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For Debate| Volume 50, ISSUE 6, P698-701, December 2015

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Risk Aversion in Vascular Intervention: The Consequences of Publishing Surgeon-specific Mortality for Abdominal Aortic Aneurysm Repair

Open ArchivePublished:September 24, 2015DOI:https://doi.org/10.1016/j.ejvs.2015.06.003
Risk Aversion in Vascular Intervention: The Consequences of Publishing Surgeon-specific Mortality for Abdominal Aortic Aneurysm Repair
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      Significant improvements in outcome have followed the reconfiguration of vascular services in the United Kingdom, a process that included the centralization of major arterial surgery and annual examination of institutional mortality rates for index procedures. Controversially, however, public reporting of surgeon-specific mortality data (SSMD) has now become mandatory for all cases of elective abdominal aortic aneurysm (AAA) repair and carotid endarterectomy performed in England, but the impact of this policy on mortality relating to AAA or carotid disease remains unknown. This paper examines the balance between the potential benefits of public SSMD reporting (transparency and quality improvement) versus the potential risks (gaming, risk-averse behaviour and/or an increase in inappropriate conservative management); and considers whether SSMD are an appropriate or meaningful metric for AAA repair and carotid endarterectomy in contemporary practice.
      In the United Kingdom (UK), the reporting of surgeon-specific mortality data (SSMD) has become mandatory for vascular surgery, with particular focus on elective abdominal aortic aneurysm (AAA) repair and carotid endarterectomy.

      Vascular Services Quality Improvement Program (VSQIP). Retrieved February 16, 2015, from http://www.vsqip.org.uk/surgeon-outcomes.

      Rigorous outcomes research, quality improvement initiatives, and national audit programmes are acknowledged to have improved patient care
      • Fung-Kee-Fung M.
      • Watters J.
      • Crossley C.
      • Goubanova E.
      • Abdulla A.
      • Stern H.
      • et al.
      Regional collaborations as a tool for quality improvements in surgery: a systematic review of the literature.
      Ann Surg. 2009; 249: 565-572
      , 
      • Guillamondegui O.D.
      • Gunter O.L.
      • Hines L.
      • Martin B.J.
      • Gibson W.
      • Clarke P.C.
      • et al.
      Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to improve surgical outcomes.
      J Am Coll Surg. 2012; 214 (discussion 714–16): 709-714
      , 
      • Sinha S.
      • Karthikesalingam A.
      • Holt P.J.
      Importance of outcomes research in surgery.
      ANZ J Surg. 2012; 82: 861-862
      and there is a widespread appetite for transparency and public accountability across the English National Health Service (NHS).
      • Ferriman A.
      Recommendations of the Francis report.
      BMJ. 2013; 346: f854
      AAA repair (in particular) has attracted considerable commentary. From 1999 to 2006, post-operative mortality was higher in England than in many other countries (7.9% vs. 1.9–4.5%).
      • European Society for Vascular Surgery
      2nd Vascunet report.
      2008
      This stimulated considerable service reconfigurations (e.g. centralization), quality improvement initiatives, the uptake of endovascular technology and the examination of institution-level mortality data,

      Framework for improving the results of elective AAA repair. http://www.vascularsociety.org.uk/library/quality-improvement.html.

