Monday, 29 November 2010

A MEERKAT REVOLUTION


This weekend, it is reported that Dr. Foster, which is an organisation that analyses outcome data, has published report cards for all acute hospitals in the National Health Service in the UK. Although they have published league tables of risk adjusted mortality rates for hospitals in the past, this is the first time they have used the 'report card' format. The outcomes they have chosen are useful but arbitrary. Spokespersons for the hospitals which have not done well have come up with the usual responses that the report cards do not accurately reflect the risk profile of their local populations .
One outcome which Dr. Foster have used and which I think is quite interesting is the death rate after low risk surgical procedures. It reminds me of a study presented at the annual meeting of our society by Samer Nashef who is a cardiac surgeon at Papworth Hospital in Cambridge and one of the founding fathers of the Euroscore system. The study had the amusing acronym FIASCO . Essentially the deaths of patients with a low Euroscore who died after cardiac surgery were analysed. The numbers involved were as expected very small and within the range expected from their Euroscore. Because of the small numbers involved, this was not a quantitative study with p values but a more of a qualitative one with an in depth analysis of the sets of notes of every individual patient who had died. One reason why this study in particular interested me is that I have written previously on M&M meetings and the way they should be conducted. Anyway back to FIASCO. The study revealed , not surprisingly that low risk deaths are frequently associated with organisational failures. The whole point of surveillance and outcome publishing is to root out correctable failings of any individual hospital. Low risk deaths are therefore a fertile ground to explore and compare.
In the mainstream media , the part of the Dr. Foster's report that has been highlighted has been the one on the small number of hospitals that have significantly higher mortality. What is rapidly becoming clear to me is that these reports, how they are presented and the significance of their content are only really understood by outcome aficionados. Patients ( at whom they are supposed to be aimed) probably never read them because the reports are bewilderingly plentiful, not easily accessible, and are mostly indigestable. The media are selective in their reports and either deliberately or through ignorance misinterpret the results. As a libertarian, I would like to see aids for patients to make choices. However despite attempts by a number of governments over the years, the whole choice agenda still seems alien to me (and even more to patients) when it comes to the National Health Service. Can you really have a market with plurality of supply when it's already paid for. If and when patients have to make a choice , we need a Compare the Meerkat or a Go Compare revolution .
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