G 162 114 37 313 Vatsia S 192 160 37 389 All Others 10 12 13 35 Total 932 932 273 2137

Rochester General Hosp Cheeran D 484 382 120 986 Kirshner R 428 622 86 1136 All Others 52 21 5 78 Total 964 1025 211 2200

Southside Hospital Hartman A 53 169 70 292 Kalimi R 197 126 35 358 Manetta F 133 44 34 211 Singh V A 16 5 3 24 Total 399 344 142 885

41

Table 8 continued Other Total Isolated Valve or Cardiac Cardiac CABG Valve/CABG Surgery Surgery

St. Elizabeth Med Ctr Akujuo A C 131 73 7 211 El Amir N 214 107 35 356 Joyce F 265 144 14 423 Total 610 324 56 990

St. Francis Hospital Bercow N 381 247 39 667 Colangelo R 662 504 46 1212 Fernandez H A 197 86 15 298 Lamendola C 285 229 32 546 Lundy E F 24 3 0 27 Robinson N 292 455 195 942 Taylor J 186 301 38 525 All Others 21 6 5 32 Total 2048 1831 370 4249

St. Josephs Hospital Green G R 230 260 98 588 Lutz C J 107 116 24 247 Marvasti M 172 226 52 450 Nazem A 312 204 54 570 Zhou Z 323 281 88 692 All Others 25 17 7 49 Total 1169 1104 323 2596

St. Peters Hosp. Bennett E 11 31 1 43 Canavan T 174 31 1 206 Edwards N 146 170 58 374 Reich H 5 0 0 5 Saifi J 199 380 61 640 Terrien C M 290 102 17 409 All Others 80 3 0 83 Total 905 717 138 1760

Staten Island Univ Hosp Asgarian K T 129 79 18 226 McGinn J 308 144 16 468 Rosell F M 272 52 19 343 Singh V A 10 0 2 12 All Others 8 0 1 9 Total 727 275 56 1058

Strong Memorial Hosp Alfieris G 0 1 27 28 Gensini P F 0 2 44 46 Hicks G 208 105 59 372 Knight P 468 476 196 1140 Massey H 88 58 147 293 Total 764 642 473 1879

42

Table 8 continued Other Total Isolated Valve or Cardiac Cardiac CABG Valve/CABG Surgery Surgery

UHS-Wilson Med Ctr Wong K 225 134 11 370 Yousuf M 233 115 16 364 Total 458 249 27 734

Univ. Hosp-Brooklyn Burack J H 11 4 2 17 Lee D C 32 12 5 49 Tak V M 123 81 21 225 Total 166 97 28 291

Univ. Hosp-Stony Brook Bilfinger T 38 16 14 68 Fernandez H A 95 74 21 190 Gupta S 147 126 48 321 McLarty A 7 4 48 59 Seifert F 214 67 12 293 Taylor J 111 125 45 281 All Others 71 64 5 140 Total 683 476 193 1352

Univ. Hosp-Upstate Fink G W 191 96 55 342 Lutz C J 157 109 23 289 All Others 28 6 2 36 Total 376 211 80 667

Vassar Bros. Med Ctr Bhutani A K 66 8 2 76 Sarabu M 148 237 39 424 Shahani R B 147 89 15 251 Zakow P 201 134 24 359 Total 562 468 80 1110

Westchester Med Ctr Lafaro R 112 54 17 183 Lansman S 62 44 24 130 Malekan R 200 63 75 338 Saunders P 1 0 5 6 Sett S S 0 1 4 5 Spielvogel D 246 183 118 547 All Others 59 36 40 135 Total 680 381 283 1344

Winthrop-Univ. Hosp Goncalves J A 203 247 290 740 Kokotos W J 210 177 32 419 Lee W W 147 39 3 189 Schubach S 176 151 13 340 All Others 4 0 0 4 Total 740 614 338 1692

STATEWIDE TOTAL 24937 22213 9774 56924

43

Criteria Used in Reporting Significant Risk Factors (2013)

Based on Documentation in Medical Records

Patient Risk Factor Definitions

Demographic

Body Surface Area Body surface area (BSA) is a function of height and weight and increases for larger heights and weights. The statistical formula used to calculate BSA in this report is: BSA (m2) =0.0003207 x H0.3 x W(0.7285 – ( 0.0188 x LOG))

Where H is Height in centimeters and W is Weight in grams.

