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Effect of public reporting of surgeons’ outcomes on patient selection, “gaming,” and mortality in colorectal cancer surgery in England: population based cohort study

BMJ 2018; 361 doi: (Published 02 May 2018) Cite this as: BMJ 2018;361:k1581
  1. Abigail E Vallance, clinical research fellow1,
  2. Nicola S Fearnhead, consultant colorectal surgeon2,
  3. Angela Kuryba, data analyst1,
  4. James Hill, professor of surgery3 4,
  5. Charles Maxwell-Armstrong, consultant colorectal surgeon5,
  6. Michael Braun, consultant medical oncologist6,
  7. Jan van der Meulen, professor of clinical epidemiology1 7,
  8. Kate Walker, lecturer of medical statistics1 7
  1. 1Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
  2. 2Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Hills Road, Cambridge CB2 0QQ, UK
  3. 3Manchester Royal Infirmary, Manchester M13 9WL, UK
  4. 4Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9NT, UK
  5. 5National Institute for Health Research, Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham NG7 2UH, UK
  6. 6The Christie NHS Foundation Trust, Manchester M20 4BX, UK
  7. 7Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
  1. Correspondence to: J van der Meulen jan.vandermeulen{at}
  • Accepted 16 March 2018


Objective To determine the effect of surgeon specific outcome reporting in colorectal cancer surgery on risk averse clinical practice, “gaming” of clinical data, and 90 day postoperative mortality.

Design National cohort study.

Setting English National Health Service hospital trusts.

Population 111 431 patients diagnosed as having colorectal cancer from 1 April 2011 to 31 March 2015 included in the National Bowel Cancer Audit.

Intervention Public reporting of surgeon specific 90 day mortality in elective colorectal cancer surgery in England introduced in June 2013.

Main outcome measures Proportion of patients with colorectal cancer who had an elective major resection, predicted 90 day mortality based on characteristics of patients and tumours, and observed 90 day mortality adjusted for differences in characteristics of patients and tumours, comparing patients who had surgery between April 2011 and June 2013 and between July 2013 and March 2015.

Results The proportion of patients with colorectal cancer undergoing major resection did not change after the introduction of surgeon specific public outcome reporting (39 792/62 854 (63.3%) before versus 30 706/48 577 (63.2%) after; P=0.8). The proportion of these major resections categorised as elective or scheduled also did not change (33 638/39 792 (84.5%) before versus 25 905/30 706 (84.4%) after; P=0.5). The predicted 90 day mortality remained the same (2.7% v 2.7%; P=0.3), but the observed 90 day mortality fell (952/33 638 (2.8%) v 552/25 905 (2.1%)). Change point analysis showed that this reduction was over and above the existing downward trend in mortality before the introduction of public outcome reporting (P=0.03).

Conclusions This study did not find evidence that the introduction of public reporting of surgeon specific 90 day postoperative mortality in elective colorectal cancer surgery has led to risk averse clinical practice behaviour or “gaming” of data. However, its introduction coincided with a significant reduction in 90 day mortality.


  • Contributors: AEV conceived and designed the study, analysed the data, and drafted and revised the paper. AK prepared and analysed the data. JH designed the study and drafted and revised the paper. NSF conceived and designed the study, interpreted the results, and drafted and revised the paper. CM-A drafted and revised the paper. MB designed the study and drafted and revised the paper. JvdM designed the study, interpreted the results, and drafted and revised the paper. KW designed the study, analysed the data, and drafted and revised the paper. All authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. JvdM is the guarantor.

  • Funding: The National Bowel Cancer Audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme, and funded by NHS England and the Welsh Government ( Neither HQIP nor the funders had any involvement in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The researchers had full independence from the Healthcare Quality Improvement Partnership.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: As the National Bowel Cancer Audit involves analysis of data for service evaluation, it is exempt from the UK National Research Ethics Committee approval. Section 251 approval was obtained from the Ethics and Confidentiality Committee for the collection of the personal health data.

  • Transparency declaration: The lead author (AEV) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Data sharing: No additional data available.

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