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J Thorac Cardiovasc Surg 2002;123:8-15
© 2002 The American Association for Thoracic Surgery
Statics for the Rest of Us |
From the Departments of Thoracic and Cardiovascular Surgery and Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio.
Received for publication Dec 13, 2000. Accepted for publication July 31, 2001. Address for reprints: Eugene H. Blackstone, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195 (E-mail: blackse@ccf.org).
Mitral valve repair versus replacement, internal thoracic artery versus saphenous vein graft conduits for coronary bypass, effect of chronic preoperative atrial fibrillation on outcome, gastric versus colon esophageal substitutes, complete versus incomplete off-pump revascularization, surgery in high- versus low-volume centers, balloon versus surgical aortic valvotomy. These are but a sample of studies of comparative outcome whose basis was clinical experience rather than a formal clinical trial. Often, a cursory glance at patient characteristics in each group reveals important differences that lead medical and statistical reviewers and readers alike to scoff, "They're comparing ‘apples and oranges!'"
What does it take to convince the skeptic that the difference in outcome attributed to difference in treatment (or patient condition) is real? The answer to this question is not academic; it can affect the way we as physicians learn to treat our patients from studies of clinical experience.
When comparison is made in the context of a properly designed, appropriate, ethical, feasible, well-analyzed, generalizable randomized trial, most of us would accept a cause-and-effect linkage between treatment and difference in outcome. In contrast, when the comparison emanates from studies of clinical experience—ubiquitous in surgical experience and reporting—cause-and-effect attribution is considered "speculative" at best.
For 3 decades, multivariable risk factor analysis has been the mainstay for identifying and quantifying treatment outcome differences adjusted for patient characteristics. However, Kirklin and Barratt-Boyes
1 recommended that these differences be treated as associations with outcomes, not causes. There is no guarantee that risk factor analysis is an effective strategy for discovery of cause-and-effect mechanisms. 2,3
During the 1980s, federal support for complex clinical trials in heart disease was abundant. Few of us noticed important advances being made in statistical methods for valid, nonrandomized comparisons. An example of the advances was the seminal 1983 Biometrika article by Paul Rosenbaum at the University of
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A. Miceli, C. Fino, B. Fiorani, M. Yeatman, P. Narayan, G. D. Angelini, and M. Caputo Effects of Preoperative Statin Treatment on the Incidence of Postoperative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting Ann. Thorac. Surg., June 1, 2009; 87(6): 1853 - 1858. [Abstract] [Full Text] [PDF]
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S. Subramanian, J. F. Sabik III, P. L. Houghtaling, E. R. Nowicki, E. H. Blackstone, and B. W. Lytle Decision-Making for Patients With Patent Left Internal Thoracic Artery Grafts to Left Anterior Descending Ann. Thorac. Surg., May 1, 2009; 87(5): 1392 - 1400. [Abstract] [Full Text] [PDF]
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J. H. Khan, E. A. Davis, L. S. Dean, M. J. Huff, N. Y. Khan, and A. Rehman The Role of Elective Perioperative Dialysis in Nondialysis Renal Failure Patients Ann. Thorac. Surg., April 1, 2009; 87(4): 1085 - 1089. [Abstract] [Full Text] [PDF]
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J Mascherbauer and H Baumgartner The authors' reply: Heart, April 1, 2009; 95(7): 592 - 593. [Full Text] [PDF]
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P. K. Mishra, R. Pandey, M. J. Shackcloth, J. McShane, A. D. Grayson, M. H. Carr, and R. D. Page Cardiac comorbidity is not a risk factor for mortality and morbidity following surgery for primary non-small cell lung cancer Eur J Cardiothorac Surg, March 1, 2009; 35(3): 439 - 443. [Abstract] [Full Text] [PDF]
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A. Zacharias, T. A. Schwann, C. J. Riordan, S. J. Durham, A. S. Shah, and R. H. Habib Late Results of Conventional Versus All-Arterial Revascularization Based on Internal Thoracic and Radial Artery Grafting Ann. Thorac. Surg., January 1, 2009; 87(1): 19 - 26. [Abstract] [Full Text] [PDF]
