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EDITORIAL |
Cambridge, UK
1 Nova Scotia, Canada
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:
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 the specific prediction of risk in very high-risk patients, where they underestimate risk. More complex models can be more accurate for individual risk assessment. The authors naturally favour the EuroSCORE risk models, but it probably does not matter too much which model is used, as long as risk is properly assessed.
THE VALUE OF PREDICTING MORTALITY
The most important advantage of assessing the risk of death is to incorporate this knowledge in the determination of the indication to operate. The corollary of this is informed consent: if the surgeon needs this information to help determine whether there is an indication for surgery, then the patient needs it before agreeing to surgery. The second benefit is in the assessment of the quality of care: risk prediction gives a standard, corrected for casemix, against which the performance of hospitals, units and surgeons can be measured.
TWO APPROACHES TO QUALITY MONITORING
There are two ways by which the quality of a surgical service can be observed. The first is by "naming and shaming" or in other words, public disclosure of outcome data, with hospitals lined up in a "league table" or "hit parade" according to their clinical outcomes. This approach discourages improvement and encourages a defensive and potentially destructive stance. The second is by peer review mechanisms, formalised into quality accreditation and the issue of good practice certificates by peers. This can be used to encourage quality improvement.
LEAGUE TABLES (KNOWN IN THE US AS REPORT CARDS)
Whenever journalists and politicians have access to information about hospital procedure numbers and mortality, they will invariably present the information as a league table, with one hospital at the top (lowest mortality) and one at the bottom (highest mortality). Having begun in New Jersey and New York, this has already happened in much of the United States and has recently spread to the United Kingdom through the work of an organisation called "Doctor Foster".6
Simplistic league tables carry a substantial risk of misinterpretation. Data may not be validated and contain errors sufficiently large to affect the true position of hospitals in the tables. Differences perceived by the layman may be due to chance and may vary with time. Most importantly, when the tables take no account of risk stratification, any conclusions from them may be invalid as a reflection of the true quality of surgical work. Even if all the above factors are dealt with there is the inevitable damage to the hospital at the "bottom" of the table: if it is perceived to be "the worst", it will close or stop working, with the inevitable result of the next hospital becoming "the worst" and so forth.
A more real and alarming concern is that the easiest way to move up a league table is to refuse to operate on high-risk patients. Since these are often the patients who stand to gain most from cardiac surgery, the human cost of such a trend will be exorbitant. Report cards in the United States have already caused problems for surgeons, institutions and patients alike. Shahian and colleagues have identified the occurrence of gaming, refusal to operate on high-risk patients and referral to distant centres as some of these problems.7 Grunkemeier has cast doubt on the validity of existing measures of casemix to deal with the statistical and medical complexity of cardiac surgical practice.8 Such a system of public release of data may actually preclude honest self-examination and improvement under the threat of public scrutiny.
Despite the substantial knowledge base on risk assessment in cardiac surgery, the Times newspaper (London) published league tables of CABG mortality in the United Kingdom without proper risk stratification. Having established a range of mortality between of 1-4% across the country, the accompanying article began: "scores of patients are dying unnecessarily..." The lesson from this is that if cardiac surgeons themselves do not carry out outcome assessment well, others will do it for them, and do it badly.
QUALITY ACCREDITATION AND GOOD PRACTICE: THE LAUNCH OF ECTSIA
The events at Bristol in the United Kingdom have highlighted the need for quality monitoring in medicine in general and in cardiac surgery in particular.9 It is now totally unacceptable for a unit or a surgeon to continue to operate in complete ignorance of their own performance. Good quality surgical work requires knowledge of three crucial variables: what the unit or surgeon is doing (activity), the expected outcome (risk prediction) and the actual outcome (performance). In addition, there must be a preset level of acceptable performance, and a robust mechanism for dealing with situations where the actual performance is below target. The Society of Cardiothoracic Surgeons (SCTS) in Britain has already begun the process of implementing programmes of quality accreditation based on these principles.4 In Europe, the three major specialist societies have agreed to establish the European Cardiovascular and Thoracic Surgery Institute of Accreditation (ECTSIA).10 The mission is to implement quality monitoring throughout Europe and worldwide.
CONCLUSION
Public dissemination of results is here to stay and is only likely to increase. In fact, performance monitoring is soon to become imperative. Achieving this using quality accreditation as planned by ECTSIA will be good for patients and surgeons. It is important to remember that this approach does not seek to compare institutions and surgeons, but simply to ensure that robust quality monitoring is present in every surgical service in our specialty. Furthermore, such a system will facilitate the next step of ongoing quality improvement. Only if surgeons are intimately involved in the process of quality assessment, rather than hostile to it, can substantial improvements in quality be made.11,12
The alternative approach, favoured by media and governments, is to publish outcomes in league table form. This will almost certainly damage both surgeons and patients. This approach of removing the "bad apples" would not solve the problem; problems are often in the process rather than the people.11,13 We have the opportunity to avoid this trap and head towards a more constructive approach that will allow for a focus on improvement of care.14
Mortality, is only one of many outcomes that determine the success of a procedure, others being morbidity, functional outcome, long-term survival and freedom from re-intervention. Operative survival, however, is the sine qua non, without which none of the other parameters can be measured. It is also the first step in establishing performance assessment, and until we have a robust method of measuring it correctly and meaningfully, attention to other areas as a performance measure may be premature. Once this has been achieved and accepted we can move on to systematic quality improvement.
To paraphrase Francois Roques, we are at the quayside and the quality assessment boat is signalling that it is about to depart. If we surgeons are not on board, we shall have no control on its course nor on its final destination, and the consequences may be equally unpleasant for us and for our patients.
Samer A M Nashef, MD
Consultant Surgeon, Papworth Hospital, Cambridge, UK
Chairman, EACTS Audit and Guidelines Committee
Joint Leader, the EuroSCORE Project
Roger J F Baskett, MD
Assistant Professor, Cardiac Surgery
Dalhousie University, Halifax
Nova Scotia, Canada
REFERENCES
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