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J Thorac Cardiovasc Surg 2005;130:234-235
© 2005 The American Association for Thoracic Surgery
Letters to the Editor |
a Denver Children’s Hospital, University of Colorado, Denver, Colo
b The Congenital Heart Institute of Florida, University of South Florida, Saint Petersburg, Fla
c The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
d St Christopher’s Hospital for Children, University College of Medicine, Philadelphia, Pa
e Institute of Child Health, University College London, London, United Kingdom
f Great Ormond Street Hospital, University College London, London, United Kingdom
g The Children’s Memorial Health Institute, Warsaw, Poland
h Hôpital Necker Enfants Malades, University of Paris, Paris, France
i Children’s Memorial Hospital, Northwestern University, Chicago, Ill
To the Editor:
We read with great interest the reviews on surgical performance in the December 2004 issue of the Journal.
1-4
These publications made clear that any system that intends to measure surgical performance should include a reliable case-mix/risk-adjustment method. New sophisticated statistical algorithms using risk adjustments are flourishing, such as cumulative risk-adjusted mortality (CRAM), risk-adjusted sequential probability ratio test (SPRT), risk-adjusted cumulative sum (CUSUM), and Funnel plots. A statistical model to adjust for case mix is easier to develop in acquired cardiac surgery than in congenital heart surgery (CHS), which deals with 200 diagnoses and 150 procedures
5
with potentially several thousands variations
6
and a volume that is a tenth of that seen with acquired cardiac surgery.
The impossibility for a pediatric heart surgeon to access a "scientific case-mix yardstick" today is quite frustrating. This problem, specific to CHS, is not addressed in these reviews, when at the same time the epicenter of the wave that affected the British cardiothoracic surgery community started at the Bristol Royal Infirmary, precisely in a pediatric cardiac surgery unit. It is reasonable to believe that the effect of the Bristol affair would have been considerably lessened if a congenital case-mix evaluation method had been available.
In light of the tremendous statistical challenge in building objective outcomes data for CHS evaluation, 2 new approaches were recently developed. Jenkins and colleagues
7
have developed a consensus-based risk-adjustment scheme for CHS named RACHS-1. Lacour-Gayet and associates
8
have developed the Aristotle score, a method of complexity adjustment to evaluate surgical results with input from 50 surgical centers from 25 countries. These 2 projects are based on subjective probability and rely on expert opinions.
As surgeons, cardiologists, and morphologists dealing with a challenging specialty, we believe that at present, no reasonable risk-adjustment system exists. The conclusion given by Eugene Blackstone
1
in the Journal’s December 2004 issue was as follows: "Unfortunately, risk adjustment tends to be particularly incomplete when there are rare or multiple measured, unmeasured, or unevaluated risk factors present, so the search for adequate unconfounded quality measures should go on." The crucial question is this: How long can we wait when the insurance companies, the media, and the courts spend their time measuring quality on the basis of totally subjective and potentially false outcome data? Many congenital cardiac surgeons feel responsible for creating a fair and reliable method to evaluate surgical performance applied to centers and individual surgeons.
The Aristotle project, which is necessarily based initially on subjective probability, is under statistical evaluation. We believe that we cannot wait a generation or longer to "let the data speak for themselves"
9
and be finally protected by a fair and reliable evaluation of quality. Our hypothesis is that the surgical-based knowledge involved in the Aristotle project will improve the test characteristics of the statistical models. Whether using subjective probability information combined with objective data will produce better statistical models than using objective information alone is a question that is testable. Our hope is that by combining the surgical-based knowledge obtained from the Aristotle project with objective data and appropriate modern, rigorous statistical theories, we can create a better adjustment tool to assess quality and performance in CHS.
References
This article has been cited by other articles:
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  L. A. Larrazabal, P. J. del Nido, K. J. Jenkins, K. Gauvreau, R. Lacro, S. D. Colan, F. Pigula, O. J. Benavidez, F. Fynn-Thompson, J. E. Mayer Jr, et al. Measurement of Technical Performance in Congenital Heart Surgery: A Pilot Study Ann. Thorac. Surg., January 1, 2007; 83(1): 179 - 184. [Abstract] [Full Text] [PDF]
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 F. Lacour-Gayet Editorial comment: The goal is performance evaluation not outcome prediction Eur. J. Cardiothorac. Surg., June 1, 2006; 29(6): 989 - 990. [Full Text] [PDF]
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