Institutional volume and postoperative efficiency as determinants of in-hospital mortality after coronary artery bypass grafting: a multilevel analysis in São Paulo, Brazil.
- 1Faculdade de Medicina, Instituto de Educação Médica - IDOMED Brasil - Rio de Janeiro (RJ), Brazil.
- 2Department of Intensive Care, Santa Casa de Misericórdia de Feira de Santana - Feira de Santana (BA), Brazil.
Abstract
Objective
To evaluate the association between hospital procedural volume, postoperative efficiency, and in-hospital mortality and costs among patients undergoing coronary artery bypass grafting in the public health system of the State of São Paulo, Brazil.Methods
This retrospective ecological study analyzed isolated coronary artery bypass grafting procedures recorded in the Brazilian Hospital Information System in São Paulo between 2008 and 2024. Outcomes included in-hospital mortality, postoperative length of stay, and inflation-adjusted hospitalization costs. We assessed mortality using Poisson regression models, while we analyzed costs and length of stay using linear mixed-effects models with hospital-level random intercepts. We performed sensitivity analyses using alternative inclusion criteria.Results
We included 82,398 procedures from 45 hospitals. Median annual hospital volume was 71 procedures. Overall in-hospital mortality was 6.75%, and mean length of stay was 12.2 days. High-performing centers showed substantially lower mortality (4.82% versus 9.94%), shorter length of stay (12.3 versus 16.5 days), and lower adjusted costs (R$24,246 versus R$28,633) compared with low-performing institutions. At the institutional level, longer mean postoperative stay was positively associated with higher hospital-level mortality rates (incidence rate ratios: 1.015 per day; 95%CI 1.006 - 1.024), though reverse causation cannot be excluded given the ecological study design. Higher annual procedural volume was independently associated with lower costs, whereas prolonged hospitalization significantly increased expenditures. Between 2008 and 2024, total surgical volume declined, while mortality decreased, suggesting progressive improvements in care quality.Conclusion
Higher institutional volume and greater postoperative efficiency are associated with lower mortality and reduced costs after coronary artery bypass grafting in the public health system of the State of São Paulo, Brazil. Postoperative length of stay emerged as a key marker of institutional performance and clinical course.
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BibTeX
@article{martins2026institutional,
title = {{Institutional volume and postoperative efficiency as determinants of in-hospital mortality after coronary artery bypass grafting: a multilevel analysis in São Paulo, Brazil.}},
author = {Gabriel Kaleb Martins and Maria Eduarda Dantas de Souza Reis and Edna Moura de Santana Brito and Gabriela Lopes Jesus and João Victor Lopes Lima and Cláudio Firmino Dantas},
journal = {Critical care science},
year = {2026},
month = oct,
doi = {10.62675/2965-2774.20260048},
url = {https://europepmc.org/article/MED/42912020},
note = {CC BY},
}
RIS
TY - JOUR
TI - Institutional volume and postoperative efficiency as determinants of in-hospital mortality after coronary artery bypass grafting: a multilevel analysis in São Paulo, Brazil.
AU - Gabriel Kaleb Martins
AU - Maria Eduarda Dantas de Souza Reis
AU - Edna Moura de Santana Brito
AU - Gabriela Lopes Jesus
AU - João Victor Lopes Lima
AU - Cláudio Firmino Dantas
PY - 2026
DA - 2026/10/16
JO - Critical care science
DO - 10.62675/2965-2774.20260048
UR - https://europepmc.org/article/MED/42912020
AB - Objective To evaluate the association between hospital procedural volume, postoperative efficiency, and in-hospital mortality and costs among patients undergoing coronary artery bypass grafting in the public health system of the State of São Paulo, Brazil.Methods This retrospective ecological study analyzed isolated coronary artery bypass grafting procedures recorded in the Brazilian Hospital Information System in São Paulo between 2008 and 2024. Outcomes included in-hospital mortality, postoperative length of stay, and inflation-adjusted hospitalization costs. We assessed mortality using Poisson regression models, while we analyzed costs and length of stay using linear mixed-effects models with hospital-level random intercepts. We performed sensitivity analyses using alternative inclusion criteria.Results We included 82,398 procedures from 45 hospitals. Median annual hospital volume was 71 procedures. Overall in-hospital mortality was 6.75%, and mean length of stay was 12.2 days. High-performing centers showed substantially lower mortality (4.82% versus 9.94%), shorter length of stay (12.3 versus 16.5 days), and lower adjusted costs (R$24,246 versus R$28,633) compared with low-performing institutions. At the institutional level, longer mean postoperative stay was positively associated with higher hospital-level mortality rates (incidence rate ratios: 1.015 per day; 95%CI 1.006 - 1.024), though reverse causation cannot be excluded given the ecological study design. Higher annual procedural volume was independently associated with lower costs, whereas prolonged hospitalization significantly increased expenditures. Between 2008 and 2024, total surgical volume declined, while mortality decreased, suggesting progressive improvements in care quality.Conclusion Higher institutional volume and greater postoperative efficiency are associated with lower mortality and reduced costs after coronary artery bypass grafting in the public health system of the State of São Paulo, Brazil. Postoperative length of stay emerged as a key marker of institutional performance and clinical course.
SN - 2965-2774
ER -