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High-risk cardiovascular procedures, but not cancer operations, are becoming safer

The well-publicized decline in postoperative deaths following cardiovascular surgery has led to a general perception that high-risk surgery is becoming safer over time. However, that is not the case for high-risk cancer operations, concludes a study supported in part by the Agency for Healthcare Research and Quality (HS10141). Organized efforts aimed at measuring surgical mortality rates—like those widely implemented in cardiac surgery—may be the first step toward making high-risk cancer surgery safer, suggests principal investigator John D. Birkmeyer, M.D., of Dartmouth-Hitchcock Medical Center.

Dr. Birkmeyer and colleagues examined national trends between 1994 and 1999 in operative mortality for 14 high-risk cardiovascular and cancer procedures in a nationally representative group of elderly Medicare patients. Mortality rates varied widely across the 14 procedures, from 2 percent for carotid endarterectomy (removal of plaque from the carotid artery) to 16 percent for esophagectomy (removal of all or part of the esophagus). Over the 6-year study period, operative mortality declined significantly for three cardiovascular procedures: 15 percent for coronary artery bypass graft (CABG) surgery, 14 percent for carotid endarterectomy, and 11 percent for mitral valve replacement.

On the other hand, operative mortality did not decline significantly for seven of eight cancer procedures studied. In fact, mortality increased for colonectomy for colon cancer, after adjusting for other factors known to affect operative mortality, such as hospital procedure volume. Mortality rates remained higher than 10 percent throughout the study period for cancer surgeries such as pneumonectomy (removal of all or part of a lung), gastrectomy (removal of all or part of the stomach), and pancreatic resection and remained at least 15 percent for esophagectomy.

Registries tracking hospital- and surgeon-specific performance have been linked to substantial reductions in operative mortality with cardiac surgery. Although there are several large cancer registries, these tend to focus on disease epidemiology and prognosis. If expanded to allow tracking of provider-level performance, these registries might be very useful as platforms for improving surgical outcomes.

See "Is surgery getting safer? National trends in operative mortality," by Philip P. Goodney, M.D., Andrea E. Siewers, M.P.H., Therese A. Stukel, Ph.D., and others, in the August 2002 Journal of the American College of Surgeons 195, pp. 219-227.

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