      which resulted in a fall in elective AAA mortality to 1.8%.
      • Waton S.J.A.
      • Groene O.
      • Cromwell D.
      • Mitchell D.
      • Loftus I.M.
      Outcomes after elective repair of infra-renal abdominal aortic aneurysm.
      The Royal College of Surgeons of England, LondonOctober 2013
      http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2013-2014/Outcomes-after-Elective-Repair-of-Infra-renal-Abdominal-Aortic-Aneurysm.pdf
      However, there is little evidence that the attribution of post-operative deaths to individual surgeons will add to this success,
      • Ketelaar N.A.
      • Faber M.J.
      • Flottorp S.
      • Rygh L.H.
      • Deane K.H.
      • Eccles M.P.
      Public release of performance data in changing the behaviour of healthcare consumers, professionals or organisations.
      Cochrane Database Syst Rev. 2011; 11: CD004538
      and there is a need to examine the balance between the suggested/potential benefits of SSMD reporting (transparency and quality improvement) versus potential risks (gaming and risk-averse behaviour).
      Public disclosure of SSMD for cardiac surgery has generated considerable controversy.
      • Westaby S.
      Publishing individual surgeons' death rates prompts risk averse behaviour.
      BMJ. 2014; 349: g5026
      , 
      • Shahian D.M.
      • Edwards F.H.
      • Jacobs J.P.
      • Prager R.L.
      • Normand S.L.
      • Shewan C.M.
      • et al.
      Public reporting of cardiac surgery performance: part 2–implementation.
      Ann Thorac Surg. 2011; 92: S12-S23
      A range of unintended adverse consequences have been reported, including risk aversion
      • Shahian D.M.
      • Edwards F.H.
      • Jacobs J.P.
      • Prager R.L.
      • Normand S.L.
      • Shewan C.M.
      • et al.
      Public reporting of cardiac surgery performance: Part 1—history, rationale, consequences.
      Ann Thorac Surg. 2011; 92: S2-S11
      and even racial profiling,
      • Werner R.M.
      • Asch D.A.
      The unintended consequences of publicly reporting quality information.
      JAMA. 2005; 293: 1239-1244
      , 
      • Werner R.M.
      • Asch D.A.
      • Polsky D.
      Racial profiling: the unintended consequences of coronary artery bypass graft report cards.
      Circulation. 2005; 111: 1257-1263
      and an adverse impact on surgical training and/or specialty recruitment.
      • Westaby S.
      • Baig K.
      • De Silva R.
      • Unsworth-White J.
      • Pepper J.
      Recruitment to UK cardiothoracic surgery in the era of public outcome reporting.
      Eur J Cardiothorac Surg. 2015; 47: 679-683
      It has been suggested that risk aversion resulting from SSMD can lead to greater population mortality, because higher-risk patients may be denied intervention. Analyses to refute these suggestions have been criticized for incomplete risk adjustment, ascertainment bias, and a lack of information regarding patients who are refused surgery.
      • Bridgewater B.
      • Grayson A.D.
      • Brooks N.
      • Grotte G.
      • Fabri B.M.
      • Au J.
      • et al.
      Has the publication of cardiac surgery outcome data been associated with changes in practice in northwest England: an analysis of 25,730 patients undergoing CABG surgery under 30 surgeons over eight years.
      Heart. 2007; 93: 744-748
      The attribution of deaths to individual surgeons has also been criticized because most deaths after cardiac surgery are due to failure of teams, institutional structures and processes rather than individual surgeon error.
      • Westaby S.
      • De Silva R.
      • Petrou M.
      • Bond S.
      • Taggart D.
      Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services.
      Eur J Cardiothorac Surg. 2015; 47: 341-345
      In the absence of an acceptable alternative, high-risk patients have shown a willingness to accept the possibility of considerable perioperative complications,
      • Cykert S.
      Risk acceptance and risk aversion: patients' perspectives on lung surgery.
      Thorac Surg Clin. 2004; 14: 287-293
      but the introduction of SSMD may reduce the likelihood of these patients being treated even if the balance of risk favours surgical intervention.
      • Yi S.G.
      • Wray N.P.
      • Jones S.L.
      • Bass B.L.
      • Nishioka J.
      • Brann S.
      • et al.
      Surgeon-specific performance reports in general surgery: an observational study of initial implementation and adoption.
      J Am Coll Surg. 2013; 217 (e631): 636-647
      For a condition such as AAA, the proportion of patients who are refused surgery is an important determinant of population outcomes, and requires specific attention.
      • Karthikesalingam A.
      • Holt P.J.
      • Vidal-Diez A.
      • Ozdemir B.A.
      • Poloniecki J.D.
      • Hinchliffe R.J.
      • et al.
      Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA.
