Surgeons’ performance data to be available from JulyBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3795 (Published 11 June 2013) Cite this as: BMJ 2013;346:f3795
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Publishing of surgeons data has not been trailed outside Cardiac surgery. Cardiac surgery and perhaps some operations like hip and knee replacements have defined end points and mortality rate is a recognised and valid outcome measure which is in some though not all respects an indicator of the surgeons performance. This unfortunately does not apply to many other specialties.
Typically, 98 per cent of in-patients survive their visit, so nearly all the data about what happens in a given hospital are ignored if we concentrate on mortality rates. Not only that, but of the 2 per cent who don’t survive, only a few will have died an ‘avoidable’ death, and it is only those deaths that can be used to measure the quality of care.
The data used for producing mortality figures is also far from perfect. Last year’s HES summary statistics record, for instance, that of the 785,263 in-patient episodes coded under Obstetrics, 16,992 were recorded for male patients!
Though no one can have any objections to publishing performance tables, my objection is to that of publishing only a fraction of a surgeons clinical activity which can be a misleading indicator of the quality of the care that he/she provides. The basic premise upon which the publishing of surgeons mortality rates, namely that it will inform the public in deciding which surgeon to choose, is flawed. Short-term mortality is not by itself an adequate indicator of quality of care or resource use. On the opposite, morbidity is a major determinant of hospital cost and quality of life after surgery. Being more frequent than mortality, it could carry more information and be measured in terms of postoperative complications and length of hospital stay. However, for most scoring models, predictive values for morbidity are considerably lower than predictive values for mortality.
A surgeon would be judged by colleagues on the extent of morbidity as well as on things like extent of tumour resection, functional restoration, postoperative pain, position of implants etc and not pure mortality alone.
Mortality depends upon patient factors but also upon the anaesthetist, cleanliness of the hospital, physiotherapy, nursing labels etc. One might make the argument that despite this, the mortality rate is still useful as it will tell the patient their chances of survival if that patient has surgery in that hospital by that surgeon. But if the then surgeon moves to another hospital, presumably the tables won't then necessarily be meaningful.
A major problem comes in the difficulty of risk stratifying. Preoperative heart failure in coronary surgery maybe a very important factor in mortality but sepsis may be the dominant factor in abdominal surgery or preoperative Glasgow coma scale might be the dominant factor in causing mortality from surgery for intracranial haemorrhage. There are certain units which would take on higher risk cases than others with the risk not being reflected in the current risk stratifying measures used which depend on comorbidities and demographic factors rather than the risk involved in the technical procedure which is harder to quantify in a table.
Certain operations like oesophagectomy carry a higher mortality in low volume centres though this is not true for many operations. As reported recently, certain regions carry a higher mortality in the actual population even within a country like England. . Surgeons operating on more vital parts of the body will have a higher mortality rate than other surgeons within the same specialty who operate on less vital parts of the body. For example vascular or skull base neurosurgeons will have a higher mortality than spinal neurosurgeons. There are currently no proposals to take these factors into account when publishing the mortality figures.
Perhaps more importantly, there is the problem of how publishing this data will influence surgeons behaviour. Consider if you have condition x (eg a large intracranial hamatoma in a elderly person)where the chances of surviving without surgery is nil and the chances of surviving with surgery is say one in two. if there is an undue emphasis placed on looking at operative mortality and no one is looking at non-operative mortality, there will be a temptation for a surgeon to manage this condition nonoperatively. By publishing league tables of operative mortality and not looking at non-operative mortality you are pushing surgeons to not operate on conditions with a known high mortality and this could in fact worsen patient outcomes.
This is like conducting a major exam without having an invigilator to make sure no one is cheating. It is irresponsible at best and criminal at worst as lives will be needlessly lost.
Competing interests: No competing interests