International Circulation: Is there any indication at this stage as to how much coronary revascularization performed in the United States is unnecessary or at least not completely necessary?
　　《国际循环》：关于在美国有多少已开展的冠状动脉血运重建是不必要的或者至少不是完全必要的，眼下有什么迹象吗？
　　Prof Brindis: That is a very important question. Up to just this year， we did not know that answer. In fact， there is a television program the equivalent of Oprah Winfrey featuring Doctor Oz and on his show， which a lot of America watches， he said that 30%-50% of all angioplasty in the United States was unnecessary. Incredible! Through our document where we could determine whether it is appropriate， inappropriate or uncertain， and using the National Cardiovascular Data Registry and Cath Angioplasty Registry we are able to evaluate whether it’s appropriate， inappropriate or uncertain to do angioplasty. Just this summer， in the major journal JAMA， we published the results of the last 600，000 angioplasties in the United States as to their appropriateness. What we found is that about 4% of all angioplasty is inappropriate， not the 30%-50% that Doctor Oz had reported. However， we did see important areas that cardiologists can improve on. We do angioplasty most of the time in the United States for patients who are having a heart attack or having accelerated angina. But about 29% of angioplasties in the United States are patients who have stable angina or no symptoms. When we looked at that 29% group， we found that there is about 12% of inappropriate angioplasty and about 35% of uncertain angioplasty. So this is the area where we have the most important opportunity to improve on minimizing waste. Not only does it cost money to do inappropriate angioplasty， there can also be untoward effects including death as a needless complication of angioplasty. This is very important information. The other piece of important information is that when we looked at all the hospitals， there is a marked range of who was doing inappropriate angioplasty. Some hospitals had a very low inappropriate rate with stable angina， but there were actually some hospitals， through their own admission of data submitted to the registry， that had a 40% inappropriate use of angioplasty. Now， with this data actually being fed back to the hospitals and physicians where it was never fed back before， we are convinced people will examine their practice patterns and improve their ability to do angioplasty to the right person at the right time for the right situation.
　　Brindis教授：这是一个非常重要的问题，直至今年，我们还不知道答案。事实上，有一个与Oprah Winfrey相当的由Doctor Oz主演的电视节目，有很多美国人在观看这个节目，在其节目中他说在美国所有血管成形术中30％~50％是不必要的。难以置信！通过我们的文档我们可以确定它是否适当，不适当或不确定，且利用全国心血管数据注册中心和导管血管成形术注册中心，我们能够评估做血管成形术是否适当、不适当或不确定。就在今年夏天，在重要的杂志《JAMA》上，我们就其适当性发表了美国近期60万例血管成形术的结果。我们所发现的是，所有血管成形术中约4％是不恰当的，而不是Doctor Oz曾报道的 30％~50％。然而，我们的确看到心脏病医生可以改善的重要领域。在美国，我们多数情况下是对正有心脏病发作或有恶化型心绞痛的患者进行血管成形术。但在美国约29％的血管成形术是对有稳定型心绞痛或无症状的患者。当我们来考察这个29％的群体时，我们发现有约12％的不适当血管成形术和约35％的不确定血管成形术。因此，这是我们最重要的机会所在以在减少浪费上有所改善。开展不恰当的血管成形术不仅花钱，还可能有不良反应，包括血管成形术的不必要并发症——死亡。这是非常重要的信息。另一个重要信息是，当我们考查所有的医院，在做不恰当血管成形术的变化范围相当大。有些医院稳定型心绞痛的不适当率非常低，但实际上有些医院通过他们提交到注册中心的数据自己承认，有40％的血管成形术为不适当使用。现在，通过将这个数据切实反馈给这些医院和医生，这是以前从来没有反馈过的，我们相信人们将审视他们的实践模式，并提高其能力以在合适的情况下于合适的时间对合适的人开展血管成形术。
　　International Circulation: People may criticize that the study was done by cardiologists and they might not trust the cardiologists to examine their own practice. Is that a question that has been raised at all?
　　《国际循环》：人们可能会挑剔由心脏病医生所做的研究，他们可能不信任由心脏病医生来检验自身的实践。这是一个已经浮现出来的问题吗？
　　Prof Brindis: It is a fair comment and as we say in the United States， it is like the fox guarding the chickens. My own comment is that no one can best determine appropriateness of care than the cardiologist can. I personally believe it is the professional responsibility of us as a professional society to arm hospitals and physicians with the infrastructure tools with which to do so. To answer directly the concept of the fox guarding the chicken coop， we have auditing strategies in place where the data itself can be looked at by independent healthcare professionals， so we have the ability to check the accuracy of the data being submitted. Certainly， to be completely honest， people can always ‘game the system’ but there is no other specialty that even has registries. There is no other specialty that has even set up parameters and there is no other specialty that is actually examining its own practice patterns to improve care. It is something we should be proud of. I am proud of my colleagues here in China because they also are now developing a registry and are also looking at patterns of care. Now again ， with the appropriateness， not only is there the issue of misuse or overuse， but there is the important issue of actual underuse where there are patients in  the United States， due to racial disparity and/or  socio-economic disparity who are not getting care. I am told here by my Chinese colleagues， that there is a big differential of care， for example， between rural areas and city areas. By having registries and examining this data， maybe we can address some of these underuse issues so we can allow care to be available to all our patients.
　　Brindis教授：这是一个公正的评论，如同我们在美国所说，这就像看守鸡的狐狸。我自己的评论是，没有人能比心脏病医生更恰当地确定治疗的适当性。我个人认为，作为一个专业的社会，用要做什么这样的基础工具来武装医院和医生是我们的专业责任。直接回答看守鸡窝的狐狸的概念，我们通过独立的专业医护人员在可以观察数据本身之处审核策略，所以我们有能力核查所提交数据的准确性。当然，老实说，人们可以永远“游戏系统”，但没有其他的专业曾有过注册中心。甚至没有其他专业曾设立参数，没有其他专业切实检验其自身的实践模式以改善医疗。这是我们应当感到自豪的地方。我为我在中国的同事们感到自豪，因为他们现在也正在建立一个注册中心，也在审视医疗的模式。现在又在审视适当性，不仅有滥用或过度使用的问题，还有目前实际应用不足的重要问题，其中有由于种族差异和（或）社会经济差异而得不到医疗的美国患者。我的中国同事告诉我，这里存在着巨大的医疗差异，例如在农村和城市地区之间。通过有注册中心并审查这个数据，也许我们可以解决某些应用不足的问题，因此我们可以使我们所有的患者都能得到医治。

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