Health Services Information: Application of Donabedian’s Framework to Improve the Quality of Clinical Care

  • A. Laurie W. Shroyer
  • Brendan M. Carr
  • Frederick L. Grover
Living reference work entry
Part of the Health Services Research book series (HEALTHSR)


This chapter provides a summary of the well-established conceptual models related to measuring and improving the overall quality of medical care as described by the Institute of Medicine and founded upon Donabedian’s historical triad for quality measures. The subcomponents required for quality measurement are first identified, including (1) patient risk factors, (2) processes of care, (3) structures of care, (4) clinical outcomes, and (5) resource utilization or costs of care. The key challenges associated with applying this quality of care conceptual model to designing and implementing new research projects are then discussed, including the following cutting-edge measurement-related topics: (1) dealing with missing data (e.g., clinical substitution versus statistical imputation), (2) differentiating planned versus unplanned processes of care (e.g., distinguishing between interventions used as a matter of routine and those interventions that were initiated in response to observed changes in the patient’s status), (3) evaluating the differential impact of sequential versus nonsequential timing of events (e.g., cascading of outcomes), and (4) assessing the relative impact of medical versus nonmedical care influences upon the quality of patient medical care rendered. Historical projects designed to define, measure, and evaluate the quality of cardiac surgical care in the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Program and Society of Thoracic Surgeons National Adult Cardiac Database are presented to illustrate how these quality of care concepts can be applied. The challenges in using clinical databases to evaluate quality of care are then summarized. Finally, several innovative approaches are described toward advancing the future practice of quality measurement research.


Coronary Artery Bypass Grafting Veteran Affair National Surgical Quality Improvement Program Left Internal Mammary Artery Unplanned Readmission 



This book chapter was supported, in part, by the Offices of Research and Development at the Northport and the Eastern Colorado Health Care System, Department of Veterans Affairs Medical Centers, as well as by the Stony Brook University School of Medicine’s Department of Surgery and the Stony Brook University Health Science Center Library. Additionally, special thanks are extended to Ms. Sarah Miller (University of Colorado at Denver), Ms. Carol Wollenstein (Nursing Editor, Stony Brook University), and Ms. Jennifer Lyon (Reference Librarian, Stony Brook University) for their proofreading and editorial assistance.


  1. Blackstone EH. Comparing apples and oranges. J Thorac Cardiovasc Surg. 2002;123(1):8–15.PubMedCrossRefGoogle Scholar
  2. Blumberg MS. Risk adjusting health care outcomes: a methodologic review. Med Care Rev. 1986;43(2):351–93.PubMedCrossRefGoogle Scholar
  3. Codman EA. The classic: the registry of bone sarcomas as an example of the end-result idea in hospital organization. 1924. Clin Orthop Relat Res. 2009;467(11):2766–70.PubMedPubMedCentralCrossRefGoogle Scholar
  4. Donabedian A. Explorations in quality assessment and monitoring vol. 1. The definition of quality and approaches to its assessment. Ann Arbor: Health Administration Press; 1980.Google Scholar
  5. Donabedian A. Criteria and standards for quality assessment and monitoring. QRB Qual Rev Bull. 1986;12(3):99–108.PubMedGoogle Scholar
  6. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743–8.PubMedCrossRefGoogle Scholar
