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Ann Thorac Surg 2002;73:489-490
© 2002 The Society of Thoracic Surgeons

Invited commentary

^a Keck School of Medicine, University of Southern California, 2025 Zonal Ave, GNH 7131, Los Angeles, CA 90033, USA

This manuscript has many features:

1. The Excellent: It has data from more than 1 million patients from 522 hospitals in the United States and Canada (2 Nations) from The Society of Thoracic Surgeons (STS) Database. It is, therefore, of great interest, is extremely valuable and documents that patient’s risks (from cardiac disease and comorbidities) have increased from 1990 to 1999 but the observed and risk-adjusted mortality have decreased. These data are essential for monitoring the operative mortality of CABG surgery.
   
2. The Problems: (A) The actual mortality in each year is not listed; (B) A large amount of baseline data are missing. For example, excluding the data from a site with more than 20% data missing for any variable, results in 65% of sites being excluded in 1990, 36% in 1994 and even 15% in 1999, raising a concern about the risk-adjusted mortality. The authors’ (indirect) suggestion that data are acceptable when 6% or less data are missing is reasonable and should be used in the future; (C) Data are not presented separately for patients less than 65 years of age. Data for the whole population and for those aged 65 or older are given. The reason for presenting data in the latter subgroup is "Medicare population is America’s largest healthcare payment outlay." Are those aged less than 65 years unimportant? Is money an obsession?; (D) This study confirms data from single centers that have shown not only the improvement in operative mortality despite increased risks but also in long-term survival, etc.
   
3. The Unattractive: (A) The reasons for the improvement in care are only "postulates," therefore why only " ... cardiothoracic surgeons should be extremely proud of the superb care..."? Pharmacological agents such as statins, ACE-I, etc, have shown improved outcomes in randomized trials in patients with coronary artery disease. From July 1998 to July 1999, 138,001 patients had acute myocardial infarction; of those who also underwent coronary artery bypass grafting (CABG) 73% did not receive lipid lowering therapy on hospital discharge. Perhaps one should be less than "extremely proud" of the superb care; (B) Appearing to "complain" about reimbursement is questionable in an "original scientific article." The revised manuscript arrived for commentary a week after our national tragedy of September 11, 2001 which has caused a lot of pain, suffering and financial difficulties for many people. Cardiac surgeons are not poor. In all fairness, individual cardiac surgeons have never complained to me about low reimbursement. Collection of data relating to performance are part of one’s "quality control;" why should this be separately funded? Moreover, surgeons should willingly fund the STS for maintaining this database.
   

The Future: The entire focus of the manuscript is on risk-adjusted mortality, which is of little practical value to the practicing physician and their patients. If the average operative mortality is 3%, the range is likely to be from 1% to 6% or 8% and will vary with different risk factors. What is needed? (A) The operative mortality for the whole group and for each risk factor should be given as mean ± SD and range. This would allow physicians to provide patients realistic estimates of expected operative mortality; (B) One has to look beyond operative mortality to patient outcomes at 1, 5, 10 and later years with regard to survival, functional class, return to work, myocardial infarction, reoperation, etc; (C) A very important, but much more difficult task for a large national database, is to determine the incidence of both inappropriate CABG and the manner in which it is performed.

Finally, enormous benefits have accrued to patients from cardiac surgery, and the STS and their Database Committee have to be congratulated for their foresight in establishing this database and for their time, effort and dedication. However, there is much more that still needs to be done.

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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

T. Bruce Ferguson, Jr, Bradley G. Hammill, Eric D. Peterson, Elizabeth R. DeLong, and Frederick L. Grover
Ann. Thorac. Surg. 2002 73: 480-489. [Abstract] [Full Text] [PDF]

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