The October 1997 issue of the Harvard Heart Letter had an article
reviewing the December 19, 1996 New England Journal of Medicine report
on brain complications following CABG.
The article states that 3.1% had Type I complications and another 3 %
had Type II complications. Type I is death due to stroke, stroke,
near-stroke or coma at the time of discharge. Type II is abnormalities
suggesting milder damage to the brain such as confusion, deterioration
of intellect, agitation, disorientation, memory loss, etc.
The rates of these complications varied from 1% to 14% among 23
different institutions.
The absolute level of 6.1 % for Type 1 plus Type II is appalling but the
factor of 14 variation between institutions is more than appalling.
That leads to the logical questions:
1. What is the cause of a 6.1 % brain damage rate?
2. What can be done to mitigate the problem?
3. How can one select a surgeon and/or anesthesiologist with a low
complication rate?
4. How do you find the institutions with a low complication rate?
Jay
Hi Jay – I read your original note with great interest. I had 3x bypass at
UMASS Med Center on 1/4/91, at an unfortunate early age of 42. (note –
UMASS, my cardio and surgeon had extreemly low Type I statistics that I
obtained prior to surgery). My surgery was successful, with no apparent
difficulties or complications – except that I began suffering from the type
II abnormalities. Since that time, most have improved, but some remain with
me. I have done extensive research on this and have found limited
information. The most common "theory" I have experience to date is that the
heart / lung machine is the area of suspicion. This is quite different than
the "risk factors" that were mentioned in the 10/97 Harvard Heart Letter.
(Note – I had none of these risk factors in my background before surgery).
Attached is a summary of what may be the 1st study (from 1987) to indicate
that there is a problem in this area. Hope this might provide you some
useful information. Unfortunately, since there does not appear to be a
definative answer to your first question, none of your other questions can
be answered. If you would like any further information that I have found,
feel free to contact me directly (deca…@gte.net).
Long-term intellectual dysfunction following coronary artery
bypass graft surgery: a six month follow-up study.
Author
Shaw PJ; Bates D; Cartlidge NE; French JM; Heaviside D;
Julian DG; Shaw DA
Address
Department of Neurology, University of Newcastle upon
Tyne.
Source
Q J Med, 1987 Mar, 62:239, 259-68
Abstract
As part of a prospective study of neurological and
neuropsychological complications of coronary bypass
surgery, 259 patients underwent psychometric assessment
before operation and at seven days and six months after
operation using a battery of 10 standard tests of intellectual
function. This report describes the natural history of
intellectual dysfunction soon after surgery and the incidence
and functional impact of late neuropsychological impairment.
The mean neuropsychological scores for the whole group
remained unchanged or improved compared with levels
before operation for the majority of the 10 tests. Analysis of
the test scores for individuals showed that 147 of 259 (57 per
cent) patients showed deterioration on at least one test score at
six months. The degree of impairment was usually mild. One
hundred and thirty of the 147 patients showed mild cognitive
dysfunction (score deterioration on one or two tests) and only
17 patients had moderate or severe impairment (score
deterioration on three or more tests). Detectable
neuropsychological deterioration at six months often did not
matter to the patient in functional terms. Seventy-one per cent
of these patients had no significant symptoms; 27 per cent had
minor symptoms and only 2 per cent were seriously disabled.
Of the patients unemployed at six months, in only one case
was intellectual impairment the factor preventing return to
work. A search for possible predisposing factors for
long-term intellectual dysfunction was made using a
multivariate analysis of 91 variables for each patient. Cardiac
failure before surgery and global impairment of left
ventricular function were the only factors showing significant
correlation.
- Hide quoted text — Show quoted text -
Robert Coe wrote:
> On Wed, 05 Nov 1997 00:19:17 -0800, Jay Schonberger <jfsc…@hicom.net> wrote:
> : Robert Coe wrote:
> : > Sometimes you can tell a lot just by visiting the hospital and looking around.