  7. Donabedian A, Wheeler JR, Wyszewianski L. Quality, cost, and health: an integrative model. Med Care. 1982;20(10):975–92.PubMedCrossRefGoogle Scholar
  8. Ferguson TB Jr, Hammill BG, Peterson ED, DeLong ER, Grover FL, S. T. S. N. D. Committee. A decade of change – risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990–1999: a report from the STS National Database Committee and the Duke Clinical Research Institute. Society of Thoracic Surgeons. Ann Thorac Surg. 2002;73(2):480–9; discussion 489–90.Google Scholar
  9. Grover FL, Hammermeister KE, Burchfiel C. Initial report of the Veterans Administration Preoperative Risk Assessment Study for Cardiac Surgery. Ann Thorac Surg. 1990;50(1):12–26; discussion 27–18.PubMedCrossRefGoogle Scholar
  10. Grover FL, Shroyer AL, Hammermeister K, Edwards FH, Ferguson Jr TB, Dziuban Jr SW, Cleveland Jr JC, Clark RE, McDonald G. A decade’s experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases. Ann Surg. 2001;234(4):464–72; discussion 472–464.PubMedPubMedCentralCrossRefGoogle Scholar
  11. Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell Jr DA, Fink AS, Mentzer Jr RM, Neumayer L, Hammermeister K, Mosca C, Healey N, S. Principal Investigators of the Patient Safety in Surgery. Successful implementation of the Department of Veterans Affairs’ National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study. Ann Surg. 2008;248(2):329–36.PubMedCrossRefGoogle Scholar
  12. O’Brien MM, Shroyer AL, Moritz TE, London MJ, Grunwald GK, Villanueva CB, Thottapurathu LG, MaWhinney S, Marshall G, McCarthy Jr M, Henderson WG, Sethi GK, Grover FL, Hammermeister KE, S. Va Cooperative Study Group on Processes and S. Outcomes of Care in Cardiac. Relationship between processes of care and coronary bypass operative mortality and morbidity. Med Care. 2004;42(1):59–70.PubMedCrossRefGoogle Scholar
  13. Shroyer AL, London MJ, VillaNueva CB, Sethi GK, Marshall G, Moritz TE, Henderson WG, McCarthy Jr MJ, Grover FL, Hammermeister KE. The processes, structures, and outcomes of care in cardiac surgery study protocol. Med Care. 1995;33(10 Suppl):OS17–25.PubMedGoogle Scholar
  14. Shroyer AL, McDonald GO, Wagner BD, Johnson R, Schade LM, Bell MR, Grover FL. Improving quality of care in cardiac surgery: evaluating risk factors, processes of care, structures of care, and outcomes. Semin Cardiothorac Vasc Anesth. 2008;12(3):140–52.PubMedCrossRefGoogle Scholar
  15. Sobolev B, Fradet G. Delays for coronary artery bypass surgery: how long is too long? Expert Rev Pharmacoecon Outcomes Res. 2008;8(1):27–32.PubMedCrossRefGoogle Scholar

Further Readings

  1. Arsenault KA, Yusuf AM, Crystal E, Healey JS, Morillo CA, Nair GM, Whitlock RP. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev. 2013;1, CD003611.PubMedGoogle Scholar
  2. Blackstone EH. Breaking down barriers: helpful breakthrough statistical methods you need to understand better. J Thorac Cardiovasc Surg. 2001;122(3):430–9.PubMedCrossRefGoogle Scholar
  3. Clark RE. The STS Cardiac Surgery National Database: an update. Ann Thorac Surg. 1995;59(6):1376–80; discussion 1380–1371.PubMedCrossRefGoogle Scholar
  4. Dowsey MM, Petterwood J, Lisik JP, Gunn J, Choong PF. Prospective analysis of rural–urban differences in demographic patterns and outcomes following total joint replacement. Aust J Rural Health. 2014;22(5):241–8.PubMedCrossRefGoogle Scholar
  5. Ferguson TB Jr, Coombs LP, Peterson ED. Internal thoracic artery grafting in the elderly patient undergoing coronary artery bypass grafting: room for process improvement? J Thorac Cardiovasc Surg. 2002;123(5):869–80.Google Scholar
  6. Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King 3rd SB, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith Jr CR, Smith Jr SC, Spertus JA, Williams SV, Anderson JL, F. American College of Cardiology Foundation/American Heart Association Task. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354–471.PubMedCrossRefGoogle Scholar
