Clinical outcomes after myocardial revascularization according to operator training status: cohort study of 22 697 patients undergoing percutaneous coronary intervention or coronary artery bypass graft surgery.
Selected in European Heart Journal by G.G. Toth
Daniel A. Jones, Sean Gallagher, Krishnaraj Rathod, Ajay K. Jain, Anthony Mathur, Rakesh Uppal, Mark Westwood, Kit Wong, Martin T. Rothman, Alex Shipolini, Elliot J. Smith, Peter G. Mills, Adam D. Timmis, Charles J. Knight, R. Andrew Archbold, Andrew Wragg
European Heart Journal (2013) 34, 2887–2895
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The impact of operators’ experience upon the success of a given procedure is of interest for the medical community, as well as for the patients themselves. Few observational studies suggested that higher grade of operators might be associated with better outcome after myocardial revascularization, including both, CABG and PCI. Considering its potential major consequences on the current training programs, as well as on health care, this study aimed to clarify, whether there is any detrimental influence on outcomes following procedures undertaken by less experienced operators.
- In this single centre observational study authors analyzed data of patients, who underwent coronary revascularization (CABG or PCI) between January 2003 and July 2011. All together 22 697 patients were enrolled, 6689 in the CABG group and 16 008 in the PCI group.
- Operators were categorized either as consultant (fully trained independent operator) or as trainee (operators, enrolled in the national specialty training program). 29.4% of the CABG and 53.1% of the PCI procedures were performed by trainees.
- In-hospital and long-term follow-up was analyzed. The median follow-up was 4.0 (2.9-5.9) years for patients after CABG and 4.1 (2.1-5.5) years for patients after PCI.
- Long-term mortality, in-hospital MACE and in-hospital non-MACE were evaluated.
- Patients, treated by consultants had higher EuroSCORE, had more comorbidities, were more often urgent and were presented more often with cardiogenic shock.
- There was no difference in in-hospital complications. Consultants’ patients had significantly higher 5-year all-cause mortality compared to trainees’ patients (13.7% vs 11.7%). However, after multiple adjustment for comorbidities the operator grade was no longer associated with worse outcome [HR 1.34 (95% CI: 1.22-1.47)].
- There was no difference in 5-year mortality rates between consultants and trainees patients in any of the five quintiles of overall baseline risk, expressed by propensity score analysis.
- Patients, treated by consultants had more comorbidities, had more often primary PCI or multi-vessel PCI and were more often presented with cardiogenic shock.
- Consultants’ patients had significantly higher rate of both, in-hospital MACE and non-MACE. In addition these patients had higher 5-year all-cause mortality compared to trainees’ patients (16.9% vs 14.1%). However, after multiple adjustment for comorbidities the operator grade was no longer associated with worse outcome [HR 1.08 (95% CI: 0.98-1.20)].
- There was no difference in 5-year mortality rates between consultants and trainees patients in any of the five quintiles of overall baseline risk, expressed by propensity score analysis
At first sight the results of this paper might suggest that myocardial revascularisation, either CABG or PCI, can be performed by a trainee with the same outcome, as if it was done by an experienced operator, which is most probably not (always) the case. If we look behind the lines, we realise that the study rather highlights the setting and the results of a well-organized training program. First of all, patient selection is crucial, namely the more severe cases or patients in critical conditions were done dominantly by the consultants. Second, as stated in the discussion, final decision about strategy was always taken by a consultant. In addition trainees always worked under direct or indirect supervision, which ensures that the supervisor can take over even before complication happens. I believe that just such a system can ensure that a training program is safe for the patients, and provides the trainees with a continuous improvement until they ‘transform’ to be consultants, without experiencing unnecessary, discouraging complications.