> : > The one that did my surgery has the best mortality statistics in the state for
> : > bypass operations (they even tell you so in their brochure), and it wasn’t
> : > hard to see why. The building was was extremely clean and well kept, and the
> : > staff, particularly the nurses, all seemed to know exactly what they were
> : > doing. And it’s good if the hospital specializes in coronary care, because
> : > the coronary unit won’t have to compete for the attention of the
> : > administration.
> :
> : Thanks for the answer but I am not at all sure whether good mortality statistics
> : and a professional atmosphere equates with low brain damage percentage. In fact,
> : a low mortality might equate with high brain damage since there are more sick
> : survivors.
> Perhaps, but I think that’s unlikely. I think it’s much more probable that a
> low mortality rate correlates with a high skill level of the surgical team and
> finicky attention to detail at all levels of the medical staff, leaving
> nothing to chance. That should result in a lower frequency of all types of
> complication, including brain damage.
> Let’s say that at an excellent hospital a patient who might have died is
> saved, but suffers brain damage. This should be offset by another patient who
> might have suffered brain damage, but escapes with no serious complications.
> —
> ___ _ – Bob
> /__) _ / / ) _ _
> (_/__) (_)_(_) (___(_)_(/_____________________________________ b…@1776.COM
> Robert K. Coe ** 14 Churchill St, Sudbury, MA 01776-2120 USA ** 978-443-3265
I agree with Bob. It would seem to be non-logical to try and find surgeon with worst
statistics for your surgery. Even given that some surgeons take on higher risk cases
with poorer results, it would seem that this is self limiting. If surgeon won’t take me
on then I have to go some with worse statistics! My objective is not to provide
employment for surgeons with poor records, however altruistic their motives are, but to
find the best doctor who can help me. In this case statistics should be an improtant
consideration.
On Wed, 05 Nov 1997 00:19:17 -0800, Jay Schonberger <jfsc…@hicom.net> wrote:
: Robert Coe wrote:
: > Sometimes you can tell a lot just by visiting the hospital and looking around.
: > The one that did my surgery has the best mortality statistics in the state for
: > bypass operations (they even tell you so in their brochure), and it wasn’t
: > hard to see why. The building was was extremely clean and well kept, and the
: > staff, particularly the nurses, all seemed to know exactly what they were
: > doing. And it’s good if the hospital specializes in coronary care, because
: > the coronary unit won’t have to compete for the attention of the
: > administration.
:
: Thanks for the answer but I am not at all sure whether good mortality statistics
: and a professional atmosphere equates with low brain damage percentage. In fact,
: a low mortality might equate with high brain damage since there are more sick
: survivors.
Perhaps, but I think that’s unlikely. I think it’s much more probable that a
low mortality rate correlates with a high skill level of the surgical team and
finicky attention to detail at all levels of the medical staff, leaving
nothing to chance. That should result in a lower frequency of all types of
complication, including brain damage.
Let’s say that at an excellent hospital a patient who might have died is
saved, but suffers brain damage. This should be offset by another patient who
might have suffered brain damage, but escapes with no serious complications.
—
___ _ – Bob
/__) _ / / ) _ _
(_/__) (_)_(_) (___(_)_(/_____________________________________ b…@1776.COM
Robert K. Coe ** 14 Churchill St, Sudbury, MA 01776-2120 USA ** 978-443-3265
Jay Schonberger <jfsc…@hicom.net> wrote:
>The October 1997 issue of the Harvard Heart Letter had an article
>reviewing the December 19, 1996 New England Journal of Medicine report
>on brain complications following CABG.
>The article states that 3.1% had Type I complications and another 3 %
>had Type II complications. Type I is death due to stroke, stroke,
>near-stroke or coma at the time of discharge. Type II is abnormalities
>suggesting milder damage to the brain such as confusion, deterioration
>of intellect, agitation, disorientation, memory loss, etc.
