Performance indicators in cardiac surgery - time for public release

In this issue of the Journal, Maytham and Kessaris [1] compared the views of United Kingdom cardiac surgeons on individual performance tables in 2005 and 2009. The responses (109 answers/206 questionnaires=53% in 2005; 134/266=50.5% in 2009) demonstrated that whilst the majority of cardiac surgeons (68.8%) were initially opposed to performance tables, the number welcoming their introduction increased significantly (from 23% to 48%) over the four-year period. Furthermore, fewer surgeons believed, in 2009 as compared to 2005, they would or may avoid high-risk patients. These are important findings. Publication of surgical results is not new, as the exponential growth of modern medicine has been continuously recorded in peer-reviewed publications and scientific sessions. However, the direct disclosure of health care outcomes of hospitals and individuals, accompanied by risk stratification, are more recent and controversial [2]. In the USA, the Pennsylvania report [3] and the New York State report [4] were, as early as the 1990s, the most sophisticated and widely published risk-adjusted data on the performance of hospitals and surgeons. These public reports already included demographic data, preoperative risk factors, intraoperative data, and postoperative intra-hospital morbidity and mortality. From the patients’ perspective, accurate clinical data detailing surgeon and hospital mortality rates fulfil a basic right to information. Furthermore, health policy experts, employers, and consumers increasingly consider reports on the outcome of medical care an important tool for improving the quality of care. Potential advantages include the selection of high quality providers and the motivation of hospitals to improve their quality of care. On the contrary, difficulties in adjusting for differences in case mix, reliability of underlying clinical data, and random fluctuation of outcomes may undermine the validity and credibility of comparative data [3]. Restriction of access to care for severely ill patients who need cardiac surgery constitutes a serious potential risk of such reports. There is, however, no solid evidence that such a problem exists [ 1,3]. For example, data from New York State show an increase over time in the average severity of illness and the prevalence of coexisting conditions among patients undergoing coronary artery bypass grafting surgery, supporting that appropriate access to care among severely ill patients had probably been maintained [ 2, 5]. In conclusion, data collection and reporting mechanisms are important and therefore they should be accurate and timely. The focus on short-term mortality should be extended to long-term outcomes and patient’s symptoms, as reflected by their functional status and quality of life, particularly in light of the growing emphasis on the appropriate use of procedures [5]. We need to understand better how the information is used by physicians, hospitals, the public, purchasers, payers, and referring doctors. Furthermore, compliance with guidelines on hospital volumes should be strongly encouraged by national and international cardiology and cardiac surgery societies and their implementation monitored by local regulatory boards. This will ultimately lead to optimal patient trust in health care providers.