Beta-blocker use fails as a CABG quality metric



LOS ANGELES – Single-institution reports regarding the benefits of beta-blocker use are conflicting, despite the fact that preoperative beta-blockade for coronary artery bypass grafting has become an accepted hospital quality metric, according to Dr. Damien J. LaPar and his colleagues.

Dr. LaPar of the University of Virginia, Charlottesville reported the results of research undertaken to assess this issue based on a study of patient records from a statewide, multi-institutional Society of Thoracic Surgeons (STS)–certified database for isolated coronary artery bypass grafting (CABG) operations (2001-2011). He and his colleagues found that there was no difference seen in mortality, length of stay, or readmission comparing patients with or without preoperative beta-blocker use.

Courtesy Martin Allred

Dr. Damien J. LaPar

Their prestigious Richard E. Clark Paper for Adult Cardiac Surgery, presented at the annual meeting of the Society of Thoracic Surgeons, utilized the STS Adult Cardiac Surgery Database to demonstrate that the perceived benefits of using beta-blockers before CABG do not stand up as statistically significant improvements in outcomes.

"Preoperative beta-blocker use is not associated with improved patient outcomes or hospital resource utilization following" CABG, said Dr. LaPar.

Patients were stratified by preoperative beta-blocker use and the influence of preoperative beta-blockers on risk-adjusted outcomes was assessed by hierarchical regression modeling with adjustment for preoperative risk using calculated STS predictive risk indices.

A total of 43,747 patients with a mean age of around 64 years were included in the study; 80.2% of these patients were treated with beta-blockers. The median STS-predicted risk of mortality scores for beta-blocker patients were incrementally lower, compared with non–beta blocker patients (1.2% vs. 1.4%, P less than .001). Non–beta blocker patients more frequently developed pneumonia (3.5% vs. 2.8%, P = .001), while beta-blocker patients had surprisingly greater intraoperative blood usage (16.0% vs. 11.2%, P less than .001).

There was, however, no difference in unadjusted mortality (beta-blocker, 1.9%, vs. non beta-blocker, 2.2%; P = 0.15). After risk adjustment, preoperative beta-blocker use was not associated with mortality (P = .63), morbidity, length of stay (P = .79), or hospital readmission (P = .97).

"These data suggest that the use of preoperative beta-blockers for [CABG] operations should not be used as a measure of surgical quality," Dr. LaPar said.

"In an era of increasing pressure on individual hospital and surgical outcomes, the identification of appropriate measures of surgical quality remains critical," Dr. LaPar added in an interview.

"More importantly, as public reporting of surgeon outcomes becomes more common, the cardiothoracic surgical community must play a central role in providing updated data from which to base health care policy, hospital and surgeon reimbursement strategies, and referral patterns for cardiac surgical patients," he stated.

"The results of our study provide an updated reexamination of an issue of increasing debate and provide current clinical estimates on the adjusted impact of preoperative beta-blocker use on outcomes following isolated CABG operations. Future randomized controlled trials are needed to more clearly define a cause-effect relationship between preoperative beta-blocker therapy and coronary artery bypass grafting outcomes before the routine use of beta-blockade should be adopted as a quality performance measure by the cardiothoracic surgical community," Dr. LaPar concluded.

Dr. LaPar reported having no relevant conflicts of interest with regard to this paper; two of his colleagues reported serving as speakers or receiving funding from a variety of drug and device companies.

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