1st November 2018 - "Effect of public reporting of surgeons’ outcomes on patient selection, “gaming,” and mortality in colorectal cancer surgery in England: population based cohort study"
Link to paper: https://www.bmj.com/content/361/bmj.k1581
Americos Argyriou 11/01 06:00PM
Hey everyone, glad you could all make it to our Journal Club. I know people will be joining us still but if you can let us know your name, Year of study and Base Hospital. My name is Amerikos, 3rd Year at MRI. Facilitating this talk is Dr Boxall, a Urology Surgeon based in Salford Royal. Thank you very much for being with us tonight.https://www.bmj.com/content/361/bmj.k1581 The paper we will be discussing.
Sacha Chiuta 11/01 06:02PM
Hello, I am Sacha, 3rd year Salford
sharanniyan 11/01 06:03PM
Hi, I am Sharanniyan and I am a 1st year
nboxall 11/01 06:04PM
Hi all, as Americos said I'm Nick and currently a research fellow in uro-oncology based in Salford and the ChristieI'll wait another couple of minutes for any more people joining before startingBefore getting into the meat of the paper whilst waiting for anyone else to join, any thoughts on the topic selected?
sharanniyan 11/01 06:10PM
I personally believe that surgeon specific outcome reporting is a good move towards transparency and empowering patients with a choice
Americos Argyriou 11/01 06:11PM
Unfortunately Dr Boxall I don't think we are going to be receiving a great turnout. That being said we can have more of a detailed discussion on the points we had with this paper and wrap it up quicker that usual. I think this paper is quite influential as I know Surgeon outcomes are public for cardiac surgery but not really out there for other Specialties. It's probably the start of many similar movements for transparency and hopefully better Standards of careThat being said I don't believe 100% that public outcomes are entirely beneficial for everyone involved. There are negatives to them
sharanniyan 11/01 06:12PM
Agreed with you AmericosBut to us as future medical professionals, I think it introduces a new factor that might not have been present in the previous generations of clinicians
Sacha Chiuta 11/01 06:14PM
I agree with the points made, surgeon specific outcomes are a very good in building a better bridge between patients and their healthcare practitioners. I know that some neurosurgeons in Salford, have them published I think on one of the NHS sites.
nboxall 11/01 06:16PM
There's no getting away from this transparency, surgeon-specific outcomes are here to stay and it's how they are used and interpreted that is important. They will help protect surgeons as well as informing patients but do have some issues.What are the perceived negatives with surgeon-specific outcomes?
sharanniyan 11/01 06:17PM
To put it bluntly, if I am a bad surgeon, I would have lesser patients in the long run
Sacha Chiuta 11/01 06:18PM
Patients may become selective of who they want to operate on them, and on an admin level it would be quite difficult and nearly impossible to navigate everyone's desired option
Americos Argyriou 11/01 06:18PM
If there is no proper way to measure Patient Illness severity accurately, outcomes are completely meaningless. The surgeon who takes on harder cases might be wrongly pointed out a worse surgeon than the one who takes on easier cases.
sharanniyan 11/01 06:19PM
Exactly, it would create an overburden especially on the administrative side particularly in a system like the NHS
nboxall 11/01 06:19PM
If you're a bad surgeon, should you be operating at all?
Angus Hotchkies 11/01 06:19PM
Hi all, apologies for being late
nboxall 11/01 06:20PM
Hi Angus, welcome!
Angus Hotchkies 11/01 06:20PM
Thank you, I'll just have a quick read of the discussion above.
sharanniyan 11/01 06:21PM
I also feel that in a for profit private healthcare system, such reporting systems would induce competition in the market much like for any other good
Americos Argyriou 11/01 06:22PM
If the bar is set so high, as I am sure it is, I presume one or two unfortunate cases in a year would be enough to label you a bad surgeon?Yes, I think in a for profit environment hospitals would definitely be advertising their Outcomes.
sharanniyan 11/01 06:23PM
Like you said earlier Americos, we can never gauge "badness" in a completely objective manner
Sacha Chiuta 11/01 06:23PM
it might become more of a numbers game for practitioners
sharanniyan 11/01 06:23PM
Which of course could lead us to the argument if healthcare should be for sale?
Sacha Chiuta 11/01 06:24PM
I agree quantifying what makes someone a bad surgeon would very subjective
Angus Hotchkies 11/01 06:25PM
It's a controversial topic isn't it! How we regulate this is going to be very difficult int the future and unfortunately how everyone interprets the "results" and what knowledge base they have is extremely varied
nboxall 11/01 06:25PM
Whilst there's a wider debate to be had about competition in the marketplace, which is nothing new in the NHS since legislation a few years ago giving you the right to choose your hospital of choice, we should probably focus more on the paper itself but glad to see the topic itself is provoking debate!
tricia.tay 11/01 06:26PM
Hi I'm Tricia - Year 3 based at Salford. Just had a read of our previous discussion and it is interesting to publicly quantify the proficiency of a surgeon using the outcomes of patients under their care
nboxall 11/01 06:26PM
welcome Tricia!So what did people think of the paper itself?
Americos Argyriou 11/01 06:31PM
The Data seems objective as its collected from The National Assoc of Coloproctology and the NHS. And they've explained that little room exists for data manipulation. I felt like they attempted to make it as objective as possible, and thats no easy task with such a topic
Angus Hotchkies 11/01 06:31PM
Good size of cohort. And sorry but to clarify this statement: "introduction coincided with a significant reduction in 90 day mortality." As in the introduction of public reporting meant patient's mortality in CRC resections went down?
