Evidence for the Full Potential of Daily Food Choices to Minimize Premature Mortality

Abstract

In Reply We welcome the comments by Forbes about our article 1 in measuring low-value endovascular repair of abdominal aortic aneurysms (EVAR), but we disagree with his conclusions.First, he objects to our use of the American Society of Anesthesiologists (ASA) classification to define "high-risk" patients. Identifying "high-risk patients with limited life expectancy" in our data is challenging. Given the available variables, our clinical advisers agreed that using the ASA classification is reasonable. Although the interrater reliability for the ASA score is moderate, the score is a valid indicator of perioperative risk. 2 It needs to be emphasized that the ASA III and IV definitions are predicated on "severe systemic disease," implying vulnerability to death or poor outcomes owing to major organ insufficiency, which may be exacerbated by invasive intervention. This is separate to having an aneurysm in isolation. Although there may be some inconsistencies in how these definitions are interpreted or recorded, we believe it is better to produce the best measurements that we can with current data, recognize their limitations, and improve them as better data become available, rather than to abandon measurement as too hard.Forbes also suggests that we have not considered the possible benefit of the procedure. A basic principle of our research program is that the balance of benefit and harm is defined by the clinical groups that produce the recommendations. The rationale for the Choosing Wisely Canada recommendation states: "Most elderly, or medically high-risk patients, have insufficient life expectancy and are at higher risk of complications following endovascular repair to warrant intervention." 3 Aneurysm size is not mentioned in this recommendation. The implication is that elderly or high-risk patients generally should not receive EVAR regardless of aneurysm size. The Society for Vascular Surgery guidelines indicate that patients with high operative risk need a high rupture risk if they are to benefit from the procedure. 4 We accepted these clinical opinions as given and focused on identifying this elderly, high-risk patient group in our data.Finally, Forbes suggests that we should not count all 508 EVAR cases as low value. We wish to clarify that, for the hospital-acquired complication analysis, we only included procedures that met our criteria for low value. 1 Furthermore, throughout our program of research in this area, we do recognize a continuum of low-value care, which we address through 2 definitions designated "narrower" and "broader" (akin to "rarely appropriate" and "may be appropriate," respectively). 5,6 The full data for the 3 years included 1163 EVAR procedures, of which we classified 508 as low value on our narrower definition. These were presented in Table 2 of the article. 1 We classified a further 142 as low value on our broader definition and presented results for 650 EVAR episodes in the article Supplement.We feel we have identified, to the extent possible with the data, patients who are unl...