Hemodynamic State Determined in the immediate pre-operative period, defined as the period prior to anesthesia taking responsibility for the patient.

Unstable Patient requires pharmacologic or mechanical support to maintain blood pressure or cardiac index.

Shock Acute hypotension (systolic blood pressure < 80 mmHg) or low cardiac index (< 2.0 liters/min/m2), despite pharmacologic or mechanical support. Records with this risk factor were excluded from all analyses in this report.

Comorbidities

Cerebrovascular Disease Cerebrovascular disease prior to surgery documented by any one of the following:• CVA (symptoms > 24 hrs after onset, presumed to be from

vascular etiology);• TIA (recovery within 24 hrs);• Non-invasive carotid test with > 79% diameter occlusion.; or• Prior carotid surgery or stenting or prior cerebral aneurysm

clipping or coil. Does not include neurological disease processes such as metabolic and/or anoxic ischemic encephalopathy.

Chronic Lung Disease The patient has chronic lung disease with pre-operative findings of one of the following:• Mild – FEV

1 60% to 75% of predicted, and/or on chronic inhaled or

oral bronchodilator therapy. • Moderate – FEV

1 50% to 59% of predicted, and/or on chronic

steroid therapy aimed at lung disease.• Severe – FEV

1 <50% predicted, and/or Room Air pO

2 < 60 or Room

Air pCO2 > 50.

Diabetes The patient has a history of diabetes diagnosed and/or treated by a physician.

Endocarditis Patients with two or more positive blood cultures without other obvious source with demonstrated valvular vegetations or acute valvular dysfunction caused by infection. Includes patients who are on antibiotics at the time of surgery. Excludes patients who have completed antibiotic therapy and have no evidence of residual infection.

44

Patient Risk Factor Definitions

Comorbidities, continued

Extensive Aortic Atherosclerosis Ascending, transverse, and/or descending aortic atherosclerosis marked by either extensive calcification or luminal atheroma such that the intended surgical procedure is altered.

Peripheral Vascular Disease Angiographic demonstration of at least 50% narrowing in a major aortoiliac or femoral/popliteal vessel, previous surgery for such disease, absent femoral or pedal pulses, or the inability to insert a catheter or intra-aortic balloon due to iliac aneurysm or obstruction of the aortoiliac or femoral arteries Ankle-Brachial Index < 0.9 is also acceptable documentation.

Renal Failure, Creatinine Last pre-operative creatinine was in the indicated range.

Renal Failure Requiring Dialysis The patient is undergoing peritoneal or hemodialysis at the time of admission.

Ventricular Function

Ejection Fraction Value of the ejection fraction taken closest to but before the start of the procedure. Intraoperative direct observation of the heart is not an adequate basis for a visual estimate of the ejection fraction. Intra-operative TEE is acceptable, if no pre-operative Ejection Fraction is available. If no ejection fraction is reported, the ejection fraction is considered “normal” for purposes of analysis and is classified with the reference category.

Previous MI One or more myocardial infarctions (MI) in the specified time period prior to surgery.

Previous Procedures

Previous Organ Transplant The patient has had any organ transplant prior to the current cardiac surgery. This includes, but is not limited to, heart, lung, kidney, and liver transplants.

Previous PCI, Before this Episode of Care

The patient has had a Percutaneous Coronary Intervention before this episode of care.

Previous Valve Surgery Prior to this cardiac surgery, the patient has previously undergone surgery or catheter based intervention for valve repair or replacement.

