Canadian Journal of Cardiology



      Cardiac surgeons have traditionally strived to be innovative while ensuring quality of care. Despite this, the uptake of new, advanced surgical techniques in the pursuit of improved outcomes varies significantly between surgeons and cardiac centres. The purpose of this study was to develop a novel “Innovation Index” to determine the degree of uptake of advanced surgical techniques at a surgical centre.


      For the purposes of this study, only non-emergent, first-time procedures being performed at the New Brunswick Heart Centre between 2010 and 2017 were considered. Five procedure categories were identified as being representative of the degree of innovation in most cardiac surgery centres, including: (1) bilateral vs. single internal mammary artery (IMA) for isolated coronary artery bypass grafting (CABG) with >=2 grafts; (2) endoscopic vein harvest (EVH) vs. open vein harvest (OVH) for any CABG with a saphenous vein graft; (3) minimally invasive vs. conventional mitral valve repair (MVrep) or replacement (MVR) for isolated mitral valve disease; (4) mitral valve repair vs. mitral valve replacement for patients with isolated mitral insufficiency; and (5) transcatheter aortic valve implantation (TAVI) vs. isolated surgical aortic valve replacement (SAVR) for severe aortic stenosis. The rates of each innovative procedure vs. a more traditional approach were calculated on yearly basis, and means of the annual rates for each of the 5 procedures were then computed to form the “overall” rate of innovation or the “Innovation Index” for that particular year. P-trend values were then determined using two-sided Cochran-Armitage test and Jonckheere-Terpstra test to determine if trends in innovation were exhibited over time. Over the course of the study period, a total of 285 patients received bilateral IMA vs. 3004 single IMA; 1605 EVH vs. 2736 OVH; 64 minimally invasive MVrep/MVR vs. 115 conventional; 224 MVrep vs. 262 MVR for mitral insufficiency; and 334 TAVI vs. 504 isolated SAVR. While significant increases in uptake of EVH (p < 0.0001), minimally invasive surgery (p=0.04) and TAVI (p < 0.0001) were noted, rates of BIMA declined (p < 0.0001) while rates of MVrep remained relatively static (p=0.51) (Figure 1). When combined, the overall trend was one of increased innovation over time (p=0.006).


      This study represents the first attempt at devising an “Innovation Index” to determine the degree of uptake of advanced surgical techniques at a surgical centre. This novel metric may be used to compare centres in terms of their willingness to innovate and to identify leaders in practice change.
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