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Eur J Cardiothorac Surg 1999;16:593-601
© 1999 Elsevier Science NL
Presidential address |
Royal Infirmary, Department of Cardiac Surgery, 10 Alexandra Parade, Glasgow, Scotland G31 2ER, UK
Tel.: +44-141-211-4730; fax: +44-141-552-0987
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1. Introduction |
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 Top 1. Introduction 2. Costs and resources3. The future role...4. Political, media and...5. Staying up to...6. Maintaining academic activityReferences |
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European political developments affect the lives of us all and also have an impact on our profession. Many of the ideals underlying European political change have parallels in our Association and offer the prospect of great benefit for cardiothoracic surgery.
Europe is characterised by remarkable diversity. The continent encompasses a wide range of landscapes and climate, nationalities and cultures, economies and political structures. Much of Europe's turbulent history of conflict has been shaped by this diversity, but so, too, has its intellectual and cultural legacy. Music, art, literature, science and medicine have all flourished in Europe since the Renaissance, often at times of great political and social upheaval, and always with contributions from a wide variety of cultures and individuals.
In the second half of this century we have witnessed considerable progress in European economic and political integration. The European Coal and Steel Community, which came into existence in 1952, put the two most economically and strategically vital industries of the time, of France, West Germany, Italy, Belgium, The Netherlands and Luxembourg under a single authority. With security concerns devolved to NATO, and political conformity enforced by the cold war, economic recovery flourished and European integration progressed.
In 1957 the Treaty of Rome established the European Economic Community and allowed creation of a common market with abolition of internal tariffs. In 1991 the Maastricht Treaty brought the European Union into existence. Though post cold war re-emergent nationalism, political mismanagement, and cumbersome bureaucracy are threats, the ‘ever closer union among the peoples of Europe’ envisaged in the preamble to the Treaty of Rome is now a reality, with direct relevance to us all and to our profession.
The second half of this century has also seen spectacular development in cardiothoracic surgery. The recent death of Dr C. Walton Lillehei, whose work on cross circulation in the early 1950s did so much for the introduction of successful open heart surgery, and who continued to contribute throughout his life to technological advance in cardiac surgery, is a reminder of this development and its time-scale [1]. As a profession we are fortunate in having been able to use our knowledge, dexterity, and ingenuity, together with modern technology, to have a major, favourable impact on some of the most widespread and serious diseases of mankind. Few manifestations of heart disease are now outside the scope of surgical intervention; coronary bypass has become one of the commonest operations of all time, and surgical resection offers virtually the only prospect of cure for lung cancer.
However, at the turn of the century, our profession is facing a number of changes and challenges, which transcend national boundaries and health care systems. These include the gathering pace of technological and medical progress, changes in the manifestations of disease, new options for prevention and treatment, economic, political and social forces, and the increasing impact of regulation and legislation.
The European Association for Cardio-thoracic Surgery was established in 1986 with many of the same ideals that underpinned European political integration, bringing together cardiothoracic surgeons from diverse backgrounds in Europe for the greater good. Its objectives are to ‘advance education in the field of cardio-thoracic surgery’ and to ‘promote, for the public benefit, research into thoracic physiology, pathology and therapy’ and to ‘correlate and disseminate the useful results thereof’.
The vision and initiative of our founders (Fig. 1) have been rewarded by the rapid growth of the Association and the success of its annual meeting and its journal. I believe that the changes and challenges faced by our profession provide our Association with an excellent opportunity to channel and co-ordinate the talents of our diverse membership into effective responses which will improve our professional life, further the speciality, and benefit our patients. The diversity, wide background, and numbers of our membership, give us manpower, expertise and critical mass which individual national societies could not match. Our Association is also large enough to speak with a unified voice for us all in European political and regulatory affairs relevant to cardiothoracic surgery. Some initiatives are already underway in our speciality, as for example, the European Board of Thoracic and Cardiovascular Surgeons examinations, but more can, and should, be done.
