Transcript Document

Should we worry about
surgical outcomes?
Rupert Pearse
Senior Lecturer in Intensive Care Medicine
William Harvey Research Institute
Barts and the London School of Medicine and Dentistry
• 234 million major surgical procedures worldwide
• 4,000 procedures per 100,000 population overall
• 11,000 procedures per 100,000 in high income countries
Number of deaths
20000
15000
10000
5000
0
1989 1990 1992 1993 1994 1995 1996 1997 1998 1999 2001 2002
Year
Number of deaths reported by the National
Confidential Enquiry into Peri-Operative Deaths
The high-risk surgical patient
• Elderly
• Co-morbid disease
• Major surgery
• Emergency surgery
Population size (millions)
15
4
10
3
2
5
1
0
Post-operative mortality (%)
5
0
Overall
Standard
Size
High-risk
Mortality
Mortality in selected UK general surgical populations
Pearse et al. Crit Care; 2006; 10 R81.
Standard risk
High risk
p
n
3,603,803
513,924
-
Age (years)
54 (38-69)
75 (63-83)
<0.0001
Emergency
procedures (%)
769,371 (21.3%)
Duration of hospital
stay (days)
3 (1-6)
16 (9-29)
<0.0001
Mortality (%)
15,038 (0.42%)
63,340 (12.3%)
<0.0001
454,924 (88.5%) <0.0001
Standard and high-risk surgical populations in the UK
Pearse et al. Crit Care; 2006; 10 R81.
Population size (thousands)
15
20
10
10
5
0
0
Overall
Standard
Size
Post-operative mortality (%)
30
High-risk
Mortality
Mortality following non-cardiac surgery in an NHS Trust
Jhanji et al Anaesthesia 2008; 63(7): 695-701
Less than 1/3 of high-risk patients
are admitted to critical care
Annual figures for the UK
high-risk surgical population
• 1.4 million in-patient general procedures
• 166,000 high-risk surgical procedures
• 100,000 patients develop complications
• 25,000 deaths
‘Quality and process improvement…. should be directed
toward prevention of postoperative complications.’
Khuri et al. Ann Surg 2005; 242: 326–343
Colo-rectal
Unruptured
AAA
Ruptured
AAA
CABG
Database
size
144,370
31,705
12,781
152,523
Overall
mortality
10,424
(7.2%)
3,246
(10.2%)
5,987
(46.8%)
3,247
(2.1%)
Effect of
Urgency
(odds ratio)
3.46
2.76
1.38
1.54
Risk prediction for common surgical procedures
performed in the UK
Aylin et al. BMJ; 2007(online first)
High-risk surgery:
Comparison with the cardiac
surgery model
7%
Number
25
6%
Mortality
5%
20
4%
15
3%
10
2%
1999-00
1998-99
1997-98
1996-97
1995-96
1994-95
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
0%
1979
0
1978
1%
1977
5
UK Cardiac Surgical Register 1977-2000
Society for Cardiothoracic Surgeons of Great Britain & Ireland
Mortality
CABG operations (thousands)
30
Why are outcomes so much better
for cardiac surgical patients?
• Younger / Fitter / Elective
• Efficient care pathway for single disease group
• Strong evidence base guides practice
• Post-operative intensive care is standard
• Outcome data influences practice
The high-risk surgical patient:
Just a UK problem?
Predicted
Mortality
Mt Sinai
Observed mortality
Portsmouth
Observed mortality
0-10%
5 (0.6%)
43 (3.8%)
11-20%
6 (5.3%)
25 (14.9%)
>20%
11 (9.7%)
84 (35.9%)
n
30 day mortality
Long term Mortality
Colectomy
19,895
6.5%
46%
Unruptured AAA
5,300
4.5%
37%
Infra-inguinal
vascular
19,117
3.0%
43%
Carotid
endarterectomy
16,880
1.2%
34%
Laparoscopic
Cholecystectomy
14,295
0.6%
17%
Total Hip Replacement
12,184
1%
21%
Mortality for common surgical procedures in the USA
Khuri et al. Ann Surg 2005; 242: 326–343.
Placebo: 72 deaths among 459 patients (16%)
Metoprolol: 74 deaths among 462 patients (16%)
Outcomes across the UK:
Comparison of England and Scotland
Number of deaths
2000
1500
1000
500
0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2004 2004 2005
Year
Number of deaths following emergency surgery
reported by the Scottish Audit of Surgical Mortality
England
Scotland
Population (millions)
50.8
5.1
ICU : Acute bed ratio
1.02/100
0.92/100
ICU beds / million
population
24.5
31.3
Critical care resources in Scotland and England
ICNARC
SICSAG
Elective
Emergency
Elective
Emergency
10.4%
30.4%
7.3%
25.3%
APACHE II
13.9
16.6
14.5
17.5
ICU stay (days)
1.0
2.0
1.2
1.9
Hospital stay (days)
15
21
14
19
56%
44%
38%
59%
Mortality
Urgency
Surgical admissions to Scottish ICUs in 2006
Kerssens J SICSAG 2008 unpublished data
Pearse et al. Crit Care; 2006; 10 R81.
High-risk surgery is an important
healthcare problem
• Acknowledge the problem
• Identifying the high-risk patient
• Effective intervention
• Adequate resources
• Quality research
• Reliable outcome data