Prospective Analysis of Clinical Outcome: Influence on Surgical Professional Development

Professor MJ Underwood

Division of Cardiothoracic Surgery,

Chinese University of Hong Kong,

Prince of Wales Hospital,

Hong Kong

Questions

What is Professional Development ?

How does it relate to Clinical Outcomes ?

How does it relate to a National Database?

Personal Viewpoint

UK System

Hong Kong Initiatives

Continuing Professional Development (CPD)

Continuing Professional Development (CPD)

Interrelates

– Clinical– Managerial– Professional

PROVISION OF HIGH-QUALITY PATIENT CARE

Interrelates

– Clinical– Managerial– Professional

PROVISION OF HIGH-QUALITY PATIENT CARE

General Medical Council Guidance - 2006

High Quality Patient Care = Quality Assurance Programme in Cardiac Surgery

AIM :

Provide ‘safest’ journey for the patient during their hospital stay with ‘acceptable’ outcome defined by international standards.

Quality Assurance Components

Quality Assurance Programme

Institutional Process

Patient Outcome (results)

Appropriate Care

Patient Satisfaction

Fiscal Responsibility

Audit,Multidisciplinary Mortality and Morbidity Meetings

Multidisciplinary Case Conferences, Audit

Audit

Audit

Audit

ESSENTIAL: Quality Assurance Components

Practical Factors

Local Data Collection– Internal/External Validation

National Data Collection– Internal/External Validation– Data Confidentiality/Safeguards

International Data Comparison– Calibration, Comparison

Personal/Surgical Factors

Commitment Culture Consistent

CPD=High Quality Care=Quality Assurance=Data Collection =Data Analysis

How do we collect data ?

How do we analyze data ?

High Quality Care

Data Collection

Data Analysis

DATA COLLECTION: Surgical Perspectives

Accurate Validated

– Internal/External

Available for Analysis– ‘real-time’ for risk monitoring

Internationally Compatible Security

Data Collection: Summary

‘Validated’

Influencing Events

1994-96 Senior Registrar Bristol Royal Infirmary

1997 Fontan Scholarship Brussels

1999-2002 Consultant/Senior Lecturer Bristol Heart Institute

1995 External Review

1998 GMC Enquiry

2001 Public Enquiry

Senior Lecturer/Consultant (1999-On)– Audit Lead Cardiac Services– Clinical Governance Lead– R and D Quality Assurance Lead

Consolidating Data Collection and Reporting

Contribution to CEPOD Public Presentation of Results External Validation of BRI Data

Collection Development of Sub-Specialist

Databases

Saturday 27 June 1998

BMJ

All changed, changed utterly

British medicine will be transformed by the Bristol case

Richard smith, Editor

Continuous Professional Development: Institutional Reporting

Continuous Professional Development: Individual Reporting

Prospective Analysis of Clinical Outcome: Where are we in Hong Kong ?

Institution of Computerized Data Collection and Analysis System

– Automated demographic data

Data Input at ‘point of clinical care’

Dedicated Database Manager– Accuracy, validation processes

Automated Demographics and Risk Calculation

Direct Comparison of Risk Scoring Systems: Testing

Receiver Operating Characteristic (ROC) Curves– Area represents probability that risk predictor accurately

discriminates between death and survival– Area of 1 = Perfect– Closer to 1 better, Closer to 0.5 less accurate

Calibration Plots– Plot observed vs expected events in calibration plot– Chi-squared value used as measure of accuracy of

matching

Risk-Scoring in the UK Population

Validation of Euroscore in Hong Kong%

Tru

e po

sitiv

es

% False positives

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80 90 100

ROC Area 0.819: modified Euroscore

ROC Curve for PWH Manual Euroscore

% T

rue

posi

tives

% False positives

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80 90 100

ROC Area 0.823: logistic Euroscore

Influence of Risk-Stratified Data Analysis on Professional

Development.

Monitor actual mortality and morbidity vs predicted– Essential for Quality Assurance Progamme

Compare with International Data

Patient status at discharge RA-CUSUM (modified Euroscore)

Actual

Expected

Deaths

Years

0

5

10

15

2005 2006

Comparison of Risk-Profiles: East vs West !

But:– Does risk-validation hold for sub-groups ?

– Is there a need for ‘population specific’ risk assessment

Hong Kong Cardiac Database: Overview

A National Database :Unique Practical Challenges from a Surgeon

Differing data collection mechanisms– How merge ?

Accuracy and validity– What infrastructure ?

Security– Who see’s the data ?

Data Analysis– Who analyses the data?

Presentation and Publication– Who ?

Hong Kong Cardiac Database: Overview

Chinese Cardiac Surgical Database

Professional Development/Clinical Outcome/National Database: Summary

Inter-related– inseparable

Inevitable– ‘consumer’/provider

driven

Irreversible– USA, UK, Europe

Editor's choice

Individual performance data: revelation and revolution

Welcome to a new world. Be brave.

Kamran Abbasi, acting editor

BMJ 2005;330: (5 March)