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J Thorac Cardiovasc Surg 2008;136:1394-1395
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor:

David M. Shahian, MD

Department of Surgery and Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass

Sharon-Lise T. Normand, PhD

Department of Health Care Policy, Harvard Medical School, Boston, Mass
Department of Biostatistics, Harvard School of Public Health, Massachusetts General Hospital, Boston, Mass

Dr Al-Ebrahim's Letter to the Editor reinforces an important concept from our article. The fact that some lower-volume cardiac surgery programs have achieved excellent results should not be viewed as a general endorsement for developing more such programs. The justification for any new cardiac surgery program must be critically evaluated, including the adequacy of resources and referral base.

Ideally, such new programs are developed to serve populations who have no other local or regional access to cardiac surgery. To be successful, smaller cardiac surgery programs must be provided with the substantial hospital resources necessary to care for these complex patients. They should also be encouraged to use the strategies mentioned in our commentary to help compensate for their smaller volumes.

The scenario described by Dr Al-Ebrahim is quite different and certainly undesirable—the regional proliferation of small cardiac surgery programs without adequate justification, planning, resources, or infrastructure. Whatever the initial motivation, the development of numerous small units in close proximity makes little sense from a health planning perspective. Regional cardiac centers shared by multiple institutions would seem to be a more rational approach.





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