Ben Bridgewater

There are obvious parallels between producing league tables in education and health care, with both agendas being driven by politicians and the media, while finding resistance from teachers and doctors. Over the last few years there has been particular scrutiny on mortality results in cardiac surgery, leading to publication of comparative mortality outcomes following coronary artery surgery, aortic valve surgery and all cardiac procedures for individual hospitals and surgeons.2^–7 The issues around “substrate”, type of outcome, analysis and interpretation regarding schools league tables also apply to cardiac surgery mortality outcomes.

Objectives: To compare implications of using the logistic EuroSCORE and a locally derived model when analysing individual surgeon mortality outcomes. Design: Retrospective analysis of prospectively collected data. Setting: All NHS hospitals undertaking adult cardiac surgery in northwest England. Patients: 14 637 consecutive patients, April 2002 to March 2005. Main outcome measures: We have compared the predictive ability of the logistic EuroSCORE (uncalibrated), the logistic EuroSCORE calibrated for contemporary performance and a locally derived logistic regression model. We have used each to create risk-adjusted individual surgeon mortality funnel plots to demonstrate high mortality outcomes. Results: There were 458 (3.1%) deaths. The expected mortality and receiver operating characteristic (ROC) curve values were: uncalibrated EuroSCORE −5.8% and 0.80, calibrated EuroSCORE −3.1% and 0.80, locally derived model −3.1% and 0.82. The uncalibrated EuroSCORE plot showed one surgeon to have mortality above the northwest average, and no surgeon above the 95% control limit (CL). The calibrated EuroSCORE plot and the local model showed little change in surgeon ranking, but significant differences in identifying high mortality outcomes. Two of three surgeons above the 95% CL using the calibrated EuroSCORE revert to acceptable outcomes when the local model is applied but the finding is critically dependent on the calibration coefficient. Conclusions: The uncalibrated EuroSCORE significantly overpredicted mortality and is not recommended. Instead, the EuroSCORE should be calibrated for contemporary performance. The differences demonstrated in defining high mortality outcomes when using a model built for purpose suggests that the choice of risk model is important when analysing surgeon mortality outcomes.

Primary cardiac sarcomas are rare tumors with an unfavourable prognosis. Complete surgical resection is currently the only mode of therapy proven to show any benefit. We report the cases of two patients presenting with features of obstruction and embolism and a presumed diagnosis of left atrial myxoma. At operation they were unexpectedly found to have large tumours raising strong suspicions of malignancy. Due to the extensive involvement of intracardiac structures with little possibility of reconstruction together with poor general condition of the patient, debulking was deemed to be the only viable option. Subsequent histology confirmed the diagnosis of sarcoma in both patients. Surgery produced immediate and effective symptom relief. The first patient died four months after the operation and second patient is still alive at 12 months after her operation. A brief review of literature on cardiac sarcoma is presented.

Objectives: To study changes in coronary artery surgery practice in the years spanning publication of cardiac surgery mortality data in the UK. Methods: A retrospective analysis of prospectively collected data from all National Health Service centres undertaking adult cardiac surgery in northwest England was carried out. Patients undergoing coronary artery surgery for the first time between April 1997 and March 2005 were included. Changes in observed, predicted and risk adjusted mortality (EuroSCORE) were studied. Evidence of risk-averse behaviour was looked for by examining the number of patients at low risk (EuroSCORE 0–5), high risk (6–10), and very high risk (11 or more), before and after public disclosure. Results: 25 730 patients underwent coronary artery surgery during the study period. The observed mortality decreased from 2.4% in 1997–8 to 1.8% in 2004–5 (p = 0.014). The expected mortality (EuroSCORE) increased from 3.0 to 3.5 (pConclusions: Publication of cardiac surgery mortality data in the UK has been associated with decreased risk adjusted mortality on retrospective analysis of a large patient database. There is no evidence that fewer high risk patients are undergoing surgery because mortality rates are published.

Objectives: To study the ability of the logistic EuroSCORE to predict operative risk in contemporary cardiac surgery. Design: Retrospective analysis of prospectively collected data. Setting: All National Health Service centres undertaking adult cardiac surgery in northwest England. Patients: All patients undergoing cardiac surgery between April 2002 and March 2004. Main outcome measures: The predictive ability of the logistic EuroSCORE was assessed by analysing how well it discriminates between patients with differing observed risk by using the area under the receiver operating characteristic (ROC) curve and studying how well it is calibrated against observed in-hospital mortality. The performance of the EuroSCORE was examined in the following surgical subgroups: all cardiac surgery, isolated coronary artery surgery, isolated valve surgery, combined valve and coronary surgery, mitral valve surgery, aortic valve surgery and other surgery. Results: 9995 patients underwent surgery. The discrimination of the logistic EuroSCORE was good with a ROC curve area of 0.79 for all cardiac surgery (range 0.71–0.79 in the subgroups). For all operations, the predicted mortality was 5.7% and observed mortality was 3.3%. The logistic EuroSCORE overpredicted observed mortality for all subgroups but by differing degrees (p = 0.02) Conclusions: The logistic EuroSCORE is a reasonable overall predictor for contemporary cardiac surgery but overestimates observed mortality. Its accuracy at predicting risk in different surgical subgroups varies. The logistic EuroSCORE should be recalibrated before it is used to gain reassurance about outcomes. Caution should be exercised when using it to compare hospitals or surgeons with a different operative case mix.

