Heart surgeons publicly counted their dead for the first time yesterday. More than a century since Florence Nightingale strode the wards of London's hospitals marking patients "dead, relieved or unrelieved", the Society of Cardiothoracic Surgeons published the first individual mortality rates for surgeons.
Heart surgeons publicly counted their dead for the first time yesterday.
More than a century since Florence Nightingale strode the wards of London's hospitals marking patients "dead, relieved or unrelieved", the Society of Cardiothoracic Surgeons published the first individual mortality rates for surgeons.
Bowing to public pressure following the Bristol children's heart surgery disaster in the 1990s, in which surgeons continued operating despite high risks, the society said that heart patients had a right to know their medics were safe.
All 222 consultant heart surgeons operating in Britain were named in the report, and their death rates assessed for one procedure: coronary bypass surgery, chosen because it is a common heart operation and indicates a surgeon's general level of skill. The results show that death rates, based on the number of operations performed over three years, are within the society's "acceptable" limits.
No individual figures are given because they have not been "risk-adjusted" to take account of the fact that some patients are sicker than others, the society said. Out of almost 25,000 coronary bypasses carried out in 2003, the average death rate was 1.8 per cent. The highest death rate for an individual surgeon was 5.5 per cent, with many scoring zero deaths.
Sir Bruce Keogh, cardiac surgeon at the Heart Hospital London, who led the study, said: "I believe we have crossed the Rubicon today. We have published a list of every cardiac surgeon in the UK with data about their performance."
Britain's record on heart surgery was the equal of any country in the world, he said. The variation in mortality among UK surgeons was half that in New York, where it ranged up to 12.5 per cent.
But Sir Bruce said "a lot of people will be disappointed" that individual death rates had not been given for each surgeon named. Instead, the report gives the number of coronary bypasses performed and says whether the surgeon meets the society standards. All do. "To present un-risk-adjusted data in the form of a league table would be irresponsible," said Sir Bruce. "It might lead to surgeons trying to avoid high-risk cases to improve their position in the table."
However, the society is collecting information on patients to enable it to publish risk-adjusted league tables of individual surgeons, which would quote their death rates. Information is currently missing in 30 per cent of patients. "We want to stimulate a debate on this. If there is a clear desire from the public to publish that information, we will do so," Sir Bruce said.
Surgeons themselves remain divided about publishing individual league tables, as happens in the US. Some cardiologists claim it is already becoming difficult to find anyone in the UK prepared to take on high-risk cases because of the impact a death could have on their ranking.
The audit revealed one surgeon with a death rate of 8 per cent over one year, which was outside the society standards. Sir Bruce said: "A number of reviews were conducted and found it completely unrelated to his performance. It was mostly related to the nature of his patients." Over three years, he said, the surgeon's death rate fell back within the average of his colleagues'. "He was in the middle of the pack," Sir Bruce said.
The audit shows that while coronary bypasses are being carried out on older, sicker patients, the death rate has still improved. The number of over-75s having the operation has risen more than fourfold in the past decade, while the death rate has fallen from 7 to 5 per cent. Death rates are higher among women than men, thought to be because their coronary arteries are smaller.
'WE TRY TO LEARN LESSONS'
Kulvinder Lall performed 46 coronary bypasses in his first three months as a consultant cardiothoracic surgeon at St Bartholomew's hospital, London. His death rate was "less than 1 per cent", he said.
The 38-year-old surgeon, who trained at Kings College Hospital, south London, and worked in Glasgow and Australia, said: "It is good to be transparent. Patients should know how well hospitals and surgeons are performing. But they have got to take account of how sick the patients are."
To become a heart surgeon involved intensive training and nearly all poor performers were weeded out. That was why all those named in the audit had very similar results.
"You can think you have been doing well for months and months then a patient dies. Generally, the people who die have had a series of heart attacks or are in heart failure. We have monthly audit meetings at which we discuss what happened and try to learn any lessons."
Learning to cope with the stress was part of every surgeon's training. Coronary bypasses were now routine but they could still involve stressful moments, when the patient's heart is stopped, especially if the operation was not going well.
But the death of a patient was not the greatest source of stress. "In a way, if someone dies, there is a finality to it. The patients I worry about are the ones having trouble because they are on dialysis or bleeding or have suffered lung damage and may be on a ventilator. They are the ones you lose sleep over."
Jeremy LauranceReuse content