      Lancet. 2014; 383: 963-969
      Turndown rates for elective AAA are poorly reported but these rates are important, because the prognosis of patients denied intervention is poor, with 35% 2-year survival being typical.
      • Karthikesalingam A.
      • Nicoli T.K.
      • Holt P.J.
      • Hinchliffe R.J.
      • Pasha N.
      • Loftus I.M.
      • et al.
      The fate of patients referred to a specialist vascular unit with large infra-renal abdominal aortic aneurysms over a two-year period.
      Eur J Vasc Endovasc Surg. 2011; 42: 295-301
      Comparisons of international practice have demonstrated that higher turndown rates are associated with significant increases in overall aneurysm-related mortality, even where the surgical outcome of ruptured AAA repair is equivalent in different healthcare systems.
      • Karthikesalingam A.
      • Holt P.J.
      • Vidal-Diez A.
      • Ozdemir B.A.
      • Poloniecki J.D.
      • Hinchliffe R.J.
      • et al.
      Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA.
      Lancet. 2014; 383: 963-969
      Few studies have focused on the proportion of patients turned down for AAA repair,
      • Karthikesalingam A.
      • Nicoli T.K.
      • Holt P.J.
      • Hinchliffe R.J.
      • Pasha N.
      • Loftus I.M.
      • et al.
      The fate of patients referred to a specialist vascular unit with large infra-renal abdominal aortic aneurysms over a two-year period.
      Eur J Vasc Endovasc Surg. 2011; 42: 295-301
      , 
      • Szilagyi D.E.
      • Smith R.F.
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      Ann Surg. 1966; 164: 678-699
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      Acta Chir Scand Suppl. 1980; 502: 85-93
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      Ann Vasc Surg. 1993; 7: 113-116
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      J Cardiovasc Surg (Torino). 1985; 26: 547-553
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      , 
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      • Chant H.
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      Suitability for endovascular aneurysm repair in an unselected population.
      Br J Surg. 2001; 88: 77-81
      , 
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      • Salenius J.
      • Zeitlin R.
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      • et al.
      The fate of AAA patients referred electively to vascular surgical unit.
      Scand J Surg. 2002; 91: 345-352
      , 
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      • Stuart W.P.
      • Sala Tenna A.
      • Murie J.A.
      • Chalmers R.T.
      Non-operative management of high-risk patients with abdominal aortic aneurysm.
      Eur J Vasc Endovasc Surg. 2003; 26: 401-404
      , 
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      • et al.
      Nonoperative management with selective delayed surgery for large abdominal aortic aneurysms in patients at high risk.
      J Vasc Surg. 2002; 36: 41-46
      even though these data are required to place peri-operative mortality in context and may be subject to considerably greater variation than operative mortality rates.
      • Karthikesalingam A.
      • Holt P.J.
      • Vidal-Diez A.
      • Ozdemir B.A.
      • Poloniecki J.D.
      • Hinchliffe R.J.
      • et al.
      Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA.
      Lancet. 2014; 383: 963-969
      The rate of aortic rupture is significant in patients with large unoperated AAA and the decision to turndown AAA repair for physiological reasons is subjective and may be incorrect, especially if the aneurysm is morphologically amenable to endovascular repair (EVAR). Patients with aneurysms that are larger than 8 cm (who are managed conservatively) have a rupture rate of 26% within 6 months, and the rate of aneurysm rupture is 32.5% within 1 year for aneurysms exceeding 7 cm in diameter.
      • Lederle F.A.
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      • Blebea J.
      • et al.
      Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair.
      JAMA. 2002; 287: 2968-2972
      Other aspects of AAA morphology can significantly impact short-term mortality
      • Karthikesalingam A.
      • Holt P.J.
      • Patterson B.O.
      • Vidal-Diez A.
      • Sollazzo G.
      • Poloniecki J.D.
      • et al.
      Elective open suprarenal aneurysm repair in England from 2000 to 2010 an observational study of hospital episode statistics.
      PLoS One. 2013; 8: e64163
      or long-term durability,
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      • Thompson L.J.
      • et al.
      Predicting aortic complications after endovascular aneurysm repair.
      Br J Surg. 2013; 100: 1302-1311
