Clifford W. Barlow (FRCS, DPhil)
Southampton General Hospital
Southampton, UK
Quality and Outcomes differ for different individuals
Are you operating for survival or symptoms
Short-term:
Survival (30 day or ‘in-hospital’)
Complications (bleeding, stroke, peri-operative MI)
Length of Stay
Long-term:
Survival
Major Adverse Clinical Events (MI, stroke)
Re-intervention (PCI or CABG)
Evidence is a two way street
 Syntax Study (evidence ‘in’)
-provides best evidence about which patients need CABG
- ‘forgotten’ aspect arising from Syntax is Heart Team role
 Should surgeons be expected to provide evidence?
-what we do and how well we do it? (evidence ‘out’)
-current UK practice of publication of Outcome data
(Hospital and Surgeon Specific Data (SSD))
 Innovation and Research are not contra –indicated but
potentially can be enhanced by both ‘in and out’ evidence
-Appropriate referral is essential for quality
-Syntax Study provides undisputable evidence that a
majority of 3 vessel disease patients benefit from CABG
(survival, MACCE events, re-intervention)
-Emphasis should not solely focus on CABG vs PCI debate
but stimulate further investigation into the debate about
who needs revascularization (ischemic myocardium)
-Role of Heart Team - ‘forgotten’ Syntax recommendation
(incl. Surgeon/Interventional Cardiologist)
-Syntax Score provides angiographic evidence
-Individual patient needs differ
-Number of publications emphasize the importance of
individual patient factors/frailty scores (eg Syntax II)
-Treatment recommendation by Heart Team, rather than
individual practitioner, to ensure most appropriate
intervention strategy for individual patient
- Trigger: Children’s Heart Surgery, Bristol UK, 1984- 1995
- Kennedy Enquiry emphasized importance of transparency,
openness and honesty in cardiac surgical practice and outcomes
-Gradual evolution, from 2002, of hospital
and, more controversially, surgeon specific
data (SSD) release in UK
-Intention two fold:
Improve quality of care
Inform patients that care safe
-Society for Cardiothoracic Surgery in the UK and Ireland (SCTS) has
taken lead in hospital and surgeon specific data (SSD) release
-Bristol events/ Sir Bruce Keogh, Medical Director of NHS, initiated
process (individual surgeon data collection commenced 2003)
-Process in evolution but ‘CABG came first’
-Advantages and disadvantages -ongoing debate and controversy
-Motivation remains to improve quality
by providing understandable, uniform,
appropriate outcome data to patients
and physicians
60
50
40
 (Dimitrios
– case mix
Surgeon
30
20
10
0
CABG
AVR
CABG &
AVR
UK
MV
SOTON
CABG &
MV
OTHER
60
50
40
30
20
10
0
CABG
AVR
CABG &
AVR
UK
MV
CW BARLOW
MV &
CABG
OTHER
Strongly conflicting views within all surgical specialties but led
by Cardiac Surgeons about publication of SSD
Controversy about advantages and disadvantages of SSD
Also, is early mortality the best primary measure of quality?
Further changes in both content and mode of data release are
proposed
-Recent reported drop in mortality after CABG is not causally related
to SSD
-UK practice currently publishes All Case mortality data (not isolated
procedures eg. CABG)
-Time periods (3 years released annually) do not show continuity
-Poor quality data and ‘gaming’ alters standard deviations and impacts
‘honest’ units
-Creation of League Tables
-Politically driven not evidence based
-Anecdotal evidence risk averse behaviour by surgeons
-’Outlier’ Surgeon is ‘second victim’ if wrongly identified
(worsens performance)
-Recent UK release all specialties – only 3 of 5000 judged
underperforming (meaningless)
-Is a 0% mortality desirable or achievable?
-Can this mechanism of unit and SSD release be extrapolated
and meaningful in different healthcare systems? (different
revalidation, case mix, resources, means improving quality)
6
5
4
3
2
1
0
2003
2004
2005
Average Log Euroscore
2006
2007
2008
Actual Mortality
2009
2010
2011
2012
-Team Working
-Sharing information drives improvement
-Transparency – guides decision making patients/physicians
-Incumbent on surgeon to be able to describe what he does and
how well
-No evidence risk-averse behaviour (overall patient risk profiles
have increased)
-Early identification of problems allows early corrective
measures for hospitals and surgeons
-Professional Cardiac Surgical Society driven SSD release
‘armours’ surgeons against potentially devastating newspaper
tabloid scandals
Elective and Urgent cases only – not Emergent
Units/Hospitals must have resources to ensure data accuracy
Internal/External ‘national sense checks’
Monitoring unit/surgeon outcomes against national ‘norms’
-Unit and Surgeon outcome divergence
from expected is a statistical end point
-Trigger to investigate accuracy of ‘outlier’
data and only then to publish
-Some data will always be less accurate
(eg age vs. unstable angina)
-Identification of an outlier should trigger
a process of support not punishment to
improve quality
Essential that evidence from clinical studies (eg Syntax) should not entrench practice but
encourage ongoing research (Evidence ‘in’)
Similarly SSD release should not allow defensive practice (Evidence ‘out’)
In CABG the major areas of future focus are:
1. The importance and means of establishing extent and location of ischemic myocardium
(FAME Study)
2. Graft choice (RAPCO Study Update, ART Trial)
3. Technique (OPCAB),Exposure etc)
Quality in CABG must be assessed with both:
1. Short-term outcomes (survival, LOS, complications)
2. Long-term outcomes (survival, MACCE events, re-intervention)
There is growing evidence as to which patients need
revascularisation and whether that should be CABG (Syntax)
Future research (ART trial) will further define optimal CABG
strategy in terms of conduit, technique and access
Unit and Surgeon specific outcome data release can potentially
improve transparency and drive quality
(CABG specific, accurate, uniform, risk-adjusted, non-punitive)