Better Options than Surgeon-Specific Mortality Data

Clinicians who see their own clinical outcomes data can use that information to promote and enhance patient safety. Although surgeon-specific mortality data (SSMD) is not generally used in the United States, it is used and publically released in the United Kingdom. Many surgeons there have rallied against SSMD, arguing that it leads the public to believe that the surgeon bears responsibility for all postoperative deaths regardless of clinical circumstance. They contend that SSMD under-appreciates the surgical team’s role and dismisses hospital staffing, infrastructure, and process as contributors to patient safety. Can one surgeon bear the entire burden when a patient dies during surgery?

A new study compares the British and American approaches, and ultimately its results heighten awareness of how transparency for the sake of transparency and without consideration of consequences is unwise. It is published by advance access in the European Journal of Cardio-Thoracic Surgery.

The American health care system employs different measurement and assessment tools—quality measures. They are derived from phase of care mortality analysis (POCMA) and failure to rescue (FTR), and are replacing SSMD.

These researchers used POCMA and FTR to analyze 1558 cardiac surgical patients operated on by 3 surgeons in the UK between 2009 and 2013. Four experienced surgeons reviewed records, circumstances of death, death certificates, and autopsy information.

Among the 1558 patients, 51 (3.3% mortality) patients died. The reviewers classified deaths into Class 1 surgeon dependent, Class 2 FTR, or Class 3 where multiple factors conspired to cause death.

Eighty-six percent of patients surveyed underwent autopsy; surgical error was identified as contributing to the death in less than 1% of those cases.

Patients who died were very likely to have high-risk status, older age, frailty, comorbidities, and or have had an emergency procedure.

FTR was the predominant factor occurring in 45% of cases. Intraoperative events were implicated in 37%. The remaining deaths were attributed to a combination of factors. Some FTR deaths occurred in low-risk patients. Scrutiny of FTR deaths provided important information that could be used for quality improvement.

The authors conclude that the operating surgeon is unable to prevent most deaths. Deaths are usually related to patient comorbidity, lack of process, or infrastructure. They opine that the UK’s current system of attributing deaths to a named surgeon disguises numerous deficiencies in NHS infrastructure that must be addressed to improve outcomes. In contrast, POCMA and FTR highlight problems of process, and are more likely to promote advances in surgical care.