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Advanced Angioplasty 2005
League Tables, High Risk Procedures &
Risk Stratification:How to avoid the surgical trap
Bruce E KeoghPresident-elect Society of Cardiothoracic Surgeons
Healthcare Commissioner
Advanced Angioplasty 2005
1977
Advanced Angioplasty 2005
1977 - 2003
1977
Advanced Angioplasty 2005
1986: HCFA & New York State
Advanced Angioplasty 2005
1990
Advanced Angioplasty 2005
The 1990’s
• A series of adverse medical incidents– Birmingham, Bristol, Leeds– Exeter
• Adverse media comment leading to political pressure
• April 1997: The profession meets the CMO– Public confidence low– Address self regulation– Forget about anonymity and confidentiality
Advanced Angioplasty 2005
Crossing the Rubicon
Surgeons criticised for not acting on Register data
Advanced Angioplasty 2005
Towards public disclosure:The Kennedy Report
• 151: Systems for clinical audit and monitoring performance should be based on accurate and complete data.
• 154: Good IT systems which facilitate data collection, validation and provide aggregated feedback
• 27 and 155: Patients must be able to obtain information as to the relative performance of the trust… and consultant units within the trust
18th July, 2001“Bristol awash with data”
Advanced Angioplasty 2005
Accuracy of data depends on use
• Professionally credible– Specialty input
• Publicly credible– Independent
Accuracy & reliability
International Institutional Individual
Advanced Angioplasty 2005
Why is Validation Necessary?
Risk factor variation in New York:Before and after report cards
COAD
Unstable angina
Year 1
1.8%
1.9%
Year 2
52.9%
20.8%
Range
1.4 - 61%
0.7 - 61.4%
New York DoH spends 3 years validating data before release
Advanced Angioplasty 2005
The importance of data quality & validation
BMJ Jan 2003
Advanced Angioplasty 2005
Towards public disclosure:Secretary of State’s Response to the Bristol Royal Infirmary Inquiry
“For data on surgical outcomes to be published, of course, it needs to be robust, rigorous and risk-adjusted. That will take inevitably time. The report does recommend publication to give both NHS staff and the public accurate information. It recommends the establishment of a new independent Office for Information on Healthcare Performance within the Commission for Health Improvement to co-ordinate the collection and publication of data.”
18th July, 2001
Advanced Angioplasty 2005
Towards public disclosure:Dr Foster arrives
19th November, 2001The Times
Advanced Angioplasty 2005
Towards public disclosure:Some converging initiatives during 2001/2
Office for InformationOn Health Care
Performance
CHD Information
Strategy
Establisheddatabase
Better information for patients, professionals and the publicGROWING DEMAND FOR INDIVIDUAL SURGEON’S RESULTS
Appraisal &validation
Advanced Angioplasty 2005
Public disclosure in the United States
Advanced Angioplasty 2005
Towards public disclosure:Meeting with ministers on 9th January 2002
• Hardware, software and data managers in all units• Mandatory collection of the Society’s dataset• Trust CEO’s to be advised by Whitehall• Data collection to be resourced adequately• Data collection and analysis would be overseen by a
group with significant surgical input• Data validation based on Nuffield / Rand collaboration• Publication in 2004 based on two financial years
would be joint SCTS/DH. Dependent on facilities.
Advanced Angioplasty 2005
Towards public disclosure:Blue Book 29 October 2002
Unit specific dataUnadjusted mortality CABG & AVR Risk factorsMissing data
Advanced Angioplasty 2005
Towards public disclosure:The Health Service JournalDec 2002
May 2003
Advanced Angioplasty 2005
Fifth National Adult Cardiac Surgical Database ReportSeptember 2004
Evolving quality improvement initiativesThe UK Cardiac Surgical RegisterThe UK Heart Valve RegistryThe Cardiac Surgical DatabaseIndividual surgeon analyses
Advanced Angioplasty 2005
Advanced Angioplasty 2005
Advanced Angioplasty 2005
The EuroSCORE still cannot be calculated for 35% patients
Advanced Angioplasty 2005
Unit comparisons not adjusted for casemix
Heart Hospital
QE Birmingham
Advanced Angioplasty 2005
Mortality adjusted for casemix
Advanced Angioplasty 2005
Surgeon-specific analyses
Advanced Angioplasty 2005
Surgeon-specific analyses: 3 years
Advanced Angioplasty 2005
General right of access to information held by public authorities.Right to information
1. - (1) Any person making a request for information to a public authority is entitled-
(a) to be informed in writing by the public authority whether it holds information of the description specified in the request, and
(b) if that is the case, to have that information communicated to him.
Freedom of Information Act 2000 Chapter 36
Advanced Angioplasty 2005
Information tsar defies doctors
Patients and families will gain access to records despite the medical profession's worries
Martin Bright and Jo RevillSunday January 2, 2005The Observer
Patients and relatives will be given access to records about individual doctors' performances in a move by the freedom of information tsar that puts him on a collision course with sections of the medical profession.
Advanced Angioplasty 2005
Avoid the trap
• Jump before you’re pushed• Accept public disclosure of angioplasty outcomes• Consider CCAD as the vehicle for audit
– Invoke strong oversight through HCC– Consider quality measures other than death
• Urgent surgery• Re-intervention rates• Post intervention drugs & secondary prevention strategies• Back to work• Peer review of processes
– Pursue data validation– Consider the pros and cons of risk stratification– Develop an outlier and an emerging findings strategy