PEER review of surgical mortality rates has been so successful and produced such positive changes to clinical practice that the public reporting of the results is “inevitable”, according to Australian safety and quality experts.
Dr James Aitken, chairman of the WA Audit of Surgical Mortality (WAASM), said peer review and the availability of data in the public domain led to better outcomes for patients.
“There are any number of papers that state that when you audit and review you get changes in practice and improved outcomes for patients”, Dr Aitken told MJA InSight.
He was responding to a review of the first 10 years of the landmark WAASM, published in the MJA, which found that the external peer-reviewed mortality audit had “changed surgical practice and reduced deaths”. (1)
“The same process should be applied to other sentinel events, and the lessons learned can also be extended to non-surgical specialties”, the review authors wrote.
The retrospective analysis of WAASM data collected from 2002 to 2011 found: the annual number of deaths peaked in 2006, then fell 30% by 2011, correcting for population growth. The researchers found that some changes in practice, for example, in pancreatic surgery, thromboembolic prophylaxis, consultant supervision and fluid management, were directly attributable to WAASM.
A shift of high-risk patients to teaching hospitals with a greater ability to “rescue” patients after complications was also a factor in improving outcomes.
Dr Aitken, who described himself as “a hawk” on the issue of public reporting, said Australia was still “miles away” from the situation in the UK where public reporting of hospital surgical mortality rate data had been routine since the 2001 report into the deaths of children undergoing complex cardiac surgery in Bristol. (2)
Dr Aitken said that since July this year all specialist surgical societies in the UK must publish their annual outcomes report.
The data show the number of times a consultant has carried out a procedure, mortality rates and whether clinical outcomes for each consultant are within expected limits. (3)
“In Australia, people want open and transparent data reporting, but we’re miles away from it”, Dr Aitken said.
He said in the UK the drive for public reporting was led by the profession because “they realised that if they didn’t get involved in the process then it would happen anyway ― it would be imposed on them by the government”.
Professor Guy Maddern, chair of the Royal Australasian College of Surgeons’ annual national audit of surgical mortality, said there was a “great cultural change” happening in Australia and progress was being made.
“There was a lot of suspicion 10 years ago but now people can see that [peer-reviewed auditing] is making a difference for the better”, Professor Maddern told MJA InSight.
“The issue of public reporting has to be supported but only when surgeons and hospitals can see that the data are reliable and robust.
“WAASM shows you can influence substantial change.”
Professor Maddern said the national audit was moving towards more open disclosure. After routinely refusing to identify states by name, this year’s report, due later this year, would allow comparison of state data.
Dr Michael Smith, clinical director of the Australian Commission on Safety and Quality in Health Care, said the success of peer-reviewed auditing came down to trust.
“This is a trusted process because it involves a small group of colleagues who know each other and have a shared culture and understanding of good practice in their field”, he told MJA InSight. “Therefore they trust the outcomes of the audit and there is a preparedness to learn from it, which leads to clinical change.”
That in turn lead to positive responses from the public, Dr Smith said.
“Having this kind of information available to the public is good because it shows that there are robust mechanisms in place for their safety and that those mechanisms are making a positive difference.”
Dr Aitken said there was scope to extend the process of peer-reviewed audit beyond mortality rates into morbidity.
“We could be targeting key events like returns to theatre — clearly defined, discrete events that can be easily measured”, he said.
1. MJA 2013; 199: 539-542
2. Department of Health 2001; The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1985: learning from Bristol
3. NHS 2013; Consultant treatment outcomes