Report cards a minefield
first introduced in New York State in 1991. The data included the raw mortality rate for each doctor, expressed as the proportion of the surgeon’s patients who died within 30 days of their operation, over the previous three years. The figure was accompanied by a risk-adjusted rate, intended to iron out skewing factors such as the tendency for very skilled doctors to see less straightforward cases in which by their nature good outcomes were less likely.
Pennsylvania and New Jersey followed in 1992, and last year the British Healthcare Commission published on its website survival rates for all UK cardiac surgeons. The commission has flagged expanding the report cards to other medical specialties.
A key impetus for the UK report cards was a scandal over mortalities in Bristol, southwest England, where two paediatric cardiac surgeons were eventually found to have death rates for a particular operation five to six times higher than the national average.
That scandal came to light after anaesthetist Steve Bolsin reported his concerns. Now the director of anaesthesia and associate professor of patient safety at Victoria’s Geelong Hospital, Bolsin is firmly in favour of report cards — and says the profession’s objections to them don’t stack up.
Better monitoring of death rates would have picked up problems with the mass murdering British GP Harold Shipman, who, Bolsin says, would probably only have killed 10 to 12 patients before being detected — as opposed to the 215 he is known to have killed (or up to 400 according to some estimates).
‘‘ Certainly my view is that they (report cards) are a very good idea for everybody — all specialists in every area, including GPs,’’ says Bolsin. ‘‘ There are a whole series of misleading arguments that are put forward . . . I think they are a bit of a smokescreen put up by some of the specialist groups. I think they (opponents) are afraid of being judged inferior, or in some way unacceptable. ‘‘ But we can’t afford not to do something about it. Errors in the American health care system kill more people than breast cancer and road traffic accidents, and there’s no evidence that Australia is any safer.’’ Bolsin says we need routine monitoring, ‘‘ and if the profession can’t accept it, it will have to accept that it may need to be imposed’’.
Like the RACS, the Australian Medical Association — the industrial body representing all doctors’ groups, not just surgeons — opposes report cards.
AMA vice-president Gary Speck says adjusting the death rates to take account of skewing factors such as patients who are sicker to begin with ‘‘ sounds easy . . . but belies the difficulty’’ involved.
‘‘ The fact that something is up and running and being used (overseas) doesn’t mean that it’s useful,’’ Speck says. ‘‘ A better way for people to choose their surgeon is in consultation with their family doctor, who will have good feedback about how patients have done (with particular surgeons).’’
Card supporter: Justin Oakley says some method of reporting is necessary, because surgeons vary widely in ability