Cardiac surgery: the fall guy in medical quality assurance

The General Medical Council has recently been grappling with the problem of measuring and comparing surgical outcomes after complex surgery in a heterogeneous patient population with differing severities of illness.1 Cardiothoracic surgery, with its immediate, and sometimes catastrophic outcomes, is the first surgical specialty to come under such scrutiny. Inevitably the media coverage has dented public confidence in the ability of the medical profession to police itself, and in particular this has been focused on cardiothoracic surgery.1 Yet, the irony is that in the United Kingdom cardiothoracic surgery has better data and is more subject to internal scrutiny than perhaps any other specialty.

The Society of Cardiothoracic Surgeons has a long history of audit. In 1977 Sir Terence English established the United Kingdom cardiac surgical register,2 which collects activity and mortality data on all cardiac surgical procedures performed in each NHS cardiac surgical unit, amounting to 35 000 procedures a year. Although apparently simple in concept, the process represented the first attempt in Britain by any specialty to collect national activity and outcome data.

All data are anonymised, since this was a prerequisite for encouraging voluntary data submission from all units. Similarly the United Kingdom heart valve registry has collected national valve surgery data since 1986. Linkage of this registry to the Office for National Statistics means we now have unique 10 year survival data following heart valve replacements in the NHS. 3 18

Both registries return aggregated data to each member of the society as an annual report containing national activity and mortality data for a wide range of cardiac operations. Since inception the presumption has been that access to national information would draw each surgeon's attention to his or her own performance and encourage …