AW: [HSF] RE: risk adjusted mortality

Tea Acuff tacuff at swbell.net
Mon Apr 14 11:36:29 EDT 2008 

No he had a 100% mortality in that 9 % preop group that reassessed as 50% post facto. Isn't math fun?

tea



----- Original Message ----
From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, April 14, 2008 7:25:38 AM
Subject: Re: AW: [HSF] RE: risk adjusted mortality

Roberto,
What do you mean? Is it that the preop Euroscore 
comes to 9% (Logistic ?) and you have a 50% 
mortality in that group, or is it that after 
surgery you reassess the Euroscore and it is 
remarkably 50%?



>Bob,
>Last Wednesday, during our monthly mortality conference, we clearly saw that
>dead patients got preoperatively a much lesser Euroscore as the presenting
>surgeon found for the presentation.( eg. 9% preop, 50% postop).We clearly
>see the patient´s seriousness(gravity)after death.
>Roberto
>
>-----Ursprüngliche Nachricht-----
>Von: openheart-l-bounces at lists.hsforum.com
>[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von
>rwmfglycar at aol.com
>Gesendet: Montag, 14. April 2008 05:54
>An: OpenHeart-L at lists.hsforum.com
>Betreff: Re: [HSF] RE: risk adjusted mortality
>
>Euroscore overestimates substantially compared with New York State and STS.
>For the individual patient and operation the outcomes remained 100% or
>zero..
>We as surgeons did not during my time refuse patients because of perceived
>excessive risk.and since the cathlab was next door to the OR there was
>constant conversation going on between cardiology and cardiac surgery and we
>had a pretty good handle on what was going on.
>We were aware?of the practices of?one cardiology colleague who ?was more or
>less personal physician to a large and very rich?global banking family.
>Members of this family were discretely referred out of town unless they were
>redo's from previous?out of town adventures (e.g. a paravalvar leak)?or
>bizarre (e.g a constrictive pericarditis that turned out to be a
>mesothelioma).
>For us, working in our developing country? which was the Bronx, the Risk
>Adjusted NY State system was an absolute boon. We went in a year from low on
>the State "league" to high.. We never used the numbers for estimating
>patient risk or advertising but rather as a moving target that served as
>a?continuing spur to our performance.
>Are these comments selfserving? Of course they are.
>(Tea, look up Michael Mack's comprehensive review of STS, NYS and Euroscore
>systems)
>
>
>-----Original Message-----
>From: Tea Acuff <tacuff at swbell.net>
>To: OpenHeart-L at lists.hsforum.com
>Sent: Sun, 13 Apr 2008 9:37 pm
>Subject: Re: [HSF] RE: risk adjusted mortality
>
>
>
>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)> >
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--
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon
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