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Eur J Cardiothorac Surg 2004;26:667-670
© 2004 Elsevier Science NL

Is no news good news? Organized follow-up, an absolute necessity for the evaluation of myocardial revascularization

Department of Thoracic and Cardiac Surgery, Heart Center, University Medical Center, St Radboud Nijmegen, 414, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands

Received 25 March 2004; received in revised form 11 May 2004; accepted 19 May 2004.

^* Corresponding author. Tel.: +31-24-361-3733; fax: +31-24-354-0129
e-mail: l.noyez{at}thorax.umcn.nl

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Objective: The objective of this study is to find out whether follow-up information is registered by a non-organized follow-up representative for mortality and morbidity after myocardial revascularization. Methods: The follow-up information registered by an organized (OFU) and a non-organized (NOFU) follow-up method is compared. The organized follow-up consists of an annual survey directly to the patient. The non-organized follow-up contains information provided by cardiologists and general practitioners. 1722 patients undergoing a CABG between 1999 and 2002 were included in this study. Completeness of the follow-up was registered as well as mortality and events, defined as return of angina, myocardial infarction, rhythm disturbances, heart failure, stroke and PTCA. Results: The OFU was 98% complete and the NOFU 51.8% (P<0.05). The NOFU registered only 10 deaths; however, in the OFU another 21 patients who died during the first year postoperative were registered (P<0.05). In the OFU, 137 patients were registered with an event and in the NOFU 53 (P<0.05). In NOFU, the mean was 108±91 days and median was 78 days. Conclusion: OFU improves the completeness of the follow-up, as expected, but informs superior about mortality and events. That in the NOFU, for 50% of the patients, the information is at the most 78 days postoperative old, let us suppose that a lot of early (6 months) postoperative information is even missed by an NOFU. The establishment of an organized follow-up and feedback of mortality and events after myocardial revascularization becomes indispensable.

Key Words: Myocardial revascularization • Survival • Events • Follow-up

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Shortening the length of postoperative stay has been advocated as a means of reducing cost of cardiac surgery. Improvements in preoperative work-up, fast track anesthesia, intensive care and postoperative management resulted in an early discharge after cardiac surgery [1]. Especially after isolated myocardial revascularization (CABG) and this even in an aging patient population with an increasing number of patients with comorbidty [2]. On the other hand, it is known, that in these higher-risk patients, there is a prolongation of the early risk mortality and morbidity after myocardial revascularization [3]. Hospital mortality and morbidity, even 30-day mortality and morbidity, frequently used as endpoints, underestimate the reality. An evaluation over a longer period, at least 6 months is recommended [4,5]. Because follow-up is time- and money-consuming most cardiac surgery centers content themselves with the information returned by cardiologists and general practitioners [4,5].

The intention of this study is to evaluate the difference of information, at 1 year postoperative, provided by a yearly performed follow-up and the information returned by cardiologists and general practitioners.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
2.1. Patients
Between January 1999 and December 2002, 1722 patients underwent an isolated myocardial revascularization at the University Medical Center Nijmegen (UMCN) St Radboud, Nijmegen, The Netherlands. Of the total group, 319 patients (18.5%) were referred by the Department of Cardiology of the UMCN, the other 1403 patients (81.5%) were referred by cardiologists from other hospitals.

Hospital mortality of the entire group was 56/1722 (3.2%). The 1666 discharged patients were included in this study. The mean hospitalization time at the UMCN was 8.2±19.5 days and the median 5 days.

2.2. Methods
All received postoperative correspondence concerning all 1666 patients, was registered and analyzed concerning mortality/survival and events. An event was registered in case of a new myocardial infarction, return of angina, a new positive treadmill test after a negative one, angioplasty, reoperation, heart failure, rhythm disturbances, and stroke. This information was stored as non-organized follow-up (NOFU) information.

The organized follow-up (OFU) consists of a written survey directly to all patients. In this survey several end-points were registered: survival/mortality, heart function using the New York Heart Association classification, quality of life by means of the EuroQol registration [6], hospital readmission and events as in the NOFU. Patients refusing to give information could return the survey indicating that they refuse to participate in this OFU and these patients were also removed from the mailing list. If mortality was reported in the NOFU before the OFU is organized, these patients were of course not included in the OFU.

Where the NOFU starts the moment of discharge of the patient, the OFU is an organized follow-up. Annually all patients receive their survey in the month following the month of their operation.

It must be clear that in this study only the data of the first postoperative year are subject of the analysis.

2.3. Analysis
The characteristics of OFU and NOFU are presented as percentages of the total number of patients included in the follow-up and as mean±SD, median and range for time periods. Differences in percentage were analyzed using the ²-test and with the Wilcoxon rank sum test for the numeric variables. Statistical significance was assumed at P0.05 (P=0.000 means P<0.0005).

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
The results are summarized in Table 1.

3.2. Mortality and events
From the NOFU we registered 10 deaths. During the OFU we additionally registered 21 deaths. The difference between 21/1656 (1.27%) and 10/1666 (0.6%) registered deaths is statistically significant (P=0.039). It must be clear, however, that of the total group of hospital survivors (1666 patients), 31 patients (1.9%) died during their first postoperative year.