  7. Fink AS, Campbell Jr DA, Mentzer Jr RM, Henderson WG, Daley J, Bannister J, Hur K, Khuri SF. The National Surgical Quality Improvement Program in non-veterans administration hospitals: initial demonstration of feasibility. Ann Surg. 2002;236(3):344–53; discussion 353–344.PubMedPubMedCentralCrossRefGoogle Scholar
  8. Garbuz DS, Xu M, Duncan CP, Masri BA, Sobolev B. Delays worsen quality of life outcome of primary total hip arthroplasty. Clin Orthop Relat Res. 2006;447:79–84.PubMedCrossRefGoogle Scholar
  9. Goldman S, Zadina K, Moritz T, Ovitt T, Sethi G, Copeland JG, Thottapurathu L, Krasnicka B, Ellis N, Anderson RJ, Henderson W, V. A. C. S. Group. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study. J Am Coll Cardiol. 2004;44(11):2149–56.PubMedCrossRefGoogle Scholar
  10. Gwadry-Sridhar FH, Flintoft V, Lee DS, Lee H, Guyatt GH. A systematic review and meta-analysis of studies comparing readmission rates and mortality rates in patients with heart failure. Arch Intern Med. 2004;164(21):2315–20.PubMedCrossRefGoogle Scholar
  11. Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg. 2009;250(3):363–76.PubMedGoogle Scholar
  12. Hamilton BH, Ko CY, Richards K, Hall BL. Missing data in the American College of Surgeons National Surgical Quality Improvement Program are not missing at random: implications and potential impact on quality assessments. J Am Coll Surg. 2010;210(2):125–39, e122.PubMedCrossRefGoogle Scholar
  13. Head SJ, Howell NJ, Osnabrugge RL, Bridgewater B, Keogh BE, Kinsman R, Walton P, Gummert JF, Pagano D, Kappetein AP. The European Association for Cardio-Thoracic Surgery (EACTS) database: an introduction. Eur J Cardiothorac Surg. 2013;44(3):e175–80.PubMedCrossRefGoogle Scholar
  14. Hiratzka LF, Eagle KA, Liang L, Fonarow GC, LaBresh KA, Peterson ED, C. Get With the Guidelines Steering. Atherosclerosis secondary prevention performance measures after coronary bypass graft surgery compared with percutaneous catheter intervention and nonintervention patients in the Get With the Guidelines database. Circulation. 2007;116(11 Suppl):I207–12.PubMedGoogle Scholar
  15. Itani KM. A celebration and remembrance. Am J Surg. 2009a;198(5 Suppl):S1–2.PubMedCrossRefGoogle Scholar
  16. Itani KM. Fifteen years of the National Surgical Quality Improvement Program in review. Am J Surg. 2009b;198(5 Suppl):S9–18.PubMedCrossRefGoogle Scholar
  17. Karthik S, Fabri BM. Left internal mammary artery usage in coronary artery bypass grafting: a measure of quality control. Ann R Coll Surg Engl. 2006;88(4):367–9.PubMedPubMedCentralCrossRefGoogle Scholar
  18. Khuri SF. The NSQIP: a new frontier in surgery. Surgery. 2005;138(5):837–43.PubMedCrossRefGoogle Scholar
  19. Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB, Chong V, Fabri PJ, Gibbs JO, Grover F, Hammermeister K, Irvin 3rd G, McDonald G, Passaro Jr E, Phillips L, Scamman F, Spencer J, Stremple JF. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228(4):491–507.PubMedPubMedCentralCrossRefGoogle Scholar
  20. Lee PJ, MacLennan A, Naughton NN, O’Reilly M. An analysis of reintubations from a quality assurance database of 152,000 cases. J Clin Anesth. 2003;15(8):575–81.PubMedCrossRefGoogle Scholar
  21. MacDermid JC, Grewal R, MacIntyre NJ. Using an evidence-based approach to measure outcomes in clinical practice. Hand Clin. 2009;25(1):97–111, vii.PubMedCrossRefGoogle Scholar
  22. Mack MJ. If this were my last speech, what would I say? Ann Thorac Surg. 2012;94(4):1044–52.PubMedCrossRefGoogle Scholar
  23. Maggard-Gibbons M. The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program. BMJ Qual Saf. 2014;23(7):589–99.PubMedPubMedCentralCrossRefGoogle Scholar
