Improving mortality of coronary surgery
http://www.100md.com
《英国医生杂志》
EDITOR—We dispute that the data presented and conclusions drawn are incompatible or that there is a paradox. We have some specific responses the points raised.
We set out to test the hypothesis that there was improvement in surgeon performance after appointment to independent practice, which was indeed detected by our observations. This was seen on crude mortality but was more noticeable after risk adjustment. We accept that all risk adjustment methods have limitations and acknowledged that in our manuscript. To understand whether "new" surgeons perform as well as older surgeons seems a valid hypothesis to test, and that is why we chose to undertake this comparison by using two groups.
The fact that the mortality seen during the fourth year of practice is lower than that of more established consultants is an interesting finding and one that we cannot answer from our existing studies. It may be down to "true" surgical factors (implying suboptimal performance in some more experienced surgeons) or may be due to limitations of existing risk models.
We agree with Reddy that a need exists for this type of study in non-coronary surgery, but we disagree with his views about alternative techniques of analysis. Whether surgeons operate on-pump or off-pump or use multiple arterial grafts is down to surgical preference. The literature is still not decisive on the benefits of either approach. The hypotheses we were testing were not to look at the influence of these factors, and to correct for them as he suggests would not have helped us to reach clearer conclusions.
Ben Bridgewater, consultant cardiac surgeon
South Manchester University Hospital, Manchester M23 9LT Ben.Bridgewater@smuht.nwest.nhs.uk
Antony D Grayson, regional clinical information analyst
Cardiothoracic Centre, Liverpool L14 3PE
We set out to test the hypothesis that there was improvement in surgeon performance after appointment to independent practice, which was indeed detected by our observations. This was seen on crude mortality but was more noticeable after risk adjustment. We accept that all risk adjustment methods have limitations and acknowledged that in our manuscript. To understand whether "new" surgeons perform as well as older surgeons seems a valid hypothesis to test, and that is why we chose to undertake this comparison by using two groups.
The fact that the mortality seen during the fourth year of practice is lower than that of more established consultants is an interesting finding and one that we cannot answer from our existing studies. It may be down to "true" surgical factors (implying suboptimal performance in some more experienced surgeons) or may be due to limitations of existing risk models.
We agree with Reddy that a need exists for this type of study in non-coronary surgery, but we disagree with his views about alternative techniques of analysis. Whether surgeons operate on-pump or off-pump or use multiple arterial grafts is down to surgical preference. The literature is still not decisive on the benefits of either approach. The hypotheses we were testing were not to look at the influence of these factors, and to correct for them as he suggests would not have helped us to reach clearer conclusions.
Ben Bridgewater, consultant cardiac surgeon
South Manchester University Hospital, Manchester M23 9LT Ben.Bridgewater@smuht.nwest.nhs.uk
Antony D Grayson, regional clinical information analyst
Cardiothoracic Centre, Liverpool L14 3PE