To the Editor: Cokis and Faris describe an intraoperative complication detected by transoesophageal echocardiography (TOE).1 Their letter is interesting in that it describes a rare complication during aortic valve surgery, and it is provocative in that it is critical of the Department of Health and Ageing decision not to rebate TOE (except in valve repair or replacement) to anaesthetists.

A rare complication is not an argument for routine monitoring. Justification for monitoring requires detailed analysis of complication rates. The number needed to monitor for this and other complications is not known. Cokis and Faris do not discuss the rate of complications from TOE, which could be similar to that of the rare complication they describe.

That there is a link between efficacy and the likelihood of a Medicare rebate is yet to be shown, and the authors themselves allude to this. TOE can be performed without a rebate. This is good for patients and also for a healthcare service which is strapped for funds. There are arguably other pressing needs for Medicare funds in the healthcare system. Presumably, both doctors were remunerated for their presence at the operation.

Eligibility for a Medicare rebate can be a “perverse incentive” leading to overservicing. I have seen this with monitoring with TOE. Procedures have a clinical and financial cost as well as perceived benefit. I have seen other diagnoses missed or misinterpreted because of routine use of TOE, and it has occasionally led to prolonged intensive care unit stays and other complications.

None of my arguments should deny TOE a place as a useful monitoring tool. It may become as routine during cardiac surgery as central venous pressure and arterial pressure monitoring is now. Whether that happens should not depend on whether TOE is eligible for a Medicare rebate. The use of TOE during surgery should depend on whether there is evidence of a meaningful benefit, and it is well to remember that the routine use of any procedure is hard to justify and can sometimes be dangerous. Early in Australian cardiac surgery, it was argued that the rebate for coronary bypass surgery should be related to the number of grafts. This argument was rightly not accepted. Similarly, the rebates for cardiac anaesthesia should not be related to the number of monitors used.

Cokis and Faris should be commended on their excellent care of the patient. However, their argument for a rebate is not compelling.

In reply: Stokes raises a number of relevant issues, but we would like to make the following points.

The case we reported occurred in a teaching hospital and neither of us undertakes routine transoesophageal echocardiography (TOE) in a private capacity.

While a Medicare rebate is not directly relevant to the clinical usefulness of a medical procedure, the Medicare Benefits Schedule functions as a surrogate marker for clinical legitimacy.

Stokes quotes anecdotes of occasional misuse or overuse of TOE. We agree that single cases neither justify nor give cause to reject a particular kind of monitoring. However, case reports, although lacking a denominator, are a start.

The main point of our letter was, in fact, to report the complication of surgery and the vital role played by TOE in achieving a good outcome.

Nevertheless, many of us who routinely use TOE consider that its advantages over other kinds of monitoring regularly benefit patients. We agree there is little “hard” evidence to support this, but detailed risk–benefit analysis for many of our routine monitoring devices is similarly non-existent. The Swan–Ganz catheter is a classic example.

We suspect that if a group of cardiac anaesthetists and surgeons was asked to review the usefulness of TOE in routine cardiac surgery, the decision of the Department of Health and Ageing might be different.