Previous CABG Surgery Prior to this cardiac surgery, the patient has previously undergone CABG surgery. This include any surgeries that occurred prior to this one including those earlier in the current admission.

Any Previous Cardiac Surgery Prior to this cardiac surgery, the patient has previously undergone a cardiac surgery other than CABG. This would include a previous catheter-based valve repair or replacement but not other catheter-based interventions.

Vessels Diseased

Left Main Disease The patient has at least a 50 percent blockage in the Left Main Coronary Artery.

Three Vessels Diseased The patient has at least a 70 percent blockage in each of the three native coronary arteries including the Left Anterior Descending (LAD), the Right Coronary Artery (RCA) and the Left Circumflex (LCX) or their major branches.

45

MEDICAL TERMINOLOGYangina pectoris – The pain or discomfort felt when blood and oxygen flow to the heart are impeded by blockages in the coronary arteries. Can also be caused by an arterial spasm.

angioplasty – Also known as percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI). In this procedure, a balloon catheter is threaded up to the site of blockage in an artery in the heart, and is then inflated to push arterial plaque against the wall of the artery to create a wider channel in the artery. Other procedures or devices are frequently used in conjunction with, or in place of, the balloon catheter. In particular, stents are used for most patients and devices such as rotoblaters and ultrasound are sometimes used.

arteriosclerosis – Also called atherosclerotic coronary artery disease or coronary artery disease, the group of diseases characterized by thickening and loss of elasticity of the arterial walls, popularly called “hardening of the arteries.”

atherosclerosis – One form of arteriosclerosis in which plaques or fatty deposits form in the inner layer of the arteries.

coronary artery bypass graft surgery (CABG) – A procedure in which a vein or artery from another part of the body is used to create an alternate path for blood to flow to the heart muscle, bypassing the arterial blockage. Typically, a section of one of the large saphenous veins in the leg, the radial artery in the arm or the mammary artery in the chest is used to construct the bypass. One or more bypasses may be performed during a single operation. When no other major heart surgery (such as valve replacement) is included, the operation is referred to as an isolated CABG. The average number of bypass grafts created during CABG is three or four. Generally, all significantly blocked arteries are bypassed unless they enter areas of the heart that are permanently damaged by previous heart attacks. Five or more bypasses are occasionally created. Multiple bypasses are often performed to provide several alternate routes for the blood flow and to improve the long-term success of the procedure, not necessarily because the patient’s condition is more severe.

cardiac catheterization – Also known as coronary angiography, a procedure for diagnosing the condition of the heart and the arteries connecting to it. A thin tube threaded through an artery to the heart releases a dye, which allows doctors to observe blockages with an X-ray camera. This procedure is generally required before coronary bypass surgery.

cardiovascular disease – Disease of the heart and blood vessels, the most common form is coronary artery disease.

coronary arteries – The arteries that supply the heart muscle with blood. When they are narrowed or blocked, oxygen-rich blood cannot flow freely to the heart muscle or myocardium.

heart valve – Gates that connect the different chambers of the heart so that there is a one-way flow of blood between the chambers. The heart has four valves: the tricuspid, mitral, pulmonic and aortic valves.

incompetent valves – A valve that does not close tightly.

ischemic heart disease (ischemia) – Heart disease that occurs as a result of inadequate blood supply to the heart muscle or myocardium.

myocardial infarction (MI) – Also called a heart attack, partial destruction of the heart muscle due to interrupted blood supply.

plaque – Also called atheroma, this is the fatty deposit in the coronary artery that can block blood flow.

risk factors for heart disease – Certain risk factors have been found to increase the likelihood of developing heart disease. Some are controllable or avoidable and some cannot be controlled. The biggest heart disease risk factors are heredity, gender and age, none of which can be controlled. Men are much more likely to develop heart disease than women before the age of 55, although it is the number one killer of both men and women. Some controllable risk factors that contribute to a higher likelihood of developing coronary artery disease are high cholesterol levels, cigarette smoking, high blood pressure (hypertension), obesity, a sedentary lifestyle or lack of exercise, diabetes and poor stress management.

