IACTS National Database—a clarion call to get rolling!

Record keeping in medicine has evolved slowly and painstakingly over time. Earlier, risk ‘scores’ were used as a way of counting events, a kind of head-count of patients developing complications. Overtime, with computer era dawning, these ‘scores’ have yielded to more complicated and detailed record keeping. From institutional and individual surgeon’s repositories, centralised state-level, national and global pooling of data have created complex and detailed disease and intervention-based databases. Static models have yielded to dynamic ones, revised periodically, with a view to generating ‘outcome’ data, pre-eminence of which was realised very early in the field of cardiovascular and thoracic surgery (CTVS).

Society of Cardiothoracic Surgery in Great Britain and Ireland was one of the first association to start its national database as early in 1977 and survival rates were monitored very actively. Soon thereafter, the German Society followed suit and a decade later the Society of Thoracic Surgery (STS) established its famed national database for outcome bench marking. Congenital cardiac surgery, however, remained a laggard and it was only towards the end of 1990s that the European Association of Cardiothoracic Surgery established the congenital cardiac surgery database. Sadly, India, despite its pre-eminence in the number games of volumes of CTVS surgeries performed per year, failed to put in place a national database. To give the devil its due, efforts were made, but sans any fervour or zeal. In addition, the lackadaisical response of the fraternity and the logistical bottlenecks drove the proverbial nail in the coffin. With this perspective, a renewed push for a National Database in CTVS has been made lately, albeit at the level of a few handpicked and willing institutions. Though delayed, but better late than never, this recent effort by the Indian Association of Cardiovascular and Thoracic Surgeons (IACTS) is indeed laudable and celebratory.

Just as we pat our backs, we need to be sensitised to the fact that very pithy to the concept of maintaining a national database is its completeness. An incomplete record, and limiting it to just a few institutions, will be antithetical to its very premise. It therefore should be sooner rather than later that the IACTS should throw open its database to the entire country to start sending their data, rather than spending too long a time improving on the existing one. Sufficient maturity and seasoning has already occurred with the current database for it to be explored by the entire fraternity. One must not forget the adage, ‘perfection is the enemy of good’. There would surely be some deficiencies in our existing database, but let us go ahead full steam with its current avatar and keep doing midcourse rectifications, rather than attempting correcting them all before launching the database for the entire country. Though a major step has been taken, we must realise that the database in its current shape is a static system. Just as when we gain momentum, with more centres joining and dataset numbers increasing, it will have to be converted into a dynamic modelling. Therefore, we should not sit back on our laurels, but make efforts to keep informing our static model, and at least for the moment, recalibrating it at regular intervals, with a final aim of developing newer dynamic models as we mature with our static modelling. In any case, we have already reasoned out that database can never ever be a fool-proof system and thus the need for dynamic modelling. Even important databases like the New York State Cardiac Surgery reporting system, the United Kingdom and Ireland Society of Cardiothoracic Surgery and the Netherland Association for Cardiothoracic Surgery revise their models virtually on yearly basis. STS does yearly recalibration and a thorough revision of the entire model every 3–5 years. We may like to choose the interval customised to our needs and resources. Another factor of paramount importance is the time lag between submission, analysis, and dissemination of information arising from the analysis. There is as such an inherent delay, as outcomes like 30-day mortality or 1-year survival will only be available after that much time after the event, by

which time the underlying construct may have changed and moved. If this is added to the avoidable delays, then the very purpose and ethos of dynamic modelling is lost if expedi- ency is not observed. In order to succeed, not only should there be diligence, honesty, and transparency in the data submitted, but also alacrity in its analysis and dissemination. The data, and thereby the guidelines, emerging from the developed European and North-American countries are not applicable to us. We must also realise that even within India, it being a diverse country, data emanating from Dravidian south may not be applicable to the Aryan north. Therefore, these databases will only come to fruition when the data is collated and analysed appropriately and efficiently, which may be aided by artificial intelligence and machine learning, at national and geographically distinct regional levels with a view to developing predictive models and generating prac- tice informing guidelines. These should be customised and personalised to the diverse population groups that abound in our plural country, based on the diversity of ethnicity, race, socio-economic factors and a panoply of geographical, climatic, cultural and anthropological factors. A caveat is in order here—in our quest of that elusive ‘Perfection’, we must not nip the ‘egg laying goose’! A sizeable number of CTVS surgeries are being performed in relatively smaller centres with limited Information Technol- ogy infrastructure. Surgeons practicing in these institutions are hampered further by lack of commitment of the admin- istrators and the corporate masters, which is an antithesis to success of such endeavours. We should therefore keep our database simple, and not copy affluent countries, so that they are neither labour, nor cost, intensive beyond a point that their universal adoption is threatened. Parsimony is the buzz word.

- By Dr. O.P. Yadava