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BMJ 2009; 339 doi: (Published 11 November 2009) Cite this as: BMJ 2009;339:b4610

Disappointing outcomes after off-pump CABG

Coronary artery bypass grafting (CABG) can be done with or without cardiopulmonary bypass. But surgery with cardiopulmonary bypass is better, according to a randomised controlled trial from the US. Patients placed on bypass during surgery (on pump) did better in the long run than those treated without bypass (off pump)—rates of death, revascularisation, or heart attack were significantly lower in the first year after surgery (7.4% (78/1099) v 9.9% (105/1104); P=0.04). Off-pump surgery did not reduce the risk of complications or death in the first month and was associated with worse graft patency after a year (82.6% (1650/1998) v 87.9% (1839/2095); P<0.01).

Researchers had hoped that off-pump surgery would help preserve patients’ cerebral function. It didn’t. Patients in both groups had similar subtle changes in neuropsychological performance. Patients treated off pump consumed as many healthcare resources as controls treated the traditional way.

These patients were somewhat younger and healthier than many patients needing coronary artery bypass surgery in clinical practice. They were almost exclusively male. Other subgroups, including women, may still benefit from avoiding cardiopulmonary bypass, says an editorial (p 1897). Further analyses should be done to identify them. Patients treated off pump in this trial were more likely than controls to receive fewer grafts than planned, which could lead to less durable revascularisation and worse outcomes.

When sacrificing a little benefit saves a lot of money

In most spheres of economic activity, consumers can choose cheaper new products if they don’t mind (slightly) poorer quality. A team of health policy experts argues that even in health care there may be room for new treatments that are almost as good as the best, but very much cheaper. A few such wise buys could, in theory, free up resources for treatments considered “higher value” by society.

But there aren’t many to choose from. A systematic search of cost-utility studies …

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