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Heart. 2007 September; 93(9): 1136.
PMCID: PMC1955009

Implications of publishing surgical results

To the Editor: The conclusion in the article by Bridgewater et al1 that mandatory reporting and public scrutiny have not resulted in risk‐averse behaviour but rather have improved surgeons' performance is simply wishful thinking not supported by data from other quality‐driven states such as New York.2 A more likely explanation for their findings is that public scrutiny increased the pressure to assign higher EuroSCORES, so despite the fact that they operated on patients at lower risk (as shown by the lower mortality), the predicted mortality was higher. A better marker of risk‐averse behaviour is the operative risk of patients who the surgeons are turning down, and those dying while waiting for surgery, but these data are not available.

EuroSCORE overestimates operative risk by around double, perhaps because of improved practice but more likely owing to assignment/ascertainment bias.3,4,5 When the EuroSCORE is adjudicated by surgeons themselves, public scrutiny of outcomes creates such a powerful conflict of interest that the data are at best questionable and at worst purely a smokescreen. In New York State, the magnitude of the resulting bias was illustrated when comparison of raw outcome registry data after multivessel stenting and coronary artery bypass grafting showed a survival benefit for stenting in most subgroups.6 After “adjustment” for patient comorbidity data routinely collected by surgeons (but not by interventionalists), the study reported the exact opposite finding, because the surgical patients were assigned greater comorbidity. The counterintuitive nature of this finding (patients with serious comorbidities are usually treated percutaneously/medically) led the authors to report both the raw and adjusted data, so it was quite obvious that this was statistical error due to ascertainment bias.7

Besides deterioration in outcomes being induced by risk‐averse behaviour, public airing of outcomes inevitably affects surgical training. Consultants are far less likely to allow trainees to attempt difficult procedures when adverse outcomes will be publicly and wholly attributed to the consultant. The result is rapid deskilling of the workforce.

With increasing pressure from our politically driven masters to feign public accountability with outcome smokescreens, we should take care not to believe our own publicity, lest it damage the core assets of the profession—our skills and our altruism for patients rather than administrators.

References

1. Bridgewater B, Grayson A D, Brooks N. et al on behalf of the North West Quality Improvement Programme in Cardiac Interventions. Has the publication of cardiac surgery outcome data been associated with changes in practice in northwest England: an analysis of 25 730 patients undergoing CABG surgery under 30 surgeons over eight years. Heart 2007. 93744–748.748 [PMC free article] [PubMed]
2. Moscucci M, Eagle K A, Share D. et al Public reporting and case selection for percutaneous coronary interventions: an analysis from two large multicenter percutaneous coronary intervention databases. J Am Coll Cardiol 2005. 451759–1765.1765 [PubMed]
3. Yap C H, Reid C, Yii M. et al Validation of the EuroSCORE model in Australia. Eur J Cardiothorac Surg 2006. 29441–446.446 [PubMed]
4. Bhatti F, Grayson A D, Grotte G. et al The logistic EuroSCORE in cardiac surgery: how well does it predict operative risk? Heart 2006. 921817–1820.1820 [PMC free article] [PubMed]
5. Nashef S. Validation of the EuroSCORE model in Australia [editorial comment]. Eur J Cardiothorac Surg 2006. 29446
6. Hannan E L, Racz M J, Walford G. et al Long‐term outcomes of coronary‐artery bypass grafting versus stent implantation. N Engl J Med 2005. 3522174–2183.2183 [PubMed]
7. Flaherty J, Davidson C. Coronary artery bypass grafting versus stent implantation. N Engl J Med 2005. 353735

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