<International circulation>:  Will you please summarize the opportunities， advantages， and or limitations of using large cardiovascular registries?

　　《国际循环》：能请您总结下大型心血管登记的机会，使用的优势，和（或）限制吗？
　　Dr Rumsfeld  :  Obviously a large question that is.  But I will pick a few things out to say.  Number 1， I think there are tremendous benefits to having a large clinical registry.  This has been proven in the US through systems such as the Department of Veteran Affairs， Kaiser， the American College of Cardiology， the American Heart Association and so forth.  What do I mean by that?  What I mean is that you can see how care is being delivered in routine clinical practice， this allows you to measure safety of therapies being routinely given in practice， it allows you to look for gaps in quality of care – where are we not doing a good job in delivery therapy， but also potentially lets you look at overuse and that is are our therapies appropriate.  And finally it gives you the real world sense you can marry the clinical data to other data sets to potentially look at cost or cost effectiveness of therapies in the real world.  So there are a lot of advantages.  What are the limitations of clinical registries?  Well they are not randomized trials so therapies are not designated so you are always going to be observing， you do not know about how much selection bias or selection went into giving a therapy.  So you have to be very careful what questions you asked.  Earlier I said that I think questions that are good are those around safety， those around gaps in care delivery， appropriateness of care， and you can do hypothesis generation.  It is a lot more challenging however to go compare Drug A to Drug B or Device A to Device B in observational data I think that is just hypothesis generating.  You need to do a clinical trial.  So that is a limitation.  Now where are we going in the future， just a couple of things.  One I think clinical registries are going to stop being so stand alone from regular clinical care delivery and that is with electronic health records