THE PUBLICATION OF SURGEON LEVEL OUTCOME DATA

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1 Association of Surgeons of Great Britain and Ireland POSITION STATEMENT on THE PUBLICATION OF SURGEON LEVEL OUTCOME DATA (June 2013) 1. INTRODUCTION The desire to improve information in the delivery of healthcare in the UK has moved up the political agenda. The Association of Surgeons of Great Britain and Ireland (ASGBI) welcomes the broad intention of the Government to move towards greater transparency in healthcare outcomes for the benefits which it brings to patients and providers alike. ASGBI pledges support to the Department of Health in order to facilitate the publication of all data which is accurate, meaningful and which can demonstrably bring tangible and measurable benefits to the health system. ASGBI recognises the excellent work done by Professor Sir Bruce Keogh, the Medical Director of the NHS, in advancing the transparency agenda in cardiac surgery, and supports the expectation that this example will be adopted progressively by all of the interventional disciplines of Medicine and Surgery. The Association also recognises that many representative bodies, including the Surgical Royal Colleges and the Surgical Specialty Associations, are currently working on responses and the implementation of the publication of surgeon level outcome data, with separate statements and policies which reflect their differing starting positions. However, it is likely that common purpose and methodologies will be developed and supported, wherever possible, as the process evolves. As the SAC-defined Specialty Association for General Surgery, with overarching responsibility for a range of sub-specialty disciplines, ASGBI recognises the complexities in securing accurate and meaningful data. These complexities must now be addressed in an intellectually rigorous and systematic way. Done well, the resulting work may be expected to advance the professional agenda worldwide, to the credit of the surgery within Great Britain and Ireland. 1

2 2. THE SCOPE OF HEALTH DATA TRANSPARENCY Health data outputs can vary considerably in their detail and information level. Broad data, such as the caseload and mortality of individual clinicians, units and institutions, can be very useful and informative in providing an overview of: How clinical work is distributed. Where it can be consolidated into higher volume units, with the potential for acquiring greater experience and securing better outcomes. Where mortality data demands detailed and urgent examination. The Association is aware that much data of such a nature is already collected in NHS activity, analysed centrally and made available for further analysis and promulgation. More detailed data arises from all areas of health care delivery. In the case of surgical activity, different procedures have differing levels of complexity and forms of morbidity, for which nationally accepted standards of resource, performance and outcome have often yet to be evidenced or agreed. 3. CONSTRAINTS ON THE COLLECTION OF ACCURATE AND MEANINGFUL HEALTH OUTCOME DATA Whilst supporting, and being committed to the direction of travel of reporting surgeon level outcome data, the Association recognises that, at the start of the process, there are a number of constraints which will need to be considered and resolved. 3.1 Variability in patient populations and in service provision The delivery of health care to human populations is much more complex and less readily standardised or measurable than in other professions or industries, such as a manufacturing production line. Populations of patients with any one disease are very variable, by virtue of many factors, including age, sex, genetics, co-morbidities, lifestyle factors such as smoking and obesity, and the action of the disease process in any individual body. Institutions and hospitals vary in the resources which they allocate and the environment which they create for different clinical activities, leading to them undertaking a particular mix of cases. Individual clinicians in any one discipline vary by age, specific experience, technical training in different techniques and clinical perceptions, leading to variation in the type of case they will undertake and in patients with different levels of risk. The net result of this substantial variability is considerable uncertainty in respect of statistical validity and risk adjustment as we move to finer and finer detail in clinical data analysis. Statistical Validity In general terms, very few individual surgeons in any one clinical domain have enough similar cases by virtue of age, sex, anthropometrics, co-morbidity, 2

3 disease stage, etc to generate meaningful comparisons. For example, it has been calculated that a colorectal surgeon needs to undertake more than 150 major procedures to demonstrate reliably a statistical significant difference in mortality outcomes. Risk Adjustment It is acknowledged that there are currently no validated risk adjustment tools which can be applied to all procedures for which published audit is proposed. Studies are, therefore, required to generate specialty and procedure-specific, quality-assured risk adjustment statistical tools. 3.2 Multi-disciplinary Team Working The professional emphasis of all healthcare delivery in the UK over the past two decades has been towards team and multi-disciplinary working, rather than individualism. The specific technical and judgemental actions and errors of individual surgeons can, of course, produce adverse, morbidity and mortality outcomes. However, clinical outcomes are a complex interplay of factors attributable to individual and collective actions by various healthcare professionals along any one care pathway; through the resources allocated to that pathway; and in the environment in which the pathway is laid. Whilst all consultant surgeons are aware of their personal duties and responsibilities to their patients, data reporting models which return sole responsibility for collective outcomes to named individual clinicians would appear to be regressive, unless those individuals are also given the authority commensurate with that responsibility to ensure that the safety environment for their patients is optimised. 3.3 Reliability of Data Collection Systems The development of reliable and usable pan-nhs information technology has not been failure-free, despite significant investment. In consequence, institutions, units and individuals have gone in different directions in the acquisition of hardware and software for health systems management. Moreover, these systems have been broadly designed and developed around management and service administration needs, rather than for the more demanding requirements of clinical outcome analysis, which must factor in the passage of time (days, weeks, months, years and decades), multiple therapeutic inputs and evolving co-morbidities. In the absence of widespread understanding of the design and application challenges of such systems, there is a danger that there will be a political temptation to focus on the short-term gain from available data audit systems, rather than the investment of better systems. 3.4 The improving UK health data infrastructure Notwithstanding the concerns expressed above, ASGBI recognises that major investments and gains have been made in developing a robust health IT infrastructure in the UK, and the considerable potential for further development. Compared with a decade ago, all hospitals are now computerised; staff are universally IT-literate, and integrated systems are in continual evolution. We can be optimistic that many of the current limitations to health data collection and analysis will be addressed locally, commercially, 3

