It was the area of manufacturing in which the idea of continuous quality improvement (CQI) originated and developed to what we consider a highly efficient model for all industries today. [1][2][3][4][5][6] Since the 1980s, when the cost of healthcare began rising faster in the United States than the cost of living, quality issues have gradually gained importance for the medical industry and the government. Furthermore, a systematic assessment of healthcare by the Institute of Medicine in 1999 revealed shocking discrepancies between outcomes. One of the main findings suggested that, despite having one of the best acute care services in the world, the United States fails to deliver consistent quality. A growing body of research has confirmed the existence of wide variations that are attributable to differences in medical practices and are unrelated to patients' preexisting medical conditions. 7 Healthcare leaders recognized long ago that education and continuous systematic development are essential to improving outcome. [8][9][10] To build on the strengths of the current system and address the weakness of inconsistent quality, healthcare organizations have initiated CQI processes with various degrees of success over the last few years. 11Our institution, the University of Wisconsin (UW), is a large transplant center with over 8000 organs transplanted to date, and it is regarded as a pioneer of organ preservation.12 This article describes the decision process, implementation, and results of a newly established dedicated liver transplant anesthesia team since 2003. PATIENTS AND METHODSAfter the commitment was made to develop a state-ofthe-art transplant anesthesiology division at UW, the CQI plan called for a series of educational, organizational, and clinical changes that were to be gradually introduced in a fashion consistent with the plan-dostudy-act cycle. The first step of the new CQI process focused on education. Creating concentrated subspecialty knowledge was accomplished by the creation of a liver transplant anesthesiology case library and the establishment of a new transplant anesthesia rotation for resident training. Evidence-based guidelines [eg, low central venous pressure (CVP) intraoperative fluid management, thromboelastography (TEG), conservative blood transfusion triggers, systematic use of antifibrinolytics for hyperfibrinolysis, and extubation in the operating room when possible] were published on the departmental intranet for all anesthesia personnel.Subsequently, we identified a group of 7 faculty volunteers who later became the dedicated liver transplant anesthesia team. None of these individuals completed a formal transplant anesthesia fellowship, but 2 were

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Purpose This study was performed to determine if there is a sex-based bias in referral practices, complexity of disease, surgical treatment, or outcomes in patients undergoing mitral valve surgery at our institution. Methods Data were collected from the Cardiovascular Research Database of the Clinical Trial Unit of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital and they were defined according to the Society of Thoracic Surgeons National Database ( www.sts.org ). All patients who had mitral valve replacement, mitral valve repair with annuloplasty ring placement, and mitral valve annuloplasty alone were evaluated, including patients who underwent concomitant tricuspid valve surgery, atrial fibrillation ablation, patent foramen ovale closure, and coronary artery bypass grafting. An unmatched comparison was made between the 836 men and 600 women in the entire cohort ( N = 1436) and propensity score-matching was performed in 423 pairs of men and women. Additional propensity score-matching for 219 pairs of men and women with Type II mitral valve functional class and no coronary artery disease and for 68 pairs of men and women with Type 1 or Type IIIb mitral valve functional class. Propensity score matching was used to compare sex differences involving a greedy algorithm with a caliper of size 0.1 logit propensity score standard deviation units. Results Between 1 April 2004 and 30 June 2017, 1436 patients (41.8% women, mean age 61.1 ± 12.6 years (men), 62.9 ± 13.3 years (women)) underwent mitral valve surgery. The unmatched comparison for the entire cohort showed that, on average, at the time of surgery, women had higher Society of Thoracic Surgery risk scores, were older and had more heart failure, coronary artery disease, and mitral stenosis than men. Women received proportionately fewer mitral repairs and more atrial fibrillation ablation, and tricuspid valve surgery. Women had longer intensive care unit and hospital stays, required more dialysis, and suffered more transient ischemic attacks and cardiac arrests postoperatively, and 30-day mortality rate was higher for women. However, propensity score-matching of 846 of the patients (423 men; 423 women) indicated that both the surgical approaches and surgical outcomes were comparable for men and women who had similar levels of disease and co-morbidities. Additional propensity score-matching of only those patients with degenerative mitral regurgitation (DMR) (219 men; 219 women) and those with Type 1 or Type III mitral valve disease showed no differences in the surgical procedures performed or in 30-day mortality rates. Conclusions Women appear to be referred for mitral valve surgery later in the course of their disease, which could possibly be on the basis of sex bias, but they may also have a more aggressive form of mitral valve disease than men. Regardless of the reasons for the later referral of women for mitral valve surgery, the clinical outcomes are dependent upon the severity of the mitral disease and associated co-morbidities at the time of surgery, not on the basis of sex bias.

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