Thursday, May 6, 2010

Medical and Surgical Safety

Patients expect that when they are treated by doctors, they will be helped not hurt in the process. This is particularly true in developed countries with sound health systems.
Throughout the world however there is evidence that patients can be hurt by the medical care that they receive. There are obvious outliers - such as the current manslaughter trial of Dr Jayant Patel in Queensland. In that case the legal authorities have determined that Dr Patel has a case to answer. Fortunately such cases are rare, and all the more unfortunate because of it.
Of more concern is the day to day occurrence of death or adverse events due to medical care. Most health jurisdictions in Australia have instituted measures to improve the performance of health care. Examples include The Australian and New Zealand Audit of Surgical Mortality. These are good initiatives, they focus on understanding causes and providing educational support to ensure that standards of treatment improve. The Victorian regional section of the ANZ audit, VASM, has only recently begun and is still gathering momentum. Nevertheless the 2009 report has already generated useful data, particularly a suggestion that venous thromboembolism prophylaxis could be improved. In simple terms that's preventative treatment to reduce the number of blood clots that can cause problems after surgery.
Numerous other initiatives are underway and some of these highlight the systems nature of health care - it's not just individuals that influence care outcomes but the structure and function of the system in which they work. These are also important initiatives.
There are however at least two other linked issues worthy of consideration:
  1. As a "health consumer" I have a right to determine, within sensible limits, who I choose to undertake a procedure;
  2. Evidence suggests that publication of performance of individual clinicians leads to enhanced performance.
Let's look at these to points. If I seek to choose a surgeon, to operate on, for instance, my back what are the sort of things I'd want to know? In my case I'd like to know things like:
  1. Does he/she regularly undertake this specific procedure?
  2. How many has he/she done in the last 12 months?
  3. What proportion of adverse events has he/she had in this procedure in the last 12 months and over longer time periods?
  4. What outcomes has he/she achieved from this procedure over time?
This isn't a comprehensive list however it does start to focus in on the particular clinician's appropriateness to undertake the specific procedure. There is strong evidence linking frequency of undertaking a given procedure to the achievement of good outcomes.
Of course there is then the question about the likely outcomes for me, given my specific condition. That question for me comes after the question about who is appropriate to see for my condition.
I cannot know these things publicly in Australia at the moment, I cannot see how doctor X compares to doctor Y. This data is not published. This despite evidence that such publication leads to improved clinician performance. This makes it difficult for me to act as an informed consumer and is in my view an area that requires urgent change. I acknowledge that my doctor will have to fully inform me of risks, side effects and outcomes so that I can make an informed consent. This doesn't provide me with comparative data however.
As a side note I also wish to know about the performance of the hospital in which the procedure is to be undertaken. This will also have a bearing on my outcome and is therefore important information.
So my question is, when are we going to bite the bullet in Australia and publish outcomes data for all clinicians performing procedures and all hospitals in which those procedures are conducted? It is only then that I can be a fully informed consumer and only then that, as a society we can reap the benefits of the performance improvements that would likely follow.

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