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Improving mortality of coronary surgery over first four years of independent practice: retrospective examination of prospectively collected data from 15 surgeons

BMJ 2004; 329 doi: (Published 19 August 2004) Cite this as: BMJ 2004;329:421
  1. Ben Bridgewater, consultant cardiac surgeon (ben.bridgewater{at},
  2. Antony D Grayson, regional clinical information analyst2,
  3. John Au, consultant cardiothoracic surgeon4,
  4. Ragheb Hassan, consultant cardiac surgeon3,
  5. Walid C Dihmis, consultant cardiac surgeon2,
  6. Chris Munsch, consultant cardiac surgeon5,
  7. Paul Waterworth, consultant cardiac surgeon1

    North West Quality Improvement Programme in Cardiac Interventions

  1. 1 South Manchester University Hospital, Manchester M23 9LT
  2. 2 Cardiothoracic Centre, Liverpool L14 3PE
  3. 3 Manchester Royal Infirmary, Manchester M13 9WL
  4. 4 Blackpool Victoria Hospital, Blackpool FY3 8NR
  5. 5 Leeds General Infirmary, Leeds LS1 3EX
  1. Correspondence to: B Bridgewater
  • Accepted 14 June 2004


Objective To study the “learning curve” associated with independent practice in coronary artery surgery.

Design Retrospective analysis of prospectively collected data.

Setting All NHS centres in north west England that carry out cardiac surgery in adults.

Participants 18 913 patients undergoing coronary artery surgery for the first time between April 1997 and March 2003, 5678 of whom were operated on by 15 surgeons in the first four years after their consultant appointment.

Main outcome measures Observed and predicted mortality (EuroSCORE) for surgeons in their first, second, third, and fourth years after appointment as a consultant compared with figures for established surgeons.

Results Overall mortality decreased over the six years of study (P = 0.01). Of the patients operated on by established surgeons or newly appointed consultants, 265/13 235 (2.0%) and 109/5678 (1.9%), respectively, died (P = 0.71). There was a progressive decrease in observed mortality with time after appointment as a consultant from 2.2% in the first year to 1.2% in the fourth year (P = 0.049). This result remained significant after adjustment for time and case mix (P = 0.019).

Conclusions Mortality in patients operated on by newly appointed consultant surgeons is similar to mortality in patients operated on by established surgeons. There are significant decreases in crude and risk adjusted mortality in the four years after appointment. These findings should influence the nature of practice in newly appointed surgeons.


  • This study has been conducted on behalf of the north west quality improvement programme in cardiac interventions, and the consultant surgeons involved were John Au, Ben Bridgewater, Colin Campbell, John Carey, John Chalmers, Walid Dhimis, Abdul Deiraniya, Andrew Duncan, Brian Fabri, Elaine Griffiths, Geir Grotte, Ragheb Hasan, Tim Hooper, Mark Jones, Daniel Keenan, Neeraj Mediratta, Russell Millner, Nick Odom, Brian Prendergast, Mark Pullan, Abbas Rashid, Franco Sogliani, Paul Waterworth, and Nizar Yonan. Narinda Bhatnagar, Albert Fagan, Bob Lawson, and Udin Nkere. Peter O'Keefe, Richard Page, Ian Weir, and David Sharpe left the collaboration during the study period. We thank the audit officers working in each centre for their hard work in collecting and validating the data and Mark Jackson for his analytical advice.

  • Contributors BB had the idea for the study and along with ADG was responsible for the study design and analysis. All authors contributed to preparation of the manuscript. BB is guarantor for the study.

  • Funding Funding for the programme was received from all primary care trusts in north west England. All authors were independent from the funding.

  • Competing interests None declared.

  • Ethical approval Ethical approval for the north west quality improvement programme was obtained from the regional ethical committee.

  • Accepted 14 June 2004
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