Should Surgical Performance League Tables be in the Public Domain?

Over the last decade, a debate around performance monitoring of healthcare personnel has raged.  Examples such as Harold Shipman have served to further public scrutiny and patient empowerment when choosing how and where to undergo surgery within a health service paid for by the public purse.  Following the Bristol Children’s Heart Surgery Inquiry, a recommendation for ‘local information collection and national reporting’[1] has been introduced to varying degrees across UK NHS Trusts.  The Society of Cardiothoracic Surgeons has recently responded to pressure to lead by example by publishing risk-adjusted mortality data[2] but it still remains pertinent to determine whether such performance recording is right to include individual clinician surgical outcomes and whether the methods of data recording are robust and unbiased.[3]

Professor Michael Bailey, Consultant General Surgeon and Director of The Minimal Access Therapy Training Unit and past President of the Association of Laparoscopic Surgeons of Great Britain says, “in essence I would welcome league table publication but am aware of the limitations of interpretation within certain surgical specialities.”

Advocates of public disclosure of surgical data, by means of named surgeon ‘league tables’ claim it will serve to inform medical practice and thereby generate clinical improvements.  Evidence suggests, however, that this type of information, despite being likely to cause a media frenzy, is less important to patients than convenience and access when choosing a hospital.[4]  Those opposed to the motion declare it as a meaningless yardstick with which to beat surgeons with, due to inherent flaws in the data collection and reporting processes.  There are also fears that such recording will result in surgeons avoiding high risk cases, which may result in multiple morbidity, even though many of these adverse health factors are not as a direct result of the surgery itself.[5]  Surgeons may also feel unjustly scrutinised as other medical professions, as yet, escape this surveillance.  Ellen Mason from the British Heart Foundation says “League tables can help to provide health professionals and patients alike with useful information, but still require careful consideration.”  So, can the publishing of surgical outcomes really influence clinical behaviour?

A 2007 study by Bridgewater et al investigated over 24,000 cases of isolated coronary artery surgery in the northwest of England, to explore the impact of publishing results on observed and predicted mortality outcomes, as well as the number of high risk patients receiving surgery.  Results showed that observed mortality (defined as in patient death) fell from 2.4% in 1997/98 to 1.8% in 2004/05, following publication of named hospital data in 2001.  This could, by sceptics, be put down to improved surgical techniques and medical equipment, but it occurred despite an increase in predicted mortality from 3.0% to 3.5% and a slight rise in the proportion of high risk and very high risk patients receiving surgical coronary artery treatment.[6]

This large scale study seems to provide evidence in support of publication of cardiac surgical data but it still remains to be seen whether such data recording can be amenable to all types of surgery and whether this information being in the public domain will influence treatment.  Whatever the effects of surgical outcome publication, it seems we may not have to wait long before speculation becomes a reality.