30 July 2009
Outcomes for adult cardiac patients have improved dramatically over the past five years even as more elderly and high risk patients are now being treated; these are the findings of a comprehensive new study of over 400,000 operations from the Society for Cardiothoracic Surgery of GB and Ireland (SCTS) published today (Thursday 30th July 2009). The results prompt the Royal College of Surgeons of England to urge all surgical specialties to follow the lead as soon as possible.
The report, entitled Demonstrating Quality: The Sixth National Adult Cardiac Surgical Database Report, conclusively proves wrong critics who suggested that publishing mortality data would lead to risk-averse behaviour from surgeons, with the most sick and elderly patients being turned down for surgery for fear of blotting statistics. In practice, the opposite has turned out to be true – the increase in reliable data has emboldened surgeons to take on more complicated cases. More people who would have been considered too sick to undergo an operation just five years ago are now routinely treated and doing well.
The database findings provide compelling evidence that, since national publication of mortality rates in cardiac surgery began in 2001, the quality of care for patients has improved. These include:
- Mortality rates for ‘coronary artery surgery’ have fallen by 21 per cent and for ‘isolated valves’ by a third. For elective surgery in the under-70s mortality rate for ‘coronary artery surgery’ is now less than one per cent.
- The proportion of elderly patients being seen for surgery has increased. One in five ‘coronary artery bypass’ patients were over 75 and five per cent over 80 years old. The average age of aortic valve replacement patients has increased from 61 in 1994 to 68 in 2008.
- More diabetic, high blood pressure and overweight or obese patients are having cardiac surgery, all known risk factors, yet overall operation mortality rates continue to fall.
- Between 2001 and 2008 there has been a 50 per cent increase in the proportion of coronary surgery patients who are diabetic.
- Between 2001 and 2008 the proportion of coronary patients with hypertension (high blood pressure) has increased from less than 60 per cent of cases to nearly 75 per cent.
- Redo operations (for bleeding or deep sternal wound infection) are rare and getting rarer. The re-do rate for bleeding fell from 3.8 to 3.2 per cent between 2004 and 2008 and for infection from 0.8 per cent to 0.6 per cent over the same period and the time between first and second operations is increasing, indicating that the grafts are lasting longer.
- More than twice as many people are now having ‘aortic valve replacement’ and ‘mitral valve operation’. Both these procedures are more commonly required for more elderly patients and this increase reflects the increasing life expectancy for those with heart disease.
The full analysis – published jointly by the SCTS and Dendrite Clinical Systems Ltd – of so many operations gives a complete breakdown of how cardiac surgery is developing and highlights areas for future improvement including unequal access to cardiac surgery across the UK. For example, while mortality rates across the board are improving there remains a persistent gap between the sexes with survival rates significantly worse for women than for men.
With mortality rates for cardiac surgery so low – cardiac surgeons are now looking at extending outcome reporting to other areas which impact on recovery time and quality-of-life such as bleeding rates, post-operative stroke, kidney failure and the need to re-do operations.
Report author and University Hospital of South Manchester Consultant cardiac surgeon, Ben Bridgewater, said:
“One of the benefits we are now seeing from public reporting of outcomes is not just about bringing poor performers ‘into the pack’ but improving the performance of the pack as a whole. The very act of auditing services brings about improvements as centres learn from one another.”
John Black, President of the Royal College of Surgeons said:
“This new report proves that open reporting works if well funded and led by the clinicians. All branches of surgery are following the trail on reporting outcomes that cardiac surgeons have blazed and this should spur those efforts on. All of medicine should take note of the findings that full audit has not resulted in risk-averse behaviour.”
Professor Roger Boyle, the Department of Health’s National Director for Heart Disease and Stroke, said:
“We warmly welcome this report which shows that cardiac surgery continues to lead the way in outcome measurement in the UK. This report provides invaluable information not just in terms of the numbers of people who have benefited but also tells us about improvements in the effectiveness of treatment, patient safety and patient experience. I am particularly pleased that the evidence shows we are treating more people successfully in older age. This report provides an example of how services can put quality at the heart of everything they do.”
David Geldard, immediate past President of the Heart Care Partnership (UK) and patient advisor to the Cardiac Database said:
"We must never forget that for patients the prospect of surgery of any kind, but heart surgery in particular, used to be a terrifying prospect. This Report, together with the website Public Portal on cardiac surgery in every centre and for every surgeon, will help to de-mystify and assuage these anxieties. I recall that fourteen years ago, on the eve of my own bypass operation, drafting my Last Will and Testament. This was tearfully witnessed by my next door neighbour and another close friend just before I set off for hospital next morning. So it's not just the patients who are concerned and overwrought, but their friends and family as well. These are still serious procedures for serious conditions, but the prospects are improving all the time, as the Report amply demonstrates.”
Dr Peter Walton, Managing Director, Dendrite Clinical Systems said:
"We're pleased to have been closely involved for the last 10 years in running the data analyses and preparing database reports for the SCTS - and it is encouraging to see other specialities wishing to adopt the same data management philosophies and methodologies we have established in cardiac surgery"
The Royal College of Surgeons of England is committed to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient care. Registered charity number: 212808.
Copies of the 6th National Cardiac Surgical Database Report (512 page A4 hardback) available from:
Dendrite Clinical Systems
59A Bell Street
Oxfordshire RG9 2BA
Phone: 0149 1411 288
Fax: 01491 411 399
£100.00 + postage
A catalogue record for this book is available from the British Library ISBN 1-903968-23-2
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