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2. Costs and resources |
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Top1. Introduction2. Costs and resources3. The future role...4. Political, media and...5. Staying up to...6. Maintaining academic activityReferences |
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Cost alone ensures that provision of health care is a political issue, particularly in Europe, where more socialist style government prevails. Just how difficult an issue this is, was recently brought home by the hail of protest evoked by the provocative question raised by the President of the German Physicians’ Association1.
The level of public and media attention to health care costs and the provision of health care is exemplified by information published on 11 July 1999 in The Sunday Times, one of the biggest national newspapers in the UK (Fig. 2). Total health care expenditure as a percentage of Gross Domestic Product (GDP), and the number of practising doctors per 1000 of population was reported. Thus, for France, 9.9% of GDP is spent on health care, and there are 2.9 doctors for every 1000 population. For the countries of Europe, expenditure on health care ranges from 6.7 to 10.4% of GDP, and number of doctors per 1000 population ranges from 1.6 to 5.3. Though exceeded by the United States, which spends 14% of GDP on health care, Europe's expenditure on health care places us among the best provided in the world. The information was used in this case to bolster claims of inadequate health care provision in the UK, but it also makes obvious the point that health care funding and practice is very much a public and political issue. In spite of unprecedented budgets, demand for health care expenditure continues to exceed provision, and cost containment is at the forefront of health care policy of all countries.
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Cost containment and ways to achieve it are familiar topics for all health care management organisations. Many new technologies will help with cost containment if applied correctly. For example, improved tumour staging now made possible by better imaging techniques, should minimise non-curative surgery for lung cancer. Beating heart surgery may reduce costs associated with cardiopulmonary bypass. Our Honoured Guest at the 10th EACTS meeting in 1996, Dr David Skinner, showed how organisational changes in cardiothoracic surgical practice could enhance efficiency and respond effectively to economic pressures, based on his experience in New York [2].
However, cost containment can only go so far. It is essential that we are able to justify our costs and continue to offer a valued ‘product’ by demonstrating that expenditure results in worthwhile outcome. At present many of us are concentrating on immediate outcome as this is easiest to do. But, most of our surgery is concerned with long-term symptom relief, impact on quality of life, and survival benefit. One has only to consider the long delay before the superiority of the internal mammary artery as a coronary bypass conduit was demonstrated to see how difficult it will be to relate longer term outcome to the newly evolving techniques.
We will always have to compete for health care resources. The only way to do this will be by demonstrating favourable long term outcome, superior to that of alternative management options, in convincing, scientifically sound ways. In Europe, we are particularly well placed to exploit multi-centre trials for recruiting adequate patient numbers with minimal delay, as a method of objectively evaluating new techniques. The use of randomised trials for evaluation of new devices and techniques has the best prospect of giving unbiased information in an acceptable scientific fashion.
An example of randomised evaluation of new technology is the Medical Research Council funded trial of transmyocardial laser revascularisation (TMLR) undertaken in Cambridge [3]. Twenty-five percent of TMLR patients had improved by at least two angina classes at 12 months but, taking into account the clinically unimportant functional improvement and the overall costs, the authors concluded that the adoption of TMLR could not be advocated. Far more confidence can be placed in the conclusions of such a study than is possible for isolated, uncontrolled series reported by enthusiasts.
Randomised trials do not always come up with the same conclusions. In the case of transmyocardial laser revascularisation, a more recently reported randomised trial from Houston [4] showed good improvement in angina class and functional status at 12 months, and the authors have advocated the technique as effective therapy for advanced cardiac patients who lack alternatives. Further trials of this nature will define the role for new technologies such as this better than any uncontrolled study.
My personal experience with introducing a new pericardial heart valve prosthesis (which was a product of my laboratory's development) in a randomised fashion, now allows us unbiased comparison with a well established valve for over 11 years of follow-up. It shows performance comparable to the Carpentier–Edwards prosthesis for valve related death and morbidity. This will surely be a rewarding strategy for introduction and acceptance of new devices in the future.
