AW: AW: [HSF] Local vs distant populations and Results

Tea Acuff tacuff at swbell.net
Tue Aug 14 20:17:01 EDT 2007 

That is the party line, but Mayo is the only one I saw that published any data about it and it showed the opposite. It should be easy to look at. Pick a disease or procedure and compare the results of the "locals" (same city or whatever you use in Germany) with all the others and see what you get. Maybe you can shut me up.

tea


----- Original Message ----
From: Dr. Roberto Battellini <battr at medizin.uni-leipzig.de>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, August 14, 2007 12:39:08 AM
Subject: AW: AW: [HSF] Local vs distant populations and Results


Tea,

If you are a referral center and you accept every case, as you need to
operate a lot for maintaining the number, and you are proud, you give the
last chance to a patient rejected anywhere, so  you get worse results.
On the other hand, this "prestige" ? brings you a lot of patients from
other states or provinces, which come walking, (low risk), and the mortality
decreases. That is our reality, and the reason why many hospitals send all
the dissections directly here. In the same province of Saxonia, with
8.000.000 inhabitants there are other two centers which operate 900 cases
per year one and 1000 the other.
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Tea Acuff
Gesendet: Dienstag, 14. August 2007 04:28
An: OpenHeart-L at lists.hsforum.com
Betreff: Re: AW: [HSF] Acute dissection - what now?

Exactly. I believe there is another effect working here (other than the
implied more makes better). Patients that go to referral centers are a
different population than local patients. Maybe Prasanna or someone can find
the report I read as a medical student (and remembered!) from the free Mayo
Clinic Proceedings. They found at the Mayo Clinic patients from their home
(local) county did less well with aortic (abd) surgery than those from
elsewhere in the hands of the same surgeons. All this argues for better ways
of thinking about medical practice than as a "science" of populations. I
would argue for systems thinking not population thinking. This is a
different type of logic.

tea



----- Original Message ----
From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, August 13, 2007 8:44:14 PM
Subject: Re: AW: [HSF] Acute dissection - what now?


So how do we define better?


Let us look at say an incidence of 2% of an event 
- mortality, infection, whatever. Most patients 
and doctors understand the concept of a point 
estimate but few will understand the concept of 
confidence intervals, which makes explanations of 
potential risk of mortality harder. They do not 
always fully understand often that a 2% risk 
means that 2/100 or 20/1000 will not survive an 
operation, but we cannot tell which are the 2 or 
20. "98% or 49/1 survival - that's pretty good 
odds, isn't it. I guess so."  Nor do they 
understand that the 95% CI for 2/100 are 0.55% - 
7% and 20/1000 are 1.3% - 3 %. Nor do they all 
understand that 95% CI mean 95% of repeated 
estimations will fall into that range.

Every measure has a degree of uncertainty. A rate 
of 2.23% sound very precise but depending on the 
numbers involved, may mean that the true rate 
lies somewhere between 0 and 15%. Confidence 
intervals are used to describe this uncertainty. 
95% confidence intervals state the range in which 
the estimate (2.23%) would lie 95% of the time, 
if multiple measurements were made.

When smaller numbers of procedures are done, the 
95% confidence intervals will be wide, and a 
single death or complication will alter the 
percentage rate enormously. This makes the use of 
a single percentage rate somewhat misleading.

The Cleveland Clinic has the advantage of large 
numbers so the CIs will be narrow. But in lower 
volume units, they will be wider and will likely 
overlap those of CC. So how do we tell who is 
better?
I suspect we can't. They will have the advantage 
of large numbers of less risky cases that will 
dilute the higher risk cases and give overall 
lower rates for each event.






