ArticleJournal of cardiothoracic surgery2026
Development efficiency and mortality after coronary artery bypass grafting: a national causal inference analysis.
Article in Journal of cardiothoracic surgery, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundWe evaluated whether development efficiency, the component of the Human Development Index independent of GDP per capita and income inequality, is associated with in-hospital mortality after coronary artery bypass grafting (CABG) in Brazil, and whether this association is mediated by access to elective surgery.
methodsWe conducted a retrospective ecological panel study using administrative data on CABG hospitalizations within the Brazilian Unified Health System from 2008 to 2024. State-year observations were linked to socioeconomic indicators. Development efficiency was defined as the residual of HDI after regression on GDP per capita and the Gini coefficient. Associations with in-hospital mortality were examined using volume-weighted multilevel models. Absolute causal effects and mediation through urgency status were estimated using g-computation and parametric causal mediation analysis.
resultsThe final analytic panel included 379 state-year observations. A 1-standard deviation increase in development efficiency was associated with a reduction in predicted in-hospital mortality from 6.8% to 5.7% (absolute risk reduction - 1.1% points; p < 0.001). At the population level, this corresponds to approximately one fewer observed death per 91 procedures in states with higher versus lower development efficiency. Mediation analysis indicated that 95.5% of the total effect was attributable to the natural direct effect, while only 4.5% was mediated through urgency status, with no significant indirect effect.
conclusionsDevelopment efficiency is an independent and clinically meaningful determinant of survival after CABG in Brazil. Higher income-independent HDI performance is associated with substantial absolute mortality reductions, driven predominantly by direct system-level pathways rather than changes in urgency profile. Strengthening health-system efficiency and perioperative capacity may therefore yield meaningful gains in cardiac surgical outcomes.
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