46

stenosis – The narrowing of an artery due to blockage. Restenosis is when the narrowing recurs after surgery.

stenotic valve – A valve that does not open fully.

valve disease – Occurs when a valve cannot open all of the way (reducing flow to the next heart chamber) or cannot close all of the way (causing blood to leak backwards into the previous heart chamber).

valve repair – Widening valve openings for stenotic valves or narrowing or tightening valve openings for incompetent valves without having to replace the valves.

valve replacement – Replacement of a diseased valve. New valves are either mechanical (durable materials such as Dacron or titanium) or biological (tissues taken from pigs, cows or human donors).

47

Appendix 1 Risk Factors for CABG In-Hospital / 30-Day Deaths in New York State in 2013The significant pre-operative risk factors for death in the hospital during the same admission as the surgery or after hospital discharge but within 30 days of surgery (in-hospital/30-day mortality) for CABG in 2013 are presented in Appendix Table 1.

Roughly speaking, the odds ratio for a risk factor represents the number of times more likely to die in the hospital during or after CABG or after discharge but within 30 days of the surgery a patient with that risk factor is than a patient without the risk factor, all other risk factors being the same. For example, the odds ratio for the risk factor Cerebrovascular Disease is 1.912. This means that a patient who has Cerebrovascular Disease prior to surgery is approximately 1.912 times as likely to die in the hospital or after discharge within 30 days of surgery as a patient who does not have Cerebrovascular Disease but who has the same other significant risk factors.

For all of the risk factors in the table except Age: Number of years greater than 65 and Chronic Lung Disease, there are only two possibilities: having the risk factor and not having it.

For age, the odds ratio roughly represents the number of times more likely to die a patient who is older than 65 is compared to a patient who is one year younger but otherwise has the same significant risk factors. Thus, the chance of in-hospital / 30-day death for a patient undergoing CABG who is 66 years old is approximately 1.065 times that of a patient 65 years old undergoing CABG, if all other risk factors are the same. All patients age 65 and younger have roughly the same odds of in-hospital / 30-day mortality if their other risk factors are identical.

In this model Chronic Lung Disease is divided into three categories: Mild to Moderate, Severe, and None. The odds ratios for patients with either of the first two levels are compared to patients with no chronic lung disease. Thus, a CABG patient with severe chronic lung disease is 4.326 times as likely to die in the hospital or within 30 days as a patient without chronic lung disease, all other significant risk factors being the same.

48

Appendix Table 1Multivariable Risk Factor Equation for CABG In-Hospital / 30-Day Deaths in New York State in 2013.