During NOFU, 53 patients were registered with at least one non-fatal ischemic event. This is 3.2% (53/1635) of the total number of surviving discharged patients based on the mortality registration during the NOFU and OFU. During OFU, 137 patients, 8.3% (137/1635) mentioned at least one event, which is statistically significant higher than 3.2% in the NOFU (P=0.000).

3.3. Spread of the follow-up information
Fig. 1 presents the spread of registration of the NOFU information (number of patients) in relation to the postoperative days. The NOFU had a mean of 108±91 days (range 7–365), a median of 78 days, a 25% percentile of 24 days, and a 75% percentile of 189 days, postoperative.

View larger version (15K): [in this window] [in a new window]   Fig. 1. Histogram presenting the number of patients registered in the NOFU in relation to the postoperative days.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

In this study, we compared our follow-up information received from NOFU with OFU, as well for quantity (completeness) as for quality (mortality, event, spread). The closing date for follow-up information in this study was 1 year postoperative.

The OFU is a yearly organized follow-up survey directly to the patient, performed in the month following the month of his operation. The reason therefore is that this annual OFU becomes a routine process, not only for the performers, but also for the patients.

Our study shows a statistical significant difference in completeness of the follow-up (98 versus 51%). The NOFU was for 51% complete. This percentage is comparable with our previous registration in 1996 (51%) and 1997 (55%) [5]. Of course the completeness of the NOFU depends on the relationship between surgeon and cardiologist, general practitioners and others. About 80% of our patients referred from other hospitals can be a reason for our low percentage NOFU, and we realize that this can be higher, and also lower in other centers. The OFU has a completeness of 98%, which is very high. It was also remarkable for us, the investigators to know how enthusiastic the response was on our OFU. The small percentage (1%) of patients refusing to complete this survey and the small percentage (2%) of patients noted as lost for follow-up are a proof of this. Moreover, a lot of patients complete this survey with questions concerning their health or even with letters of sympathy.

The difference of reported mortality between the OFU and NOFU reach statistical significance. But important is that we realize that the reported mortality by the NOFU is underestimating the reality. Also for reported events, there is a statistical significant difference between the OFU and the NOFU. The event registration of the NOFU, however, has more guarantee. If a cardiologists report a documented myocardial infarction, or angina there is more certitude than when a patients inform us that he had a new onset of angina. On the other hand, all patients with a reported event in the NOFU and completing the OFU-registration also reported an event. Important is, however, that as well for the mortality as for non-fatal event registration the adage ‘no news is good news’ is not true.

The period of the registration of information in relation to the operative day of the OFU is about 1 year. This is of course a result of our OFU organization. The spreading of the NOFU shows a mean of 108 days and a median of 78 days postoperative. This median means that for 50% of our included patients, the reported information is maximal of 78 days postoperative. This means that for 50% of the patients, the NOFU does not inform us even about the so-called early phase [3]. The 25% percentile indicates that for 25% of the included patients information was not older than 24 days postoperative. Fig. 1 shows clearly that most of the NOFU information is received in the first 2–3 weeks postoperative. Mostly this is so called ‘discharge’-information, reported when patients, discharged from our hospital, to the referring hospital are discharged from this hospital at home.

In conclusion, the present study confirms, as expected, that an OFU is more complete than a NOFU. However, the importance of this study is to prove that the adage ‘no news is good news’, is not acceptable for the evaluation of the results post-CABG.

Cardiac surgeons must realize that a follow-up is necessary for the evaluation of the performed surgery, and that this follow-up is a part of their duty. Cardiologists, general practitioners and others taking part in the medical treatment of these patients must realize how important the information of events and mortality is and see it as a part of their duty to report this back to the cardiac surgeon.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 

1. Loubani M., Mediratta N., Hickey M.S., Galianes M. Early discharge following coronary bypass surgery: is it safe?. Eur J Cardiothorac Surg 2000;18:22-26.[Abstract/Free Full Text]
2. Noyez L., Janssen D.P.B., van Druten J.A.M., Skotnicki S.H., Lacquet L.K. Coronary bypass surgery: what is changing? Analysis of 3834 patients undergoing primary isolated myocardial revascularization. Eur J Cardiothorac Surg 1998;13:365-369.
3. Sergeant P., Blackstone E.H., Meyns B. Validation and interdependence with patient-variables of the influence of procedural variables on early and late survival after CABG. Eur J Cardiothorac Surg 1997;12:1-19.[Abstract]
4. Osswald B.R., Blackstone E.H., Tochtermann U., Thomas G., Vahl C.F., Hagl S. The meaning of early mortality after CABG. Eur J Cardiothorac Surg 1999;15:401-407.
5. Noyez L., Verheugt F.W.A., Peppelenbosch A.G., Skotnicki S.H., Brouwer M.H.J. Aortocoronary bypass surgery: at least six months' follow-up required for assessment of postoperative course. Ned Tijdschr Geneeskd 2000;144:1874-1877.[Medline]
6. Brooks R., EuroQol Group EuroQol: the current state of play. Health Policy 1996;37:53-72.[CrossRef][Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Luc Noyez Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wouters, C. W. Articles by Noyez, L. Search for Related Content PubMed PubMed Citation Articles by Wouters, C. W. Articles by Noyez, L. Related Collections Cardiac - other Coronary disease Professional affairs