Saturday, 23 March 2013

Surgical Outcomes Reporting - why we are Missing the Point.

JAMA Network | JAMA Surgery | Failure to Rescue Patients After Reintervention in Gastroesophageal Cancer Surgery in EnglandFailure to Rescue in Gastroesophageal Cancer

Although cardiac surgery is very different from other surgical specialties (and cardiac surgeons seem alien to many!) there is a lot I, as a cardiac surgeon can learn from more conventional surgical specialties. I often browse through thoracic and general surgical journals. I even enjoy reading the Annals of my College - the Royal College of Surgeons of England. I stop short however of reading orthopaedic rags - I have never had ANY professional affinity with that lot - no offence boys/odd female!!
I digress. This paper in JAMA surgery (the journal formerly known as Archives of Surgery!) is fascinating. It confirms what has been previously publicized in yet another excellent piece by surgeon racconteur, Atul Gawande in this piece in the New Yorker. Gawande describes the findings of a research study from University of Michigan that demonstrated that a major reason for variation in mortality rates after surgical procedures between different hospitals was not the incidence of things going wrong or morbid events but the ability of the institution to rescue patients once things went pear shaped. This study from England looking at events occurring after (o)esophagectomy replicates these findings. If one thinks about the incidence of morbid events or death after surgery, these findings are perhaps not so surprising. We know from many studies in different surgical specialties that a major contributor to the spread of incidences of complications are the patients themselves - advanced age, co-morbid conditions etc.   But how much does the surgeon's ability contribute to variation in mortality between centres after surgery? In any one developed country, the vast majority of surgeons are trained to the same standards -standards which  do not vary greatly between schools of surgery. In addition graduates from each school end up working all over the country. Both these factors contribute to the uniformity and narrow standard deviations of surgical ability in any one country.  This  paper is therefore significant on a number of levels - it confirms the fact on both sides of the Atlantic that variation between surgical outcomes are due predominantly to systemic institutional factors. It is also important because Bruce Keogh, medical director of the National health service in England and ex cardiac surgeon has decided that many surgical specialties should follow the Cardiac Surgeons and publicly report individual surgeons' outcomes. There is a moral case for this - patients are entitled to know what the clinical outcomes of the surgeon who is about to operate on them, are. This paper above, other studies and common sense suggest however that Bruce Keogh and many of the colleges and professional societies who support this stance, are missing the point.