  24. Magno G. The healing hand; man and wound in the ancient world. Cambridge, MA: Harvard University Press; 1975.Google Scholar
  25. Main DS, Henderson WG, Pratte K, Cavender TA, Schifftner TL, Kinney A, Stoner T, Steiner JF, Fink AS, Khuri SF. Relationship of processes and structures of care in general surgery to postoperative outcomes: a descriptive analysis. J Am Coll Surg. 2007;204(6):1157–65.PubMedCrossRefGoogle Scholar
  26. Malenka DJ, O’Connor GT. The Northern New England Cardiovascular Disease Study Group: a regional collaborative effort for continuous quality improvement in cardiovascular disease. Jt Comm J Qual Improv. 1998;24(10):594–600.PubMedGoogle Scholar
  27. Marshall G, Shroyer AL, Grover FL, Hammermeister KE. Time series monitors of outcomes. A new dimension for measuring quality of care. Med Care. 1998;36(3):348–56.PubMedCrossRefGoogle Scholar
  28. Mavroudis C, Mavroudis CD, Jacobs JP, Siegel A, Pasquali SK, Hill KD, Jacobs ML. Procedure-based complications to guide informed consent: analysis of society of thoracic surgeons-congenital heart surgery database. Ann Thorac Surg. 2014;97(5):1838–49; discussion 1849–51.PubMedPubMedCentralCrossRefGoogle Scholar
  29. Miller T, Leatherman S. The National Quality Forum: a ‘me-too’ or a breakthrough in quality measurement and reporting? Health Aff (Millwood). 1999;18(6):233–7.CrossRefGoogle Scholar
  30. Milstein A, Galvin RS, Delbanco SF, Salber P, Buck Jr CR. Improving the safety of health care: the leapfrog initiative. Eff Clin Pract. 2000;3(6):313–6.PubMedGoogle Scholar
  31. Murphy BM, Elliott PC, Le Grande MR, Higgins RO, Ernest CS, Goble AJ, Tatoulis J, Worcester MU. Living alone predicts 30-day hospital readmission after coronary artery bypass graft surgery. Eur J Cardiovasc Prev Rehabil. 2008;15(2):210–5.PubMedCrossRefGoogle Scholar
  32. Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg. 1999;16(1):9–13.PubMedCrossRefGoogle Scholar
  33. Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, Lockowandt U. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41(4):734–44; discussion 744–735.PubMedCrossRefGoogle Scholar
  34. National Committee for Quality Assurance. About NCQA. 2014a. Retrieved 21 Nov 2014, from
  35. National Committee for Quality Assurance. Persistence of beta-blocker treatment after a heart attack. 2014b. Retrieved 21 Nov 2014, from
  36. National Institutes of Health. PROMIS: Patient Reported Outcomes Measurement Information System. 2014. Retrieved 25 Oct 2014, from
  37. National Quality Forum. National voluntary consensus standards for cardiac surgery. Washington, DC: National Quality Forum; 2004.Google Scholar
  38. National Quality Forum. NQF patient safety terms and definitions. Washington, DC: National Quality Forum; 2009.Google Scholar
  39. Nawal Lutfiyya M, Bhat DK, Gandhi SR, Nguyen C, Weidenbacher-Hoper VL, Lipsky MS. A comparison of quality of care indicators in urban acute care hospitals and rural critical access hospitals in the United States. Int J Qual Health Care. 2007;19(3):141–9.PubMedCrossRefGoogle Scholar
  40. Nielsen ME. The legacy of Ernest A. Codman in the 21st century. J Urol. 2014;192(3):642–4.PubMedCrossRefGoogle Scholar
  41. Norcini JJ, Boulet JR, Dauphinee WD, Opalek A, Krantz ID, Anderson ST. Evaluating the quality of care provided by graduates of international medical schools. Health Aff (Millwood). 2010;29(8):1461–8.CrossRefGoogle Scholar
  42. O’Brien SM, Shahian DM, DeLong ER, Normand SL, Edwards FH, Ferraris VA, Haan CK, Rich JB, Shewan CM, Dokholyan RS, Anderson RP, Peterson ED. Quality measurement in adult cardiac surgery: part 2 – statistical considerations in composite measure scoring and provider rating. Ann Thorac Surg. 2007;83(4 Suppl):S13–26.PubMedCrossRefGoogle Scholar