      yet are not captured in SSMD reports for AAA repair. SSMD are uninterpretable without reference to turndown rates, aneurysm diameter, morphologic suitability for EVAR, and the principle reasons for turndown. Without these data, the extent of selection bias remains unknown and it is not possible to mitigate or exclude risk-averse behavior.
      • Karthikesalingam A.
      • Nicoli T.K.
      • Holt P.J.
      • Hinchliffe R.J.
      • Pasha N.
      • Loftus I.M.
      • et al.
      The fate of patients referred to a specialist vascular unit with large infra-renal abdominal aortic aneurysms over a two-year period.
      Eur J Vasc Endovasc Surg. 2011; 42: 295-301
      In addition to complete case ascertainment, accurate risk adjustment is required in order to report credible SSMD. In cardiac surgery, the fitness for use of established risk adjustment tools has been subject to renewed appraisal,
      • Hickey G.L.
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      • et al.
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      , 
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      • et al.
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      Eur J Cardiothorac Surg. 2013; 43: 1146-1152
      and the challenge is even greater for AAA repair. Existing risk-adjustment tools for AAA repair in England have combined surgeon-submitted data for both open and endovascular repair, rather than allowing analysis of each operation in isolation, despite evidence that the determinants of outcome after EVAR are morphological, whereas those after open repair are physiological.
      • Patterson B.O.
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      • Holt P.J.
      • Loftus I.M.
      • Thompson M.M.
      Importance of aortic morphology in planning aortic interventions.
      J Endovasc Ther. 2010; 17: 73-77
      , 
      • Patterson B.O.
      • Holt P.J.
      • Hinchliffe R.
      • Loftus I.M.
      • Thompson M.M.
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      Eur J Vasc Endovasc Surg. 2008; 36: 637-645
      , 
      • Patterson B.O.
      • Karthikesalingam A.
      • Hinchliffe R.J.
      • Loftus I.M.
      • Thompson M.M.
      • Holt P.J.
      The Glasgow aneurysm score does not predict mortality after open abdominal aortic aneurysm in the era of endovascular aneurysm repair.
      J Vasc Surg. 2011; 54: 353-357
      Current tools for risk adjusting the outcome of AAA repair in the NHS have not been subject to rigorous external validation, lack adjustment for AAA morphology, have not quantified long-term durability or protection from AAA-related mortality for EVAR,
      • Ambler G.K.
      • Gohel M.S.
      • Mitchell D.C.
      • Loftus I.M.
      • Boyle J.R.
      • Audit
      • et al.
      The abdominal aortic aneurysm statistically corrected operative risk evaluation (AAA SCORE) for predicting mortality after open and endovascular interventions.
      J Vasc Surg. 2015; 61: 35-43
      , 
      • Grant S.W.
      • Grayson A.D.
      • Mitchell D.C.
      • McCollum C.N.
      Evaluation of five risk prediction models for elective abdominal aortic aneurysm repair using the UK National Vascular Database.
      Br J Surg. 2012; 99: 673-679
      and do not account for the life expectancy of patients who are refused AAA repair as a result of the application of these tools prior to surgery. There is, therefore, an unmet need for an accurate and objective algorithm to predict which patients will benefit from AAA repair and this is the subject of considerable ongoing research funded by the National Institute for Health Research (NIHR HTA 09/91/39). In the absence of an accepted national algorithm to contextualize case selection, a policy of national reporting for SSMD is difficult to justify.
      Institutions, rather than individual surgeons, appear to have a more powerful impact on the outcome of AAA repair and this makes SSMD difficult to interpret. The case for centralizing vascular services and reporting institution-level results is now widely accepted in the English NHS. A robust relationship has been repeatedly demonstrated between higher annual caseload (volume) and lower operative mortality for AAA repair and this correlation exists across a wide range of arterial surgical procedures.
      • Karthikesalingam A.
      • Hinchliffe R.J.
      • Loftus I.M.
      • Thompson M.M.
      • Holt P.J.E.
      Volume-outcome relationships in vascular surgery: the current status.
      J Endovasc Ther. 2010; 17: 356-365
      Institution (rather than surgeon) level outcome reporting is appealing, because AAA repair is performed by a team (rather than an individual) and, increasingly, by joint consultant operating. The outcomes of vascular surgery vary considerably between different hospitals
      • Sinha S.
      • Karthikesalingam A.
      • Poloniecki J.D.
      • Thompson M.M.
      • Holt P.J.
      Inter-relationship of procedural mortality rates in vascular surgery in England: retrospective analysis of hospital episode statistics from 2005 to 2010.
