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Eur J Cardiothorac Surg 2006;29:858-859
© 2006 Elsevier Science NL

Letter to the Editor

Concerning the Editorial comment by Dr Menicanti

^a National Centre of Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Via Giano della Bella, 34, I-00161 Rome, Italy
^b Department of Epidemiology – ASL RME, Rome, Italy

Received 3 February 2006; accepted 14 February 2006.

^_* Corresponding author. Tel.: +39 06 49904234; fax: +39 06 49904230. (Email: fulvias{at}iss.it).

Key Words: Coronary artery bypass graft • Outcome • Risk-adjustment • Mortality

The editorial comment by Menicanti [1] raises many tough criticisms to our paper [2] which would deserve extensive answers. Unlikely, in this short letter we can focus only on some crucial points.

Control of confounding is the rationale of risk adjustment. A confounder must be associated with the outcome, heterogeneously distributed between exposure categories and should not act as effect modifier or intermediate between exposure and outcome (complications). Risk factors, quoted by Menicanti, are actually included in the risk adjustment model because they are heterogeneously distributed between Centres. Their definitions were those reported by known systems of risk stratification (EuroSCORE, NY) [3,4].

Information has been voluntarily supplied by the surgeons of Centres. Clinical monitoring had been designed to improve quality of information, not to exert a sort of police control on the validity of reporting. We are inclined to deny that Centres were purposely reporting false information. Therefore, data must be considered reliable and their frequency as representing the actual variability.

Prevalence of emergency and cardiogenic shock is consistent to literature (3.8% vs 4.9% and 1.1% vs 1.0%, respectively) [2,3]. The ‘suspected’ too high frequency of diabetes, pulmonary disease, etc. can be explainable. Some conditions show a higher prevalence among elderly populations and males. Among Italian CABG patients, 19.3% are older than 75 and 79.1% are males. In the EuroSCORE population, which dates back to early nineties when the profile of patients undergoing CABG was less severe than nowadays, only 9.6% of patients were over 75 and males were 72.2% [2,3].

The outcome-volume association shows complex patterns, changes over the time and seems not to work for mature health technologies. Mainly southern Italian large volume hospitals show higher mortality after CABG; this observation resists every sensitivity analysis for falsification and deserves clinical auditing and careful investigations.

No scientific evidence supports a given duration of recruitment to be considered for comparison. For large volume hospitals, average estimates for long periods could hide time heterogeneity of outcome. The minimum recruitment period has been defined before the analysis, the cardiac surgeons aiming to include the largest amount of Centres. Obvious limitation is power of comparison. Only one Centre collected data for 6 months consecutively, the other Centres participated for at least 10 months, including summer; mean and median length of data collection was 21 months.

Finally, we did not report identifier of Centres (the objective was different from listing ‘bad’ and ‘good’ hospital!). Menicanti does it. San Donato Cardiac Surgery (n.23 in the website http://bpac.iss.it) shows a RAMR of 4, confirmed in the direct comparison toward the ‘benchmark’ and even using current data from discharge records. Apart from labelling as ‘unreliable’ our work and, consequently, ignoring the excellent work of the large majority of cardiac surgery in Italy, we trust that Centre ‘23’ is trying to understand and remove actual reasons of that poor observed performance. If so, we are confident that in the comparative analysis next year Centre ‘23’ will emerge for a very low mortality rate and we will proudly and, as always, honestly report this excellent performance.

References

1. Menicanti LA. Editorial comment. Eur J Cardiothorac Surg 2006;29(1):63-64.[Free Full Text]
2. Seccareccia F, Perucci CA, D’Errigo P, Arca M, Fusco D, Rosato S, Greco D, On behalf of the Research Group of the Italian CABG Outcomes. The Italian CABG Outcome Study: short-term outcomes in patients with coronary artery bypass graft surgery. Eur J Cardiothorac Surg 2006;29(1):56-62.[Abstract/Free Full Text]
3. Nashef SA, Roques F, Hammill BG, Peterson ED, Michel P, Grover FL, Wyse RKH, Ferguson TB. Validation of European System for cardiac operative risk evaluation (EuroSCORE) in North American cardiac surgery. Eur J Cardiothorac Surg 2002;22:101-105.[Abstract/Free Full Text]
4. New York State Department of Health. Adult cardiac surgery in New York State 2000–2002. Albany, NY: New York State Department of Health; 2004.

This article has been cited by other articles:

				P. D'Errigo, F. Seccareccia, D. Fusco, and C. A. Perucci Re: Editorial comment by Dr Menicanti. Eur. J. Cardiothorac. Surg., August 1, 2008; 34(2): 468 - 469. [Full Text] [PDF]

				L. A. Menicanti Reply to seccareccia et Al. Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 859 - 860. [Full Text] [PDF]

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