advanced angioplasty 2005 league tables, high risk procedures

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


1977


1977 - 2003

1977


1986: HCFA & New York State


1990


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


Crossing the Rubicon

Surgeons criticised for not acting on Register data


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”


Accuracy of data depends on use

• Professionally credible– Specialty input

• Publicly credible– Independent

Accuracy & reliability

International Institutional Individual


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


The importance of data quality & validation

BMJ Jan 2003


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


Towards public disclosure:Dr Foster arrives

19th November, 2001The Times


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


Public disclosure in the United States


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.


Towards public disclosure:Blue Book 29 October 2002

Unit specific dataUnadjusted mortality CABG & AVR Risk factorsMissing data


Towards public disclosure:The Health Service JournalDec 2002

May 2003


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


The EuroSCORE still cannot be calculated for 35% patients


Unit comparisons not adjusted for casemix

Heart Hospital

QE Birmingham


Mortality adjusted for casemix


Surgeon-specific analyses


Surgeon-specific analyses: 3 years


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


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.


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

advanced angioplasty 2005 league tables, high risk procedures

Documents

public accurate information

publication of data

accuracy of data

register data

data managers

complete data

public authoritywhether

public authorities