Surgical Mortality in Europe

A fascinating paper just published in the Lancet, outlining rates of mortality up to 7 days post operatively across 28 European countries. Data on over 46000 patients was collected. Crude mortality ranged from 1.2% of all cases in Iceland to >20% in Latvia. When adjusted for confounding variables, e.g. smoking, COPD etc, there was a TEN FOLD difference between the best and worst performing systems.

"When compared with the UK, the recorded mortality rates for Poland, Latvia, Romania, and Ireland were higher even after adjustment for all identified confounding variables. This pattern could relate to cultural, demographic, socioeconomic, and political differences between nations, which might affect population health and health-care outcomes."

However there may be other explanations, including the size and volume of surgical units, availability and expertise of intensive care, staffing, training and use (or lack of use) of approaches known to reduce morbidity and mortality such as pre-operative briefings (Gawande and others), appropriate antimicrobial prophylaxis and VTE prophylaxis. Regardless of the cause, yet again we see evidence of huge variation. Time to start learning why this exists. 
 

Gawande and 200 years of surgery

A wonderful piece of writing from Medicines prose laureate. This comes from the NEJM 200th anniversary series and Atul Gawande writes about the history of surgery. My favourite paragraph,

"It would take a little while for surgeons to discover that the use of anesthesia allowed them time to be meticulous. Despite the advantages of anesthesia, Liston, like many other surgeons, proceeded in his usual lightning-quick and bloody way. Spectators in the operating-theater gallery would still get out their pocket watches to time him. The butler's operation, for instance, took an astonishing 25 seconds from incision to wound closure. (Liston operated so fast that he once accidentally amputated an assistant's fingers along with a patient's leg, according to Hollingham. The patient and the assistant both died of sepsis, and a spectator reportedly died of shock, resulting in the only known procedure with a 300% mortality.)"

Coaching

A great and as ever thought provoking piece from Gawande. He discussed the value of coaching and describes his experience and initial results of using a surgical coach. Well worth a read.

Cowboys and Pit Crews

A great piece, as usual, from Gawande, with the aforementioned title. Bottom line, we have to change the way we think and work.

Eliminate Variation, Part 2

A piece in the BMJ by John Wennberg summarizes much of the knowledge around variation in medical practice. He breaks unwanted variation into three categories, effective care, preference sensitive care and supply sensitive care.

• Effective care. This is care that is the right treatment for the vast majority of patients, and variation in this element relates to underuse, e.g. vaccination
• Preference Sensitive Care. This is care provided when there are more than one effective treatment, and choice of therapy should be dictated by patient preference; in fact, physician choice often determines this. Mastectomy rather than lumpectomy plus radiation for breast cancer for example. 
• Supply sensitive care. This is care that is dependent on the supply of services in a region. Roehmers law is one example of this; this states that in an insured popualtion, a hosoital bed is a filled bed. Dartmouth have found no corrleation between the amount of care received and outcomes, suggesting that there are areas with massive overuse of resources. Gawande in a brilliant article two years ago examined this discrepancy.

Also check out the NHS health Atlas. There are huge variations in care evident. Likely that this occurs everywhere.

Torture and Solitary Confinement

Not strictly medical improvement and certainly not seasonal, but a very powerful piece from Gawande just published in the New Yorker. Well worth a read.

Checklists

Since the study published two years ago in the New England Journal of Medicine by Gawande, which showed the value of checklists in reducing surgical morbidity and mortality in a variety of care settings, developed and developing world, there has been increasing interest in the benefits of checklists in improving patient safety. However the Gawande study has been criticized on a number of fronts, with many people doubting the benefits. The cardinal message of that study was that each of us, no matter how brilliant, will make mistakes. The purpose of the checklist is to reduce the risk of each team member making a mistake. Importantly, two major studies have just been published, which support Gawande's contention that the use of checklists are associated with improved outcomes. De Vries et al writing in the NEJM report a dramatic reduction in mortality and complications.

Neily et al writing in JAMA last month report similarly impressive results. It would appear that the jury is in; the use of checklists as part of a comprehensive approach to reducing surgical complications appears to be proven. Let the checklist reign.