[HSF] RE: risk adjusted mortality

Sun Apr 13 19:37:02 EDT 2008

John Hunter made several efforts to resuscitate "patients" after public hangings but this proved not to reveal much about the border between life and death except that it favors one direction. I think the recurring experience is that earlier intervention is more successful. Way earlier if possible.

It is my understanding that while it is hard to calculate the risk of not yet dead as in Ani's 70% Euroscore referral that often the mortality is over estimated. Does anyone have specific observations on that point? Obviously one or a few cases is not a meaningful observation. If my speculation is correct, where does that "extra" mortality risk "credit" go stastically? I have some ideas. We, or LVAD programs, might be able to buy them like carbon credits.
tea

----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sunday, April 13, 2008 4:07:57 PM
Subject: Re: [HSF] RE: risk adjusted mortality

Ani,
Our practice is similar to yours - we take everything that comes in the
door, and refuse to operate on few (but we at least will try something).
The only reason we harp over our statistics is because that is the way
people keep score - why I am sure few 0-mortality surgeons are the ones
bragging, my guess it is the marketing people and hospital administrators
who are unaware that before anyone has the chance to die in their hospital
they get shipped off to the same centers whom they are bashing.  I dont
think there is anything wrong with turning people down, cherry picking, or
performing the same operations that were state of the art 20 years/ago -
much like how we each gravitate towards different environments and
practices.  The problem I have is the public deceptions - but I guess if
enough of your neighbors have bad outcomes at the local community cath
factory with no surgical back-up, then you will think twice about going
there - I get that response from many patients.

I too was in Boston - had a couple of presentations.  Did no see anything
too ground braking - however my concern with everyone getting the same
crappy results from operating on disaster salvage patients is that at some
point society will stop paying for them.  I get the weekly reports of the
hospital charges of our inpatient census and million dollar bills are not
uncommon.  How much are we really willing to spent for an extra year of
"existence"?

