The dilemma of commissioning. The Isle of Wight Orthodontic Managed Clinical Network : a 3 year review. Part 1 : patterns of referrals

The key objective of developing the Isle of Wight orthodontic service managed clinical network (IOWOS MCN) was to create an integrated service measuring the referral patterns and, ultimately, the current orthodontic need. The first part of this two part series will describe the referrals to the integrated service during the period 2006–2009. A total of 2801 referrals was analysed of which 80% of the 11–18 year-old cohort referrals were considered to have high need for treatment, 8.5% were of moderate need and 11.8% of referrals were considered inappropriate. There was a high level of appropriate referral for orthodontic treatment within the IOWOS MCN but the method of calculating orthodontic need is complex. Clinical Relevance: This first part of a two part series provides an insight into some of the complexities of commissioning orthodontic care by reference to the referral data collected over the first three years of a recently established orthodontic managed clinical network on the Isle of Wight. </jats:p

The dilemma of commissioning. The Isle of Wight Orthodontic Managed Clinical Network : a 3 year review. Part 2 : referral outcomes

The key objective of creating the Isle of Wight orthodontic service managed clinical network (IOWOS MCN) was to create an integrated service measuring the referral and outcome data to inform future commissioning and service re-organization. Data were collected as part of a central referral triage process and were analysed from 2006 to 2009. The theoretical orthodontic need was assessed in the IOW population and compared to other methods of assessing need reported in the literature. The IOWOS referral outcomes were then compared to the expected theoretical outcomes. The referral outcomes were described and discussed in the first part of this two-part series. This second part provides an insight into some of the complexities of commissioning orthodontic care by reference to the referral outcome data. Clinical Relevance: There was a high level of appropriate referral for orthodontic treatment within the IOWOS MCN but the method of calculating orthodontic need is complex. </jats:p

Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy

BACKGROUND: the survival benefit of a strategy of coronary-artery bypass grafting (CABG) added to guideline-directed medical therapy, as compared with medical therapy alone, in patients with coronary artery disease, heart failure, and severe left ventricular systolic dysfunction remains unclear. METHODS: From July 2002 to May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to undergo CABG plus medical therapy (CABG group, 610 patients) or medical therapy alone (medical-therapy group, 602 patients). The primary outcome was death from any cause. Major secondary outcomes included death from cardiovascular causes and death from any cause or hospitalization for cardiovascular causes. The median duration of follow-up, including the current extended-follow-up study, was 9.8 years. RESULTS: A primary outcome event occurred in 359 patients (58.9%) in the CABG group and in 398 patients (66.1%) in the medical-therapy group (hazard ratio with CABG vs. medical therapy, 0.84; 95% confidence interval [CI], 0.73 to 0.97; P=0.02 by log-rank test). A total of 247 patients (40.5%) in the CABG group and 297 patients (49.3%) in the medical-therapy group died from cardiovascular causes (hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006 by log-rank test). Death from any cause or hospitalization for cardiovascular causes occurred in 467 patients (76.6%) in the CABG group and in 524 patients (87.0%) in the medical-therapy group (hazard ratio, 0.72; 95% CI, 0.64 to 0.82; P&lt;0.001 by log-rank test). CONCLUSIONS: In a cohort of patients with ischemic cardiomyopathy, the rates of death from any cause, death from cardiovascular causes, and death from any cause or hospitalization for cardiovascular causes were significantly lower over 10 years among patients who underwent CABG in addition to receiving medical therapy than among those who received medical therapy alone. (Funded by the National Institutes of Health; STICH [and STICHES] ClinicalTrials.gov number, NCT00023595)

Coronary-artery bypass surgery in patients with left ventricular dysfunction

&lt;p&gt;BACKGROUND The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established.&lt;/p&gt; &lt;p&gt;METHODS Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes.&lt;/p&gt; &lt;p&gt;RESULTS The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P&#60;0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG.&lt;/p&gt; &lt;p&gt;CONCLUSIONS In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes.&lt;/p&gt

Myocardial viability and survival in ischemic left ventricular dysfunction

BACKGROUND: The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS: In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS: Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS: The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.)