Americos Argyriou 11/01 06:33PM
Yeah I think so. But that only applied to elective and scheduled Surgery. Emergency Surgery showed no change.
sharanniyan 11/01 06:34PM
Yes that's what they are trying to get at
Americos Argyriou 11/01 06:35PM
Which might be due to improvements in Pre and Post -Op care and not actually to do with the surgery itself.
tricia.tay 11/01 06:35PM
Feel that the abstract was well written and clearly signposted but could have included how the results can be applied in clinical practice
sharanniyan 11/01 06:35PM
But they did clarify it was not because of surgeon skill
Angus Hotchkies 11/01 06:37PM
nboxall 11/01 06:40PM
I don't think it's anything you'd necessarily put into clinical practice, but it does reflect trends (or at least is trying to demonstrate a lack of change of trends) within clinical practicewhat I'm not sure about from the paper, is how this data is actually reported. Are colorectal surgeons self-reporting their outcomes? I'm not sure if anyone else managed to see that from the paper? Certainly in Urology in the UK outcomes are self-reported but in the USA external people assess outcomes
sharanniyan 11/01 06:45PM
Isn't self reporting the reason as to why there could be possible "gaming"
Americos Argyriou 11/01 06:45PM
I'm not sure. I remember reading that Death is recorded from the Office of National Statistics so that measurement is objective
nboxall 11/01 06:45PM
not necessarily, selecting your patients does become a thing
Sacha Chiuta 11/01 06:46PM
I don't think it mentioned how this data was actually reported, but it is an interesting point because if it self reported does that not leave room for bias
Americos Argyriou 11/01 06:46PM
I think the actual outcomes ie 90 day mortality is objective in that senseThe matter they considered was the recording of patient Severity. Thats a possible point to manipulate To prevent Gaming they said this:
“the Association of Coloproctology of Great Britain and Ireland has recommended that the ASA grade of each patient should be determined by the anaesthetist rather than by the surgeon and that this grade should be recorded before the resection of the cancer.”
The anesthetist isn’t exactly objective as he has a working and sometimes personal relationship with the surgeon. It would be interesting to see a study assessing objectively the ASA Grade of patients prior to surgery and comparing that score with what the Anesthetist gives them.
nboxall 11/01 06:50PM
the ASA grade should only ever determined by an anaesthetist anyway. It would, however, be possible for surgeons to influence anaesthetistsI'm not sure what you mean about assessing the ASA of patients prior to surgery and comparing with the score the anaesthetist gives them
Americos Argyriou 11/01 06:52PM
I meant to see if the Anesthetist upgrades the Severity of patients
nboxall 11/01 06:53PM
in the small print it is, however, only a recommendation that the ASA grade should be determined by the anaesthetistjust looking at the time, it seems we're nearly an hour so we're going to have to wrap things up shortlybefore we wrap up, any other opinions on the paper?
tricia.tay 11/01 06:56PM
Just thought the authors could have summarised the numbers in a table
sharanniyan 11/01 06:56PM
Yea definitely the data could have been presented in a clearer fashion
Sacha Chiuta 11/01 06:57PM
I think more clarity in the method would have been better aswell
nboxall 11/01 06:57PM
I do think the data could have been better presented as well, I agree
tricia.tay 11/01 06:57PM
Did the authors check at the end if they have met the primary and secondary aims of the study?
nboxall 11/01 06:59PM
I'm not sure they've explicitly stated they have but it would appear they have answered their research questions
Americos Argyriou 11/01 06:59PM
They wrote in their Objectives that there is adjustment for characteristics of patients and tumour in results. Dr Boxall, how would they quantify tumour risk?They haven't really written anything on how this is doneYou can give us your final thoughts before we wrap the session up.
nboxall 11/01 07:01PM
I'm presuming the tumour risk is related to tumour characteristics which are microscopic. Nuclear grade, degree of differentiation, etc
Angus Hotchkies 11/01 07:02PM
Agreed that it's not completely clear in presentation, they seemed to have answered there proposed questions. As ever, further research needs to be done and it's important because as we have demonstrated it is bound to be a highly debated topic
nboxall 11/01 07:05PM
To summarise, I don't think there's any getting away from reporting surgical outcomes. It is important for patient safety and I think it's how we use these and how they're reported as to how useful they can be. Rubbish in = rubbish out. The paper itself is generally quite well written I thought and, whilst we haven't discussed it, the statistical analysis seems relatively appropriate. I imagine it will be an ever-evolving concept and as we become more defensive as a profession will probably be reflected in this data but I think this won't happen straightaway. Any other thoughts?
sharanniyan 11/01 07:06PM
I think that sums it up really well
Americos Argyriou 11/01 07:08PM
I think we will continue to get better at reporting outcomes as this is literally the very beginning with very few studies done on this topic. Its actually incredible to think that outcomes are not reported anywhere for most surgeries.
nboxall 11/01 07:09PM
Right, I'm afraid I'm going to have to dash, thank you everyone these evening!
Americos Argyriou 11/01 07:09PM
Thank you Dr Boxall!
sharanniyan 11/01 07:09PM
Thank you for having us Dr Boxall
Sacha Chiuta 11/01 07:10PM
Thank you very much Dr Boxall
Americos Argyriou 11/01 07:10PM
Guys post your emails below for a Certificate of Attendance before you leaveAnd thanks for joining in to the discussion
tricia.tay 11/01 07:11PM
Thanks Dr Boxall and all for this discussion - my email is firstname.lastname@example.org
sharanniyan 11/01 07:11PM
Mine is email@example.com and thank you everyone for a good discussion
Americos Argyriou 11/01 07:15PM
Have a goodnight everyone