  43. Osnabrugge RL, Speir AM, Head SJ, Jones PG, Ailawadi G, Fonner CE, Fonner E Jr, Kappetein AP, Rich JB. Cost, quality, and value in coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2014a ;148(6):2729-35.Google Scholar
  44. Osnabrugge RL, Speir AM, Head SJ, Jones PG, Ailawadi G, Fonner CE, Fonner Jr E, Kappetein AP, Rich JB. Prediction of costs and length of stay in coronary artery bypass grafting. Ann Thorac Surg. 2014b;98(4):1286–93.Google Scholar
  45. Ozker E, Saritas B, Vuran C, Yoruker U, Ulugol H, Turkoz R. Delayed sternal closure after pediatric cardiac operations; single center experience: a retrospective study. J Cardiothorac Surg. 2012;7:102.PubMedPubMedCentralCrossRefGoogle Scholar
  46. Paone G, Brewer R, Likosky DS, Theurer PF, Bell GF, Cogan CM, Prager RL, T. Membership of the Michigan Society of and S. Cardiovascular. Transfusion rate as a quality metric: is blood conservation a learnable skill? Ann Thorac Surg. 2013;96(4):1279–86.PubMedCrossRefGoogle Scholar
  47. Papanikolaou PN, Christidi GD, Ioannidis JP. Patient outcomes with teaching versus nonteaching healthcare: a systematic review. PLoS Med. 2006;3(9), e341.PubMedPubMedCentralCrossRefGoogle Scholar
  48. Parsons HM, Henderson WG, Ziegenfuss JY, Davern M, Al-Refaie WB. Missing data and interpretation of cancer surgery outcomes at the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2011;213(3):379–91.PubMedCrossRefGoogle Scholar
  49. Public Law 99–166. Veterans’ Administration Health-Care Amendments of 1985. Public Law. 1985;99–166.Google Scholar
  50. Puskas JD, Kilgo PD, Thourani VH, Lattouf OM, Chen E, Vega JD, Cooper W, Guyton RA, Halkos M. The society of thoracic surgeons 30-day predicted risk of mortality score also predicts long-term survival. Ann Thorac Surg. 2012;93(1):26–33; discussion 33–25.PubMedCrossRefGoogle Scholar
  51. Rodkey GV, Itani KM. Evaluation of healthcare quality: a tale of three giants. Am J Surg. 2009;198(5 Suppl):S3–8.PubMedCrossRefGoogle Scholar
  52. Rumsfeld JS, Magid DJ, O’Brien M, McCarthy Jr M, MaWhinney S, Scd ALS, Moritz TE, Henderson WG, Sethi GK, Grover FL, Hammermeister KE, S. Department of Veterans Affairs Cooperative Study in Health Services: Processes and S. Outcomes of Care in Cardiac. Changes in health-related quality of life following coronary artery bypass graft surgery. Ann Thorac Surg. 2001;72(6):2026–32.PubMedCrossRefGoogle Scholar
  53. Rumsfeld JS, Ho PM, Magid DJ, McCarthy Jr M, Shroyer AL, MaWhinney S, Grover FL, Hammermeister KE. Predictors of health-related quality of life after coronary artery bypass surgery. Ann Thorac Surg. 2004;77(5):1508–13.PubMedCrossRefGoogle Scholar
  54. Shahian DM, Blackstone EH, Edwards FH, Grover FL, Grunkemeier GL, Naftel DC, Nashef SA, Nugent WC, Peterson ED, S. T. S. w. o. e.-b. surgery. Cardiac surgery risk models: a position article. Ann Thorac Surg. 2004;78(5):1868–77.PubMedCrossRefGoogle Scholar
  55. Shann KG, Giacomuzzi CR, Harness L, Myers GJ, Paugh TA, Mellas N, Groom RC, Gomez D, Thuys CA, Charette K, Ojito JW, Tinius-Juliani J, Calaritis C, McRobb CM, Parpard M, Chancy T, Bacha E, Cooper DS, Jacobs JP, Likosky DS. Complications relating to perfusion and extracorporeal circulation associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease. Cardiol Young. 2008;18 Suppl 2:206–14.PubMedCrossRefGoogle Scholar
  56. Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77(6):534–42.PubMedCrossRefGoogle Scholar
  57. Shih T, Zhang M, Kommareddi M, Boeve TJ, Harrington SD, Holmes RJ, Roth G, Theurer PF, Prager RL, Likosky DS, T. Michigan Society of and C. Cardiovascular Surgeons Quality. Center-level variation in infection rates after coronary artery bypass grafting. Circ Cardiovasc Qual Outcomes. 2014;7(4):567–73.PubMedPubMedCentralCrossRefGoogle Scholar