Logistic Regression

Patient Risk Factor Prevalence (%) Coefficient P-Value Odds Ratio

Demographic

Age: Number of years greater than 65 —- 0.0629 <0.0001 1.065

Female Gender 24.65 0.4901 0.0056 1.632

Ventricular Function

Ejection Fraction < 30% 8.01 1.0350 <0.0001 2.815

Previous MI < 24 hours 3.10 1.4278 <0.0001 4.170

Hemodynamic State

Unstable 0.73 1.1465 0.0141 3.147

Comorbidities

Cerebrovascular Disease 14.75 0.6482 <0.0008 1.912

Chronic Lung Disease

None 79.91 — Reference — 1.000

Mild to Moderate 15.46 0.6308 0.0028 1.879

Severe 4.63 1.4646 <0.0001 4.326

Renal Failure

Creatinine >2.5 mg/dl or requiring dialysis 4.52 0.9775 0.0007 2.658

Previous Procedures

Previous CABG Surgery 1.97 1.2258 0.0008 3.407

Vessels Diseased

LMT Disease 33.68 0.5060 0.0032 1.659

Intercept = -5.5040C Statistic = 0.791

49

Appendix 2 Risk Factors for CABG 30-Day Readmissions in New York State in 2013The significant pre-procedural risk factors for 30-day readmissions following CABG in 2013 are presented in the table that follows. Female Gender, Ejection Fraction, Previous MI, and Chronic Lung Disease are interpreted in the same way as Cerebrovascular Disease in Appendix 1. The patient either has the risk factor or does not. For example, the odds ratio for the risk factor Previous MI within 20 days is 1.260. This means that a patient with a previous MI within 20 days is approximately 1.260 times more likely to be readmitted to a hospital within 30 days following discharge after CABG than a patient without a previous MI within 20 days who has the same other significant risk factors.

The interpretation for Age is very similar to that presented in Appendix 1 except in this case each

year of age over age 50 is associated with an increased risk of readmission.

In this model, the risk factor for Diabetes is divided into three categories: Patients who do not have diabetes or have diabetes that is treated without insulin; those with untreated diabetes; those with diabetes treated with insulin.  Patients in each of the latter two categories are compared to patients in the first category.

Renal Failure is expressed in terms of renal failure with dialysis and elevated creatinine without dialysis. The odds ratios for all three Renal Failure categories are relative to patients with no dialysis and whose last creatinine measured prior to surgery was not greater than 1.5 mg/dL.

50

Appendix Table 2

Multivariable Risk Factor Equation for CABG 30-Day Readmission in New York State in 2013.

Logistic Regression

Patient Risk Factor Prevalence (%) Coefficient P-Value Odds Ratio

Demographic

Age: Number of years greater than 50 — 0.0139 <0.0001 1.014

Female Gender 24.68 0.3305 <0.0001 1.392

Ventricular Function

Ejection Fraction < 30% 7.75 0.4098 0.0002 1.507

Previous MI within 20 days 29.97 0.2309 0.0013 1.260

Comorbidities

Chronic Lung Disease 20.18 0.2293 0.0036 1.258

Diabetes

Diabetes, No disease or treatment other than insulin 79.74 — Reference —- 1.000

Diabetes, No Therapy 3.66 0.3723 0.0235 1.451

Diabetes, Insulin Therapy 16.60 0.4677 <0.0001 1.596

Renal Failure

No Renal Failure 89.16 — Reference — 1.000

Renal Failure, Creatinine 1.6-2.0 mg/dl 5.05 0.4347 0.0013 1.544

Renal Failure, Creatinine > 2.1 mg/dl 2.57 0.6224 0.0003 1.863

Renal Failure, Requiring Dialysis 3.22 0.9813 <0.0001 2.668

Intercept = -2.5199C Statistic = 0.630

51

Appendix 3 Risk Factors For Valve Surgery In-Hospital / 30-Day Mortality in 2011-2013The significant pre-procedural risk factors for in-hospital/30-day mortality following valve surgery in the 2011-2013 time period are presented in the table that follows.

Age: number of years greater than 55 is interpreted in a similar fashion to Appendix 1 and 2 except in this case each year over age 55 is associated with an increased risk of mortality.

Body surface area (BSA) is a function of height and weight and increases for larger heights and weights. This model includes terms for both BSA and BSA-squared, reflecting the complex relationship between BSA and in-hospital/ 30-day mortality. The quadratic function of BSA (BSA-squared) used in this statistical model reflects the fact that patients with very high or very low BSAs tend to have higher risks of in-hospital/30-day mortality than patients with intermediate levels of BSA. This functional form is used to improve the model’s ability to predict mortality, but it means that the odds ratios for these terms do not have a straightforward interpretation.

The odds ratio for type of valve surgery represents the number of times a patient with a specific valve surgery is more likely to die in the hospital during or after that particular surgery or after discharge but within 30 days of surgery than a patient who has had aortic

valve replacement surgery, all other risk factors being the same. For example, a patient who has a mitral valve replacement surgery is 1.725 times as likely to die in the hospital during or after surgery or after discharge but within 30 days of surgery as a patient with aortic valve replacement surgery, all other significant risk factors being the same.

