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![Page 1: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/1.jpg)
Does transparency improve quality?
lessons learnt from cardiac surgery
BCIS meeting 2006
Ben BridgewaterSMUHT
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History of cardiac surgical audit
• Cardiac surgery register since 1977
![Page 3: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/3.jpg)
• Cardiac surgery register since 1977
• UK database since 1994
History of cardiac surgical audit
![Page 4: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/4.jpg)
• Cardiac surgery register since 1977
• UK database since 1994
• Dr Foster/The Times 2001
History of cardiac surgical audit
![Page 5: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/5.jpg)
• Cardiac surgery register since 1977
• UK database since 1994
• Dr Foster/The Times 2001
• Named unit mortality SCTS 2001
History of cardiac surgical audit
![Page 6: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/6.jpg)
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
![Page 7: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/7.jpg)
• 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 audit
![Page 8: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/8.jpg)
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
![Page 9: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/9.jpg)
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
![Page 10: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/10.jpg)
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
![Page 11: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/11.jpg)
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
![Page 12: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/12.jpg)
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
![Page 13: Does transparency improve quality? lessons learnt from cardiac surgery BCIS meeting 2006 Ben Bridgewater SMUHT.](https://reader036.fdocuments.us/reader036/viewer/2022070323/56649da65503460f94a919f5/html5/thumbnails/13.jpg)
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Issues
• Has public accountability improved quality?
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Issues
• Has public accountability improved quality?
• Is there now a culture of ‘risk-averse’ behaviour?
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Has public accountability improved quality?
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00.5
11.5
22.5
33.5
4
% mortality
SMUHT CABG mortality
Mortality significantly higher
than average – Dr Foster
Mortality significantly lower
than average – Healthcare commission
Has public accountability improved quality?
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Risk adjusted mortality – National data – isolated CABG
0102030405060708090
100
Risk adjusted SMR
2001/02 2002/03 2003/04 2004/05
Increased predicted risk
Decreased observed mortality
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Hawthorn effect
• New York state database• Pennsylvania report cards• SCTS database
• Northern New England Cardiovascular study group
• VA database• NW regional audit project 1997 to 2001
Public
discl
osure
Nodis
closu
re
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Collecting and using data improves the quality of outcomes
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Why is public reporting important?
Because it has driven data collection and use
Clinicians managers
support staff professional organisations
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Is there now a culture of risk averse behaviour?
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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
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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
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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
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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
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Results
• Significant decrease in observed mortality
• Significant increase in overall predicted mortality
• Significant decrease in risk adjusted mortality
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Results
• Significant decrease in observed mortality
• Significant increase in overall predicted mortality
• Significant decrease in risk adjusted mortality
0
100
200
300
400
500
600
1997-2001
2001-2005
Number of high risk patients
High risk
Veryhigh risk
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Is there now a culture of risk averse behaviour?
• No overall effect
• May be transient or individual effects
• Important that this is ‘mopped up’
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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
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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
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Risk adjustment
• ‘No model is perfect – some are useful’
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Risk adjustment
• ‘No model is perfect – some are useful’
• Need clarity around ‘fit for purpose’
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Risk adjustment
• ‘No model is perfect – some are useful’
• Need clarity around ‘fit for purpose’
• Arguments about models can paralyse developments
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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
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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
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Good Luck!