|The President's Meeting|
|Monday, 03 June 2013|
On 8 March, leaders from across the profession were in Edinburgh to discuss the latest thinking on surgical outcomes. The President's Meeting included international experts on outcomes, such as Dr John Birkmeyer from the USA, as well as parallel sessions from the UK's specialty Associations. Here, chairs of the various sessions review the discussion and debate that helped make the event a success.
Opening Plenary Session
It was a privilege to Chair the opening session of the President’s Meeting on Surgical Outcomes. The Lister Legacy Lecture was delivered by our keynote speaker, Dr John Birkmeyer, who started the proceedings with a lecture that was superbly delivered and very clear in its message.
For me, the take-home message was that a skilled surgeon will have good results because he or she is good at their job, and that skill applies not only to delivering the straight forward operations, but also to dealing with the complications. The other message which I took from this part of the meeting was that volume is important but it is not the only determinant of success for individual surgeons. The critical issue is the skill of the surgeon and the skill of the team that is working for the benefit of the patient.
The rest of the session was diverse, in that the speakers came from a variety of backgrounds. Roger Black, from the Information Services Division of NHS National Services Scotland, explained how centrally collected statistics can help in providing objective data for surgeons. This, of course, is an area where there is much debate, particularly around the reliability of the data collected.
Ewen Harrison, from the Royal Infirmary of Edinburgh, delivered a spectacular lecture showing how longitudinal data can be presented in such a way as to hold the attention and make relevant points about the activity of hospitals and individual surgeons. Finally, Professor George Youngson, whose role as RCSEd’s Vice President encompassed patient safety and revalidation, explored the differences between the reality and the aspirations of current discussion about surgical outcomes. The session was an excellent start to what proved to be a very good and productive meeting.
Professor John Primrose, ASGBI President, introduced the session with an overview of outcomes and cancer, highlighting the importance of an accurate definition of incidence, prevalence, mortality and survival. Within the UK, there have been significant changes in survival in many cancers, but when compared with other countries there is an apparent lower survival for colorectal cancer. This, however, does not appear to be borne out when staged specific data is compared.
Professor Primrose highlighted the differences between countries with respect to registration at the time of diagnosis (which should be mandatory in the UK), as this will have an impact on survival figures. But the problem of late diagnosis and lack of new cancer drugs are also factors within the UK, contributing to poorer outcomes.
Professor Paul Finan, past President of ACPGBI and Chair of the National Cancer Intelligence Network Bowel Cancer Group, demonstrated the value of a national audit programme for improving outcomes in colorectal cancer. By 2010, case ascertainment across England and Wales had reached 89%, with 97% of patients with colorectal cancer being discussed at a multidisciplinary team meeting. From this data analysis, Trusts were able to receive their own figures for mortality and survival.
Professor Finan highlighted the importance of risk adjustment and allowing for differences in case mix, but nevertheless demonstrated that there were variations in mortality and survival across Trusts. Accurate and complete data collection was highlighted as essential for the programme’s success in monitoring outcomes and influencing change in surgical practice.
Mr Bill Allum, AUGIS President, presented on improving outcomes in upper GI cancer. Over an eight-year period from 2000 to 2008 there has been a significant change in the number of oesophagectomies and gastrectomies, with very few hospitals now doing less than 10 oesophagectomies per year. The 30-day mortality for both operations has fallen from 8.4% to 4.8% and 8% to 4.2% respectively, with this degree of specialisation.
Data was presented from the National OG Cancer Audit (NOGCA), which included over 17,000 patients registered in England and Wales. There had been 3,800 resections with a 30-day mortality of 3.1% and 4.2% for oesophagectomy and gastrectomy respectively. Mr Allum emphasised the importance of surgeon and hospital volume on both mortality and survival, as well as the importance of case referral to specialist teams, multidisciplinary team meetings and feedback to the local Trusts. In view of the significant percentage of oesophageal and pancreatic cancer patients being diagnosed in an emergency setting, often with advanced disease, resources should be concentrated on early diagnosis by GP referral and surveillance programmes.
The last speaker, Mr Richard Welbourn, President of the British Obesity & Metabolic Surgery Society, presented results from the National Bariatric Surgery Registry (NBSR). A report in 2011 contained data on over 8,000 patients. He presented a very detailed proforma for data collection and from this it was apparent that Roux-en-Y gastric bypass was the most common procedure (55%), followed by gastric band (31%) and sleeve gastrectomy (8%). Co-morbidity data showed that co-existing disease increased with increasing BMI, with 25% of patients classified as ASA III or IV.
Following surgery, Mr Welbourn demonstrated a significant reduction in co-morbidity at one year follow-up, with significant improvement in patients with conditions such as hypertension, diabetes and hyperlipidaemia. Despite the obvious benefits of bariatric surgery, funding in most NHS hospitals remains limited.
This session featured representatives of the Specialty Associations reporting on audit and outcome measures.
Mr David Chadwick of BAETS discussed the variety of surgical members from endocrine, through general surgery to ENT and then concentrated on thyroid surgery outcomes. Data illustrates the improved outcomes and reduced hospital stay brought about by new technology. It allows outcomes to be risk-adjusted and for outliers to be identified. It was added that open publishing of data may be coming soon.
Professor Nirmal Kumar discussed outcomes in ENT with many validated generic or disease-specific questionnaires including the gloriously-named sinonasal version ‘SNOT-22’. These have been used to refute the government’s Policies of Limited Clinical Effectiveness documents. Quality of life assessments show morbidity of childhood tonsillitis is comparable with juvenile arthritis and moderate asthma, and falling tonsillectomy rates are alongside rising peritonsillar abscess rates.
