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Ann Thorac Surg 2005;80:1572-1581
© 2005 The Society of Thoracic Surgeons

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Ethics in cardiothoracic surgery

Should Coronary Artery Bypass Grafting Be Regionalized?

^a Health Services Research & Development Center of Excellence, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
^b Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
^c University of Michigan Cardiovascular Center, Ann Arbor, Michigan
^d Division of Cardiovascular and Thoracic Surgery, Linda and Jack Gill Heart Institute, University of Kentucky Chandler Medical Center, Lexington, Kentucky
^e Department of Surgery and the Institute of Human Values in Health Care, Medical University of South Carolina, Charleston, South Carolina

^_* Address correspondence to Dr Sade, 96 Jonathan Lucas St, Suite 409, PO Box 250612, Charleston, SC 29425 (Email: sader@musc.edu).

The first 300 words of the full text of this article appear below.

	Introduction

 
Robert M. Sade, MD
Several studies have shown that cardiac care centers that provide a high volume of cardiac services, particularly coronary artery bypass grafting (CABG), have better outcomes than those with low volumes. Some analysts have used these data to suggest that patients in need of care for coronary artery disease would be best served if they were referred only to those centers that treat a large number of these patients. They reason that regionalizing coronary artery disease treatment will result in fewer deaths, because low volume-high mortality programs would be deleted and may have additional advantages in efficiencies of scale.

Those who oppose regionalization claim that the data justifying regionalization are seriously flawed. Reliable measurement of outcomes requires accurate risk stratification; technologies for accomplishing this are being developed and used, but are far from perfect. Moreover, although it is true that many studies show a relationship between volume and outcome, a few well-designed recent studies have not found such a relationship.

In the unregulated referral system that now exists in this country, regionalization already occurs informally; primary care physicians are more likely to refer their patients to centers with good results, and many large-volume centers achieved their dominant status by virtue of good outcomes. Formal regionalization already exists in other countries, such as Canada and Great Britain, and it exists on a small scale in this country (eg, in the VA hospital system). Many have suggested formal regionalization of CABG in the United States on grounds of achieving better outcomes and gaining efficiency, whereas others object on the grounds of inadequate supportive data. Do currently available data justify regionalization of CABG?

The cases for opposing points of view (ie, for and against regionalization) are made herein by scholars with deep and persistent interest in this question.

	Pro

 
Brahmajee K. Nallamothu, MD, MPH, and Kim A. Eagle, MD
A quarter of a century has . . . [Full Text of this Article]

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