Similarly, a randomised trial in which I participated, [5] comparing a mechanical valve to a porcine bioprosthesis, is about to be reported for a 20-year follow-up, with useful lessons for current clinical practice given added authority as a result of objective randomised assessment. Survival without major event was significantly better for aortic valve than for mitral valve with both valve types, and for single mitral valve replacement it was better with the mechanical valve. I believe that this type of evaluation will increasingly come to be demanded of us and will become an important way of attracting health care resources.
The need for accurate information about the practice of cardiothoracic surgery in Europe is crucial, and the work of our EACTS database committee in establishing the European Cardiac Surgical Registry, [6] with a Thoracic Surgical Registry to follow, is of vital importance. Efforts being made to develop risk stratification for European patients are to be encouraged as a means of more fairly showing our outcomes and justifying our costs. Initiatives to implement detailed documentation of outcomes such as the UK National Adult Cardiac Surgical Database should be supported. National societies and professional bodies can certainly have an important role, but pooling information, resources and know-how through EACTS would be more efficient and generally applicable.
Thus, cost containment, though important, has limitations. We will always have to justify costs. Accurate documentation of our activity and scientifically acceptable demonstration of good, long term benefit, to show cardiothoracic surgery as having a valued role, has to be our best response for competing for available funding.
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3. The future role for our speciality |
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Top1. Introduction2. Costs and resources3. The future role...4. Political, media and...5. Staying up to...6. Maintaining academic activityReferences |
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The diversity of European life extends to its diseases, creating great interest for epidemiologists and giving lessons for us all. Coronary disease is a good example. There is a difference in mortality from coronary disease between the warmer Mediterranean and the colder northern European countries, and an even more striking difference between western Europe and the newly independent states and countries of central and eastern Europe [7].
The World Health Organisation Monica Project has more recently reported on coronary event rates in selected centres world-wide, where strict criteria could be applied to classification of events [8]. The mean annual number of coronary events, fatal and non-fatal, in men aged 35–64 years, ranged from 835 per 100 000 males in North Karelia, Finland, through 777 for Glasgow and 695 for Belfast, showing reduction moving south through Europe into Southern France, with the lowest number of 210 in Catalonia (Fig. 3).
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Risk factor reduction was achieved, and has been accompanied by an impressive 72% fall in coronary mortality from the pre-project period to the last followup in 1995 for the 35–64-year-old male population of North Karelia. Nationwide, the changes have been almost as great with a fall of 64% in coronary mortality.
Cessation of smoking was encouraged as part of life-style change – only 20% of men now smoke in Finland. For the same 35–64-year-old male group the mortality rate from lung cancer, which was 147 per 100 000 population 30 years ago had fallen by 71% in North Karelia, and by 57% nationwide during the study.
Imposition of social change on this scale was not easy, being in conflict with established economic, social and political order, but its success in reducing the prevalence of coronary disease and lung cancer will not be lost on Europe's health care planners, and should not be lost on us.
Less persuasion is needed to impose the medically justifiable belief that regular intake of wine has protective influence on the coronary arteries. A recently reported study from France [10] of 34 000 men aged 40–60 years showed a 35% reduction in cardiovascular mortality over some 10–15 years in those who had a moderate regular wine intake.
The West of Scotland is another part of Europe with a high prevalence of heart disease. Over a 3-year period from 1989, 6595 men aged 45–64 years, without previous myocardial infarction, with a mean plasma cholesterol level of 272 mg/dl (7.0 mmol/l), were randomly allocated to receive either a placebo, or the lipid lowering drug, pravastatin [11]. Over a 6-year follow-up there was a 31% reduction in the combined primary end point of non-fatal myocardial infarction, and death from coronary heart disease. In this ‘intention to treat’ study some 30% were non-compliant.
A subsequent study [12] of those with compliance of 75% or more showed 38% risk reduction for definite coronary heart disease death, or non-fatal myocardial infarction, and a 46% reduction in risk of coronary revascularisation for the pravastatin group. Cholesterol reduction by statins appears to confer plaque stability, and it is possible that this effect is independent of, and additional to the lipid-lowering effect, and may even be greater with different statins.