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R. J. Moraca, M. R. Moon, J. S. Lawton, T. J. Guthrie, K. A. Aubuchon, N. Moazami, M. K. Pasque, and R. J. Damiano Jr Outcomes of Tricuspid Valve Repair and Replacement: A Propensity Analysis Ann. Thorac. Surg., January 1, 2009; 87(1): 83 - 89. [Abstract] [Full Text] [PDF]
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A. Szekely, Z. Cserep, E. Sapi, T. Breuer, C. A. Nagy, P. Vargha, I. Hartyanszky, A. Szatmari, and A. Treszl Risks and Predictors of Blood Transfusion in Pediatric Patients Undergoing Open Heart Operations Ann. Thorac. Surg., January 1, 2009; 87(1): 187 - 197. [Abstract] [Full Text] [PDF]
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 D. H. Kwon, C. M. Halley, T. P. Carrigan, V. Zysek, Z. B. Popovic, R. Setser, P. Schoenhagen, R. C. Starling, S. D. Flamm, and M. Y. Desai Extent of left ventricular scar predicts outcomes in ischemic cardiomyopathy patients with significantly reduced systolic function: a delayed hyperenhancement cardiac magnetic resonance study. J. Am. Coll. Cardiol. Img., January 1, 2009; 2(1): 34 - 44. [Abstract] [Full Text] [PDF]
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 P. Agostoni, L. Testa, and G. G.L. Biondi-Zoccai Comment on 'Comparison of operator radiation exposure with optimized radiation protection devices during coronary angiograms and ad hoc percutaneous coronary interventions by radial and femoral routes' Eur. Heart J., November 2, 2008; 29(22): 2820 - 2821. [Full Text] [PDF]
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 T. Warwick, M. Kali, W. Carter, K. Lucas, S. Masood, R. Dawli, M. Broce, and B. Reyes Effect of Neurology Consults on Outcomes for Patients Suffering Transient Ischemic Attacks After Coronary Artery Bypass Grafting American Journal of Medical Quality, November 1, 2008; 23(6): 457 - 464. [Abstract] [PDF]
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J. D. Puskas, P. D. Kilgo, O. M. Lattouf, V. H. Thourani, W. A. Cooper, T. A. Vassiliades, E. P. Chen, J. D. Vega, and R. A. Guyton Off-Pump Coronary Bypass Provides Reduced Mortality and Morbidity and Equivalent 10-Year Survival Ann. Thorac. Surg., October 1, 2008; 86(4): 1139 - 1146. [Abstract] [Full Text] [PDF]
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U. Benedetto, S. Sciarretta, A. Roscitano, B. Fiorani, S. Refice, E. Angeloni, and R. Sinatra Preoperative Angiotensin-Converting Enzyme Inhibitors and Acute Kidney Injury After Coronary Artery Bypass Grafting Ann. Thorac. Surg., October 1, 2008; 86(4): 1160 - 1165. [Abstract] [Full Text] [PDF]
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D. P. Mason, L. Thuita, J. M. Alster, S. C. Murthy, M. M. Budev, A. C. Mehta, G. B. Pettersson, and E. H. Blackstone Should lung transplantation be performed using donation after cardiac death? The United States experience. J. Thorac. Cardiovasc. Surg., October 1, 2008; 136(4): 1061 - 1066. [Abstract] [Full Text] [PDF]
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A. Kourliouros, N. Roberts, and M. Jahangiri Statins with equivalent lipid-lowering capacity exhibit differential effects on atrial fibrillation after cardiac surgery. J. Thorac. Cardiovasc. Surg., October 1, 2008; 136(4): 1100 - 1101. [Full Text] [PDF]
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J. F. Sabik III, A. Stockins, E. R. Nowicki, E. H. Blackstone, P. L. Houghtaling, B. W. Lytle, and F. D. Loop Does Location of the Second Internal Thoracic Artery Graft Influence Outcome of Coronary Artery Bypass Grafting? Circulation, September 30, 2008; 118(14_suppl_1): S210 - S215. [Abstract] [Full Text] [PDF]
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 P. C. Austin Primer on Statistical Interpretation or Methods Report Card on Propensity-Score Matching in the Cardiology Literature From 2004 to 2006: A Systematic Review Circ Cardiovasc Qual Outcomes, September 1, 2008; 1(1): 62 - 67. [Abstract] [Full Text] [PDF]
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F. Shikata, T. Yagihara, K. Kagisaki, I. Hagino, S. Shiraishi, J. Kobayashi, and S. Kitamura Does the off-pump Fontan procedure ameliorate the volume and duration of pleural and peritoneal effusions? Eur J Cardiothorac Surg, September 1, 2008; 34(3): 570 - 575. [Abstract] [Full Text] [PDF]
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M. E. Halkos, J. D. Puskas, O. M. Lattouf, P. Kilgo, R. A. Guyton, and V. H. Thourani Impact of Preoperative Neurologic Events on Outcomes After Coronary Artery Bypass Grafting Ann. Thorac. Surg., August 1, 2008; 86(2): 504 - 510. [Abstract] [Full Text] [PDF]
