Tuesday, December 02, 2003
PRACTICE MAKES PERFECT II:
From Medscape a paper published in Annals of Surgery about in-hospital mortality following gastrectomy and colecomy in New York State. The results:
Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10).
So, on the surface it appears that "subspecialty" training as loosely defined by the authors (membership in the Society of Colon and Rectal surgeons does not require fellowship training) translates into better in-hospital mortality rates.
I don't have alot of time right now to fully pick this apart but what I noticed from the tables (scroll down) is that for both gastrectomy and colectomy the "non-subspecialists" had higher percentages of patients with CHF, ischemic heart disease, COPD, diabetes and peripheral vascular disease than those treated by "subspecialist" surgeons. A limit alluded to by the authors:
An important limitation of this study is that we used administrative data to assess the volume-specialty-mortality relationship. This did not allow us to account for the appropriateness of patient selection or for detailed comorbid conditions, nor does it give us long-term follow-up. We reduced the likelihood of confounding, however, by adjusting for risk based on comorbidities ascertained in the claims data and controlling for other demographic variables.
The authors go on to describe the impact on such studies might have on managed-care referral patterns. One problem with this is that if elective operations (colectomies, gastrectomies, ect.) are all sent off to the high-volume centers, will your average Joe community general surgeon be able to deal with the patients on an emergent basis? Will it become like cholecystectomy where the lack of experience with elective open operations (due to laparoscopy) hampers the ability of surgeons to handle the unexpected need to perform an open cholecystectomy? If the mortality rates are bad for low-volume surgeons doing elective cases, just you wait for the figures for no-volume surgeons doing emergency cases. Got to go. |
From Medscape a paper published in Annals of Surgery about in-hospital mortality following gastrectomy and colecomy in New York State. The results:
Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10).
So, on the surface it appears that "subspecialty" training as loosely defined by the authors (membership in the Society of Colon and Rectal surgeons does not require fellowship training) translates into better in-hospital mortality rates.
I don't have alot of time right now to fully pick this apart but what I noticed from the tables (scroll down) is that for both gastrectomy and colectomy the "non-subspecialists" had higher percentages of patients with CHF, ischemic heart disease, COPD, diabetes and peripheral vascular disease than those treated by "subspecialist" surgeons. A limit alluded to by the authors:
An important limitation of this study is that we used administrative data to assess the volume-specialty-mortality relationship. This did not allow us to account for the appropriateness of patient selection or for detailed comorbid conditions, nor does it give us long-term follow-up. We reduced the likelihood of confounding, however, by adjusting for risk based on comorbidities ascertained in the claims data and controlling for other demographic variables.
The authors go on to describe the impact on such studies might have on managed-care referral patterns. One problem with this is that if elective operations (colectomies, gastrectomies, ect.) are all sent off to the high-volume centers, will your average Joe community general surgeon be able to deal with the patients on an emergent basis? Will it become like cholecystectomy where the lack of experience with elective open operations (due to laparoscopy) hampers the ability of surgeons to handle the unexpected need to perform an open cholecystectomy? If the mortality rates are bad for low-volume surgeons doing elective cases, just you wait for the figures for no-volume surgeons doing emergency cases. Got to go. |