For some time the prevalence of coronary disease has been falling in North America and much of Western Europe [13]. Already we have experienced an increase in the average age of surgically managed patients which is not just due to increased ability to operate on the elderly with safety, but reflects also the fall in early onset coronary disease manifestations. There is a potential problem arising from current trends in surgical practice, where we are operating on older, sicker, or more complex patients. Results will not be impressive if advanced age and co-morbidity detract from quality and quantity of life after surgery. The ability to operate should not be equated with the need to operate and we will have to be careful not to find ourselves excusing disappointing results on the basis of age and co-morbidity.
There is no need to emphasise to the cardiac surgeon the increasing success of interventional cardiology, with thrombolysis, angioplasty and stenting, in particular, having established a major, and often alternative role to surgery. Changes in disease presentation, preventative measures and alternative treatments are not confined to coronary disease. Examples such as rheumatic valvular heart disease, bronchiectasis and gastro-oesophageal reflux could all be used to illustrate recent changes in the role for cardiothoracic surgery. Increasing medical knowledge will ensure that we will face continued challenges over our role from competing management options.
Lest anyone think that cardiothoracic surgery will become superfluous in the near future, the continuing rise in open heart surgery and coronary bypass procedures in the United States over a recent 17-year period will be reassuring. Three hundred and sixty seven thousand patients were estimated to have had coronary surgery in 1996 in the USA, in spite of the growing practice of coronary angioplasty during the latter 10 years [14].
A similar trend in coronary surgery in the United Kingdom, as well as the constant demand for valvular heart surgery and congenital heart surgery, has been documented, and the demand for thoracic surgery remains steady.
The alarming rise in coronary disease in Eastern Europe and the continued efforts of the tobacco industry, will surely provide work for cardiothoracic surgeons for some time to come. World-wide mortality from tobacco is estimated by the World Health Organisation to be likely to rise from 4 million deaths per year in 1998 to about 10 million a year in 2030 – half in the 35–69 year age group [15].
We welcome favourable changes in disease patterns in populations, and have a moral requirement to promulgate preventative strategies. Similarly, we must accept and assist with evaluation of alternative treatment strategies as they evolve. We need to work hard to demonstrate and justify the existing role for our speciality, as well as to develop new fields. Scientifically sound information on our practice can be the only effective response in justifying and defending its future role.
Guidelines to clinical practice are increasingly likely to be used to justify practice, to ensure funding, and to mount medico-legal defence when necessary. For some time now, task forces established jointly by the American College of Cardiology and the American Heart Association have produced an impressive number of management guidelines covering many aspects of heart disease, from surgery for coronary disease [16], to coronary angiography [17], and, most recently, management of stable angina [18]. Since then, cardiologists in Europe have followed suit [19], and task forces have been implemented by the European Society of Cardiology which have produced guidelines and recommendations covering many aspects of management of cardiovascular problems.
In the UK the Society of Cardiothoracic Surgeons and the British Thoracic Society have combined resources to produce authoritative and helpful guidelines for the diagnosis, staging and further management of patients with lung cancer.
The Scottish Intercollegiate Guidelines Network has been helpful in attracting further resources for coronary surgery, demonstrating as they did, that our practice has a good evidence-linked base, and that calls for more resources are justified [20].
The time and work involved in establishing guidelines for our clinical practice are such that it would be best undertaken by an organisation such as ours in collaboration with other professional groups.
In addition to defining and justifying our existing role, the development of new fields will be essential for guaranteeing a secure future role for us. The scope of cardiothoracic surgery has widened spectacularly in the past 50 years – transplantation, possibly xenotransplantation, long-term artificial assistance for the heart or lungs, lung reduction surgery and minimal access surgery were difficult to foresee, and are only some examples of surgical ingenuity which seem likely to ensure a promising and continuing surgical future for us.