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K. P. Savonen, V. Kiviniemi, J. A. Laukkanen, T. A. Lakka, T. H. Rauramaa, J. T. Salonen, and R. Rauramaa Chronotropic incompetence and mortality in middle-aged men with known or suspected coronary heart disease Eur. Heart J., August 1, 2008; 29(15): 1896 - 1902. [Abstract] [Full Text] [PDF]
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 J.-C. Roze, S. Denizot, R. Carbajal, P.-Y. Ancel, M. Kaminski, C. Arnaud, P. Truffert, S. Marret, J. Matis, G. Thiriez, et al. Prolonged Sedation and/or Analgesia and 5-Year Neurodevelopment Outcome in Very Preterm Infants: Results From the EPIPAGE Cohort Arch Pediatr Adolesc Med, August 1, 2008; 162(8): 728 - 733. [Abstract] [Full Text] [PDF]
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R. S. Khalafi, D. W. Bradford, and M. G. Wilson Topical application of autologous blood products during surgical closure following a coronary artery bypass graft Eur J Cardiothorac Surg, August 1, 2008; 34(2): 360 - 364. [Abstract] [Full Text] [PDF]
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B. F. Meyers, P. K. Sultan, T. J. Guthrie, S. S. Lefrak, G. E. Davis, G. A. Patterson, J. D. Cooper, and R. D. Yusen Outcomes After Unilateral Lung Volume Reduction Ann. Thorac. Surg., July 1, 2008; 86(1): 204 - 212. [Abstract] [Full Text] [PDF]
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N. F. Mamoun, M. Xu, D. I. Sessler, J. F. Sabik, and C. A. Bashour Propensity Matched Comparison of Outcomes in Older and Younger Patients After Coronary Artery Bypass Graft Surgery Ann. Thorac. Surg., June 1, 2008; 85(6): 1974 - 1979. [Abstract] [Full Text] [PDF]
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A. J. White, G. Kedia, J. M. Mirocha, M. S. Lee, J. S. Forrester, W. C. Morales, S. Dohad, S. Kar, L. S. Czer, G. P. Fontana, et al. Comparison of Coronary Artery Bypass Surgery and Percutaneous Drug-Eluting Stent Implantation for Treatment of Left Main Coronary Artery Stenosis J. Am. Coll. Cardiol. Intv., June 1, 2008; 1(3): 236 - 245. [Abstract] [Full Text] [PDF]
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 Y.-Y. Chen, A. F. Connors Jr, and A. Garland Effect of Decisions to Withhold Life Support on Prolonged Survival Chest, June 1, 2008; 133(6): 1312 - 1318. [Abstract] [Full Text] [PDF]
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A. M. Gillinov, E. H. Blackstone, E. R. Nowicki, W. Slisatkorn, G. Al-Dossari, D. R. Johnston, K. M. George, P. L. Houghtaling, B. Griffin, J. F. Sabik III, et al. Valve repair versus valve replacement for degenerative mitral valve disease. J. Thorac. Cardiovasc. Surg., April 1, 2008; 135(4): 885 - 893.e2. [Abstract] [Full Text] [PDF]
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H. Kamiya, K. Kallenbach, A. Haverich, and M. Karck Reply to the Editor J. Thorac. Cardiovasc. Surg., March 1, 2008; 135(3): 714 - 714. [Full Text] [PDF]
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J. A.C. Ennker, A. A. Albert, U. P. Rosendahl, I. C. Ennker, F. Dalladaku, and I. Florath Ten-Year Experience With Stentless Aortic Valves: Full-Root Versus Subcoronary Implantation Ann. Thorac. Surg., February 1, 2008; 85(2): 445 - 453. [Abstract] [Full Text] [PDF]
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E. E. Roselli, G. B. Pettersson, E. H. Blackstone, M. E. Brizzio, P. L. Houghtaling, R. Hauck, J. M. Burke, and B. W. Lytle Adverse events during reoperative cardiac surgery: Frequency, characterization, and rescue J. Thorac. Cardiovasc. Surg., February 1, 2008; 135(2): 316 - 323. [Abstract] [Full Text] [PDF]
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J. C. Y. Lu, M. Shaw, A. D. Grayson, M. Poullis, M. Pullan, and B. M. Fabri Do beating heart techniques applied to combined valve and graft operations reduce myocardial damage? Interact CardioVasc Thorac Surg, February 1, 2008; 7(1): 111 - 115. [Abstract] [Full Text] [PDF]
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H. A. Vohra, T. Bahrami, S. Farid, A. Mafi, G. Dreyfus, M. Amrani, and J. A. R. Gaer Propensity score analysis of early and late outcome after redo off-pump and on-pump coronary artery bypass grafting Eur J Cardiothorac Surg, February 1, 2008; 33(2): 209 - 214. [Abstract] [Full Text] [PDF]
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O. M. Lattouf, J. D. Puskas, V. H. Thourani, J. Noora, P. D. Kilgo, and R. A. Guyton Does the Number of Grafts Influence Surgeon Choice and Patient Benefit of Off-Pump Over Conventional On-Pump Coronary Artery Revascularization in Multivessel Coronary Artery Disease? Ann. Thorac. Surg., November 1, 2007; 84(5): 1485 - 1495. [Abstract] [Full Text] [PDF]
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