Delays for coronary artery bypass surgery: how long is too long?

Sobolev, Boris; Fradet, Guy

doi:10.1586/14737167.8.1.27

Cited by 11 publications

(7 citation statements)

References 31 publications

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“…5,7 Several authors have argued, however, that other contributing factors, such as local expertise and patient preference, could favour one revascularization method over another. 24 In health systems where budgetary considerations may delay patients' planned treatments, 25 the time to treatment is one factor that has not been studied in the context of comparative treatment effectiveness. 12 However, there is a strong argument that doctors have a duty to inform their patients of the expected delays and the associated risks when choosing between treatments.…”

Section: Discussionmentioning

confidence: 99%

Mediation analysis to inform policy on coronary revascularization by expected time to treatment: Analytical framework

Sobolev

Kuramoto

2022

Preprint

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Objectives Clinical guidelines favor coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) for patients with stable complex coronary disease. Yet the benefit of CABG as established in trials may not be generalizable to populations in which treatment method determines time to treatment, typically being longer for CABG. For cases in which the cardiac anatomy is suitable for either treatment, it is unclear whether it is appropriate to recommend CABG, which is likely to be delayed, if PCI can be performed sooner. This paper outlines an analytical framework for a policy analysis of the timing of coronary revascularization. Methods We constructed a thought experiment to examine whether time to treatment will influence the advantage of CABG. We substantiated the use of mediation analysis to estimate the extent to which differences in outcomes between CABG and PCI would change if times to CABG were the same as times to PCI. Results We designed a study that uses data from a population-based patient registry to obtain effect measures of mediation analysis: the total effect, the natural indirect effect, and the natural direct effect. The partitioning of the total effect will allow us to estimate the proportional reduction in the risk of an outcome if the time to CABG was similar to that of PCI. Interpretation Treatment recommendation, resource allocation and scheduling benchmarks will be guided by understanding the extent to which the time to treatment mediates the relation between revascularization method and outcome.

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Section: Discussionmentioning

confidence: 99%

Mediation analysis to inform policy on coronary revascularization by expected time to treatment: Analytical framework

Sobolev

Kuramoto

2022

Preprint

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“…5,7 However, Head and colleagues 35 have argued that other contributing factors, such as local expertise and patient preference, could favour a particular revascularization method. 35 In health systems where budgetary considerations may delay patients' planned treatments, 19 the time to treatment is a factor that has not been studied in the context of comparative treatment effectiveness. 14 However, there is a strong argument that doctors have a duty to inform their patients of the expected delays and the associated risks when choosing between treatments.…”

Section: Discussionmentioning

confidence: 99%

Time of coronary revascularization: methodology of a mediation analysis study

Sobolev

Kuramoto

2022

cmajo

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here has been debate about the appropriate treatment method for patients with multivessel or left main coronary artery disease who do not need emergency treatment. [1][2][3][4] Recent clinical guidelines favour coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) for patients with the cardiac anatomy suitable for either procedure. [5][6][7][8] This recommendation reflects findings from randomized controlled trials (RCTs) showing that CABG, relative to PCI, results in higher or similar survival, but fewer cardiac events and less need for repeat revascularizations. 9,10 However, the findings of RCTs in which the time from decision to treatment is the same for both procedures may not apply to populations in which the method of treatment determines the time to treatment, with times to CABG being longer than times to PCI. 11,12 The therapeutic effect of revascularization can vary over time. Disease progression during an extended treatment delay is thought to increase disease severity and lead to incomplete revascularization. 13,14 Factors that cause variation in time to treatment may also cause the comparative effectiveness of the 2 treatments to vary from one patient to another. As the clinical guidelines do not address the relative benefits of CABG when treatment is delayed, 5,8 it is unclear whether patients will have better outcomes if they undergo PCI instead of CABG, given the uncertain timing of CABG.We describe a conceptual framework to assess how changes in time to treatment may affect the comparative effectiveness of these 2 methods of coronary revascularization. We justify the use of a causal mediation analysis by showing the need to compare counterfactual scenarios to assess how the differences in outcomes would have changed if patients who received CABG had the same treatment time as patients who received PCI. This new evidence will make it easier to determine the appropriate care for patients and guide decisions about resource allocation. MethodsWe describe the framework for examining the effect of the changes in CABG treatment time on the difference in outcomes between CABG and PCI. We will use an observational study to assess the extent to which times to treatment mediate the comparative effectiveness of the 2 treatment methods. We will use the Strengthening the Reporting of Observational Studies in Epidemiology statement for reporting the results of our study.

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“…However, we employ a much larger sample, which includes the whole population of CABG patients over eleven years in England. Sobolev and Fradet (2008) provide a review of the literature for CABG and suggest that long waits may worsen symptoms and clinical outcomes. Waits may also increase the probability of preoperative death (while waiting) and unplanned emergency admission (Rexius et al, 2004;Sobolev et al, 2006Sobolev et al, , 2012Sobolev and Kuramoto, 2010).…”

Section: Literaturementioning

confidence: 99%

Do waiting times affect health outcomes? Evidence from coronary bypass

Moscelli

Siciliani

Tonei

2016

Social Science & Medicine

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Long waiting times for non-emergency services are a feature of several publicly-funded health systems. A key policy concern is that long waiting times may worsen health outcomes: when patients receive treatment, their health condition may have deteriorated and health gains reduced. This study investigates whether patients in need of coronary bypass with longer waiting times are associated with poorer health outcomes in the English National Health Service over 2000-2010. Exploiting information from the Hospital Episode Statistics (HES), we measure health outcomes with in-hospital mortality and 28-day emergency readmission following discharge. Our results, obtained combining hospital fixed effects and instrumental variable methods, find no evidence of waiting times being associated with higher in-hospital mortality and weak association between waiting times and emergency readmission following a surgery. The results inform the debate on the relative merits of different types of rationing in healthcare systems. They are to some extent supportive of waiting times as an acceptable rationing mechanism, although further research is required to explore whether long waiting times affect other aspects of individuals' life.

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Delays for coronary artery bypass surgery: how long is too long?

Cited by 11 publications

References 31 publications

Mediation analysis to inform policy on coronary revascularization by expected time to treatment: Analytical framework

Mediation analysis to inform policy on coronary revascularization by expected time to treatment: Analytical framework

Time of coronary revascularization: methodology of a mediation analysis study

Do waiting times affect health outcomes? Evidence from coronary bypass

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