Excerpt
With the ever evolving world order, the mechanics of practice of medicine too have changed. Earlier the catheter (hic… Cardiologist) was moving from one hospital to the other, but now the epithet—‘The Roving Scalpel’ (hic… Cardiac Surgeon) seems more apt and infact ubiquitous. Dwindling volumes as a result of onset of percutaneous interventions, both for coronaries and valves, as also a large number of mergers and acquisitions with new strategies based on networking of multiple low-volume centres, and they being serviced by a single team, have opened up new vistas. The dissemination of off-pump coronary artery bypass graft (CABG) seems to have added fuel to this, notwithstanding the fact that elaborate open heart surgery paraphernalia may not be even present in a centre, where these surgeries are being performed. Does this affect the patient care? What if a patient crashes and needs cardiopulmonary bypass support? What if a surgeon is involved in a major operation, just as when he is required for a previously operated patient in another institution? A recent study by Shroyer et al. [
1] looks at just this scenario which now seems to be common-place in India. They use the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Data base for 543,403 CABG procedures performed between 2011 and 2014 spread across 1120 centres and involving 2676 cardiac surgeons. Nearly one fourth of the surgeons were operating at multiple centres and their observed-to-expected mortality ratios were higher than single centre surgeons (1.06 vs 0.97,
p < 0.001). When data for multi-centre surgeon was further sub-analysed, the observed-to-expected mortality ratio was higher for surgeries performed at the satellite centre versus the primary operating facility (1.17 vs 1.01;
p < 0.001). Compared with single centre surgeons, multi-centre surgeons had higher mortality rate (1.7 vs 1.6%,
p < 0.001) and a higher major adverse complication rates (11.9 vs 10.5%;
p < 0.0001). As more and more centres with tertiary care facilities are burgeoning in tier two and three cities, with very limited supply of the tertiary care human resources, this issue assumes paramount importance in our country. For the sake of economic expediency, a lot of corporate groups maintain one single team, which is made to rotate on daily basis by a rota to various satellite centres in a ‘wheel and spoke’ model of delivery of health care. This has found favours with both the health care providers as also the patients, who get delivery of tertiary health care services at their door steps. However, is this trend benign or does this compromise the interests of the patients? My take—no and yes respectively. …
