Lessons from the cardiac surgery experience!从心脏手术的经验教训！

1、Does transparency improve quality?lessons learnt from cardiac surgery BCIS meeting 2006Ben BridgewaterSMUHTHistory of cardiac surgical auditCardiac surgery register since 1977Cardiac surgery register since 1977UK database since 1994History of cardiac surgical auditCardiac surgery register since 1977

2、UK database since 1994Dr Foster/The Times 2001History of cardiac surgical auditCardiac surgery register since 1977UK database since 1994Dr Foster/The Times 2001Named unit mortality SCTS 2001History of cardiac surgical auditHistory of cardiac surgical auditCardiac surgery register since 1997UK databa

3、se since 1994Dr Foster/The Times 2001Named unit mortality SCTS 2001SCTS individual standards 2003Cardiac surgery register since 1997UK database since 1994Dr Foster/The Times 2001Named unit mortality SCTS 2001SCTS individual standards 2003Guardian named surgeon data 2005Freedom of Information ActHist

4、ory of cardiac surgical auditHistory of cardiac surgical auditCardiac surgery register since 1977UK database since 1994Dr Foster/The Times 2001Named unit mortality SCTS 2001SCTS individual standards 2003Guardian named surgeon data 2005Healthcare commission named surgeon data 2006History of cardiac s

5、urgical auditCardiac surgery register since 1997UK database since 1994Dr Foster/The Times 2001Named unit mortality SCTS 2001SCTS individual standards 2004Guardian named surgeon data 2005Healthcare commission named surgeon data 2006History of cardiac surgical auditCardiac surgery register since 1997U

6、K database since 1994Dr Foster/The Times 2001Named unit mortality SCTS 2001SCTS individual standards 2004Guardian named surgeon data 2005Healthcare commission named surgeon data 2006History of cardiac surgical auditCardiac surgery register since 1997UK database since 1994Dr Foster/The Times 2001Name

7、d unit mortality SCTS 2001SCTS individual standards 2004Guardian named surgeon data 2005Healthcare commission named surgeon data 2006History of cardiac surgical auditCardiac surgery register since 1997UK database since 1994Dr Foster/The Times 2001Named unit mortality SCTS 2001SCTS individual standar

8、ds 2004Guardian named surgeon data 2005Healthcare commission named surgeon data 2006IssuesHas public accountability improved quality?IssuesHas public accountability improved quality?Is there now a culture of risk-averse behaviour?Has public accountability improved quality?Mortality significantly hig

9、her than average Dr FosterMortality significantly lowerthan average Healthcare commissionHas public accountability improved quality? Risk adjusted mortality National data isolated CABGIncreased predicted riskDecreased observed mortalityHawthorn effectNew York state databasePennsylvania report cardsS

10、CTS databaseNorthern New England Cardiovascular study groupVA databaseNW regional audit project 1997 to 2001PublicdisclosureNodisclosureCollecting and using data improves the quality of outcomesWhy is public reporting important?Because it has driven data collection and useClinicians managers support

11、 staff professional organisations Is there now a culture of risk averse behaviour?Is there now a culture of risk averse behaviour?Newsnight survey of UK cardiac surgeons 200080% surgeons in favour of public accountability90% felt that high risk cases would be turned downOnly 6% felt that available a

12、lgorithms adjusted appropriately for riskSee also Burack 1999, Schneider and Epstein 1996, Narins 2005 Existing dataLittle hard statistical data investigating the influence of public accountability on cardiac surgical practiceNY experience suggests conflicting dataHannan 1996Dranove 2003Is there ris

13、k averse behaviour in the UK?Very difficult to measure surgical turndownsIf there was significant risk averse behaviour you would expect to see a decrease in the number of high risk cases coming to surgeryComplex issues with respect to surgical case mix due to PCI developmentsNorthwest data 1997 to

14、200525,730 patients under 30 surgeonsIsolated CABG aloneObserved and predicted mortalityNumber of low risk, high risk and very high patients each year2 time periods1997 to 2001 prior to public disclosure2001 to 2005 post public disclosureResultsSignificant decrease in observed mortalitySignificant i

15、ncrease in overall predicted mortalitySignificant decrease in risk adjusted mortalityResultsSignificant decrease in observed mortalitySignificant increase in overall predicted mortalitySignificant decrease in risk adjusted mortalityIs there now a culture of risk averse behaviour?No overall effectMay

16、 be transient or individual effectsImportant that this is mopped upIs 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 makingIs there now a culture of risk averse behaviour?What is perceived by someon

17、e as risk-averse behaviour is perceived by another as good clinical decision makingTransparency may have focussed the multidisciplinary team on optimising treatment strategies for individual patientsRisk adjustmentNo model is perfect some are usefulRisk adjustmentNo model is perfect some are usefulNeed clarity around fit for purposeRisk adjustmentNo model is perfect some are usefulNeed clarity around fit for purposeArguments about models can paralyse developmentsRisk adjustmentNo model is perfect some are usefulNeed clarity around fit for purposeArguments about models can paralyse develop