Monday, 4 June 2018

Coronary Bypass and Hemodynamics: the amount matters

In the article "Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain", signed by a Spanish-English team in which Sandra García Armesto (IACS) and Enrique Bernal (REDISSEC) participated, it was concluded that the Spanish hospitals of the study operated in general with a smaller number of cases than the English (it was coronary bypass). Therefore, it is suggested that the number of cases intervened should be a tracer that could explain why mortality from this process is twice as high in Spain as in England.

European Collaboration for Healthcare Optimization (ECHO) is a European network of administrative databases for the analysis of clinical practice variations. In the following article: "Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine Safe Threshold", carried out by almost the same authors as the previous one, based on data from the ECHO project, confirms that for interventions of coronary bypass there is a clear relationship between volume and mortality and concludes that the minimum limit of interventions of a cardiac surgery team, if you want to safeguard the safety of patients, should be 415 per year. In the following graph (from the previous article) it is observed how the Spanish hospitals that participated in the study (dark spots), generally underwent fewer coronary bypasses (many did not reach 200) and showed greater mortalities.

Along the same lines, the following document "Coronary Revascularization in Spain" includes an ECHO report on coronary revascularization in Spain. Observe how in the analysis of coronary angioplasty, which shows this report, repeats the model we had seen for coronary bypass operations. The Spanish hospitals (also in dark) accredited low volumes of activity and many of them had mortalities higher than expected (they are the points that fly over the frame of the CI 99).

As Joan Escarrabill explained in "Do we need bonsai hospitals?" everything indicates that in Spain the key question is not whether there are enough beds, but if there are too many hospitals. Without wanting to enter into such a thorny issue, the data presented indicates that no cardiac surgery team should intervene in less than 415 coronary bypasses per year, and as regards angioplasties, without having specified the figure, in the last chart it is observed how many of the hospitals that have less than a thousand annual processes have difficulties in keeping the number of deaths below the expected figures.

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