4 nationally and through the work of agencies such as the Healthcare Quality Improvement Partnership (HQIP). 3.5 The quality and design of Audits In their Consensus Statement on the Publication of Surgeon Level Outcomes, the Federation of Surgical Speciality Associations (FSSA) pointed out that current audits of political interest were generally not set up to deliver the political mandate of publication at individual surgeon level. Data quality is often poor and unreliable, from the point of generation, through coding and entry error. The FSSA identified many areas which require careful evaluation before audits and league tables are published nationally. These factors include: The development of appropriate indicators for each condition and procedure under study. The refinement of Hospital Episode Statistics (HES) data. Checks and balances in the investigation of outlier data. Methodologies for release and publication of comparative data. The attitudes and behaviour of external agencies and the media to the uncritical use of published data. Universal training and preparation of clinicians for data transparency and its publication. Translation of processes and experience from one discipline to another. Consultation and the workings of the law of unintended consequences as arising from expedient political directives which have not been sufficiently thought through. 3.6 Participation in Audit ASGBI recognises that, where participation in (national) audit within any one discipline or sub-specialty is incomplete, the early publication of individual audit data will unevenly reflect fact and ground truths. For example, data from the long-running national audit of Thyroid and Para-thyoid Surgery, managed by the British Association of Endocrine and Thyroid Surgeons (BAETS), is compromised because a significant number of surgeons undertaking such surgery are neither members of BAETS, nor contribute to the Audit. 4. A SUMMARY OF THE POSITION OF THE ASGBI IN RESPECT OF THE PUBLICATION OF SURGEON LEVEL OUTCOMES Having examined and debated the current national situation in respect of available audit and data systems, ASGBI takes the view that: 4.1 Exemplary work in cardiac surgery has set standards and direction for much wider surgical data transparency across the UK. 4.2 ASGBI is committed to progressive movement towards greater data transparency, and to the publication of high quality, accurate and meaningful clinical data which can be used to improve patient safety and efficient service delivery. 4.3 Having examined the evidence and arguments in respect of data quality, statistics and technology, ASGBI feels that the most intellectually and 4

5 professionally rigorous approach is through a staged methodology through Institutional and Unit outcome data towards individual clinician (both Physician and Surgeon) level outcomes. Such a methodology will allow all institutions, hospitals, units and multi-disciplinary teams to examine their data collection and validation processes, and to take appropriate action on quality improvement over an urgent time frame. ASGBI recognises that such a staged approach could possibly be misconstrued as a delaying tactic. Nevertheless, the Association believes that the benefits of a structured and systematic approach, with rigorous debate and concurrent and parallel developmental activity in all of the interventional specialties of Medicine and Surgery will produce the best long-term results, for the Government, for healthcare providers and for patients. 5. THE NEXT STEPS ASGBI will, as a matter of urgency, use its resources and influence to advance this agenda within its remit of professional practice. The issue of Surgeon Level Outcome Data was presented in the Hot Topic session at the 2013 ASGBI International Surgical Congress in Glasgow, where concerns were voiced over the potential for premature release of data into the public domain which could, in fact, only confuse or alarm patients. The Association has also supported the launch and development of the Surgical Outcomes Club of Great Britain and Ireland (SOCGBI), mirroring an established model and club in the USA, which aims to educate and inform the surgical profession about the collection, evaluation, validation, interpretation and publication of outcome data. The Association is now working with a range of subject matter experts to publish a booklet, in the ASGBI Issues in Professional Practice series, which will comprehensively examine all issues relating to the publication of surgeon level outcome data and offer definitive advice to members. Association of Surgeons of Great Britain and Ireland Lincoln s Inn Fields, London, WC2A 3PE Tel: Fax: admin@asgbi.org.uk A Company limited by guarantee registered in England VAT No. GB