In this model, vessels diseased includes patients with disease of the left main coronary artery and/or three diseased vessels. Left main disease is defined as at least a 50 percent blockage of the Left Main coronary artery. Three vessels diseased refers to patients with at least a 70 percent blockage in three of the native coronary arteries including the Left Anterior Descending (LAD), the Right Coronary Artery (RCA) and the Left Circumflex (LCX) or their major branches. The odds ratio is relative to patients who have neither left main disease nor three vessels disease.

The interpretation of renal failure in this model is similar to that provided in Appendix 2 except in this case there is only one level of elevated creatinine.

All other variables can be interpreted in the same way as described in Appendix 1 for risk factors with only two possibilities.

52

Appendix 3

Multivariable Risk Factor Equation for Valve Surgery In-Hospital / 30-Day Deaths In NYS, 2011-2013.

Logistic Regression

Patient Risk Factor Prevalence (%) Coefficient P-Value Odds Ratio

Demographic

Age: Number of years greater than 55 — 0.0492 <0.0001 1.050

Female Gender 47.22 0.4088 0.0004 1.505

Body Surface Area (10 m2) — -0.4740 0.0048 —

Body Surface Area – squared (100 m4) — 0.0113 0.0072 —

Type of Valve Surgery

Aortic Valve Replacement 51.56 — Reference — 1.000

Mitral Valve Replacement 12.40 0.5454 0.0002 1.725

Mitral Valve Repair 16.81 -0.1237 0.5372 0.884

Multiple Valve Repair/Replacement 19.23 0.7346 <0.0001 2.085

Hemodynamic State

Unstable 0.52 1.4658 <0.0001 4.331

Comorbidities

Endocarditis 4.90 0.5472 0.0026 1.728

Peripheral Vascular Disease 7.12 0.5661 <0.0001 1.761

Renal Failure

No Renal Failure 88.72 — Reference — 1.000

Renal Failure, Creatinine > 1.5 mg/dl 8.22 0.8566 <0.0001 2.355

Renal Failure, Requiring Dialysis 3.06 1.8101 <0.0001 6.111

Previous Procedres

Any Previous CABG Surgery 8.83 0.5948 <0.0001 1.813

Any Previous Cardiac Surgery 12.09 0.4228 0.0011 1.526

Vessels Diseased

Left Main Disease or Three Vessels Diseased

1.78 0.5665 0.0210 1.762

Intercept = -0.4354

C Statistic = 0.762

53

Appendix 4 Risk Factors for Valve and CABG Surgery In-Hospital/30-Day Mortality in New York State in 2011-2013The significant pre-procedural risk factors for in-hospital/30-day mortality following valve and CABG surgery in the 2011-2013 time period are presented in the table that follows.

Age and Body Surface Area are interpreted as described earlier. The interpretation for Renal Failure is similar to that presented in Appendix 2, except that in this case there are five categories: no renal failure, three different levels of elevated creatinine without dialysis, and renal failure requiring dialysis. The reference for all other groups is patients without dialysis whose last pre-operative creatinine was less than 1.6 mg/dl.

The odds ratio for Type of Valve with CABG surgery represents the number of times a

patient with a specific Valve with CABG surgery is more likely to die in the hospital during or after that particular surgery or after discharge but within 30 days than a patient who has had aortic valve repair or replacement and CABG surgery, all other risk factors being the same. For example, a patient who has a mitral valve replacement and CABG surgery is 1.131 times as likely to die in the hospital or within 30 days after discharge as a patient with aortic valve repair or replacement and CABG surgery, all other significant risk factors being the same.

All other risk factors are interpreted as described in Appendix 1 for risk factors with only two possibilities.

54

Appendix Table 4

Multivariable Risk Factor Equation for Valve and CABG Surgery In-Hospital/ 30-Day Deaths in NYS, 2011-2013.

