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Publishing individual surgeons’ death rates prompts risk averse behaviour

BMJ 2014; 349 doi: (Published 12 August 2014) Cite this as: BMJ 2014;349:g5026
  1. Stephen Westaby, consultant cardiac surgeon, Oxford, UK
  1. swestaby{at}

Most deaths are related to team dynamics and hospital infrastructure rather than surgical error, says Stephen Westaby, and publishing surgeon specific mortality data is unhelpful for the profession—and patients

A surgeon was recently castigated in the press for allegedly manipulating operative data.1 Failing to ask why, journalists missed the bigger picture—that of a surgical profession under stress. Repeating the US experience, publication of surgeon specific mortality data (SSMD) has shifted emphasis from patient care to self preservation.2 3 Meanwhile, surgeons struggle to maintain low death rates in outdated facilities with inconsistent teams and without circulatory support devices available in other European countries.4

In the 1980s the US Health Care Financing Administration collected but did not disclose individual death rates for New York state cardiac surgeons.3 A newspaper sued and then published the information, but was criticised, and soon afterwards, risk averse behaviour and gaming with risk stratification were widely documented.5 The answer was to avoid high risk patients. In Massachusetts, the risk profile in centres with higher mortality fell.3 Cardiologists struggled to obtain coronary artery bypass grafts for comorbid patients, but not in cases exempt from reporting. Published outcomes for primary percutaneous coronary angioplasty showed that patients with cardiogenic shock were less likely to receive treatment.3 Risk adjustment provided little consolation. Patients do not understand or engage with risk algorithms.6

Risk averse behaviour exists. …

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