High-Volume Hospitals and Surgeons Still Safest
An updated study demonstrates that the surgeons who perform the most coronary artery bypass surgeries and the hospitals where such surgery is performed most commonly remain the safest, according to a report in this week’s issue of the journal Circulation (Circulation. 2003;108:795–801OpenUrl).
The study, led by Edward L. Hannan, PhD, of the State University of New York at Albany, sought to update older reviews of such procedures. Data from New York State’s clinical coronary artery bypass graft surgery registry from 1997 to 1999 were reviewed to determine the impact of annual hospital and surgeon volume on the death rates of patients in the hospital. The data were adjusted for differences in severity of illness.
The risk-adjusted mortality rate for patients who underwent their surgeries in hospitals where 600 or more such procedures were performed annually and whose surgeons performed 125 or more such operations each year was 1.89%. When the surgery was performed by surgeons who did fewer than 125 CABG procedures each year in hospitals where the annual volume was less than 600, the risk-adjusted mortality rate was much higher—2.67%.
However, the researchers warned that the data do not represent an absolute. “It is also important to emphasize that even if mortality rates were reduced if patients were channeled to higher-volume hospitals, there are numerous challenges in implementing such a policy, including travel time constraints, unwillingness of patients to travel to distant hospitals, the loss of continuity with the primary physician, and the potential detrimental effects of further reducing volumes at low-volume hospitals so that their performance with emergency patients who cannot be transported to a distant hospital deteriorates.”
“Thus, although it may be wise to judiciously channel some patients to higher-volume hospitals, we must realize that there are low-volume hospitals that provide excellent care and high-volume hospitals that provide relatively poor care. We must regard volume as a transitional, crude proxy while we attempt to develop clinical databases that will enable us to obtain risk-adjusted outcome rates.”
Carotenoids and Vitamin E: No Myocardial Infarction Panacea
Results from the Physicians’ Health Study showed that vitamin E (tocopherol) and carotenoids (alpha- and beta-carotene, b-cryptoxanthin, lutein, and lycopene) had no protective effects against myocardial infarction in men who had no history of cardiovascular disease, according to a report in this week’s issue of the journal Circulation (Circulation. 2003;108:802–807OpenUrl).
In this study, led by A. Elizabeth Hak, MD, PhD, of the Departments of Epidemiology and Nutrition at Harvard School of Public Health, researchers conducted a prospective, nested case-control analysis of physicians who were followed up for as long as 13 years as part of the Physicians’ Health Study. Samples from 531 physicians who had had myocardial infarctions were analyzed with samples from paired control subjects who were matched for age and smoking. The analysis looked at levels of the 5 major carotenoids, retinol, and alpha and gamma tocopherol (vitamin E).
There were no data to support the notion that higher baseline levels of retinol or the carotenoids protected against myocardial infarction. High levels of beta-carotene tended to be associated with a lower risk of myocardial infarction in men who currently smoked or had smoked in the past. The association did not exist for those who had never smoked.
Those with higher plasma levels of gamma tocopherol tended toward a higher risk of myocardial infarction, according to the researchers. They wrote: “Although in our current analyses we found no apparent inverse associations of any of the plasma carotenoids and tocopherols with MI [myocardial infarction] risk (apart from b-carotene among smokers), intake of fruit and vegetables has been shown to protect against CHD [coronary heart disease]. Our search for nutrients responsible for this beneficial effect should not keep us from recommending consumption of fruits and vegetables. Current trials testing higher doses of supplemental alpha-tocopherol will provide important data on their role in primary prevention in low-risk populations.”
Herbal Extract Guggulipid Does Not Improve Short-Term Cholesterol Levels
Despite earlier studies that indicated that compounds found in the herbal extract guggulipid were potent antagonists of 2 receptors involved in cholesterol metabolism, researchers in the August 13, 2003, issue of The Journal of the American Medical Association (JAMA. 2003;290:765–772) found that the compound had no effect on total cholesterol, high-density lipoprotein cholesterol, triglycerides, or very low-density lipoprotein cholesterol. However, they found that the compound taken in dosages of 1000 mg three times daily or 2000 mg three times daily increased levels of low-density lipoprotein cholesterol by 4% and 5%, respectively.
The researchers, led by Philippe O. Szapary, MD, of the University of Pennsylvania School of Medicine in Philadelphia, randomized 103 healthy adult volunteers with high cholesterol to receive either of the two doses of guggulipid or placebo. Guggulipid is an extract of the mukul myrrh tree and has been used in India and other Asian countries as a cholesterol-lowering agent.
Dr Szapary found that guggulipid was well tolerated overall, but 6 subjects who received the compound developed a rash, whereas none of those who received placebo did.
“These results do not support the use of dietary supplements containing guggulipid for reduction of LDL-C [low-density lipoprotein cholesterol] levels by the general population, and raise 2 important issues. With regards to efficacy, our findings reinforce the importance of performing well-designed, placebo-controlled, randomized trials to scientifically evaluate dietary supplements, even those supplements with supportive evidence from the basic sciences. With regards to safety, this study reminds us that supplements cannot be assumed to be safe and that they require clinical trial evidence of safety before being widely used or recommended,” the researchers wrote.
Thirteen Percent of Coronary Artery Bypass Graft Surgery Patients Readmitted Within 30 Days
Thirteen percent of coronary artery bypass graft surgery patients treated in the state of New York in the calendar year 1999 were readmitted to the hospital within 30 days of their surgery for problems related to the procedures, said Edward Hannan, PhD, of the State University of New York at Albany. Dr Hannan (who has a study in this week’s issue of Circulation that is described earlier in this report) published his report in the August 13, 2003, issue of The Journal of the American Medical Association (JAMA. 2003;290:773–780OpenUrlCrossRefPubMed).
Of the 16 235 New York patients who underwent the procedure during 1999, 2111 or 12.9% were readmitted within 30 days of the procedure because of problems related to the surgery, including infection and heart failure. The factors most commonly associated with readmission included being older, female, or African-American. Also among those readmitted were patients with greater body surface area, myocardial infarction within 1 week of the surgery, disease in the femoral/popliteal artery, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and hepatic or renal failure.
When the researchers controlled the data for patient risk factors, patients were more likely to be readmitted if the physicians who treated them did fewer than 100 CABG procedures each year or had hospital risk-adjusted death rate in the top 10%. Those who were discharged to a nursing home or a rehabilitation or acute care facility were also at increased risk of early readmission, as were those whose stay in the hospital after the procedure totaled 5 or more days.