Demand for Cardiac Surgery

[gasattack3]

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What do you think about this? Perspective from the cardiac folks is particularly welcome.



http://circ.ahajournals.org/content/120/6/488.full

The elimination of open revascularization would significantly decrease the demand for cardiothoracic surgeons. Although CABG is only one of many cardiothoracic procedures performed in the United States annually, it represents a large proportion of operative time for cardiac surgeons. Using average relative value units, we estimate that almost 39% of cardiothoracic surgeons’ total time is spent caring for CABG patients intraoperatively or perioperatively. As a result, complete elimination of open bypass procedures would be expected to decrease the demand for cardiothoracic surgery services by nearly 40%. However, all of the scenarios tested demonstrate an increase in demand for cardiothoracic surgery driven by the aging of the population, even with complete elimination of CABG.
According to Nationwide Inpatient Sample data, non-CABG, cardiothoracic discharges increased for valve procedures (28%), other open heart procedures (24%), and lobectomies or pneumonectomies (11%) over the last decade. Moreover, the overall incidence of lung and bronchus cancer in the United States remained virtually unchanged between 1983 and 2003 and is likely to be unchanged in the coming decades as early detection and resection increase.27,28http://circ.ahajournals.org/content/120/6/488.full#ref-28 We therefore modeled a 20% increase in the per capita rates of non-CABG cardiac and general thoracic operations as well.
Baseline demand for cardiothoracic surgeons is projected to rise throughout the next 2 decades given the current epidemiology of disease; however, the demand estimates we present are conservative and do not assume the increased per capita consumption of services that others have suggested.29 The estimates presented are aggressively reduced by the modeling of a complete elimination of open revascularization, which few suggest will occur in the next decade.

 

[drmwvr]

It's real and happening right now. When I started my main facility had 5 ct surgeons doing over 800 procedures a year. Not a lot by some standards, granted, but they were slow 🙁 Now there are 3, they're faster and might do 300 hearts a year. The cardiologists aren't done yet as the hospital is preparing for the first TAVR in the Fall. There is minimal to no increase in their thoracic procedures as there are thoracic dedicated surgeons in the practice. Bleak for the short run anyway, but there's no telling what the future holds.

 

[deleted126335]

Maybe these underutilized CT surgeons will start doing more valves🙄

 

[Brookstacular]

Seems like there's an overshooting pendulum right now with over-utilization of PCI despite results that aren't all that impressive compared to CABG (especially with regard to mortality). With fewer people pursuing CT surgery fellowship training, my guess is that there'll be a rebound as the demand continues to increase with higher patient acuity and increases in CAD prevalence. Also seems like an improvement in work hours for cardiac surgeons would send more people into the field and drive a greater number of procedures.

 

[Bertelman]

Seems like there's an overshooting pendulum right now with over-utilization of PCI despite results that aren't all that impressive compared to CABG (especially with regard to mortality). With fewer people pursuing CT surgery fellowship training, my guess is that there'll be a rebound as the demand continues to increase with higher patient acuity and increases in CAD prevalence. Also seems like an improvement in work hours for cardiac surgeons would send more people into the field and drive a greater number of procedures.

Plus the trend of integrated CT programs, making the training path shorter. Guys finishing now endured 5-7 years of gen surg followed by 3 yrs of CT. 10 years of training. Sheesh. I don;t know th elength of the integrated programs, but if you could take 2-3 years off of that, it would be far more attractive.

 

[gasattack3]

Seems like there's an overshooting pendulum right now with over-utilization of PCI despite results that aren't all that impressive compared to CABG (especially with regard to mortality). With fewer people pursuing CT surgery fellowship training, my guess is that there'll be a rebound as the demand continues to increase with higher patient acuity and increases in CAD prevalence. Also seems like an improvement in work hours for cardiac surgeons would send more people into the field and drive a greater number of procedures.

That's what I took from it. Continued % decreases, but met by larger increases in patients requiring surgery.

 

[foxtrot]

Maybe these underutilized CT surgeons will start doing more valves🙄

Maybe they will start doing pain management since CMS thinks CRNA's with no training in interventional training can do it. Unbelievable....

 

[badasshairday]

The numbers for PCI has dropped off as well since the COURAGE trial.

I won't hold my breath for TAVR becoming main stream. It will be used for patient who are poor operative candidates. Otherwise surgical valve replacement is and will continue to be the main treatment for valvular disease. It is just more durable.

 

[dhb]

The numbers for PCI has dropped off as well since the COURAGE trial.

Yeah elective PCI has repeatedly been shown not to be superior to medical management slight advantage in mortality and functional capacity for CABG.

 

[drmwvr]

The numbers for PCI has dropped off as well since the COURAGE trial.

I won't hold my breath for TAVR becoming main stream. It will be used for patient who are poor operative candidates. Otherwise surgical valve replacement is and will continue to be the main treatment for valvular disease. It is just more durable.

And just how do you know this?

 

[Bertelman]

And just how do you know this?

For starters, mech valves are more durable than tissue.

 

[badasshairday]

And just how do you know this?

Look at the PARTNER study, they compare TAVR with surgical AVR in the short term (1 years) for high risk patients. TAVR had a rate of stroke/TIA that was twice as high compared to AVR. We don't know the long term durability as of now, but if you have seen valve surgery you can surmise that something put in with a catheter probably won't have the durability of current surgical technique. We'll see, but I'd put my money on it. Again, the patients were high risk in PARTNER trial, so what about the average surgical valve candidate versus TAVR?

 

[OB1🤙]

Look at the PARTNER study, they compare TAVR with surgical AVR in the short term (1 years) for high risk patients. TAVR had a rate of stroke/TIA that was twice as high compared to AVR. We don't know the long term durability as of now, but if you have seen valve surgery you can surmise that something put in with a catheter probably won't have the durability of current surgical technique. We'll see, but I'd put my money on it. Again, the patients were high risk in PARTNER trial, so what about the average surgical valve candidate versus TAVR?

The stroke risk may not end up being as high as the original PARTNER data suggested. As the technique has been refined, it may be that the stroke risk becomes noninferior or maybe even superior to open AVR. Then again, maybe not.

Here's a screen grab from http://www.theheart.org/article/1348117.do , which shows some postmarketing data compared with the transapical cohort of PARTNER A, presented at the STS earlier this year. CAP=continued-access program. Specifically for the transapical approach (I wish they had more transfemoral data, but oh well), stroke rates came way down from the original PARTNER A numbers, maybe because the people doing the procedure got better at it, and passed their improved techniques on to other centers. Speculation, but we'll learn more as more of these get done.

I'm a huge fan of these procedures.