Balancing quality and quaternary care imperative using a high-risk case review committee in adults.

OBJECTIVES: Quaternary care centers have an imperative to serve as hospitals of last resort and must also meet professional quality targets. We developed a high-risk review committee (HRC) to evaluate cases meeting pre-defined predicted risk cut-offs as a part of an overall quality improvement drive.

METHODS: We describe the structure, outcomes and effects of the Penn high risk committee (HRC). Using propensity-matching, we investigated whether the committee modifies or screens risk. We used multivariable analysis to examine impact of unmeasured variables on clinical outcomes in this cohort.

RESULTS: Institutional predicted and observed mortality had already been in decline prior to HRC institution in 2017, due to a multi-facetted quality improvement initiative. Between 2017-2020, the HRC discussed 205 patients with a median predicted risk of mortality of 10.6% (range 0.4-66%). CABG was the most commonly presented operation. 155 patients underwent operation (risk 10.3%), 12 had surgery deferred for optimization (risk 6%), 50 had surgery declined (risk 11.7%) and 12 patients had a deferred decision for further investigation. Overall 30-day survival was 86% for the entire cohort and 89% for operated patients. A matched analysis of similar patients prior to and following the HRC showed that the HRC did not directly modify outcomes. Most patients had better than expected survival (observed: expected mortality < 1). Predicted risk did not predict 30 day mortality among this high risk cohort.

CONCLUSIONS: HRCs serve as an important element in quality-improvement by encouraging a thoughtful approach and channeling the collective experience of a group of senior surgeons. It may improve patient selection by identifying a cohort with extremely poor survival, while allowing safe operation with acceptable outcomes among a group with very high operative risk.