Het volume van chirurgische ingrepen en de impact ervan op ... - KCE
Het volume van chirurgische ingrepen en de impact ervan op ... - KCE
Het volume van chirurgische ingrepen en de impact ervan op ... - KCE
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<strong>KCE</strong> Reports 113 Volume Outcome 153<br />
OUTCOME<br />
In this <strong>KCE</strong> study, in-hospital mortality was 4.7% overall: 3.5% after isolated CABG,<br />
5.6% after isolated heart valve interv<strong>en</strong>tion, and 8.6% after combined interv<strong>en</strong>tion. The<br />
or<strong>de</strong>r of magnitu<strong>de</strong> of these rates can be compared to the in-hospital mortality (or<br />
<strong>op</strong>erative mortality, <strong>de</strong>fined as in-hospital or within 30 days after <strong>op</strong>eration) published<br />
by the studies summarized in Table 6.25. Differ<strong>en</strong>ces in rates can be indicative of<br />
differ<strong>en</strong>ces in pati<strong>en</strong>t p<strong>op</strong>ulation and procedure selection (isolated CABG or CABG and<br />
combined interv<strong>en</strong>tion).<br />
Table 6.25: CABG with/without heart valve repairs or replacem<strong>en</strong>ts:<br />
Comparison of Volume-Outcome <strong>KCE</strong> study with primary studies<br />
Study Year of Type of procedure Mortality Age<br />
Male pati<strong>en</strong>ts<br />
interv<strong>en</strong><br />
rate (mean or (%)<br />
-tions<br />
median)<br />
Volume 2004 Isolated CABG 3.5% 68 years (for 69.4%<br />
Outcome<br />
Isolated heart valve 5.6% all<br />
(for all<br />
study <strong>KCE</strong> Combination 8.6% procedures) procedures)<br />
Hannah 271<br />
and Wu 273<br />
1997- Isolated CABG 2.2% - -<br />
1999<br />
Peterson 272 2000-<br />
2001<br />
Isolated CABG 2.7% 66 years 70.7-72.1%<br />
Christian 93 1999-<br />
2000<br />
Isolated CABG 3.9% 65.5 years 71%<br />
Carey 269 1997- Isolated CABG 3.0% - -<br />
1999 Isolated heart valve 5.0%<br />
Combination 9.2%<br />
Birkmeyer 115,<br />
1994- Isolated CABG From 4.8%<br />
64.6-65.1%<br />
116<br />
1999<br />
to 6.1%<br />
Gammie 274 2000-<br />
2003<br />
Isolated Heart valve 2.12%<br />
Ricciardi 275 2003 CABG (isolated and<br />
combined)<br />
3.3% 67.5%<br />
PATIENT CASE MIX<br />
The age of pati<strong>en</strong>ts (mean age is 68 years old) and 69.4% of them are male. This is<br />
comparable to studies <strong>de</strong>scribed in literature (see Table 6.25).<br />
However, the perc<strong>en</strong>t of pati<strong>en</strong>ts with a Charlson score ≥ 3, as <strong>de</strong>scribed by Birkmeyer<br />
and Ricciardi, does not correspond at all to our data. Birkmeyer and Ricciardi <strong>de</strong>scribe<br />
that, respectively, 10 and 7% of pati<strong>en</strong>ts in their study had a Charlson score ≥ 3.<br />
115, 116, 275<br />
This is not at all comparable to the 25% of pati<strong>en</strong>ts in our study. This might be<br />
explained by the fact that in the studies of Birkmeyer, the Charlson Score exclu<strong>de</strong>d<br />
conditions that “were likely to reflect either the primary indication for surgery or<br />
post<strong>op</strong>erative complications”. The authors also explored two alternative approaches to<br />
incorporating coexisting conditions in their risk adjustm<strong>en</strong>t mo<strong>de</strong>l, and reported that<br />
the three approaches gave virtually id<strong>en</strong>tical results. In our analyses, wh<strong>en</strong> principal<br />
diagnoses were not tak<strong>en</strong> into account in the calculation of the Charlson score, the<br />
perc<strong>en</strong>t of pati<strong>en</strong>ts with AMI (ICD-9 410 or 411) was still 22%. This can indicate some<br />
overcoding in the co morbidities in the MCD.<br />
No other clinical predictors of CABG mortality, such as those <strong>de</strong>scribed by Hannan<br />
were available in our analysis (e.g. a lower ejection fraction, rec<strong>en</strong>t myocardial<br />
infarction, left main artery diseases, compromised hemodynamic state, previous <strong>op</strong><strong>en</strong><br />
heart <strong>op</strong>eration). 271<br />
It has to be acknowledged that the Charlson score is not the most appr<strong>op</strong>riate risk<br />
score for risk adjustm<strong>en</strong>t. For the prediction of mortality after cardiac surgery, the<br />
Society of Thoracic Surgeons mortality risk score (STS) and the Eur<strong>op</strong>ean System for<br />
Cardiac Operative Risk Evaluation (EuroSCORE) scoring system are the two most<br />
frequ<strong>en</strong>tly used risk profile systems. 276