Mr Richard Nelson discussed neurosurgical data, the Glasgow Outcome Scale and the Oswestry Disability Index. He demonstrated the value of data collection with a review of neurosurgical mortality figures showing how case mix adjustment was essential, peer group review of cases was valuable but time-consuming and that obligate mortality had to be noted. CEPOD has helped the drive for increased staffing and theatre space.
Mr Kavin Andi of OMFS rounded up the session by showing us the future. He demonstrated the development of databases using secure portable devices which are touch-screen enabled for use in head and neck cancer patients. Data security implications and server facilities were discussed, but the presentation highlighted the ability to obtain and record with ease a significant amount of detail in almost real-time.
The audience agreed that outcome measures were going to be an important tool in dealing with commissioning, revalidation and justifying service requirements.
Opening the session, BOA President Martyn Porter discussed the National Joint Registry (NJR) in England, Wales and Northern Ireland. Its aim is to improve outcomes through patient, surgeon and implant audit, and compliance is 93%. It has matured since it started 10 years ago, and is now the largest arthroplasty registry in the world with over 1.2 million records and 180,000 uploads added annually.
Bruce Tulloh presented the British Hernia Society’s audit of outcomes after incisional hernia repair. This is a small group interested in hernia surgery and does not claim to be a comprehensive cover of hernia surgery, but they try to address many unanswered questions where good evidence is lacking, particularly for the repair of incisional hernias. Laparoscopic repair of incisional hernias has increased in popularity and has a shorter length of stay and fewer wound infections. But recurrence can be troublesome after laparoscopic repair and the big worry is occult small bowel injury. Also lacking in the literature are long-term results, especially after laparoscopic surgery where ‘pseudo-recurrence’ is particularly important because it relates directly to repair quality. Therefore, it would be fair for patients to ask their surgeon about complication rates. But retrospective reviews are tedious and out of date, and prospective audit (or registry) is difficult to set up. At present, it is impossible in the UK. Other countries have done it, and there is the European Registry of Abdominal Hernias, which uses online data entry with details only of the hernia, not the patient. It is open to UK surgeons, but there will still be difficulties for UK surgeons to record follow-up data.
Andrew Sinclair from BAUS talked about ‘Validating Hospital Episode Statistics Data: The Key to Acceptance’. He used the work done by the Urethral Surgeons Group looking at urethral stricture disease and reconstruction – a small group examining a discrete subject. HES data goes back to 1996, follows the patient and is not limited to one hospital or one surgeon, and allows analyses down to procedure/patient/surgeon/hospital. However, it is entirely reliant on accurate coding, and does not cover private hospitals, and requires considerable time and effort to set up analytical parameters.
Simon Kenny from BAPS outlined how outcomes in paediatric surgery were measured and used for revalidation, service commissioning and improvement, and benchmarking. Whilst there has been a steady decline in childhood mortality, UK figures still lag behind the best in Europe, particularly for emergency presentations and for survival of childhood cancer. Paediatric surgery comprises high-volume, low-complexity procedures in DGHs and Primary Care, and low-volume, high-complexity work in specialist centres. Using Hirschsprung’s disease as an example, the average caseload per surgeon was only 1.5 cases per year, and the highest was still less than six new cases per year. Because of the low numbers, a power calculation showed it would take thousands of surgeon years to statistically demonstrate outcome data. But that will not stop Freedom of Information requests or unqualified media snapshots. Population-based data, or national or unit data, may however be the way forward, and there is some evidence that UK surgeons are leading the way with this. For high-volume, low-complexity work, there have been attempts to integrate the HES data into everyday practice. As ever, the HES data’s validity should be checked regularly for true readmission rates. Having done that, there is a clear message that setting and measuring care standards will improve patient outcomes.
The session was well-attended and there was much interactive discussion following the presentations, all of which were different but all of which were stimulating in their own specialist way.
It was particularly fascinating to hear what happened in vascular surgery following the launch of audit, which led the way for many other specialties. David Mitchell, from the Vascular Society, outlined this work very clearly and was followed by Graham Cooper, of the Society of Cardiothoracic Surgeons, who took a slightly different view towards results by looking at the impact of outcomes on medical and surgical professionalism and its relationship to appraisal and revalidation.
The Transplantation Society’s Professor Chris Watson’s talk on the outcomes of transplantation was particularly fascinating because there have been so many developments in this field, with outstanding results. It was a revelation to learn of the excellent outcomes that are now possible using new techniques.
New BAPRAS President, Graeme Perks gave a very graphic presentation on the problems envisaged by plastic and reconstructive surgeons, who must often deal with problems caused by other surgeons.
Closing Plenary Session
The final session of the day was worth waiting for. Clare Marx, Chair of our sister College in England’s Invited Review Mechanism Committee, gave the meeting a very interesting insight into the workings of this process which provides independent advice to Trusts about their surgical service and problems which have arisen.
The contribution from our colleagues in cardiac surgery in publishing outcome data on a named surgeon basis has been an example to us all. Professor Ben Bridgewater, Clinical Lead at the National Institute for Clinical Outcomes Research at the University of London, went through the production and dissemination of the cardiac surgery data, explaining how it can be used to improve results overall.
Derek Feeley, Chief Executive of the NHS in Scotland, discussed his role in promoting patient safety and explained the role and work of the Scottish Patient Safety Programme. He was able to demonstrate the decrease in standardised mortality ratios in Scotland and the contribution of the Scottish Patient Safety Programme to the improvement. It was a very thoughtful and thought-provoking presentation.
John Birkmeyer provided the final presentation of the meeting. He outlined a set of research findings showing the relationship of surgical skill to complication rates and how improvements in outcomes are achievable by collaborative working and learning from others; very impressive work.
Video footage of presentations from the President's Meeting are available at www.rcsed.ac.uk.