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PEER review of surgical mortality rates has been so successful and produced such positive changes to clinical practice that the public reporting of the results is “inevitable”, according to Australian safety and quality experts.
Dr James Aitken, chairman of the WA Audit of Surgical Mortality (WAASM), said peer review and the availability of data in the public domain led to better outcomes for patients.
“There are any number of papers that state that when you audit and review you get changes in practice and improved outcomes for patients”, Dr Aitken told MJA InSight.
He was responding to a review of the first 10 years of the landmark WAASM, published in the MJA, which found that the external peer-reviewed mortality audit had “changed surgical practice and reduced deaths”. (1)
“The same process should be applied to other sentinel events, and the lessons learned can also be extended to non-surgical specialties”, the review authors wrote.
The retrospective analysis of WAASM data collected from 2002 to 2011 found: the annual number of deaths peaked in 2006, then fell 30% by 2011, correcting for population growth. The researchers found that some changes in practice, for example, in pancreatic surgery, thromboembolic prophylaxis, consultant supervision and fluid management, were directly attributable to WAASM.
A shift of high-risk patients to teaching hospitals with a greater ability to “rescue” patients after complications was also a factor in improving outcomes.
Dr Aitken, who described himself as “a hawk” on the issue of public reporting, said Australia was still “miles away” from the situation in the UK where public reporting of hospital surgical mortality rate data had been routine since the 2001 report into the deaths of children undergoing complex cardiac surgery in Bristol. (2)
Dr Aitken said that since July this year all specialist surgical societies in the UK must publish their annual outcomes report.
The data show the number of times a consultant has carried out a procedure, mortality rates and whether clinical outcomes for each consultant are within expected limits. (3)
“In Australia, people want open and transparent data reporting, but we’re miles away from it”, Dr Aitken said.
He said in the UK the drive for public reporting was led by the profession because “they realised that if they didn’t get involved in the process then it would happen anyway ― it would be imposed on them by the government”.
Professor Guy Maddern, chair of the Royal Australasian College of Surgeons’ annual national audit of surgical mortality, said there was a “great cultural change” happening in Australia and progress was being made.
“There was a lot of suspicion 10 years ago but now people can see that [peer-reviewed auditing] is making a difference for the better”, Professor Maddern told MJA InSight.
“The issue of public reporting has to be supported but only when surgeons and hospitals can see that the data are reliable and robust.
“WAASM shows you can influence substantial change.”
Professor Maddern said the national audit was moving towards more open disclosure. After routinely refusing to identify states by name, this year’s report, due later this year, would allow comparison of state data.
Dr Michael Smith, clinical director of the Australian Commission on Safety and Quality in Health Care, said the success of peer-reviewed auditing came down to trust.
“This is a trusted process because it involves a small group of colleagues who know each other and have a shared culture and understanding of good practice in their field”, he told MJA InSight. “Therefore they trust the outcomes of the audit and there is a preparedness to learn from it, which leads to clinical change.”
That in turn lead to positive responses from the public, Dr Smith said.
“Having this kind of information available to the public is good because it shows that there are robust mechanisms in place for their safety and that those mechanisms are making a positive difference.”
Dr Aitken said there was scope to extend the process of peer-reviewed audit beyond mortality rates into morbidity.
“We could be targeting key events like returns to theatre — clearly defined, discrete events that can be easily measured”, he said.
1. MJA 2013; 199: 539-542
2. Department of Health 2001; The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1985: learning from Bristol
3. NHS 2013; Consultant treatment outcomes
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I think this is absolutely essential. I myself am a consumer – ie – I had the whipple procedure in 2008 – one of the rare ones still around.
I think people who are considering surgery for any gastrointestinal cancer should be able to have a look and see what the success rate is from surgeon to surgeon.
I am just fortunate that I landed in the hands of [a competent surgeon -edit].
I totally agree with the first two comments, by anonymous and 60y old specialist, respectively. Literal and inadequate interpretation of the data as well as quality of data collection is a major problem. Data collection and assessment and audit has to be objective. “Quality and Safety” is relevant to products, services and toys (5). Engendering the right climate for collegiate support requires objective and prospective independent evaluation methods and independent review of decisions made by Tribunals and the Medical Board is essential. The goal of assessment is not mortality and or morbidity statistics. Valuing patient Rights and our responsibility are at the heart of “due care” to ensure the goal of medical treatment, i.e. patient “happiness”.
Responding to “60 yr old specialist”: I don’t agree that “taking on the hard, the difficult, or the controversial” can only result in a negative outome. The literature clearly shows that poor communication and insufficient patient involvement in hard, difficult or controversial decisions DOES result in problems, but if patients and or carers are fully involved they are much less likely to complain / accuse. (Non surgical cases included)
If you are referring to statistical outcomes then I would hope that the data is properly adjusted for those sorts of cases.
And if there are consistently bad surgical outcomes for these cases then there must surely be something wrong somewhere ( Bristol being a case in point).
To anonymous: I agree – any kind of vilification is not helpful. The art of this is that there needs to be maturity and collegiality and support when confronted with unpleasant data.
THE SPECIALIST COMMENT MAKES A LOT OF SENSE. FIGURES SUCH AS THESE COULD BE FUDGED AND THEREFORE COULD NOT REALLY BE BELIEVED.
To ask people to find and/or report errors for the benefit of patients and future patients requires strong ethical and altruistic drivers.
If there is any negative outcome to the individual or institution for being upfront, willing and honest, the numbers will be at best ‘gamed’ and at worst totally corrupt.
Public reporting of peer review in non-aggregated or identifiable form is a recipe for bad outcomes to patients, individual doctors and institutions.
Why would a specialist take on the hard, the difficult or the controversial patient when the outcome can only be negative? Operating on or treating the ‘nearly-well’ is the best career choice in such a system.
Clearly defined outcomes based reporting that cannot be gamed is the correct public information.
Given any two numbers, one will be greater than the other. That’s the problem in a nutshell. Unacceptable outliers should be dealt with under a defined system, not villified in public. Who’d become a doctor?