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Eur J Cardiothorac Surg 2006;29:62-63
© 2006 Elsevier Science NL
Papworth Hospital, Cardiac Surgery, Cambridge, CB3 8RE, UK
* Tel.: +44 1480 364299; fax: +44 1480 364744. (Email: sam.nashef{at}papworth.nhs.uk).
In the Italian CABG Outcome Study, Seccareccia and colleagues reported the immediate (30-day) mortality figures for coronary surgery in 64 Italian centres. The study covers more than 34,000 patients and relates the outcome to a national risk model developed using logistic regression. Outcomes are corrected for risk according to the national model and the findings are reported with anonymity for the participating centres. Outcomes are not given for individual surgeons.
The study, as reported, has some weaknesses. We may wonder about the criteria used for data validation (we are informed that data validation was carried out, but not about any preset criteria for good data or whether the participating units satisfied these criteria). We may question the need for a new 22-factor risk model in which 16 factors are identical or similar to EuroSCORE [1] factors. We may ask why the European model was not used alongside the new Italian model to see whether the authors' assertion that local models are superior is indeed supported by the data. Nevertheless, the importance of this paper transcends its weaknesses.
Two crucial findings emerge from this study. The first is that there is truly a difference in mortality outcomes between Italian centres, even when corrected for risk. This is not surprising in cardiac surgery, or any other medical field. The profession and the public will have to learn to live with this fact of life. The second is that one of the simplest ways to improve outcomes is to measure them. Although it did not quite reach statistical significance, the authors showed a compelling trend of outcome improvement over the period of the study. This so-called ‘registry effect’ is well recognised and forms one of the best motives for continually monitoring performance: it makes performance better.
Italy now joins the USA and the UK in regular monitoring of cardiac surgical outcomes. In the UK, these outcomes are no longer anonymous: they are published, by centre and even by named surgeon, in the Society of Cardiothoracic Surgeons Database Report [2] and, thanks to the recent passage of the Freedom of Information Act, in the national press [3]. The scrutiny of medical performance by governments, health care purchasers, the media and the public is here to stay. We surgeons have a choice: we can ignore the trend until it becomes strong enough to damage us, or we can take the lead in shaping the way outcome monitoring is done so as to protect our patients and ourselves from the publication of crude, unadjusted and unvalidated data. The Italian study and the recent UK experience provide good examples of surgeons collaborating with government and epidemiology authorities to produce meaningful data from which we can all learn. They are examples, which should be followed elsewhere. After all, if surgeons do not collaborate in such ventures, they will not stop the process: all that will happen is that information will still be somehow obtained and published, but it will be done badly.
Furthermore, if our profession is to survive and maintain the respect that it deserves, we must have quality monitoring built into the system at the level of the local centre. We should not wait until a national exercise in data collection highlights problems in local performance. The European specialty associations have already established the mechanism by which this can be done (www.ectsia.org) and are prepared to give due recognition to those centres which satisfy the criteria of robust local quality monitoring. If you believe your centre satisfies these criteria, why not put it to the test?
Finally, the nagging question remains: what should we do when centres perform less well than others, or as the paper so quaintly and delicately puts it, when there is ‘heterogeneity between outcomes’? In this regard, we have to distinguish two aspirations: the pursuit of excellence and the assurance of competence. Excellence will never be achieved everywhere. The purpose of such monitoring exercises is not to make every centre equally ‘excellent’. After all, when everyone is excellent, no one is. The most important target we should aim for is that every European cardiac surgical centre should perform to an acceptable standard. Our monitoring should allow us to identify those that do not and to implement action plans to improve performance so that they do reach the standard. Cardiac surgical patients and their families do not necessarily want the best surgeon at the best centre to perform all heart operations in Europe, even if that were possible. They do, however, have a right to know that when they or their loved ones are admitted to the local hospital for cardiac surgery, the care they will receive will be quality-assured and of an acceptable standard. They have a right to know that the care is monitored for the possibility of underperformance and that, if such underperformance is detected, corrective action is taken. Essential to the achievement of any of these aspirations is to know what we are doing and how well we are doing it. By providing data on national CABG outcomes in Italy, this paper is a step in the right direction.
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  L. A. Menicanti Reply to d'errico et Al. Eur. J. Cardiothorac. Surg., August 1, 2008; 34(2): 469 - 469. [Full Text] [PDF]
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L. A. Menicanti The surgeon, the statistics and the data Eur. J. Cardiothorac. Surg., March 1, 2008; 33(3): 323 - 324. [Full Text] [PDF]
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G. G.L. Biondi-Zoccai, M. Fusaro, and L. Inglese Potentials and pitfalls of clinical outcome research studies in cardiac surgery. Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 855 - 856. [Full Text] [PDF]
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K. Hekmat, U. Mehlhorn, and T. Wahlers Do we need the new Italian risk stratification model for CABG patients? Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 856 - 857. [Full Text] [PDF]
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