Public Reporting of Surgical Outcomes

In this weeks Lancet, a discussion around public reporting of surgical outcomes. Specific mention is made of the Society for Cardiothoracic Surgery in Great Britain and Ireland. Since 2005, the society has made outcome data freely available to the public; this has been associated with a 50% reduction in risk adjusted mortality, i.e. half as many people have died as would have been expected to die.

In terms of cost savings, the program costs £1.5 million annually, but is estimated to save £5 million per year in reduced length of stay costs.

While clinicians may be resistant to public reporting of data, it is inevitable. My opinion is that it is better to be proactive, seek to develop such databases and ensure the data represents as accurately as possible the reality, i.e. risk adjusted. 

See also this post from Paul Levy.

Trends in youth mortality around the world

Published in The Lancet today, an analysis of WHO data looking at mortality trends in children and young adults around the world over the last 50 years. There have been dramatic improvements in mortality reduction around the world, as much as a 93% reduction in children aged 1-4. The smallest reduction occurred in young men, aged 15-24. More focus should be directed on reducing mortality in this group. However, this is a very encouraging and optimistic paper, showing that greta work can be achieved.

Medical Education; Fit for the 21st Century?

My personal view is that the current model of medical education is no longer fit for purpose; it is too heavily oriented to rote learning, is excessively hospital focused, pays little attention to the overwhelming needs of disease prevention, is excessively focused on providing healthcare as opposed to health, does not have a word to say about systems thinking and pays lip service to the concept of teamwork. There is no emphasis on the need to provide value, it does not provide the tools that allow professionals to continuously improve their service and has nothing to say about the economics of health and importantly our obligations as professionals to ensure money is spent to ensure that society receives the maximal benefit.
A very clever intern spoke to me recently, and I was discussing the concept of safety and quality. She told me she had never heard anyone in 6 years of medical school discuss these concepts. A shocking state of affairs.
Which brings me to the purpose of this post. A paper was recently published in the Lancet, and I will let the authors speak for themselves. Fundamentally, it is a call to arms, laying out the clear need to radically reform the model of medical education, in similar fashion to the Flexner report 100 years.


"Professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems are systemic: mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification of professional status; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labour market; and weak leadership to improve health-system performance. Laudable efforts to address these deficiencies have mostly floundered, partly because of the so-called tribalism of the professions—ie, the tendency of the various professions to act in isolation from or even in competition with each other.


Redesign of professional health education is necessary and timely, in view of the opportunities for mutual learning and joint solutions offered by global interdependence due to acceleration of flows of knowledge, technologies, and financing across borders, and the migration of both professionals and patients. What is clearly needed is a thorough and authoritative re-examination of health professional education, matching the ambitious work of a century ago."

Is informed consent bad for your health?

A letter in this weeks Lancet is worth considering. Having been involved in a number of clinical studies in paediatric intensive care units, this resonated with me. The purpose of seeking informed consent from an individual enrolled in a clinical study is to ensure that they are protected in so far as possible and are fully aware of any possible risks entering this study may entail. The benefits of enrolling in a study, apart from the societal good of increasing knowledge is that there is some evidence that patients in a clinical study, regardless of whether they receive the experimental treatment or conventional treatment receive  better quality of care. There is also the possibility that they may benefit from the experimental intervention.
Using data from the CRASH trial, researchers estimated that in hospitals which sought consent from relatives, there was a 1.2 hour delay in initiating treatment compared to those hospitals in which no consent was sought. Applying these data to an analysis of the CRASH-2 trial, the researchers estimated that a one hour delay in commencing treatment resulted in a reduction in the percentage of patients responding to treatment from 63% to 49% with a likely increase in death and disability being the result.
There are two consequences; first the delay results in an increased risk of poor outcomes, second, the delay may obscure benefits that accrue from administering a time sensitive treatment.
 This has important ethical and scientific implications.