Does transparency improve quality lessons learnt from cardiac surgery
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Does transparency improve quality? lessons learnt from cardiac surgery . BCIS meeting 2006 Ben Bridgewater SMUHT. History of cardiac surgical audit. Cardiac surgery register since 1977. History of cardiac surgical audit. Cardiac surgery register since 1977 UK database since 1994.

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Does transparency improve quality lessons learnt from cardiac surgery

Does transparency improve quality?lessons learnt from cardiac surgery

BCIS meeting 2006

Ben Bridgewater

SMUHT


History of cardiac surgical audit

History of cardiac surgical audit

  • Cardiac surgery register since 1977


History of cardiac surgical audit1

History of cardiac surgical audit

  • Cardiac surgery register since 1977

  • UK database since 1994


History of cardiac surgical audit2

History of cardiac surgical audit

  • Cardiac surgery register since 1977

  • UK database since 1994

  • Dr Foster/The Times 2001


History of cardiac surgical audit3

History of cardiac surgical audit

  • Cardiac surgery register since 1977

  • UK database since 1994

  • Dr Foster/The Times 2001

  • Named unit mortality SCTS 2001


History of cardiac surgical audit4

History of cardiac surgical audit

  • Cardiac surgery register since 1997

  • UK database since 1994

  • Dr Foster/The Times 2001

  • Named unit mortality SCTS 2001

  • SCTS individual ‘standards’ 2003


History of cardiac surgical audit5

History of cardiac surgical audit

  • Cardiac surgery register since 1997

  • UK database since 1994

  • Dr Foster/The Times 2001

  • Named unit mortality SCTS 2001

  • SCTS individual ‘standards’ 2003

  • Guardian named surgeon data 2005

    • Freedom of Information Act


History of cardiac surgical audit6

History of cardiac surgical audit

  • Cardiac surgery register since 1977

  • UK database since 1994

  • Dr Foster/The Times 2001

  • Named unit mortality SCTS 2001

  • SCTS individual ‘standards’ 2003

  • Guardian named surgeon data 2005

  • Healthcare commission named surgeon data 2006


History of cardiac surgical audit7

History of cardiac surgical audit

  • Cardiac surgery register since 1997

  • UK database since 1994

  • Dr Foster/The Times 2001

  • Named unit mortality SCTS 2001

  • SCTS individual ‘standards’ 2004

  • Guardian named surgeon data 2005

  • Healthcare commission named surgeon data 2006


History of cardiac surgical audit8

History of cardiac surgical audit

  • Cardiac surgery register since 1997

  • UK database since 1994

  • Dr Foster/The Times 2001

  • Named unit mortality SCTS 2001

  • SCTS individual ‘standards’ 2004

  • Guardian named surgeon data 2005

  • Healthcare commission named surgeon data 2006


History of cardiac surgical audit9

History of cardiac surgical audit

  • Cardiac surgery register since 1997

  • UK database since 1994

  • Dr Foster/The Times 2001

  • Named unit mortality SCTS 2001

  • SCTS individual ‘standards’ 2004

  • Guardian named surgeon data 2005

  • Healthcare commission named surgeon data 2006


History of cardiac surgical audit10

History of cardiac surgical audit

  • Cardiac surgery register since 1997

  • UK database since 1994

  • Dr Foster/The Times 2001

  • Named unit mortality SCTS 2001

  • SCTS individual ‘standards’ 2004

  • Guardian named surgeon data 2005

  • Healthcare commission named surgeon data 2006


Issues

Issues

  • Has public accountability improved quality?


Issues1

Issues

  • Has public accountability improved quality?

  • Is there now a culture of ‘risk-averse’ behaviour?


Has public accountability improved quality

Has public accountability improved quality?


Has public accountability improved quality1

Has public accountability improved quality?