>1. What is the cause of a 6.1 % brain damage rate?
Probably a varying combination of
(a) patients with diffuse atherosclerotic disease, including
cerebrovascular disease, unable to tolerate the transient insults that
are unavoidable in major interventions like cardiopulmonary bypass and
bypass surgery; and
(b) suboptimal surgical/anesthesiologic technique.
>2. What can be done to mitigate the problem?
Avoid low-volume surgeons and anesthesiologists. Don’t have major
procedures unless you really need them.
>3. How can one select a surgeon and/or anesthesiologist with a low
>complication rate?
There may be no good way to use data other than volume. Historical
rates of bad outcomes are hard to interpret; they are usually
impossibly confounded by variations in the patient population. New
York State starting publishing outcome statistics for its
institutions, and there were a few articles in the New England Journal
discussing these. As I recall, the raw statistics turned out to be
almost meaningless, with the relative rankings of hospitals varying
wildly from year to year. It may seem easy to decide how sick one
group of patients is, compared to another, but it isn’t.
Robert R. Fenichel, M.D.
(true email address is as above, but without initial NOTQUITE)
- Hide quoted text — Show quoted text -
Jay Schonberger <jfsc…@hicom.net> wrote:
>Robert Coe wrote:
>> On Sun, 02 Nov 1997 00:59:23 -0800, Jay Schonberger <jfsc…@hicom.net> wrote:
>> : The October 1997 issue of the Harvard Heart Letter had an article reviewing
>> : the December 19, 1996 New England Journal of Medicine report on brain
>> : complications following CABG. …
>> :
>> : The absolute level of 6.1 % for Type 1 plus Type II is appalling but the
>> : factor of 14 variation between institutions is more than appalling.
>> :
>> : That leads to the logical questions:
>> :
>> : 1. What is the cause of a 6.1 % brain damage rate?
>> :
>> : 2. What can be done to mitigate the problem?
>> :
>> : 3. How can one select a surgeon and/or anesthesiologist with a low
>> : complication rate?
>> :
>> : 4. How do you find the institutions with a low complication rate?
>> Questions 1 and 2 are outside my area of expertise. Question 3 is almost a
>> subset of question 4: while there are exceptions, you’re statistically more
>> likely to find the best doctors at the best hospitals.
>> Question 4 is trickier. Ideally, your cardiologist will be willing to tell
>> you. (Mine did.) If (s)he won’t, you can go find one who will. If that’s
>> not feasible, you may be able to get the statistics from your state
>> government. You may even be able to find them on the Web.
>> Sometimes you can tell a lot just by visiting the hospital and looking around.
>> The one that did my surgery has the best mortality statistics in the state for
>> bypass operations (they even tell you so in their brochure), and it wasn’t
>> hard to see why. The building was was extremely clean and well kept, and the
>> staff, particularly the nurses, all seemed to know exactly what they were
>> doing. And it’s good if the hospital specializes in coronary care, because
>> the coronary unit won’t have to compete for the attention of the
>> administration.
>> —
>> ___ _ – Bob
>> /__) _ / / ) _ _
>> (_/__) (_)_(_) (___(_)_(/_____________________________________ b…@1776.COM
>> Robert K. Coe ** 14 Churchill St, Sudbury, MA 01776-2120 USA ** 978-443-3265
> Robert,
>Thanks for the answer but I am not at all sure whether good mortality statistics
>and a professional atmosphere equates with low brain damage percentage. In fact,
>a low mortality might equate with high brain damage since there are more sick
>survivors.
>There is a FACTOR of 14 difference between the best and the worst institution.
>That is 1400 % and very certainly statistically significant. Why? I am sure
>that some will claim that the bad performers handle sicker patients. Maybe, but I
>would suggest that the medical profession to lift the secrecy and explain the
>differences.
>Jay
I hope you’re not holding your breath.
The Prof