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Ann Thorac Surg 1995;60:1651
© 1995 The Society of Thoracic Surgeons
DR BRACK G. HATTLER, JR (Pittsburgh, PA): I enjoyed your paper, Dr Kay, and congratulate you on a well-designed and thoughtful presentation. After receiving the manuscript, which you supplied to us, we also analyzed our recent experience with isolated coronary artery bypass grafting and its relation to ejection fraction.
Our data corroborate what you have presented to us today and show that there is a breakoff point around an ejection fraction of less than 0.40. We, however, have not been as fortunate as you have in being able to obtain cost data from the administration. They hold these very close to their heart and are reluctant to part with them. As you say, they will give you charges, but they do not want you to know what their profit margin is, which you can figure out fairly easily if they give you cost. So we use length of stay as a measure of resource use. If you are going to operate on a large group of patients with ejection fractions less than 0.20, you are in for an increased mortality, significant morbidity, and a significant length of stay.
So, again, I congratulate you. I think this is the type of data that we are all going to be in need of as the government starts tracking us with its own programs.
DR IRVING L. KRON (Charlottesville, VA): We have had an interest in patients with low ejection fraction and seem to have attracted them through no fault of our own. These are important data. I would like to ask one question and make one comment.
The question is, can you subdivide your low ejection fraction group? In other words, is there some group of patients who are either very old or with poor hearts who have such a high cost or morbidity that you can tell us right now they are not worth operating on?
The comment is that eventually, the government will not just look at surgical results. In other words, if we turn down a patient because the cost is high and the morbidity is high, our individual records are clean, but the patients do not go home, usually. As you know, these people are stuck in the hospital, and the cost to society is still there. So let me address this as a question: has this been analyzed in any way by your group?
DR KAY: Doctor Kron, that is a very good comment. It is often difficult for a cardiac surgeon to turn down a desperately ill patient for operation. We have a long-standing interest in treating patients with poor ventricular function and do not believe that poor ejection fraction alone is reason enough to deny operation. In evaluating the patient with poor ventricular function we like to keep in mind the following points: (1) the likelihood that the myocardium is ischemic and not simply dead, (2) the likelihood that coronary disease is extensive enough to explain the overall ventricular function, (3) the quality of the vessels we need to bypass to achieve improvement, (4) the quality of the conduit that is available, (5) comorbidities or risk factors, and (6) patient age.
Age deserves special note. We have arrayed age against mortality for various risk groups ranging from no risk factors to a worst-case scenario. For example, the worst-case scenario is a patient on a balloon pump before operation with a myocardial infarction 1 to 2 days before operation and an ejection fraction less than 0.30. Age is a very important determinant in that a 40-year-old patient with all the problems I have noted will have a 90% expected survivorship. An 80-year-old patient with the same problems can be expected to have only a 55% survivorship.
In the no risk factor group, however, the survivorship figures for the 40-year-old and the 80-year-old are hardly different. That is to say, age is not a risk factor, but in our opinion is a magnifier. Advanced age will magnify the impact of any other problem the patient has. Based on our data we think that the risk increases substantially in the mid 70s.
We can also look at the data differently using discharge analysis, the tool we introduced today. When $20,000 is spent on the low-risk patient group, 98% of the patients are discharged to home. When the same money is spent on the high-risk group, only 45% of patients are discharged to home. Clearly this tool gives us a powerful handle on cost. Once we agree on the preoperative risk factors, this too allows us to compare programs, treatments, hospitals, and physicians fairly. The key is having a standard for defining discharge and using the right statistical tools.
Getting the needed information from the hospital can be difficult if your administration does not understand that the future of all hospitals and physicians depends on understanding the true cost of patient care. Fortunately, these difficult economic times are enlightening for administrators as well as physicians.
DR THEODORE G. PHILLIPS, MD (Allentown, PA): This week Pennsylvania will be releasing the Health Care Cost Containment Council's report on bypass grafting. The aim of this report is to publish physician-specific mortality statistics, hospital costs, and ultimately morbidity with regard to coronary artery bypass grafting. This study generates all of its data from billing criteria. In their study, ejection fraction has been omitted as part of a risk stratification, and in their study, redo procedures were found to carry no significant increase in operative risk or mortality compared with first-time procedures. This study is used by the state and by insurance agencies and hospital administrators to judge individual cardiac surgeons' performances.
I believe that your study is excellent in that it shows the impact of ejection fraction on hospital morbidity and mortality and resource consumption in a way that even laymen can understand. I strongly believe that The Society of Thoracic Surgeons should develop and endorse a risk stratification format that we can use as surgeons to evaluate our own statistics and outcomes. If we do not provide the public, hospital administrators, and insurers with a way to judge our work properly, then it will be judged for us in studies like the Pennsylvania Health Care Cost Containment Council Study, which has little clinical merit.
DR KAY: Nature abhors a vacuum. Administrators are grappling with these cost problems. The trouble is that they do not have the right tools. Administrative data sets are used for reimbursement purposes and are often optimized to this end. They make little distinction between hospital-acquired problems and prehospitalization problems. Their inaccuracy in assessing clinical outcomes is well recognized.
Various states are exploring ``rating'' physicians and programs based on these administrative concerns. This will not have the desired result. High-risk patients will be denied needed medical care.
Our obligation is to educate the administrators and the general public or accept the fact that health care may be withheld from some patients who need it most.
Related Article
Ann. Thorac. Surg. 1995 60: 1640-1651.
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