>Of course you are making the point that the 
>"leap frog effect" (all cases should go to high 
>volume centers) has serious flaws from the 
>potential patient side, even if it is superior 
>from the doctor perspective, e.g. Cleveland 
>Clinic has "better results". Such is generally 
>the problem with doctor as authority arguments. 
>More on this idea later. tea ----- Original 
>Message ---- From: Dr. Roberto Battellini 
><battr at medizin.uni-leipzig.de> To: 
>OpenHeart-L at lists.hsforum.com Sent: Monday, 
>August 13, 2007 4:48:30 PM Subject: AW: [HSF] 
>Acute dissection - what now? Hal, my "non 
>arrived "case of Friday was the second dying in 
>the transport in the last 5 years, only for one 
>surgeon. How many may have died for 10? One case 
>years ago was in the middle of a hard winter, no 
>helicopter flights, came from some mountains 200 
>Km far away, the maximal velocity for driving 
>was 50... To night we are operating two Type A 
>simultaneously in 2 OR...(my case is in 
>reperfusion ) Roberto -----Ursprüngliche 
>Nachricht----- Von: 
>openheart-l-bounces at lists.hsforum.com 
>[mailto:openheart-l-bounces at lists.hsforum.com] 
>Im Auftrag von hgrmd at aol.com Gesendet: Sonntag, 
>12. August 2007 18:27 An: 
>OpenHeart-L at lists.hsforum.com Betreff: Re: [HSF] 
>Acute dissection - what now? Dave, ? I've never 
>seen or heard of staging an acute dissection, 
>but your strategy seems to be working so far.? I 
>suspect if you had tried to fix the whole thing 
>acutely, the patient would have died from RV 
>failure.? Still, I would think it's a small 
>minority of acute Type A dissections that can be 
>staged.? If I'm not mistaken, the mean survival 
>of untreated Type A's is only a couple of days. 
>Hal -----Original Message----- From: David 
>Harris <drdharris at yahoo.co.uk> To: 
>OpenHeart-L at lists.hsforum.com Sent: Sun, 12 Aug 
>2007 12:45 pm Subject: Re: [HSF] Acute 
>dissection - what now? Hi Prasannah, There was 
>no definite site on the aorta, and the aorta was 
>not thinned out and ready to rupture like I have 
>usually seen. The adventitia was slightly 
>thickened / inflamed. There was a small amount 
>of liquid  blood, and clots, which were around 
>the whole ventricle. Posterior clots were 
>removed only once we were on pump. I took him 
>back on 9 Aug for formal closure of the chest so 
>we could wean and extubate (I had left the 
>sternum open to prevent any compression of the 
>RV, which looked horrid at that stage). By this 
>stage the RV looked normal, the aorta did not 
>look worse (45mm) externally, and echo showed no 
>extension of dissection. He was extubated 
>yesterday, and is still delirious / confused. 
>Kidneys are working, creat now 330mmol/l. I 
>guess I should plan for later this week? Dave 
>--- psimha <prasannasimha at gmail.com> wrote: > 
>Dave, > How did he Tamponade ? > Prasanna > 
>David Harris wrote: > > 60 yr old male presents 
>with `acute coronary > syndrome` > > to 
>physician, inferior infarct pattern. > > > > 
>Cardiac cath done next day. L side normal, 
>RCA > > blocked. Aortic valve intact. Aortic 
>dissection > then > > diagnosed. CT confirms 
>that it extends from RCA to > > below 
>brachiocephalic. > > > > Patient then referred 
>to me: dehydrated, obtunded, > > creatinine 
>570mmol/l, anuric. > > > > Arrests soon after, 
>resuscitated. BP 50 - 60 > systolic > > for 30 
>mins. Taken to OR for salvage. Put on pump > > 
>(cannulated innominate) to keep him alive. > 
>Tamponade > > relieved, vein graft on beating 
>heart to prox RCA. > > Aorta looks stable (not 
>thinned out - yet) > > Weaned with difficulty 
>with IABP. > > > > Now on 40%, ventilated, GCS 
>10, passing good > urine, > > creatinine 500. 
>Timing for full repair? Attempt > cross > > 
>clamp during repair? > > > > > > > > Dr. David 
>G. Harris, FCS, MMED, > > Cardiothoracic Surgeon 
>> > Suite 207                                > > 
>Kuils River Private Hospital,        > > PO Box 
>1200, Kuils River, 7579, Cape Town, South > 
>Africa.            > > Tel +27-21-9006411 
>> > Fax +27-21-9006412      Mobile 
>+27-83-3309587 > > 
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>----------------------------------------- > Dr. 
>David G. Harris, FCS, MMED, Cardiothoracic 
>Surgeon        Suite 207 
>Kuils River Private Hospital,        PO Box 
>1200, Kuils River, 7579, Cape Town, South 
>Africa.            Tel +27-21-9006411 
>Fax +27-21-9006412      Mobile +27-83-3309587 
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--
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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