  58. Sobolev B, Mercer D, Brown P, FitzGerald M, Jalink D, Shaw R. Risk of emergency admission while awaiting elective cholecystectomy. CMAJ. 2003;169(7):662–5.PubMedPubMedCentralGoogle Scholar
  59. The Joint Commission. Ernest Amory Codman Award. 2014. Retrieved 23 Oct 2014, from
  60. The Society of Thoracic Surgeons. Consumer Reports and STS Public Reporting. 2012. Retrieved 27 Oct 2014, from
  61. The Society of Thoracic Surgeons. Adult Cardiac Anesthesia Module. 2013. Retrieved 30 Oct 2014, from
  62. The Society of Thoracic Surgeons. NQF# 0696: The STS CABG Composite Score. NQF: Quality Positioning System. 2014a. Retrieved 30 Oct 2014, from
  63. The Society of Thoracic Surgeons. STS CABG Composite Score. 2014b. Retrieved 30 Oct 2014, from
  64. The Society of Thoracic Surgeons. STS National Database. 2014c. Retrieved 30 Oct 2014, from
  65. Tran C, Wijeysundera HC, Qui F, Tu JV, Bhatia RS. Comparing the ambulatory care and outcomes for rural and urban patients with chronic ischemic heart disease: a population-based cohort study. Circ Cardiovasc Qual Outcomes. 2014;7(6):8, 35–43.Google Scholar
  66. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith Jr SC. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA. 2009;301(8):831–41.PubMedCrossRefGoogle Scholar
  67. van Kasteren ME, Mannien J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis. 2007;44(7):921–7.PubMedCrossRefGoogle Scholar
  68. Veterans Health Administration. VHA handbook 1102.3: criteria and standards for cardiac surgery programs. Washington, DC: Veterans Health Administration; 2008.Google Scholar
  69. Veterans Health Administration and Department of Defense. VA/DoD clinical practice guideline for the management of ischemic heart disease. Washington, DC: Veterans Health Administration, Department of Defense; 1997.Google Scholar
  70. Veterans Health Administration CARE-GUIDE Working Group, Denver VA Medical Center CARE-GUIDE Coordinating Team and United States Veterans Health Administration Office of Quality Management, Denver VA Medical Center CARE-GUIDE Coordinating Team, United States Veterans Health Administration Office of Quality Management. Veterans Health Administration CARE-GUIDE for ischemic heart disease. Washington, DC: Department of Veterans Affairs; 1996.Google Scholar
  71. VillaNueva CB, Ludwig ST, Shroyer AL, Deegan NI, Steeger JE, London MJ, Sethi GK, Grover FL, Hammermeister KE. Variations in the processes and structures of cardiac surgery nursing care. Med Care. 1995;33(10 Suppl):OS59–65.PubMedGoogle Scholar
  72. Wakeam E, Hyder JA, Tsai TC, Lipsitz SR, Orgill DP, Finlayson SR. Complication timing and association with mortality in the American College of Surgeons’ National Surgical Quality Improvement Program database. J Surg Res. 2014,193(1):77–87.Google Scholar
  73. Winkley Shroyer AL, Bakaeen F, Shahian DM, Carr BM, Prager RL, Jacobs JP, Ferraris V, Edwards F, Grover FL. The society of thoracic surgeons adult cardiac surgery database: the driving force for improvement in cardiac surgery. Semin Thorac Cardiovasc Surg. 2015 Summer;27(2):144–51. PubMed PMID: 26686440.Google Scholar
  74. Yasa H, Lafci B, Yilik L, Bademci M, Sahin A, Kestelli M, Yesil M, Gurbuz A. Delayed sternal closure: an effective procedure for life-saving in open-heart surgery. Anadolu Kardiyol Derg. 2010;10(2):163–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA) 2015

Authors and Affiliations

  • A. Laurie W. Shroyer
    • 1
  • Brendan M. Carr
    • 2
  • Frederick L. Grover
    • 3
  1. 1.Department of Surgery, School of MedicineStony Brook UniversityStony BrookUSA
  2. 2.Department of Emergency MedicineMayo ClinicRochesterUSA
  3. 3.Department of Surgery, School of Medicine at the Anschutz Medical CampusUniversity of ColoradoAuroraUSA

Personalised recommendations