Response to mostafaie and harrington

Abstract

3. Garces CV. Doctor-patient consultations in dyadic and triadic exchanges. Interpreting. 2005;7:193-210. 4. Jacobs E, Chen AH, Karliner L, Agger-Gupta N, Mutha S. The need for more research on language barriers in health care: a proposed research agenda. Milbank Quart. 2006;84:111-33. 5. Tocher TM, Larson E. Quality of diabetes care for non-English-speaking patients: a comparative study. West J Med. 1998;168:504-11. 6. Tocher TM, Larson EB. Do physicians spend more time with non-English-speaking patients? J Gen Intern Med. 1999;14:303-9. 7 concludes that preoperative b-blocker was significantly underutilized when compared with the current guideline recommendations. Despite the authors' acknowledgment that part of this underutilization is because of ongoing clinical questions regarding the appropriate selection of candidates for this therapy, the study design and the population described in this publication assumes that there is adequate evidence-based data supporting perioperative b-blocker use in patients with coronary artery disease (CAD) risk factors. We make objection to this conclusion. The authors cite the results of 2 randomized clinical trials carried out by Mangano and Poldermans and their colleagues. Mangano's study of 200 patients has been criticized since its publication a decade ago. Many concerns have been appropriately raised with regard to the analysis of only postdischarge data and the exclusion of 6 inpatient deaths (while patients were receiving the study drug postrandomization). Inclusion of these deaths in the analysis contradicts the conclusion of the study. Poldermans' study of 112 patients was un-blinded and limited to a very small group of highly selected patients undergoing vascular surgery. Data from 3 recent large null studies totaling 1,521 subjects (MaVS, POBBLE and DIPOM) failed to show any benefit. Additionally, Devereaux's review of 22 trials (that randomized a total of 2,437 patients) concluded that the evidence is too unreliable to allow definitive conclusions to be drawn. This meta-analysis clearly demonstrates that preoperative b-blockade is not without risk. Devereaux concluded that the individual safety outcomes in patients treated with perioperative b-blockers showed a relative risk for bradycardia needing treatment of 2.27 (95% confidence interval [CI] 1.53 to 3.36) and nominally statistically significant relative risk for hypotension requiring treatment of 1.27 (95% CI 1.04 to 1.56).In addition, the authors cite that many organizations have identified perioperative b-blockade as a quality measure. 2 We acknowledge that pay for performance is inevitable. Yet, the public and medical community's perception is that quality measures are based on recommendations derived from data supported by body of evidence-based literature. However, it can be readily appreciated that many guidelines, including those recently published by ACC/American Heart Association, 3 are not based on high quality evidence but instead on consensus opinion. Inevitably, this is further biased as man...