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The Risk Of Waiting Up To One Year For Cardiac Surgery
Márcio Madeira1, Jose Neves1, Tiago Nolasco1
1Cardiothoracic department, Santa Cruz Hospital, Portugal.
Insights
Cardiac surgery waiting times significantly impact patient mortality, with longer waits, especially in 2021, increasing risk. Implementing stricter surgical waiting list (SWL) time limits could reduce deaths.
Area of Science:
- Cardiovascular Surgery
- Health Services Research
- Epidemiology
Background:
- Cardiac disease poses significant mortality risks, compounded by comorbidities and extended waiting times for surgical intervention.
- The COVID-19 pandemic critically impacted surgical capacity and patient health, potentially exacerbating risks associated with delayed cardiac procedures.
- Understanding the dynamics of surgical waiting lists (SWL) is crucial for managing patient outcomes in cardiovascular care.
Purpose of the Study:
- To analyze the impact of waiting times on mortality for adult patients on the surgical waiting list (SWL) for cardiac surgery.
- To evaluate the influence of patient priority, age, and pandemic-related factors on mortality during the waiting period.
- To assess the potential benefits of implementing stricter time limits for SWL, drawing parallels with oncology waiting time protocols.
Main Methods:
- A prospective cohort study of 1914 adult patients registered on the SWL between January 2019 and December 2021.
- Analysis excluded urgent cases and outliers, focusing on waiting times from 4 days to one year.
- Patient priority was categorized using national criteria for non-oncologic and oncology surgery; mortality predictors were identified using Cox regression.
Main Results:
- During the study, 74% of patients underwent surgery, 19.2% remained on the SWL, and 4.3% were lost to follow-up.
- The overall mean waiting time was 167 ± 135 days, with significantly longer waits for higher priority groups (p<0.001).
- Mortality on the SWL was 2.5%, with independent predictors including age and the year 2021 (HR 2.07 vs. 2019). Applying oncology time limits could have significantly reduced risk (p=0.011).
Conclusions:
- Increased mortality in 2021, potentially linked to the COVID-19 pandemic, highlights the critical role of waiting time and pandemic-related factors.
- Waiting time, rather than risk stratification alone, is the most significant factor influencing mortality on the SWL.
- Implementing stricter time limits for cardiac surgery waiting lists, similar to oncology protocols, could substantially decrease patient mortality.
Introduction:
Cardiac disease is associated with a risk of death, both by the cardiac condition and by comorbidities. The waiting time for surgery begins with the onset of symptoms and includes referral, completion of the diagnosis and surgical waiting list (SWL). This study was conducted during the COVID-19 pandemic, which affected surgical capacity and patients' morbidities.
Methods:
The cohort includes 1914 consecutive adult patients (36.6% women, mean age 67 ±11 years), prospectively registered in the official SWL from January 2019 to December 2021. We analyzed waiting times ranging from 4 days to one year to exclude urgencies and outliers. Priority was classified by the national criteria for non-oncologic or oncology surgery.
Results:
During the study period, 74% of patients underwent surgery, 19.2% were still waiting, and 4.3% dropped out. Most cases were valvular (41.2%) or isolated bypass procedures (34.2%). Patients were classified as non-priority in 29.7%, priority in 61.8%, and high priority in 8.6%, with significantly different SWL mean times between groups (p<0.001). The overall mean waiting time was 167 ± 135 days. Mortality on SWL was 2.5%, or 1.1 deaths per patient/weeks. There were two mortality independent predictors: age (HR 1.05) and the year 2021 versus 2019 (HR 2.07) and a trend toward higher mortality in priority patients versus non-priority (p=0.065). The overall risk increased with time with different slopes for each year. Using the time limits for SWL in oncology, there would have been a significant risk reduction (p=0.011).
Conclusion:
The increased risk observed in 2021 may be related to the pandemic, either by increasing waiting time or by direct mortality. Since risk stratification is not entirely accurate, waiting time emerges as the most crucial factor influencing mortality, and implementing stricter time limits could have led to lower mortality rates.
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