I recently gave a talk in a debate at a UK regional meeting of vascular surgeons, proposing the motion that “vascular surgeons' mortality data should be published in the press.” The initial request came through for a “light hearted” presentation for five to 10 minutes at the end of the day. Before the meeting I suggested that the publication of named clinician outcome data was one of the biggest things to happen to cardiac surgery over the past 20 years and that it would inevitably happen to vascular surgery. I also said that the subject was not light hearted and would merit more time in the programme. The debate went ahead as initially planned, and an eminent vascular surgeon was invited to the meeting to oppose the motion. I based my talk around the fictitious premise that my 78 year old father had recently been diagnosed as having an abdominal aortic aneurysm, and now required urgent surgery. I used the example to demonstrate the paucity of data available to patients and their carers undergoing this type of major surgery. There is insufficient data available from hospital websites, professional organisations, or the Healthcare Commission to demonstrate that there is satisfactory clinical …

Objectives: To define best practice standards for mitral valve repair surgery. Design: Development of standards for process and outcome by consensus. Setting: Multidisciplinary panel of surgeons, anaesthetists, and cardiologists with interests and expertise in caring for patients with severe mitral regurgitation. Main outcome measures: Standards for best practice were defined including the full spectrum of multidisciplinary aspects of care. Results: 19 criteria for best practice were defined including recommendations on surgical training, intraoperative transoesophageal echocardiography, surgery for atrial fibrillation, audit, and cardiology and imaging issues. Conclusions: Standards for best practice in mitral valve repair were defined by multidisciplinary consensus. This study gives centres undertaking mitral valve repair an opportunity to benchmark their care against agreed standards that are challenging but achievable. Working towards these standards should act as a stimulus towards improvements in care.

Objectives To present named surgeon mortality for isolated first time coronary artery surgery and aortic valve surgery. Design Retrospective analysis of prospectively collected data. Setting All NHS hospitals undertaking adult cardiac surgeryin north west England. Participants 25 consultant surgeons carrying out coronary arterysurgery and aortic valve replacement between April 2001 andMarch 2004. Main outcome measures Mortality for both operations accordingto surgeon. EuroSCORE to stratify patients into low and highrisk. Results 10 163 patients underwent surgery under 25 surgeons.The average number of patients per surgeon was 363 for coronaryartery surgery and 44 for aortic valve replacement. Seventeenper cent of the patients undergoing coronary artery surgeryand half of those undergoing aortic valve surgery were consideredhigh risk. The average mortality was 1.8% (range 0-3.8%) forcoronary surgery and 1.9% (0-12.5%) for aortic valve surgery.Mortality for all surgeons fell below 99% control limits ofthe national mean for both operations. Conclusions The presented mortality figures for the two cardiacoperations fell within accepted limits for all surgeons. Thedivision of outcomes according to low and high risk patientsis imperfect but may help to inform the public about the complexitiesof this type of analysis and prevent surgeons avoiding highrisk patents who may benefit from an operation.

Objective To study the “learning curve” associated with independent practice in coronary artery surgery. Design Retrospective analysis of prospectively collected data. Setting All NHS centres in north west England that carry out cardiac surgery in adults. Participants 18 913 patients undergoing coronary artery surgery for the first time between April 1997 and March 2003, 5678 of whom were operated on by 15 surgeons in the first four years after their consultant appointment. Main outcome measures Observed and predicted mortality (EuroSCORE) for surgeons in their first, second, third, and fourth years after appointment as a consultant compared with figures for established surgeons. Results Overall mortality decreased over the six years of study (P = 0.01). Of the patients operated on by established surgeons or newly appointed consultants, 265/13 235 (2.0%) and 109/5678 (1.9%), respectively, died (P = 0.71). There was a progressive decrease in observed mortality with time after appointment as a consultant from 2.2% in the first year to 1.2% in the fourth year (P = 0.049). This result remained significant after adjustment for time and case mix (P = 0.019). Conclusions Mortality in patients operated on by newly appointed consultant surgeons is similar to mortality in patients operated on by established surgeons. There are significant decreases in crude and risk adjusted mortality in the four years after appointment. These findings should influence the nature of practice in newly appointed surgeons.