Mortality significantly higher

than average – Dr Foster

Mortality significantly lower

than average – Healthcare commission


Risk adjusted mortality national data isolated cabg

Risk adjusted mortality – National data – isolated CABG

Increased predicted risk

Decreased observed mortality


Hawthorn effect

Hawthorn effect

Public

disclosure

  • New York state database

  • Pennsylvania report cards

  • SCTS database

  • Northern New England Cardiovascular study group

  • VA database

  • NW regional audit project 1997 to 2001

No

disclosure


Collecting and using data improves the quality of outcomes

Collecting and using data improves the quality of outcomes


Why is public reporting important

Why is public reporting important?

Because it has driven data collection and use

Clinicians

managers

support staff

professional organisations


Is there now a culture of risk averse behaviour

Is there now a culture of risk averse behaviour?


Is there now a culture of risk averse behaviour1

Is there now a culture of risk averse behaviour?

  • Newsnight survey of UK cardiac surgeons 2000

    • 80% surgeons in favour of public accountability

    • 90% felt that high risk cases would be turned down

    • Only 6% felt that available algorithms adjusted appropriately for risk

See also Burack 1999, Schneider and Epstein 1996, Narins 2005


Existing data

Existing data

  • Little ‘hard’ statistical data investigating the influence of public accountability on cardiac surgical practice

  • NY experience suggests conflicting data

    • Hannan 1996

    • Dranove 2003


Is there risk averse behaviour in the uk

Is there risk averse behaviour in the UK?

  • Very difficult to measure surgical ‘turndowns’

  • If there was significant risk averse behaviour you would expect to see a decrease in the number of high risk cases coming to surgery

  • Complex issues with respect to surgical case mix due to PCI developments


Northwest data 1997 to 2005

Northwest data 1997 to 2005

  • 25,730 patients under 30 surgeons

    • Isolated CABG alone

  • Observed and predicted mortality

  • Number of low risk, high risk and very high patients each year

  • 2 time periods

    • 1997 to 2001 – prior to public disclosure

    • 2001 to 2005 – post public disclosure


Results

Results

  • Significant decrease in observed mortality

  • Significant increase in overall predicted mortality

  • Significant decrease in risk adjusted mortality


Results1

Results

  • Significant decrease in observed mortality

  • Significant increase in overall predicted mortality

  • Significant decrease in risk adjusted mortality


Is there now a culture of risk averse behaviour2

Is there now a culture of risk averse behaviour?

  • No overall effect

  • May be transient or individual effects

  • Important that this is ‘mopped up’


Is there now a culture of risk averse behaviour3

Is there now a culture of risk averse behaviour?

  • What is perceived by someone as risk-averse behaviour is perceived by another as good clinical decision making


Is there now a culture of risk averse behaviour4

Is there now a culture of risk averse behaviour?

  • What is perceived by someone as risk-averse behaviour is perceived by another as good clinical decision making

  • Transparency may have focussed the multidisciplinary team on optimising treatment strategies for individual patients


Risk adjustment

Risk adjustment

  • ‘No model is perfect – some are useful’


Risk adjustment1

Risk adjustment

  • ‘No model is perfect – some are useful’

  • Need clarity around ‘fit for purpose’


Risk adjustment2

Risk adjustment

  • ‘No model is perfect – some are useful’

  • Need clarity around ‘fit for purpose’

  • Arguments about models can paralyse developments


Risk adjustment3

Risk adjustment

  • ‘No model is perfect – some are useful’

  • Need clarity around ‘fit for purpose’

  • Arguments about models can paralyse developments

  • Model ‘drift’

    • Calibration and weightings


Risk adjustment4

Risk adjustment

  • ‘No model is perfect – some are useful’

  • Need clarity around ‘fit for purpose’

  • Arguments about models can paralyse developments

  • Model ‘drift’

    • Calibration and weightings

  • Progress will be too slow for some and too quick for others


Does transparency improve quality lessons learnt from cardiac surgery

Good Luck!


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