Logistic Regression

Patient Risk Factor Prevalence (%) Coefficient P-Value Odds Ratio

Demographic

Age: Number of years greater than 55 — 0.0425 <0.0001 1.043

Female Gender 35.11 0.4589 0.0007 1.582

Body Surface Area (10 m2) — -0.6929 0.0007 —

Body Surface Area – squared (100 m4) — 0.0169 0.0009 —

Type of Valve (with CABG)

Aortic Valve Replacement 63.15 — Reference — 1.000

Mitral Valve Replacement 9.68 0.1233 0.5408 1.131

Mitral Valve Repair 15.14 0.0686 0.7107 1.071

Multiple Valve Repair/Replacement 12.03 0.8615 <0.0001 2.367

Hemodynamic State

Unstable 0.86 1.0703 0.0073 2.916

Ventricular Function

Ejection Fraction < 30% 8.98 0.5647 0.0011 1.759

Any Previous MI 32.85 0.3056 0.0142 1.357

Comorbidities

Peripheral Vascular Disease 13.90 0.3755 0.0093 1.456

Renal Failure

No Renal Failure 83.83 — Reference — 1.000

Renal Failure, Creatinine 1.6 – 2.0 mg/dl 8.03 0.5389 0.0033 1.714

Renal Failure, Creatinine 2.1 – 3.0 mg/dl 3.10 0.6781 0.0085 1.970

Renal Failure, Creatinine > 3.0 mg/dl 1.00 1.3308 0.0004 3.784

Renal Failure Requiring Dialysis 4.04 1.4694 <0.0001 4.347

Previous Procedures

Any Previous CABG Surgery 5.48 0.8210 <0.0001 2.273

Organ Transplant 0.59 1.2580 0.0057 3.518

Intercept = 2.1357

C Statistic = 0.726

55

Appendix 5 Risk Factors for Isolated CABG In-Hospital/30-Day Mortality in New York State 2011-2013The significant pre-procedural risk factors for in-hospital/30-day mortality following isolated CABG in the 2011-2013 time period are presented in the table that follows. The risk factors in this model are interpreted as described in Appendices 1 – 4.

Appendix Table 5

Multivariable Risk Factor Equation for CABG In-Hospital / 30-Day Deaths in New York State in 2011-2013.

Patient Risk Factor Prevalence (%)

Logistic Regression

Coefficient P-Value Odds Ratio

DemographicAge: Number of years greater than 50 — 0.0527 <0.0001 1.054Female Gender 25.04 0.4254 0.0006 1.530Body Surface Area (10 m2) — -0.4186 0.0150 —Body Surface Area – squared (100 m4) — 0.0114 0.0051 —

Hemodynamic StateUnstable 0.74 0.8431 0.0082 2.324

Ventricular FunctionEjection Fraction

Ejection Fraction 50% or greater 64.34 — Reference — 1.000Ejection Fraction < 30% 7.59 1.1904 <0.0001 3.288Ejection Fraction 30-49% 28.07 0.4504 0.0002 1.569

Previous MIPrevious MI less than 1 day 2.94 1.1749 <0.0001 3.238Previous MI 1 – 14 days 25.14 0.5209 <0.0001 1.684

ComorbiditiesCerebrovascular Disease 16.33 0.5529 <0.0001 1.738Chronic Lung Disease 22.88 0.3603 0.0014 1.434Extensive Aortic Atherosclerosis 4.05 0.4193 0.0193 1.521Peripheral Vascular Disease 11.63 0.3304 0.0130 1.391Renal Failure Requiring Dialysis 3.02 1.0956 <0.0001 2.991

Vessels DiseasedLeft Main Disease 33.44 0.2187 0.0443 1.244

Previous Procedures Previous Valve Surgery 0.37 1.4621 0.0002 4.315PCI Before This Admission 25.27 0.2919 0.0131 1.339

