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Ann Thorac Surg 1996;61:513-514
© 1996 The Society of Thoracic Surgeons
Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
More than two centuries ago, Adam Smith [1] first described the ``invisible hand,'' the forces that allocate resources efficiently in the free market. In the absence of a market and the invisible hand, one must rely on central planning and queuing to distribute resources. In this issue of The Annals, Maziak and colleagues [2] describe the system by which patients are placed into queues for cardiac operations in Ontario, Canada.
Maziak and colleagues state that their findings will ``enable health care providers to rationalize costs without jeopardizing patient care.'' Skeptics may believe that they have confused the terms ration and rational, the former describing the method by which health services are distributed by the Ontario Provincial Adult Care Network. As part of the rationing, or ``rationalization'' of health care, the costs of waiting lists need to be factored into global health care budgets. For bypass operations, these costs include preoperative myocardial infarctions and their long-term sequelae, deaths, resources required to manage patients who become unstable while waiting for operation, resources consumed by patients who ``cross the border'' for operation, and the psychological consequences of waiting for patients and their families.
One of the main objectives of this study is to determine whether a system that allocates surgical priority for patients with left main disease according to symptoms rather than degree of left main stenosis based on the angiogram is safe, relying on comparisons between ``early'' and ``late'' operation groups. Patients with critical left main stenosis are particularly concerning in triage decisions. In the event of sudden left main occlusion, they are difficult to resuscitate due to global ischemia and severe pump failure. Among patients with greater than 50% left main stenosis, there is likely to be a spectrum of risk for left main occlusion. The degree of risk is likely to be related to symptom severity, and the Ontario triage system is a logical attempt to separate patients across this risk spectrum.
Unfortunately, this study lacks an appropriate control group with which safety can be substantiated. What is needed is a group of patients with left main disease allocated to operation within several days regardless of symptoms. Outcomes should then be compared on the basis of ``intention to treat.'' The outcomes of patients who cross over from late to early operation should be counted with those patients who remain in the late operation group. Despite the lack of a control group, the present study does demonstrate that the Ontario system has the mechanisms in place by which the proper experiments can be performed. To determine whether their current system is safe, they should randomly assign patients with left main disease to one of the two triage systems described above. The ideal experiments would measure all of the potential costs, both economic and clinical, of operation queues noted above.
In the absence of a randomized study, a more detailed accounting for all patients coming through the cardiac catheterization laboratory would provide the next-best study design. Maziak and colleagues refer to deaths and nonfatal infarctions on the waiting list, but the exact circumstances of the events are unclear. Only with a design including all patients undergoing angiography can a study account for patients with left main disease who never made it to operation. What we need to know is the aggregate impact of the queuing system on all patients with left main disease and the impact of the queuing system in left main disease on the outcomes of other patients who may be candidates for operation.
A second objective of this study is to examine the relationship between left main stenosis and early surgical outcomes. Again, the interpretation of the data may vary according to the perspective of the reader. Maziak and colleagues note that low output syndrome, myocardial infarction, and death occur infrequently and similarly between patients with and without left main stenosis. By univariate analysis, there is a trend toward low output syndrome and death occurring more commonly in the left main stenosis group. The conclusions in this report are limited by the relatively small sample size, such that increases in relative risk of more than 50% are not detectable. More patients will need to be examined and other risk factors will need to be accounted for to be sure that these trends do not continue toward statistical and clinical significance.
Maziak and colleagues and the Ontario Provincial Adult Care Network should be encouraged in their efforts to examine the bypass operation queuing system, as their work will lead to better systems of bypass operation allocation in Canada and elsewhere. Their current system represents a reasonable approach to allocating bypass operations, particularly with provisions to examine outcomes and potentially modify the triage system accordingly. We agree with their conclusion that given the shortcomings of the current study, the lack of a suitable control group and the lack of accounting for all the costs of waiting, this preliminary work should not be used as a basis for the justification of surgical waiting lists or for the central allocation of health care resources.
Footnotes
Address reprint requests to Dr Califf, Box 31123, Duke University Medical Center, Durham, NC 27710.
References
Related Article
This article has been cited by other articles:
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  C. D. Naylor, J. G. Jollis, and R. M. Califf Left Main Stenosis Ann. Thorac. Surg., October 1, 1996; 62(4): 1239 - 1241. [Full Text]
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