National Survey of UK Consultant Surgeons’ Opinions on Surgeon-Specific Mortality Data in Cardiothoracic Surgery

Abstract

Background-In the United Kingdom, cardiothoracic surgeons have led the outcome reporting revolution seen over the last 20 years. The objective of this survey was to assess cardiothoracic surgeons' opinions on the topic, with the aim of guiding future debate and policy making for all subspecialties. Methods and Results-A questionnaire was developed using interviews with experts in the field. In January 2015, the survey was sent out to all consultant cardiothoracic surgeons in the United Kingdom (n=361). Logistic regression, bivariate correlation, and the χ 2 test were used to assess whether there was a relationship between answers and demographic variables. Free-text responses were analyzed using the grounded theory approach. The response rate was 73% (n=264). The majority of respondents (58.1% oppose, 34.1% favor, and 7.8% neither) oppose the public release of surgeonspecific mortality data and associate it with several adverse consequences. These include risk-averse behavior, gaming of data, and misinterpretation of data by the public. Despite this, the majority overwhelmingly supports publication of team-based measures of outcome. The free-text responses suggest that this is because most believe that quality of care is multifactorial and not represented by an individual's mortality rate. Conclusions-There is evident opposition to surgeon-specific mortality data among UK cardiothoracic surgeons who associate this with several unintended consequences. Policy makers should refine their strategy behind publication of surgeon-specific mortality data and possibly consider shift toward team-based results for which there will be the required support. Stakeholder feedback and inclusive strategy should be completed before introducing major initiatives to avoid unforeseen consequences and disagreements. (Circ Cardiovasc Qual Outcomes. 2016;9:414-423.

The Effect of Feedback on Surgeon Performance: A Narrative Review

“…Fostering surgeons to exhibit risk-averse behavior is another commonly cited reason to refrain from tracking individual surgeon data [ 8 , 14 – 16 ]. According to Jenkins and Cooper, this topic is the most frequently cited issue pertaining to negative consequences of publishing surgeon-specific data.…”

“…They define risk aversion behavior as when a “surgeon chooses not to operate on a patient perceived to be at risk of a poor outcome in order to improve results.” They also suggest that risk aversion reduces innovation [ 8 ]. In a study published by Jarral et al in the United Kingdom (UK), 86.6% of surveyed cardiothoracic surgeons believed that monitoring surgeon-specific mortality data has led to risk-averse behavior [ 14 , 17 ]. They also noted less-experienced surgeons are likely to share this opinion, and those playing an active role in tracking the mortality data were less likely to share this view.…”

“…In these scenarios, mortality data does not reflect the difference between an inability to rescue from death versus death due to surgeon error. Additionally, publicly reported outcome data creates an additional layer of risk taking, and more experienced surgeons may be more accustomed to taking risks [ 14 ]. Regardless, a majority of correspondents (74.7%) felt that trainee experience was harmed due to monitoring surgeon-specific mortality data, perhaps because surgeons are less likely to give independence to trainees [ 14 ].…”

Fostering a Culture to Support Surgical Outcome Measures

“…In this issue of Circulation: Cardiovascular Quality and Outcomes, these issues are highlighted in a study by Jarral et al 7 evaluating UK surgeons' attitudes about public reporting of surgeon-specific, risk-adjusted mortality rates. Astoundingly, three fourths of surgeons responded to the survey, an indication that surgeon-specific mortality rates are highly controversial.…”

Are there negative consequences of public reporting? The hype and the reality

“…It is noteworthy that there are 361 consultant cardiothoracic surgeons in the United Kingdom; thus, this newspaper article survey with 115 respondents captured less than one third of the cardiothoracic surgeons in the United Kingdom. 7 The incongruous statistics of the Telegraph article notwithstanding, if a surgeon felt that surgery were likely to result in death, then wouldn't a ''different treatment path'' be a reasonable consideration?…”