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Ann Thorac Surg 2000;70:693-694
© 2000 The Society of Thoracic Surgeons
a Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, New Hampshire, USA
Address reprint requests to Dr O’Connor, Northern New England Cardiovascular Disease Study Group, Center for the Evaluative Clinical Sciences, 7251 Strasenburgh Hall, Rm 330, Dartmouth Medical School, Hanover, NH 03755-3863
e-mail: gerald.t.o’connor{at}dartmouth.edu
Since the release of cardiac surgery outcomes by the Health Care Financing Administration in 1987, there has been a burgeoning of statewide programs to collect outcome data and release it to the public [1, 2]. The states of New York, New Jersey, Pennsylvania, and California have active cardiac surgery outcomes reporting programs and others are planned. In Minnesota, Virginia, Colorado, and Northern New England, physician led groups have organized to collect and share cardiac surgery data in order to improve the efficiency and outcomes of clinical care.
In this issue of The Annals of Thoracic Surgery, Richard Goss and colleagues report on their initial efforts to organize a physician-led cardiac outcomes reporting system for the state of Washington [3]. This project was proposed as an alternative to a 1993 plan by the state
Health Care Authority to identify "centers of excellence" for selective contracting of cardiac surgery. All 14 of Washington’s cardiac surgery centers participated in the project. A governance structure was established and a pilot data collection project was completed. This initial project examined the functional outcomes of cardiac surgery patients. They learned that functional outcomes improved after cardiac surgery and that real-time accurate data collection is not simple. The lessons learned from this pilot study will serve them well as they move toward the reporting of risk-adjusted clinical outcomes. The first clinical outcome report is scheduled for release during 2000.
If the experience of the Washington group is like that of others, they will find that real differences exist in the processes and outcomes of clinical care. Two- to threefold differences in risk-adjusted cardiac surgery mortality rates are commonly found [4, 5]. This finding is very likely in Washington and it will test their resolve and the strength of their group. They will contest their own data and eventually get to agreement. Then they can move toward learning from the data. These differences in clinical outcomes are treasures [6]. They demonstrate that improvement is possible. This improvement should not be confused with remediation; every medical center can and should improve by examining their processes of clinical care and learning from each other.
Large regional data sets are an important prerequisite to improving clinical care. In Northern New England, cardiac surgeons average 140 cases of isolated coronary artery bypass graft surgery per year. There are 2 to 4 patient deaths per surgeon. It is almost impossible to learn from your own daily experience in cardiac surgery. The number of adverse events is too small to draw strong inference, and clinical anecdote is notoriously unreliable as a teacher. The availability of a large and trusted risk-adjusted database facilitates rapid learning. We have maintained a cardiac surgery database in Northern New England since 1987. It now contains data from approximately 50,000 consecutive cardiac surgery procedures. We have learned some lessons. Most important is to keep it simple and to get it right. Our primary data collection form is one page, one side. It is self-coding and the data definitions are on the back. The form follows the patient through the system. The keypunching of data forms is outsourced and reports are sent to clinicians and hospitals three times per year. We validate both the numerator and denominator of the mortality rate using hospital discharge data. This system has been reliable, flexible, and has served us well for 13 years. However, the data and the reports are a means not an end. The data are for action. They are for solving problems not for admiring them. Two-day regional meetings are held three times per year and provide a venue to discuss the data and to look for outcomes to improve clinical care.
These data can provide an answer to some of the important questions in cardiac surgery. The physician asks: "How am I doing?" The patient asks: "What are my chances?" The profession asks: "How can we improve?" The physician needs to know the clinical outcomes of their care, and a primary purpose of the regional cardiac surgery groups is to provide a trusted source of these data. Further, these data need to be contemporaneous and accurate. They must represent the current events of clinical care not its archaeology. The patient deserves an accurate and quantitative answer to their questions about the risks and benefits of cardiac surgery [7]. There is enormous potential to use the data collected in daily care to improve informed consent and clinical decision making. The organization of regional professional collaborative groups also builds the trust required to do meaningful benchmarking and to improve clinical care [8, 9]. In benchmarking, multidisciplinary cardiac surgery teams make structured visits to other medical centers. This technique, which is common in industry but relatively rare in health care, is a superb way to gain ideas for change and to accelerate the rate of improvement in cardiac surgery.
Improving the quality of clinical care is a goal shared by government, insurers, clinicians, and patients. The public expects that the physician will take the primary responsibility for the quality of clinical care provided. It is very important for physicians to capture the high ground on quality of care. Genuine improvement requires data, organization, and changing processes of clinical care. Physicians are on the front line of health care and are uniquely able to advance these goals. It is a serious responsibility of physicians to take the lead on improving clinical care. If they do not accept that responsibility, governments, insurers, or managed care organizations will assume it. The physicians will become the white mice in someone else’s experiment. Neither the patients nor the physicians will be well served by this eventuality. Sometimes technological advances will result in an improvement of clinical outcomes, but more commonly, improvement will be gained by improving the hundreds of clinical processes that characterize cardiac surgery. The ready availability of contemporaneous risk-adjusted data, and the ability to organize multidisciplinary teams and to benchmark with your peers in other institutions will result in rapid progress. These physician-led cardiac surgery collaborative groups are at once regional projects and fundamental reorganizations of clinical care. We congratulate Dr Goss and his colleagues and wish them success.
References
This article has been cited by other articles:
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  D. M. Shahian, S.-L. Normand, D. F. Torchiana, S. M. Lewis, J. O. Pastore, R. E. Kuntz, and P. I. Dreyer Cardiac surgery report cards: comprehensive review and statistical critique Ann. Thorac. Surg., December 1, 2001; 72(6): 2155 - 2168. [Abstract] [Full Text] [PDF]
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