UK heart surgeons are among the best in the world

The most thorough investigation ever into individual surgeons' performance at the operating table has found that the United Kingdom's cardiac surgeons are among the best in the world, with more adults surviving surgery despite patients being sicker and older than elsewhere.

All 222 cardiac surgeons who operate on adults in the United Kingdom met safety limits laid down by the Society of Cardiothoracic Surgeons, with none working at a mortality higher than 6% for coronary bypass surgery and many with much lower rates.

Figure 1.

Of almost 25 000 bypass operations done in the United Kingdom each year, the average mortality for 2003 was 1.8%, slightly less than that reported by surgeons in the United States. Professor Bruce Keogh, president elect of the society and author of the report, however, acknowledged that American surgeons deal with a more complex case mix, with many more obese and diabetic patients than UK surgeons, which accounted for the difference in outcomes.

The report is the fifth collection of outcome measures on adult cardiac surgery since 1996 and is based on the analysis of 210 000 patients who have recently had heart surgery. What started out as a 12 page pamphlet has grown, however, into a 340 page document, mainly due to demands from the public and the profession to measure performance more rigorously after the Bristol children's heart surgery scandal in the late 1990s (BMJ 2001;323: 18111473900).

Then it took a whistleblower to report on surgeons at the Royal Infirmary who were operating on babies and children despite higher mortality than similar units elsewhere. Now the society has taken the lead and can identify any surgeon whose results are outside the norm and investigate the reasons why, said Professor Keogh.

The society has stopped short of publishing individual surgeon's death rates, however, because it says it cannot yet take account of each patient's personal risk during a procedure. Instead, the society has published the number of bypass operations each surgeon has done in a year, whether surgeons meet the society's safety criteria (they all do), and the hospital's average survival rate.

Professor Keogh said that presenting results that were not risk adjusted would be grossly unjust and might lead to surgeons wanting to avoid high risk cases to improve their performance.

Currently, more experienced surgeons tend to take on more complex cases, and the types of procedures vary between hospitals. Although some surgeons deal only with elective patients, others take on a large proportion of emergency or urgent cases which carry greater risks.

To do more robust analyses on outcomes for each surgeon, the society needs to collect more complete data sets using a system called EuroSCORE (European system for cardiac operative risk evaluation), which looks at 15 variables for each patient, including age, ejection fraction, blood pressure, diabetes status, and weight. This information is missing for 30% of patients currently undergoing cardiac surgery in the United Kingdom, according to the report.