Patrick Magee

Underuse of Coronary Revascularization Procedures in Patients Considered Appropriate Candidates for Revascularization

BACKGROUND Ratings by an expert panel of the appropriateness of treatments may offer better guidance for clinical practice than the variable decisions of individual clinicians, yet there have been no prospective studies of clinical outcomes. We compared the clinical outcomes of patients treated medically after angiography with those of patients who underwent revascularization, within groups defined by ratings of the degree of appropriateness of revascularization in varying clinical circumstances. METHODS This was a prospective study of consecutive patients undergoing coronary angiography at three London hospitals. Before patients were recruited, a nine-member expert panel rated the appropriateness of percutaneous transluminal coronary angioplasty (PTCA) and coronary-artery bypass grafting (CABG) on a nine-point scale (with 1 denoting highly inappropriate and 9 denoting highly appropriate) for specific clinical indications. These ratings were then applied to a population of patients with coronary artery disease. However, the patients were treated without regard to the ratings. A total of 2552 patients were followed for a median of 30 months after angiography. RESULTS Of 908 patients with indications for which PTCA was rated appropriate (score, 7 to 9), 34 percent were treated medically; these patients were more likely to have angina at follow-up than those who underwent PTCA (odds ratio, 1.97; 95 percent confidence interval, 1.29 to 3.00). Of 1353 patients with indications for which CABG was considered appropriate, 26 percent were treated medically; they were more likely than those who underwent CABG to die or have a nonfatal myocardial infarction--the composite primary outcome (hazard ratio, 4.08; 95 percent confidence interval, 2.82 to 5.93)--and to have angina (odds ratio, 3.03; 95 percent confidence interval, 2.08 to 4.42). Furthermore, there was a graded relation between rating and outcome over the entire scale of appropriateness (P for linear trend=0.002). CONCLUSIONS On the basis of the ratings of the expert panel, we identified substantial underuse of coronary revascularization among patients who were considered appropriate candidates for these procedures. Underuse was associated with adverse clinical outcomes.

The effect of completeness of revascularization on event-free survival at one year in the arts trial ☆

OBJECTIVES We sought to assess the relationship between completeness of revascularization and adverse events at one year in the ARTS (Arterial Revascularization Therapies Study) trial. BACKGROUND There is uncertainty to what extent degree of completeness of revascularization, using up-to-date techniques, influences medium-term outcome. METHODS After consensus between surgeon and cardiologist regarding the potential for equivalence in the completeness of revascularization, 1,205 patients with multivessel disease were randomly assigned to either bypass surgery or stent implantation. All baseline and procedural angiograms and surgical case-record forms were centrally assessed for completeness of revascularization. RESULTS Of 1,205 patients randomized, 1,172 underwent the assigned treatment. Complete data for review were available in 1,143 patients (97.5%). Complete revascularization was achieved in 84.1% of the surgically treated patients and 70.5% of the angioplasty patients (p < 0.001). After one year, the stented angioplasty patients with incomplete revascularization showed a significantly lower event-free survival than stented patients with complete revascularization (i.e., freedom from death, myocardial infarction, cerebrovascular accident and repeat revascularization) (69.4% vs. 76.6%; p < 0.05). This difference was due to a higher incidence of subsequent bypass procedures (10.0% vs. 2.0%; p < 0.05). Conversely, at one year, bypass surgery patients with incomplete revascularization showed only a marginally lower event-free survival rate than those with complete revascularization (87.8% vs. 89.9%). CONCLUSIONS Complete revascularization was more frequently accomplished by bypass surgery than by stent implantation. One year after bypass, there was no significant difference in event-free survival between surgically treated patients with complete revascularization and those with incomplete revascularization, but patients randomized to stenting with incomplete revascularization had a greater need for subsequent bypass surgery.

Public confidence and cardiac surgical outcome: Cardiac surgery: the fall guy in medical quality assurance

The General Medical Council has recently been grappling with the problem of measuring and comparing surgical outcomes after complex surgery in a heterogeneous patient population with differing severities of illness.1 Cardiothoracic surgery, with its immediate, and sometimes catastrophic outcomes, is the first surgical specialty to come under such scrutiny. Inevitably the media coverage has dented public confidence in the ability of the medical profession to police itself, and in particular this has been focused on cardiothoracic surgery.1 Yet, the irony is that in the United Kingdom cardiothoracic surgery has better data and is more subject to internal scrutiny than perhaps any other specialty. The Society of Cardiothoracic Surgeons has a long history of audit. In 1977 Sir Terence English established the United Kingdom cardiac surgical register,2 which collects activity and mortality data on all cardiac surgical procedures performed in each NHS cardiac surgical unit, amounting to 35 000 procedures a year. Although apparently simple in concept, the process represented the first attempt in Britain by any specialty to collect national activity and outcome data. All data are anonymised, since this was a prerequisite for encouraging voluntary data submission from all units. Similarly the United Kingdom heart valve registry has collected national valve surgery data since 1986. Linkage of this registry to the Office for National Statistics means we now have unique 10 year survival data following heart valve replacements in the NHS. 3 18 Both registries return aggregated data to each member of the society as an annual report containing national activity and mortality data for a wide range of cardiac operations. Since inception the presumption has been that access to national information would draw each surgeons attention to his or her own performance and encourage …