      Circ Cardiovasc Qual Outcomes. 2014; 7: 131-141
      and inter-provider variation has been reported across a range of emergency medical conditions.
      • Holt P.J.
      • Sinha S.
      • Ozdemir B.A.
      • Karthikesalingam A.
      • Poloniecki J.D.
      • Thompson M.M.
      Variations and inter-relationship in outcome from emergency admissions in England: a retrospective analysis of hospital episode statistics from 2005–2010.
      BMC Health Serv Res. 2014; 14: 270
      The detection and treatment of postoperative complications (failure to rescue) also plays an important role,
      • Sinha S.
      • Ata Ozdemir B.
      • Khalid U.
      • Karthikesalingam A.
      • Poloniecki J.D.
      • Thompson M.M.
      • et al.
      Failure-to-rescue and interprovider comparisons after elective abdominal aortic aneurysm repair.
      Br J Surg. 2014; 101: 1541-1550
      while institutional infrastructure and processes are powerful determinants of mortality for patients with AAA across a variety of healthcare systems.
      • Karthikesalingam A.
      • Holt P.J.
      • Vidal-Diez A.
      • Ozdemir B.A.
      • Poloniecki J.D.
      • Hinchliffe R.J.
      • et al.
      Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA.
      Lancet. 2014; 383: 963-969
      Most deaths after AAA repair are not related to the operation itself. Mortality generally results from an institutional failure to identify and treat important complications and morbidities that follow the procedure; a concept deemed “failure to rescue” after surgery. Failure-to-rescue rates are closely related to a variety of hospital characteristics, including staffing and intensive care resource. The importance of the treating institution in determining clinical success makes SSMD difficult to interpret or justify. Improvements in AAA outcomes are also affected by myriad other non-surgical factors including specialist vascular anaesthesia, intensive care expertise,
      • Holt P.J.
      • Poloniecki J.D.
      • Khalid U.
      • Hinchliffe R.
      • Loftus I.M.
      • Thompson M.M.
      Effect of endovascular aneurysm repair on the volume outcome relationship in aneurysm repair.
      Circ Cardiovasc Qual Outcomes. 2009; 2: 624-632
      and even the day of the week on which surgery occurs,
      • Karthikesalingam A.
      • Holt P.J.
      • Vidal-Diez A.
      • Ozdemir B.A.
      • Poloniecki J.D.
      • Hinchliffe R.J.
      • et al.
      Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA.
      Lancet. 2014; 383: 963-969
      while the procedure is increasingly performed by dual consultant operating rather than a single operator.
      SSMD reported in isolation is, at best, an incomplete reflection of overall quality of care. At worst, sensationalist journalism surrounding the release of SSMD, including reports that some surgeons were “thirty times worse than their colleagues”,
      The surgeons whose patients were up to 30 times likelier to die: NHS to publish death rates of doctors for the first time.
      Daily Mail. 2015; (Retrieved February 15, 2015, from)
      http://www.dailymail.co.uk/news/article-2350376/The-surgeons-patients-30-times-likelier-die-NHS-publish-death-rates-doctors-time.html
      could adversely impact the rate of aneurysm-related mortality in the UK. A comprehensive approach is required and should include publicly accountable data regarding institutional structure/process factors, safety data (including failure to rescue, institutional reporting of adverse events), resource availability, and the uptake of endovascular technology, timeliness of care, equity of access to AAA repair, efficiency of care (length of stay and morbidity data), patient-reported outcomes, and, most importantly, turndown rates. Appropriate risk adjustment tools must be developed and include aneurysm morphology data. Until the potentially adverse impact of SSMD can be monitored and understood, caution is advocated in the attribution of deaths after AAA repair to individual surgeons.

      Conflict of Interest

      Prof. Thompson is the Chair of the CRG (Clinical Reference Group) for commissioning Vascular Surgery in NHS England. Prof. Loftus is the Chair of the National Vascular Committee for Audit and Quality Improvement and is the National Lead for Revalidation in Vascular Surgery.

      Funding

      None.

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      Article info

      Publication history

      Published online: September 24, 2015
      Accepted: June 2, 2015
      Received: June 2, 2015

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      DOI: https://doi.org/10.1016/j.ejvs.2015.06.003

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      © 2015 European Society for Vascular Surgery. Published by Elsevier Inc.

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