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Ann Thorac Surg 2000;70:783-784
© 2000 The Society of Thoracic Surgeons
Discussion
DR HOOSHANG BOLOOKI (Miami, FL): This is a very nice study, Dr Thourani. Congratulations. As I understood from your presentation, if you operated as an "emergency," you had between 20% and 40% more cost and mortality, respectively. As I see it, it all comes down to the definition of "emergency." There are a lot of emergencies, as you know, which involve time constraints and cardiologist or family requests at times disregarding the clinical or pathologic presentation of the patient. Were there some patients that could have had their operation on an elective schedule?
I also noted that patients needing emergency mitral valve surgery and coronary operation urgently had a 40% operative mortality, which is almost similar with past reports. It is possible that nonurgent operations in these patients would have resulted in better outcomes. I appreciate your comments. Thank you.
DR THOURANI: Doctor Bolooki, thank you for those insightful questions. The Emory University Cardiac Surgery Database defines urgent operations as those requiring surgical intervention within 24 hours of presenting to our cardiac surgeons. Emergent operations are defined as those cases in which the patient is taken directly to the operating room. Although the group of Emory surgeons are aggressive, we attempt to base the necessity of an urgent or emergent operation on true pathology, instead of intervening social or personal situations. The authors do agree that if the cardiac surgeon can temporize the patient such that the mitral valve replacement is performed as an elective procedure, not as an urgent or emergent procedure, the chances of survival may be higher.
DR A. MARC GILLINOV (Cleveland, OH): That was an excellent paper and I enjoyed it very much. I was wondering if you analyzed the impact of mitral valve pathology on your results for survival, morbidity, and cost? Any discussion about patients who have mitral valve surgery with concomitant coronary artery bypass grafting involves discussing a varied group of valvular pathologies. Patients who have ischemic mitral regurgitation, that is, mitral regurgitation caused by coronary artery disease, represent a higher risk group. In our institution those patients have an increased operative mortality, they are much more prone to complications, and I am sure that they cost us more money. So I was wondering if you looked at that factor.
DR THOURANI: Doctor Gillinov, I would assume, and this is a large assumption, that the patients who had acute ischemic mitral regurgitation, for example a papillary rupture, were those patients who underwent emergency surgical procedures and therefore the costs, along with morbidity and mortality, were increased. However, in the present study, we did not look at the specific etiology requiring mitral valve replacement and therefore cannot make any definitive comments on this.
DR MICHAEL J. REARDON (Houston, TX): I enjoyed your paper, which represented a lot of data and a lot of hard work. I certaintly know since the early 1980s when I first did mitral valve replacement until now I have changed the way I perform the operation and the way I care for my patients, and I am sure that is true for all of us. Did you analyze the changes by time periods to see what happened both to your patient mortality and costs? If so, I would like to know your impressions. If not, when you publish this paper, I think it would be interesting to see how mortality and costs changed over time.
DR THOURANI: Doctor Reardon, I agree with you that there have been numerous changes in the performance, choice, and management of patients undergoing mitral valve replacement since the early 1980s. In the present study, we did not perform temporal comparisons among groups. However, in a manuscript by our group presented at the American Heart Association in 1998 and accepted for publication in The Annals of Thoracic Surgery entitled "Ten Year Trends in the Treatment of Valvular Heart Disease" by Thourani and colleagues, we looked at trends of all patients undergoing mitral valve replacement. We reported that over a 10-year period, patients undergoing mitral valve replacement were significantly older and sicker, yet there was no statistically significant difference in morbidity (Q-wave myocardial infarction or stroke) or in-hospital mortality. However, there was a statistically significant trend toward reduced length of stay and hospital cost for those study patients from 1988 to 1997.
DR CLINTON E. BAISDEN (Temple, TX): It is an interesting paper and I enjoyed it very much. The question I have is how did you determine what your costs were? Did you use a formula based on hospital charges that the patient had or were you able to actually break down the cost based on actual resource utilization?
Don Burwick, who is the president of the Institute for Health Care Improvement, has been able to show that operating time for heart surgery probably costs in the range of $22 to $25 per minute. At night or after the regular working day, or if staff are on overtime, the cost is up to about $30 or $35 per minute. My question is, did you take these things into account when calculating the differences between elective and urgent or emergency surgery?
DR THOURANI: Doctor Weintraub, one of the coauthors and the chief of the Emory University Center for Outcomes Research, is a well-established cardiologist/economist in the field of cardiology and cardiac surgery. The costs were determined from the hospital charges. Hospital charges were obtained from the UB92 formulation of the hospital bill provided by the hospital finance department. Charges were then reduced to costs using departmental cost to charge ratios obtained from the hospital cost report, which is provided to the Health Care Financing Agency yearly. All costs were inflated to 1997 costs using the Medicare cost inflation rate. In the current study, we did not break down the specific charges for the individual peripheral costs.
I would like to thank the Association for the privilege of the podium to present our data. Thank you.
Related Article
Ann. Thorac. Surg. 2000 70: 778-783.
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