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No evidence of risk averse behaviour after publishing death rates for UK bowel surgeons

Thu, 05/03/2018 - 11:26
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The results show that the introduction of public reporting of individual surgeons' outcomes coincided with a substantial reduction in mortality for patients having non-emergency bowel cancer surgery

There is no evidence that publishing patient death rates for individual bowel surgeons in England has led to risk averse behaviour or 'gaming' of data, according to a published by The BMJ. In fact, the results show that the introduction of public reporting of individual surgeons' outcomes coincided with a substantial reduction in mortality for patients having non-emergency bowel cancer surgery. However, the papers authors found similar improvements were not found for emergency surgery, suggesting that improvements in care before, during and after major bowel surgery - only possible for elective procedures - may explain the findings.

When patient death rates for individual surgeons were first published in June 2013, the move was hailed as a major breakthrough in transparency that would drive up standards of care in England. Nevertheless, critics argue that public reporting of outcomes encourages risk averse behaviour, whereby surgeons are less likely to offer surgery to patients at higher risk, and manipulation of data to increase patients' predicted risk or to make patients ineligible for public reporting, so-called ‘gaming’. So far, the evidence that public reporting leads to improvements in the quality of patient care is surprisingly weak, and its effect has been studied only in cardiac surgery and almost exclusively in the US.

As a result, a team of UK researchers led by Dr Kate Walker from the London School of Hygiene & Tropical Medicine, London, UK, decided to look for evidence of risk averse behaviour, manipulation of data, and change in death rates immediately before and after the introduction of surgeon specific outcome reporting in colorectal cancer surgery across the NHS in England.

To investigate risk averse behaviour, they compared the proportion of patients who had elective surgery, predicted 90-day mortality and observed 90-day mortality, before and after the introduction of public outcome reporting. The analyses included data from 111,431 patients diagnosed as having colorectal cancer included in the National Bowel Cancer Audit (NBOCA).

After factors that could have affected the results, such as patient characteristics and tumour grade, were taken into account, the researchers found that the proportion of patients with colorectal cancer who had major surgery did not change after the introduction of public outcome reporting (63.3% before vs. with 63.2% after, p=0.8).

The proportion of urgent or emergency procedures - and therefore ineligible for public reporting - also did not change after the introduction of public reporting (15.5% before compared with 15.6% after).

The predicted 90-day mortality remained the same (2.7% vs 2.7%, p=0.3), but the observed 90-day mortality fell from 2.8% before to 2.1% after. Further analysis showed that this reduction was over and above the existing downward trend in mortality before the introduction of public reporting (p=0.03).

“The potential positive and negative consequences of public reporting are widely speculated on but are largely unexplored. This national study provides unique evidence that the introduction of public reporting of outcomes for individual colorectal cancer surgeons has not led to a decrease in the number of patients at high risk undergoing a major resection and has coincided with an improvement in 90-day mortality for eligible patients,” the authors conclude. “Public reporting of outcomes for individual clinicians seems to have triggered an improvement in outcomes after elective procedures that can be achieved only through the involvement of the entire clinical team. We did not find similar improvements in the outcome of emergency procedures. This points to improved preoperative preparation and planning of perioperative and postoperative care, only possible for elective procedures, as a potential possible explanation for the reduction in surgical mortality.”

To access the paper, 'Effect of public reporting of surgeons’ outcomes on patient selection, gaming, and mortality in colorectal cancer surgery in England: population based cohort study', please click here

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