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4. Political, media and social pressures |
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Top1. Introduction2. Costs and resources3. The future role...4. Political, media and...5. Staying up to...6. Maintaining academic activityReferences |
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In Britain, our speciality has been cast in a particularly unfavourable light as a result of the very public allegations of inadequacies in clinical management of paediatric cardiac surgery in Bristol. A public enquiry is currently in progress, reported verbatim on the internet. Details of practice, including maintenance of clinical records, and the role of professional organisations in assessing and comparing standards of outcome, are being probed.
From Germany comes another example of our speciality being scrutinised in a very public and damaging way, including regular reports on the internet. The so-called ‘German heart valve scandal’ involves an allegation that the high cost of heart valve prostheses in Germany was a result of improper financial support given to individual surgeons by valve companies. The manner and scope of the investigation of individual surgeons has come as an unpleasant shock, and the final outcome is still awaited. In common with the Bristol enquiry, this investigation is likely to be a long, drawn-out affair, benefiting no-one other than the lawyers.
In a wider setting, there is now very ready access to medical information on the internet, and the level of sophistication and knowledge of many patients is changing rapidly. Although we may not always feel comfortable with what is reported on the internet – and I have shown instances portraying the medical profession unfavourably – its opportunities should be grasped. The internet can be a useful resource for doctors and patients alike.
There is a move in medicine to require an ‘evidence base’ for all clinical practice. The undeniable logic of underpinning clinical decisions with the best available evidence has been avidly taken up by Government in Britain, and two new statutory bodies have come into existence with ‘evidence based medicine’ as their common creed. The National Institute for Clinical Excellence will define ‘best practice’ across medicine, and the Commission for Health Improvement will ensure that ‘best practice’ is applied nationwide. The General Medical Council, reacting to the Bristol affair, in line with public and media pressures, is defining mechanisms for revalidation of all doctors on a regular basis throughout their careers in order to demonstrate their continuing fitness to practice.
Within the regulatory context of the European Union, medically relevant legislation which directly affects our speciality includes the need for CE marking of medical products - the equivalent of the FDA in America, the right of unrestricted movement of doctors for employment within Europe, recognition of medical qualifications of member countries, and legislation restricting hours of work for junior doctors.
The only defence against pressures to demonstrate our competence and effectiveness is to keep at the forefront of knowledge and techniques – not just in our own speciality, but also in such related fields as cardiology, respiratory medicine and oncology – and also to show that we are applying this knowledge and competence appropriately. Adherence to clinical guidelines will be one way of demonstrating appropriate application, and will aid (or censure) individual surgeons when called on to defend their own practice.
We must also encourage critical review of our practice. The Society of Cardiothoracic Surgeons of Great Britain and Ireland has taken tentative steps in this direction by requiring simple mortality data for common procedures from each practising cardiothoracic surgeon [21]. This at least gives our profession the opportunity of identifying potential poor performance and taking early action, as well as deflecting some of the criticism to which we have been vulnerable. There are mechanisms in place in other countries which have the same aim of ensuring good practice. With robust methods to ensure continuing education and assessment we would have nothing to fear from recertification or revalidation, should this become a reality.
European legislation will provide challenges and opportunities. The restriction on hours of work for junior doctors is a particular concern in a speciality such as ours, and will require imaginative solutions if we are not to leave our trainees disadvantaged. The ability to have direct input into the licensing of medical products by taking part in clinical trials and evaluation of devices will be another opportunity for us, particularly if we can respond as a broad-based expert European group.
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5. Staying up to date in our work |
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Top1. Introduction2. Costs and resources3. The future role...4. Political, media and...5. Staying up to...6. Maintaining academic activityReferences |
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Professional bodies in many countries have recognised this problem and the requirement for showing evidence of Continuing Medical Education is common to established or proposed recertification mechanisms. This is a field in which EACTS could well expand its activities.
Our Association is developing post-graduate teaching allied to the annual meeting, and the European Journal is a further method of dissemination of knowledge. We must do more to help surgeons to stay well educated. In my opinion, this will be best achieved by building on the widespread computer literacy of our young surgeons and using Information Technology together with teaching, training and instructional presentations aimed at surgeons and produced by surgeons. The collaborative efforts of our own and our sister American societies in bringing the CTSNet to all, and in encouraging awareness of Information Technology, show us the way. The publicity opportunity available via CTSNet for advertising teaching or training courses is yet another way of ensuring awareness of educational opportunities.
