| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1995;59:1380-1381
© 1995 The Society of Thoracic Surgeons
 |
Introduction |
|---|
 Top Introduction References |
|---|
DR SIDNEY LEVITSKY (Boston, MA): Doctor Clark and the STS Committee for the National Database for Thoracic Surgery are to be commended for providing us with the STS Cardiac Surgery National Database.
Doctor Clark's report documents the exponential growth in the registry, its representation of the entire national effort in cardiac surgery, and recent trends demonstrating a decrease in length of stay and operative mortality for patients undergoing coronary revascularization. He also has provided us with anecdotal material suggesting new uses for the database, such as quality assurance, the development of critical clinical pathways designed to decrease length of stay, thus increasing hospital profitability, and clinical practice response to managed care initiatives regarding outcomes.
As noted in the recent editorial by Dr Anderson [1], this database is an unprecedented voluntary effort by American cardiothoracic surgeons to combine their observations for the purpose of self-assessment and the advancement of knowledge.
The next question is whether the promises made by this database have been met. In reality, the question is whether the output is good data that accurately reflects our work and clinical outcomes. For this critical review I have been assisted by my chief resident at the New England Deaconess Hospital, Dr Christian Campos, who is completing his PhD in epidemiology and is one of the principal investigators in the POSH study.
The first question is, does the database accurately reflect the population at risk and the variety of surgical groups performing this service? This was an initial issue as large institutional results overshadowed data from small practices. Although it is assumed that eventually the larger volume of patients from numerous small practices will eliminate this bias, the authors have not provided us with any statistical methodology to validate this assumption of population homogeneity.
The second and probably most important issue is the quality and accuracy of data entered into a voluntary database. Doctor Fred Edwards, in a recent presentation at the National Symposium on Using Outcomes Data to Improve Clinical Practice: Building on Models from Cardiac Surgery [2], has discussed these problems. The major question is: are all patients at a given institution being entered into the database? Should the patient undergoing closed chest massage, being transported from the angioplasty suite to the operating room, who has an eventual poor outcome, represent a salvage case whose mortality is not entered into the database? Or should the rules of the database mandate that all patients undergoing coronary artery bypass grafting, regardless of circumstances, be entered?
Whereas the Health Care Financing Administration in New York, Pennsylvania, and the Veterans Affairs databases have the force of law to guarantee accurate data output, the STS database only has volunteerism and good faith. Perhaps unannounced site visits for external audits should be employed, although I doubt whether this methodology is feasible with a voluntary system. Alternatively, internal audits could be performed at institutions where legally mandated government data are available for comparison.
The third issue is data completeness, clinical inconsistencies, and ``gaming.'' Are all data fields completed, and what are the cutoff criteria for registering a patient into the database? Perhaps Dr Clark will provide us with rejection criteria or the minimal numbers for each entry risk factor that allow the calculation of conditional probabilities for the risk model.
Finally, in these days of intense institutional competition for managed care, ``gaming'' enters into the equation. Because most of us believe that we operate on the ``sick patients'' and our competition operates on healthy patients, some surgical groups have gone to extraordinary means to upgrade severity or to rapidly discharge sick patients, such as those with postoperative strokes, to subacute hospital-rehabilitation facilities to avoid having the eventual operative mortality attributed to their institution. Doctor Clark should inform us as to how the Database Committee deals with these issues.
Nevertheless, the STS database is still in its adolescence and is constantly being refined as exemplified by the recent adaptation of an annual revision of the Bayesian conditional probability model based on changing population and severity of illness. This effort by the STS to report our operative outcomes deserves the respect and admiration of the entire community of cardiothoracic surgeons and offers promise for self-regulation, which has been the cornerstone of our profession.
DR BENSON R. WILCOX (Chapel Hill, NC): The STS is an organization of a thousand committees. Most of us serve on or even chair these committees without fanfare or expectation of reward or recognition, just grateful for the opportunity to be of service, and such is the case with Dr Clark.
However, The Society on rare occasions takes special notice of individuals who have made an unusual contribution, well beyond the call of duty, and such is the case with Dr Clark. Dick Clark is literally the father of the STS database, it having been his brainchild more than a decade ago. He has nurtured it into maturity and is now passing the responsibility for its care to a new chairman, Dr Fred Grover, after next year.
The Society would like to recognize Dr Clark's tremendous contributions to our welfare with a tangible award that we hope you will enjoy, Dr Clark, over the years to come, and with just as heartfelt a recognition, a warm round of applause.
|
References |
|---|
|
TopIntroductionReferences |
|---|
| ||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
