Bypass surgery mortality is blunt measure of performance
http://www.100md.com
《英国医生杂志》
EDITOR—Kmietowicz reports that UK heart surgeons are among the best in the world as measured by crude mortality of isolated coronary artery bypass surgery.1 This marker of surgical performance is widespread.
Imagine the following scenario. A patient undergoing isolated bypass grafting has an uneventful procedure. During closure, the systemic blood pressure drops, and the electrocardiogram shows that the patient is becoming ischaemic. Cardiopulmonary bypass is reintroduced rapidly, but a further attempt to wean from circulatory support is unsuccessful. The surgeon, who is subject to mandatory reporting of such cases, notes the small and insignificant jet of mitral regurgitation seen on the intraoperative transoesophageal echo. He readministers cardioplegia and performs a mitral valve repair. The patient dies, but the death is not recorded on the surgeon's ledger, as no longer is the procedure an isolated coronary artery graft case.
Corridor whispers imply that the above vignette has occurred. I have written previously on the potential negative consequences of mandatory performance reporting.2 Patients will continue to be at risk of being denied potentially life saving surgery or worse, be inappropriately managed intraoperatively while such blunt tools are used.
I am not opposed to my outcomes being examined, but risk adjusted audit of my total practice is the minimum standard that is acceptable. This would go some way to lessen the potential for harm for cardiothoracic surgeons but also, more importantly, for their patients.
Ian S Gilfillan, cardiothoracic surgeon
Fremantle Hospital, Fremantle, WA 6160, Australia ian.gilfillan@health.wa.gov.au
Competing interests: None declared.
References
Kmietowicz Z. UK heart surgeons are among the best in the world. BMJ 2004;329: 644. (18 September.)
Gilfillan IS. Ranking heart surgeons has pitfalls. BMJ 2003;327: 107-b.
Imagine the following scenario. A patient undergoing isolated bypass grafting has an uneventful procedure. During closure, the systemic blood pressure drops, and the electrocardiogram shows that the patient is becoming ischaemic. Cardiopulmonary bypass is reintroduced rapidly, but a further attempt to wean from circulatory support is unsuccessful. The surgeon, who is subject to mandatory reporting of such cases, notes the small and insignificant jet of mitral regurgitation seen on the intraoperative transoesophageal echo. He readministers cardioplegia and performs a mitral valve repair. The patient dies, but the death is not recorded on the surgeon's ledger, as no longer is the procedure an isolated coronary artery graft case.
Corridor whispers imply that the above vignette has occurred. I have written previously on the potential negative consequences of mandatory performance reporting.2 Patients will continue to be at risk of being denied potentially life saving surgery or worse, be inappropriately managed intraoperatively while such blunt tools are used.
I am not opposed to my outcomes being examined, but risk adjusted audit of my total practice is the minimum standard that is acceptable. This would go some way to lessen the potential for harm for cardiothoracic surgeons but also, more importantly, for their patients.
Ian S Gilfillan, cardiothoracic surgeon
Fremantle Hospital, Fremantle, WA 6160, Australia ian.gilfillan@health.wa.gov.au
Competing interests: None declared.
References
Kmietowicz Z. UK heart surgeons are among the best in the world. BMJ 2004;329: 644. (18 September.)
Gilfillan IS. Ranking heart surgeons has pitfalls. BMJ 2003;327: 107-b.