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Time Until Treatment Equipoise A New Concept in Surgical Decision Making

Alia Noorani, MRCS1; Mikko Hippelainen, MD2; Samer A. M. Nashef, FRCS1
[+] Author Affiliations
1Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, England
2Department of Cardiothoracic Surgery, Kuopio University Hospital, Kuopio, Finland
JAMA Surg. 2014;149(2):109-111. doi:10.1001/jamasurg.2013.3066.
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When operations are performed purely on prognostic grounds, the decision to operate is based on weighing the risk of the intervention against that of no intervention (conservative treatment). Because the risk of the former is usually immediate and that of the latter is spread out, the time over which the risk is measured becomes important, and this is heavily dependent on the patient’s age. There is no accepted method of comparing risk between conservative and invasive therapies. Furthermore, there is no agreed standard that relates the magnitude of risk to the passage of time. We therefore propose a new approach to help in decision making for both physicians and patients contemplating invasive interventions for purely prognostic indications. This approach is not proposed for operations carried out to relieve symptoms.

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A, Survival vs time for a hypothetical condition with 10% surgical and 5% annual mortality for conservative management. Time until treatment equipoise (TUTE) occurs at 56 months. B, TUTE for asymptomatic tight left main stem coronary artery stenosis is 2 months. C, TUTE for acute type A aortic dissection is 46 hours. D, TUTE for a 6-cm ascending aortic aneurysm is 38 months. E, TUTE for anatomic repair of congenitally corrected transposition of the great arteries is 55 years.

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