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ICVTS on-line discussion A

University hospital Sestre milosrdnice, Zagreb 10000, Croatia Email Narcis Hudorovic

Fast-track approach in abdominal aortic surgery: left subcostal incision with blended anesthesia

The authors stated that they have not pointed out the cost savings, and they only calculated that merely reducing hospital stay saved 2,550 for a single patient in a fast-tracking multidisciplinary program in patients who had undergone elective abdominal aortic surgery [1]. This retrospective population-based study shows that results of the fast-track approach for abdominal aortic surgery can be achieved in the "real world". However, these findings highlight the need for continuous outcome monitoring and associated quality improvement efforts to ensure that all further health providers and institutions involved are achieving desired outcomes. For that reason this multidisciplinary program could be based on research commissioned by the National Coordinating Centre for Health Technology Assessment (NCCHTA). The purpose of the NCCHTA method is to ensure that high quality research information on the costs, effectiveness and cost-effectiveness (CE) is produced in the most effective way for those who use, manage and provide care in the National Health System (NHS). Furthermore, every year the NCCHTA decide which of the many suggestions received from NHS and its users should become research priorities. The main objective of such a study could be the diffusion of state of the art evidence without any mandatory role regarding guidelines implementation or rationing in health care. However, collected results could not be questionable in the sense that an improvement of the quality of life is dependent on the pre-procedural base case values and independent of the pre-operative co-morbidities. Following conventional practice, utility values for the different health states could be obtained from appropriate CUA database, using the states of perfect health and death as anchor values in order to estimate the disutility that would inform the model.

At this point it would be wise to mention that recently the Leapfrog Group have made surgical case volumes and mortality rates key criteria for high-risk procedures [2]. This might seem reasonable at first glance for abdominal aortic surgery, but a recent study on the use of mortality as a surgical quality indicator for hospitals, showed that a very large caseload is necessary to provide a valid measure of quality. In this regard, novel statistical approaches, such as cumulative sum charts (CUSUM), may be appropriate, as these methods permit detection of concerning outcome trends shortly after the occurrence of adverse events.

The authors show that the short-term results for abdominal aortic surgery in fast-tracking multidisciplinary program can be replicated in a large "realworld" setting in the majority of hospitals, and for that reason I would like to congratulate the authors. However, the excess adverse event rate in some hospitals is of continuing concern and underlines the need for continued quality improvement efforts and new statistical approaches to provide valid and timely measures of outcome.

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1. Brustia P, Renghi A, Fassiola A, Gramaglia L, Della Corte F, Cassatella R, Cumino A. Fast-track approach in abdominal aortic surgery: left subcostal incision with blended anesthesia. Interact CardioVasc Thorac Surg doi: 10.1510/icvts.2006.137562 [update!].[Abstract/Free Full Text]
2. Birkmeyer JD, Dimick JB. Potential benefits of the new Leapfrog standards: Effect of process and outcomes measures. Surg 2004; 135:569–575.

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