-michael

On Sun, Apr 13, 2008 at 4:12 PM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> Michael
>
> We get three or so patients a year transferred from other centers with a
> BiVAD for postcardiotomy shock. As a rule they die, so salvage rate is
> extremely low (not managed to save one yet). Prognosis is poor usually
> because one of two conditions usually precipitated the postcardiotomy shock
> either i) the patient was undergoing the wrong surgery - typically redo CABG
> in low EF patient rather than referring patient for transplant, so potential
> of recovery is zero and chances of bridge to transplant at this stage low
> because of sepsis and multiorgan dysfunction in the background of a 'dead'
> heart or ii) postcardiotomy failure arising from medical misadventure such
> as an occluded coronary artery or poor preservation which results in
> irreversible cardiac damage. While I always try to say no to these transfers
> and the end of the day I say yes because on balance the chances of survival
> (even if ultraslim) would be better if the patient was in a VAD/transplant
> center, so we are there best chance.  These patients however haemorrhage
> resources and money and are often a financial loss to the institution so no
> one wants them.
>
> I pay no attention to state or STS reports so have no idea where these
> mortalities stand. Only surgeons who have impeccable results and ultra low
> mortalities tend to care about statistics. I do not aspire for a
> zero-mortality. I know I have deaths and always will so far as I am in the
> business of VADs, heart failure and low-EF surgery so does not bother me
> whether a death goes under my name or someone else's. Few great surgeons,
> department chiefs etc have these ultralow mortalities - they give all comers
> a chance and try and try and try to save life and in the process many die
> but a few are saved. They never say no.
>
> I find the whole thing (mortality tables) to be a farce - as Hal points
> out more often than not patient selection (or rejection) rather than
> superior provision of surgery is responsible for these ultra-low
> mortalities. Maybe a good study will be to look at mortality by patients'
> zip code rather than by surgeon or center and i suspect you will find that
> in many of these zero mortality hospitals, the true mortality rates for the
> disease (e.g. severe AS) in that community will be higher because the sicker
> or higher risk patients are turned down and die without surgery, or go
> elsewhere and some end up dying. Sometimes the selection, unbeknownst to the
> surgeon who states he never turns patients down, is done by cardiologists
> who send all the nice or easy cases to his center (which then ends up with
> ultralow mortality) and sends the technically-difficult or high risk cases
> to center B (who will have a higher mortality). Risk adjustment does not
> deal with this effect as technical difficulties (for example 4th time
> sternotomy, infected graft, prior homograft, congenital anomalies etc),
> patient factors (e.g. jehovah's witness in redo patient) and non-cardiac
> diseases (e.g. awaiting liver transplant) that drive such tertiary referrals
> are not factored into risk models. One can easily get a feel for such
> selection process by inquiring on the duration of ICU stay or tracheostomy.
> A center where 9 of 10 are out of ICU in a day and the ICU gets empty on a
> Sunday cannot be doing much complex or high-risk surgery as it is impossible
> to do these cases, such as the triple valve in cachetic lady Hal described
> today, without the majority needing extended (>24h) ICU stay and some
> needing protracted ICU stay and tracheostomy. Yet if you looked at risk
> scores most centers will appear to have similar complexity and risk load.
>
> The Boston meeting (international society for heart and lung
> transplantation) was okay. Some new stuff on VADs mainly - I am sure your
> colleague will feed back to you - but reassuring to know we all get the same
> disaster patients and all have the same problems! Two things you can think
> of though was a paper from Texas heart with several fatalities and major
> thormbotic events from Factor VII administration and a comment from a
> Vancouver surgeon that they run all ECMO cases (longest duration 2 weeks)
> without heparin (using bonded circuits only).
>
> Ani
>
>
>
>
>
> > From: msfirst at gmail.com> Subject: Re: [HSF] RE: risk adjusted mortality>
> Date: Sun, 13 Apr 2008 07:58:49 -0400> To: OpenHeart-L at lists.hsforum.com>
> CC: > > Ani,> Being a major VAD center - how many post-op failure to weans
> do you > get? How many of those survive?> and those that dont - do they show
> up on the local (or STS for that > matter) reports?> > Hope you enjoyed
> Boston - too bad we didnt meeting - but anything in > particular catch your
> eye?> > -michael> On Apr 13, 2008, at 7:01 AM, Hgrmd at aol.com wrote:> > >
> Ani,> > It is frustrating to have the docs in the community braying > >
> about their> > great results when it's a dirty little secret that they are
> also > > depriving a> > few deserving patients an operation. Last week, I
> did a redo > > triple valve maze> > on a cachectic 81 yo lady who had been
> turned down by another > > surgeon in> > town 2 years earlier. According to
> the daughter, the surgeon said > > the CT showed> > too much aortic
> calcification to do the operation safely. Well, I > > got a> > cath and did
> note there was heavy calcification of the root with a > > line of> > calcium
> going up the right side of the ascending aorta. However, > > the aorta was>
> > definitely not porcelain. I did the operation uneventfully (AVR, > >
> mitral and> > tricuspid repairs, C-M). There was no problem clamping the
> aorta, > > and she woke> > up neurologically intact. Unfortunately, she was
> so cachectic, I > > couldn't> > wean her from the vent (good O2 on 35% and
> +5). She was trached > > last Friday,> > and I predict she will eventually
> recover. The lessons? I've > > found CT> > generally overestimates the
> amount of clinically relevant > > calcification. Fluoro> > is a much better
> predictor. Finally, surgeons can keep their > > records> > pristine if they
> cherry pick. However, unless their are guys like > > me to take care> > of a
> lot of their rejects, the community suffers from unnecessary > > deaths of>
> > omission.> >> > Hal> >> >> >> > **************It's Tax Time! Get tips,
> forms and advice on AOL Money &> > Finance. (
> http://money.aol.com/tax?NCID=aolcmp00300000002850)> >
> _______________________________________________> > OpenHeart-L mailing list>
> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To
> UNSUBSCRIBE, to CHANGE email address, or to view archives:> >
> http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages
> transmitted by the OpenHeart-L are subject to the > > policies and> >
> disclaimers posted at:> > http://www.hsforum.com/listdisclaim> >
> -----------------------------------------> >
> _______________________________________________> OpenHeart-L mailing list> >
> Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to
> CHANGE email address, or to view archives:>
> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages
> transmitted by the OpenHeart-L are subject to the policies and > disclaimers
> posted at:> http://www.hsforum.com/listdisclaim>
> -----------------------------------------
> _________________________________________________________________
> The next generation of Windows Live is here
>
> http://www.windowslive.co.uk/get-live_______________________________________________
> OpenHeart-L<http://www.windowslive.co.uk/get-live_______________________________________________OpenHeart-L>mailing list
>
> Send postings to:
>  OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the policies
> and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>
_______________________________________________
OpenHeart-L mailing list

Send postings to:
OpenHeart-L at lists.hsforum.com

To UNSUBSCRIBE, to CHANGE email address, or to view archives:
http://mmp.cjp.com/mailman/listinfo/openheart-l

All messages transmitted by the OpenHeart-L are subject to the policies and 
disclaimers posted at:
http://www.hsforum.com/listdisclaim
-----------------------------------------