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EDUCATION AND DEBATE: Bruce Keogh, David Spiegelhalter, Alan Bailey, James Roxburgh, Patrick Magee, and Colin Hilton The legacy of Bristol: public disclosure of individual surgeons' results BMJ 2004; 329: 450-454 [Full text]

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Would this have worked?

Kevin E Pearce   (22 August 2004)

Professional and organizational accountability required for report cards.

Faizal Baharuddin   (28 August 2004)

public disclosure of individual surgeons' results

Paul Aylin, Brian Jarman   (17 September 2004)

Would this have worked? 22 August 2004
Kevin E Pearce, GP Harrow HA26HL Send response to journal: Re: Would this have worked?	Would this process have detected those surgeons deemed to have failed in Bristol? Competing interests: None declared
Professional and organizational accountability required for report cards. 28 August 2004
Faizal Baharuddin, Postgraduate Student Dept of Epidemiology and Preventive Medicine,Monash University, Melbourne 3141VIC Send response to journal: Re: Professional and organizational accountability required for report cards.	Editor – I write with reference to the article by Keogh et al (1) on the public disclosure of individual surgeons results. The increasing awareness of medical errors and patient safety and the significant contribution to cost of healthcare has contributed to the development of systems that can improve the processes and delivery of healthcare. Major discussions throughout quality circles on what range of parameters constitutes the best measurement of quality have been ongoing. The complexities and controversies surrounding the definition and measures of quality further complicates the issue which is confounded by the information asymmetry between the provider (healthcare systems, healthcare professional systems) and consumer (public, patients). The step taken by the Society of Cardiothoracic Surgeons of Great Britain and Ireland to standardize data across the board is an excellent first step in clinical risk management and ensuring professional accountability (an accountability tool) (2) to the public and patients. As the authors, I too believe that the issuing of report cards (efforts for quality improvement and performance measures) as a reflection of competence based on the clinical outcome of the patient is a controversial issue as it involves very complex dynamics of care (the patient, the surgery, the surgeon etc). In his paper, it was mentioned that of the surgeons reviewed, issues of process and organization rather than technical, surgical ability have usually been the underlying problem. If this is the case it would then seem appropriate for factors which contribute to organizational accountability be included in the report card. It would be interesting to see what are the organizational factors that were causing the ‘problems’, how they manifest, what are the reliable methods of measuring this manifestations and whether they are specialty specific and how they can be treated. (1) Keogh B, Spiegelhalter D, Bailey A, Roxborough J, Magee P, Hilton C. The legacy of Bristol: public disclosure of individualsurgeons’ results. BMJ 2004;329:450-4. (2) Timmermans S, Berg M. The Gold Standard: The Challenge of Evidence Based Medicine and Standardization in Health Care. Temple University Press 2003 pg 112. Competing interests: None declared
public disclosure of individual surgeons' results 17 September 2004
Paul Aylin, Clinical Senior lecturer in Epidemiology Imperial College, St. Mary's Campus Norfolk Place, London, W2 1PG, Brian Jarman Send response to journal: Re: public disclosure of individual surgeons' results	We welcome the initiative to publish surgeon specific data in cardiac surgery. However although we recognise that the report card is not intended as a surveillance system, we would argue that the method proposed by Keogh et al. for presentation of surgeon specific data is limited in its usefulness. Taking Mr Keogh’s published annual caseload of 80 coronary artery bypass operations per year (240 over three years) as an example, a surgeon would meet SCTS standards even with a mortality of three times the national average. The surgeon could continue to meet the society's standards at this high level of mortality for the rest of their career (assuming a rolling three year assessment period). Although the paper addresses adult cardiac surgery, it is interesting to apply the same standards to the situation that occurred in Bristol. Taking the published figures provided to the Bristol Inquiry into paediatric cardiac surgery,[1] based on Hospital Episode Statistics from the period 1991-95, the unit was carrying out an average of just under 35 open operations per year on children aged under one year. Assuming the work load was split evenly between two surgeons, this would equate to an average workload of some 50 cases per three year period. The unit’s mortality was 29% compared to a national average of 12%. Using the 4 SD limit proposed by the society, each surgeon would still be deemed to have met SCTS standards. We suggest that a truly transparent process would make more detailed information available, including actual death rates by surgeon. References [1] Aylin P, Alves B, Best N, Cook A, Elliott P, Evans SJW, Lawrence AE, Murray GD, Pollock J, Spiegelhalter D, Comparison of UK paediatric cardiac surgical performance by analysis of routinely collected data 1984-96: was Bristol an outlier? Lancet 2001;358: 181-87 Competing interests: Funded by a research grant from Dr Foster Ltd.