I have advocated the use of clinical guidelines for justifying costs, defining our role and insulating us from criticism about practice. Familiarity with well constructed guidelines would also be a very good way for clinicians to stay up to date. EACTS must surely become involved in production of such guidelines in the future.
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6. Maintaining academic activity |
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Top1. Introduction2. Costs and resources3. The future role...4. Political, media and...5. Staying up to...6. Maintaining academic activityReferences |
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A recent policy brief from the Organisation for Economic Co-operation and Development [22], in reflecting on the wider field of science and technology, expresses two opinions which apply equally to cardiothoracic surgery. ‘Knowledge will increasingly be the main source of competitive advantage, wealth creation and improvement in quality of life’ – which sums up the need for academic activity – and ‘The apparent lack of interest among young people in scientific research raises concerns about a future shortage of scientists’ – which sums up the fears for its future.
My experiences within our Association, and my visits to North America give me great encouragement that academic activity is still valued in our speciality and that many are making great efforts, though the pressures are very real. I know that we are not alone in the UK in finding it very difficult to recruit academic surgeons in our speciality.
The need to encourage an academic environment within our speciality is essential for its continued development. Our senior surgeons must be encouraged and given the time and resources to pass on their experience to young surgeons. My own observations of Dr Norman Shumway, both in his training role on the other side of the operating table from his residents, and in integrating high quality research into clinical transplant practice, is an example which should be emulated. Many of the educational activities of EACTS will help to stimulate curiosity in our young surgeons, and the opportunities that our increasing European integration offers for medical manpower movement should help us to ensure exposure of our brightest trainees to the best academic surgical centres in Europe. There is no doubt in my mind that early exposure of young surgeons to an academic background, and inspiration from academic leaders, before the pressures of routine clinical activities take hold, are the best ways of ensuring a sound academic future.
The rapid advances which are occurring in the basic sciences make it impossible for most of us to keep pace, but these advances must be harnessed to clinical problems for our patients to benefit. Hence the need for multidisciplinary research groups.
My own research concerns development of novel heart valve prostheses. Our goal of a biostable, durable and non-thrombogenic valve prosthesis seems achievable, but only as a result of our collaboration with design and mechanical engineers, polymer chemists and material scientists, physicists and academic surgeons (Fig. 4). This collaboration promises real advances which small groups working in isolation would be unlikely to achieve. Demonstration of such collaboration is very often an essential requirement for obtaining the necessary research and development funding which is available within Europe, as well as attracting industrial partners.
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In summary, I have identified a number of issues and problems which confront our speciality. I have suggested responses to these issues, and these responses have a common theme. They each require us to have a sound knowledge of the scientific basis of our speciality, an open, transparent, evidence-based practice, with documentation of outcome and critical review of our practice. These requirements already partly coincide with the stated aims of our Association. We are now at a stage in the evolution of EACTS where it is appropriate to expand its role, in a European setting, for our future benefit. I hope that in this address I have outlined a blueprint for this role.
The practice of medicine should essentially be about helping and caring for individual patients and their families to the best of our ability. No doubt most of us have had similarly encouraging letters, and these extracts from a letter from the daughter of a recently deceased former patient of mine, operated on 21 years ago, captures for me the real reward of our work. This is a privileged speciality in a privileged profession.
Cardiothoracic surgery offers some of the most effective interventions known to medicine for common diseases, and has seen truly spectacular advances in the last half century. Europe offers us the benefits both of diversity and integration; we can use both to our professional advantage, and EACTS has a major role to play. I have no doubt that we can respond well to the pressures on our speciality and I am confident that the next century holds great promise for cardiothoracic surgery.
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Footnotes |
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References |
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Top1. Introduction2. Costs and resources3. The future role...4. Political, media and...5. Staying up to...6. Maintaining academic activityReferences |
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