In Reply We welcome the comments by Forbes about our article1 in measuring low-value endovascular repair of abdominal aortic aneurysms (EVAR), but we disagree with his conclusions.
First, he objects to our use of the American Society of Anesthesiologists (ASA) classification to define “high-risk” patients. Identifying “high-risk patients with limited life expectancy” in our data is challenging. Given the available variables, our clinical advisers agreed that using the ASA classification is reasonable. Although the interrater reliability for the ASA score is moderate, the score is a valid indicator of perioperative risk.2 It needs to be emphasized that the ASA III and IV definitions are predicated on “severe systemic disease,” implying vulnerability to death or poor outcomes owing to major organ insufficiency, which may be exacerbated by invasive intervention. This is separate to having an aneurysm in isolation. Although there may be some inconsistencies in how these definitions are interpreted or recorded, we believe it is better to produce the best measurements that we can with current data, recognize their limitations, and improve them as better data become available, rather than to abandon measurement as too hard.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Badgery-Parker T, Elshaug AG. In Low-Value Care, Less Is (Not Always) More—Reply. JAMA Intern Med. 2019;179(8):1148. doi:10.1001/jamainternmed.2019.1659
Coronavirus Resource Center
Customize your JAMA Network experience by selecting one or more topics from the list below.