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Eur J Cardiothorac Surg 2006;29:859-860
© 2006 Elsevier Science NL
Letter to the Editor |
Centro E. Malan, Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milano, Italy
Received 13 February 2006; accepted 14 February 2006.
* Corresponding author. Tel.: +39 0252774514; fax: +39 0252774327. (Email: menicanti{at}libero.it).
Key Words: Surgery • Coronary artery by-pass graft • Surgical risk • Outcome
The reply of Seccareccia et al. [1] to my editorial comment [2] does neither change the sense of my remarks nor address the concerns I raised.
Dr Seccareccia claims that the risk factors rate is in agreement with the literature, and this is true, of course, for the mean rate.
The problem is the large variation from the mean: cardiogenic shock mean rate was 1.1%, but with a 2300% variation between the lower (0.2%) and the higher (7.2%) single institution reported rates.
Emergency rate was 3.8%, but the variation is about 7000% (from 0.2% to 14%). So the mean rates are in agreement with the literature, but what about institutions quoting 7.2% cardiogenic shock or 14% emergency procedures or 62% unstable angina?
These discrepancies created a dramatic impact on the mortality adjustment.
There is a problem of accordance of definitions.
For instance, one institution, reporting 7.2% of cardiogenic shock, had a crude mortality rate of 3.3%, which was adjusted to 1.85%; another had a crude mortality of 3.10 adjusted to 1.72%, probably due to the amazing frequency of unstable angina (62.5%).
Conversely, as Dr Seccareccia reminds me, our adjusted mortality was 4.3%. However, she forgets to mention that our crude mortality was 3.4% (of course, we reported a very normal rate of 0.5% cardiogenic shock).
Crude mortality should always be included in a mortality report, namely when a ‘ranking’ is produced and delivered to mass newspapers.
Dr Seccareccia quoted the New York State database [3]; she should have noticed that in that report the crude mortality is reported, as always is done in all reports dealing with surgical results.
The authors affirm, ‘We are inclined to deny that Centres were purposely reporting false information’ and that they did not want to ‘exert a sort of police control’.
A strict control of the quality of the collected data is not a police control, is just good clinical practice for researchers. This control is a specific responsibility of the researchers, and the journals reviewing scientific articles usually ask specific requirements to be fulfilled and may even request specific documentations to check the data. What the authors are ‘inclined to deny’ does not play any role in this process.
Finally, I want to reassure Seccareccia that quality control is our first commitment, for this reason all results are matched with the EuroSCORE monitoring system and the data collected are certified by an independent rating agency (Italcert, via Sarca 336-IT, 20126 Milano); to my knowledge this is the only hospital in this country to do so.
I believe that national database is important to keep a good quality level; as a matter of fact San Donato Hospital with 2062 patients is the major contributor to this survey. I am convinced that the authors did a good job and I really hope that they will carry on the study to improve the quality of our surgery and of their skills; this was the first time they did a study of surgical outcome and the learning curve exists for everybody.
References
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