Lessos from the cardiac surgery experience!從心臟手術(shù)的經(jīng)驗教訓！

1、does transparency improve quality?lessons learnt from cardiac surgery bcis meeting 2006ben bridgewatersmuhthistory of cardiac surgical audit cardiac surgery register since 1977 cardiac surgery register since 1977 uk database since 1994history of cardiac surgical audit cardiac surgery register since

2、1977 uk database since 1994 dr foster/the times 2001history of cardiac surgical audit cardiac surgery register since 1977 uk database since 1994 dr foster/the times 2001 named unit mortality scts 2001history of cardiac surgical audithistory of cardiac surgical audit cardiac surgery register since 19

3、97 uk database since 1994 dr foster/the times 2001 named unit mortality scts 2001 scts individual standards 2003 cardiac surgery register since 1997 uk database since 1994 dr foster/the times 2001 named unit mortality scts 2001 scts individual standards 2003 guardian named surgeon data 2005 freedom

4、of information acthistory of cardiac surgical audithistory of cardiac surgical audit cardiac surgery register since 1977 uk database since 1994 dr foster/the times 2001 named unit mortality scts 2001 scts individual standards 2003 guardian named surgeon data 2005 healthcare commission named surgeon

5、data 2006history of cardiac surgical audit cardiac surgery register since 1997 uk database since 1994 dr foster/the times 2001 named unit mortality scts 2001 scts individual standards 2004 guardian named surgeon data 2005 healthcare commission named surgeon data 2006history of cardiac surgical audit

6、 cardiac surgery register since 1997 uk database since 1994 dr foster/the times 2001 named unit mortality scts 2001 scts individual standards 2004 guardian named surgeon data 2005 healthcare commission named surgeon data 2006history of cardiac surgical audit cardiac surgery register since 1997 uk da

7、tabase since 1994 dr foster/the times 2001 named unit mortality scts 2001 scts individual standards 2004 guardian named surgeon data 2005 healthcare commission named surgeon data 2006history of cardiac surgical audit cardiac surgery register since 1997 uk database since 1994 dr foster/the times 2001

8、 named unit mortality scts 2001 scts individual standards 2004 guardian named surgeon data 2005 healthcare commission named surgeon data 2006issues has public accountability improved quality?issues has public accountability improved quality? is there now a culture of risk-averse behaviour?has public

9、 accountability improved quality?mortality significantly higher than average dr fostermortality significantly lowerthan average healthcare commissionhas public accountability improved quality? risk adjusted mortality national data isolated cabgincreased predicted riskdecreased observed mortalityhawt

10、horn effect new york state database pennsylvania report cards scts database northern new england cardiovascular study group va database nw regional audit project 1997 to 2001publicdisclosurenodisclosurecollecting and using data improves the quality of outcomeswhy is public reporting important?becaus

11、e it has driven data collection and useclinicians managers support staff professional organisations is there now a culture of risk averse behaviour?is there now a culture of risk averse behaviour? newsnight survey of uk cardiac surgeons 2000 80% surgeons in favour of public accountability 90% felt t

12、hat high risk cases would be turned down only 6% felt that available algorithms adjusted appropriately for risksee also burack 1999, schneider and epstein 1996, narins 2005 existing data little hard statistical data investigating the influence of public accountability on cardiac surgical practice ny

13、 experience suggests conflicting data hannan 1996 dranove 2003is there risk averse behaviour in the uk? very difficult to measure surgical turndowns if there was significant risk averse behaviour you would expect to see a decrease in the number of high risk cases coming to surgery complex issues wit

14、h respect to surgical case mix due to pci developmentsnorthwest data 1997 to 2005 25,730 patients under 30 surgeons isolated cabg alone observed and predicted mortality number of low risk, high risk and very high patients each year 2 time periods 1997 to 2001 prior to public disclosure 2001 to 2005

15、post public disclosureresults significant decrease in observed mortality significant increase in overall predicted mortality significant decrease in risk adjusted mortalityresults significant decrease in observed mortality significant increase in overall predicted mortality significant decrease in r

16、isk adjusted mortality01002003004005006001997-20012001-2005number of high risk patientshigh riskveryhigh riskis there now a culture of risk averse behaviour? no overall effect may be transient or individual effects important that this is mopped upis there now a culture of risk averse behaviour? what

17、 is perceived by someone as risk-averse behaviour is perceived by another as good clinical decision makingis there now a culture of risk averse behaviour? what is perceived by someone as risk-averse behaviour is perceived by another as good clinical decision making transparency may have focussed the

18、 multidisciplinary team on optimising treatment strategies for individual patientsrisk adjustment no model is perfect some are usefulrisk adjustment no model is perfect some are useful need clarity around fit for purposerisk adjustment no model is perfect some are useful need clarity around fit for purpose arguments about models can paralyse developmentsrisk adjustment no model is perfect some are useful need clarity around fit for purpose arguments about models can paralyse dev