Intercept = -2.6741

C Statistic = 0.784

56

NEW YORK STATE CARDIAC SURGERY CENTERSAlbany Medical Center New Scotland Avenue Albany, New York 12208

Arnot Ogden Medical Center 600 Roe Avenue Elmira, New York 14905

Bassett Medical Center Atwell Road Cooperstown, New York 13326

Bellevue Hospital Center First Avenue and 27th Street New York, New York 10016

Buffalo General Medical Center 100 High Street Buffalo, New York 14203

Champlain Valley Physicians Hospital*** 75 Beekman Street Plattsburgh, New York 12901

Ellis Hospital 1101 Nott Street Schenectady, New York 12308

Erie County Medical Center *** 462 Grider Street Buffalo, New York 14215

Good Samaritan Hospital Medical Center** 1000 Montauk Highway West Islip, New York 11795

Good Samaritan Hospital of Suffern 255 Lafayette Avenue Suffern, New York 10901

Lenox Hill Hospital 100 East 77th Street New York, New York 10021

Long Island Jewish Medical Center 270-05 76th Avenue New Hyde Park, New York 11040

Maimonides Medical Center 4802 Tenth Avenue Brooklyn, New York 11219

Mercy Hospital of Buffalo 565 Abbott Road Buffalo, New York 14220

Millard Fillmore Hospital *** 3 Gates Circle Buffalo, New York 14209

Montefiore Medical Center @ Henry & Lucy Moses Division 111 East 210th Street Bronx, New York 11219

Montefiore Medical Center @ Jack D. Weiler Hospital of A. Einstein College 1825 Eastchester Road Bronx, New York 10461

Mount Sinai Beth Israel 10 Nathan D. Perlman Place New York, New York 10003

Mount Sinai Hospital One Gustave L. Levy Place New York, New York 10019

Mount Sinai St. Luke’s 11-11 Amsterdam Avenue at 114th Street New York, New York 10025

New York Hospital Medical Center – Queens 56-45 Main Street Flushing, New York 11355

New York Methodist Hospital 506 Sixth Street Brooklyn, New York 11215

NY Presbyterian Hospital @ Columbia Presbyterian Center 161 Fort Washington Avenue New York, New York 10032

NY Presbyterian Hospital @ New York Weill – Cornell College 525 East 68th Street New York, New York 10021

NYU Hospitals Center 550 First Avenue New York, New York 10016

North Shore University Hospital 300 Community Drive Manhasset, New York 11030

Rochester General Hospital 1425 Portland Avenue Rochester, New York 14621

57

St. Elizabeth Medical Center 2209 Genesee Street Utica, New York 13413

St. Francis Hospital Port Washington Boulevard Roslyn, New York 11576

St. Joseph’s Hospital Health Center 301 Prospect Avenue Syracuse, New York 13203

St. Peter’s Hospital 315 South Manning Boulevard Albany, New York 12208

Southside Hospital 301 East Main Street Bayshore, New York 11706

Staten Island University Hospital – North 475 Seaview Avenue Staten Island, New York 10305

Strong Memorial Hospital 601 Elmwood Avenue Rochester, New York 14642

UHS Wilson Medical Center 33-57 Harrison Street Johnson City, New York 13790

University Hospital at Stony Brook Stony Brook, New York 11794-8410

University Hospital of Brooklyn 450 Lenox Road Brooklyn, New York 11203

Upstate University Hospital – State University of New York 750 East Adams Street Syracuse, New York 13210

Vassar Brothers Medical Center 45 Reade Place Poughkeepsie, New York 12601

Westchester Medical Center Grasslands Road Valhalla, New York 10595

Winthrop University Hospital 259 First Street Mineola, New York 11501

** Began performing cardiac surgery after 2013 *** No longer performing cardiac surgery.

Additional copies of this report may be obtained through the Department of Health web site at http://www.health.ny.gov

or by writing to:

Cardiac Box 2006 New York State Department of Health Albany, New York 12220

Departmentof Health

9/16

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