Understanding and Addressing Variation in Healthcare-Associated Infections After Adult Cardiac Surgery

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Project Summary/Abstract Nearly 250,000 patients annually undergo surgical coronary revascularization and/or valve repair or replacement in the US. Despite improvements in operative care and technology, patients remain at substantial risk of postoperative complications that adversely impact quality of life and survival. Healthcare-acquired infections “HAIs” (e.g., pulmonary, bloodstream, deep-sternal wound) occur in ~10% of patients undergoing these operations and significantly increase 90-day payments by $10-$13K. Patients at higher versus lower HAI tercile hospitals have higher (18% versus 9%) risk of major morbidity and mortality, p < 0.001. Despite existing efforts focused on in-hospital HAI prevention practices (e.g., appropriate timing and type of antibiotics, nursing intensive care unit bundle adherence), substantial interhospital variability persists in HAI rates. Only 2% of hospital variation in HAI rates is explained by traditional factors, highlighting the need to identify significant determinants. Our team has mapped provider care delivery networks serving cardiac surgery patients that reflect coordination of patient disease management and care optimization (e.g., communication and information exchange) to accomplish collaborative tasks (e.g., patient selection, timing of surgery, intensive care unit recovery, post- discharge care) across multiple provider specialties and settings. We have merged national administrative claims with clinical registry data among patients undergoing durable left ventricular assist devices and found: (1) networks serving racially segregated communities display greater care fragmentation (i.e., weaker connectivity among care providers) than those serving more integrated communities; (2) increased care fragmentation of these networks operating at the hospital level is significantly associated with an increase in the probability of 90- day HAIs and (3) the relationship between care fragmentation (a measure of network performance) and post- discharge payments is significantly mediated by postoperative HAIs. Understanding the barriers and facilitators for enhancing care delivery networks across phases of care delivery (pre-admission, index admission, post- discharge) for the most commonly performed cardiac surgical operations would serve as the foundation for targeted improvement strategies to address interhospital HAI variability. Community-based partnerships, that help patients access community and health system resources as well as address healthcare inequities, would serve as a novel focus for developing evidence-based, action-oriented HAI prevention recommendations. The objective of this proposal is to identify areas of intervention within care delivery networks that enhance HAI outcomes. This large-scale mixed methods proposal addresses the following aims: (1) Evaluate provider care delivery networks as significant determinants of postoperative infections after cardiac surgery; (2) Develop a comprehensive understanding of structural barriers and facilitators to optimal care delivery and (3) Develop a best practices toolkit to address the impact of provider care delivery networks on infections after cardiac surgery.