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Quality Assessment in Cardiac Surgery: Do Not Miss the Boat!

Cambridge, UK
¹ Nova Scotia, Canada

The first 20% of the full text of this article appears below.

We are on the threshold of a brave new world in which the measurement of cardiac surgical performance will no longer be peripheral to our work, but an integral part of it: as important as the indication for surgery. Moreover, the tools and mechanisms we devise and develop are likely to form the models on which the quality of care is assessed in other surgical and perhaps medical specialties.

CRUDE MORTALITY IS NOT ENOUGH

Doctors have traditionally done their best for their patients. For physicians, if the treatment failed and the patient succumbed, the blame fell normally on the disease, not on the treatment or on the practitioner. It is different for surgeons, where there is an inevitable link between operative mortality and the measurement of surgical performance. Whenever operative mortality is mentioned, surgeons proclaim that they operate on higher risk patients than their colleagues. When mortality for a specific procedure is higher for one surgeon (or hospital) than another, this can be due to one of three reasons, or a combination of the three:

1. The difference is due to chance
   
2. The difference is due to variation in the predicted risk of the patients (different casemix)
   
3. The difference reflects better and safer service to correct for casemix, some measure of risk assessment or predicted mortality must be available.
   

HOW DO WE MEASURE RISK?

Risk models abound. They range from simple additive scoring systems, such as Parsonnet¹ and EuroSCORE² to complex Bayesian and logistic models such as the Society of Thoracic Surgeons (STS) database model,³ the UK Bayesian model⁴ and the EuroSCORE logistic model.⁵ Additive models are easy to use, and are sufficiently simple to remember so that a quick mental calculation can be made at the bedside or "on the back of an envelope". Their main weakness is in . . . [Full Text of this Article]