Download The Ro oyal Wo olverha ampton NHS T Trust

The Ro
oyal Wo
olverha
ampton NHS Trust
T
Trust Board Report
R
Mee
eting Date:
24
2 th March 2014
Title
e:
Surgeon-sp
S
pecific Morta
ality Data
Exe
ecutive Sum
mmary:
This
T
reportt provides the Board with the ssurgeon-spe
ecific
data
d
publisshed throu
ugh NHS England ccovering Royal
R
Wolverham
W
mpton Trust services.
Action Reques
sted:
To
T note: cu rrent progre
ess
Rep
port of:
Clinical
C
Dire
ector
Autthor:
Con
ntact Details:
Head of Pe
erformance & Complian
nce
Res
source
Imp
plications:
None
Pub
blic or Priva
ate:
Public Sesssion
Tel:
T 01902 694366 Em
mail: simon.e
[email protected]
(with
h reasons if priv
vate)
Refferences:
(e.g. from/to other
mittees)
comm
App
pendices/
Refferences/
Bac
ckground Reading
R
NHS
S Constituttion:
(How
w it impacts on any
decis
sion-making)
In determin
ning this ma
atter, the Bo
oard should have regard to
the
t Core prrinciples con
ntained in th
he Constituttion of:
Equality off treatment and access to services
High stand
dards of excellence and profess
sionalism
Service usser preferences
Cross com
mmunity working
g
Best Value
e
Accountab
bility through loc
cal influence and
d scrutiny
Page
P
1 of 2
The surgeon-specific mortality data that has been published through NHS England covers
the following RWT services: Colorectal Surgery, Head and Neck Surgery, Orthopaedic
Surgery, Upper Gastro-intestinal Surgery, Urology and Vascular Surgery. No data have
been submitted for endocrine surgery, and no bariatric surgery is done by RWT consultants.
The summary is that no RWT surgeon has mortality rates that lie outside the range of
expected mortality rates for that specialty, but these data need to be interpreted with some
caution.
Mortality is a crude index of surgical performance – good surgery may not prevent death,
and bad surgery rarely causes it. Mortality is never going to be high in elective orthopaedics
unless there is murderous intent, but it may be high for sick patients having major
procedures on vital organs. Surgeons work in teams, and the surgeon is not always preeminent in determining the patient’s outcome – every surgical patient is cared for by
anaesthetists, dieticians, laboratory staff, nurses, pharmacists, radiologists, surgeons and
therapists. In some patients, key roles are played by oncologists and physicians. Attributing
an outcome to one individual is unlikely to be accurate.
The risk of postoperative death is influenced by the patient’s co-morbidities. Some of the
mortality data that has been produced has been analysed by adjusting the risk of death for
each patient according to their co-morbidities – (“adjusted mortality”). The risk of mortality is
also affected by the patient’s level of social deprivation (for which adjustments have not
been made).
Mortality rates and complication rates vary over time. Adverse outcomes can occur in
clusters rather that at regular and predictable time intervals. Any time limited audit may yield
insufficient cases to make an accurate assessment of a surgeon’s true performance. Walker
et al (Lancet 2013 July 4dri:pii: S0140-6736 (13) 61491-9) have calculated that it would
require an audit of a minimum of 150 cases to have an 80% chance of detecting statistically
genuine poor performance.
Each of the specialties whose outcomes have been published used different approaches to
the data analysis. The audit work was done by the relevant specialty organizations using
data from national, voluntary audits that were not designed to examine the death rates of
individual operators. For each specialty, the range of cases for which mortality has been
calculated is only a small sample of the normal workload of a consultant in that specialty.
Page 2 of 2
Adult Cardiac Surgery
After consultation with patient representatives, The Society for Cardiothoracic Surgery chose to display risk adjusted mortality data in the form of funnel
plots. The operations included in these charts are adult cardiac surgery operations on all patients over the age of 18, excluding heart transplants, insertion
of artificial mechanical hearts and trauma cases (as these are all subjected to separate analyses). The decision was also taken to remove emergency
operations from the analyses (and by emergency we mean patients who are taken immediately to the operating theatre for surgery, not those who have to
wait in hospital until surgery is carried out), as these patients are relatively infrequent and we know that it is very difficult to make appropriate adjustments
for predicted risk in this setting.
The funnel plots show how risk adjusted mortality rates of particular hospitals/surgeons compare to the national average, which is the standard that we
have set for outcomes. The risk adjusted mortality rates of hospitals/surgeons are plotted on the chart against the number of procedures undertaken. Each
hospital is represented by one dot on the funnel. The dot is the risk adjusted mortality, which means that each dot has been adjusted using complex
methods so that effectively it is shown what the mortality would have been had each hospital or surgeon operated on the average case mix.
An adaptation of the EuroSCORE risk adjustment model has been used for these analyses, and whilst it is known that this model is an accurate predictor
overall, and discriminates well in general between patients with higher and lower risk, it is also known that it is not designed to adjust for surgeons or
hospitals with very unusual casemix profiles, and great caution should be taken in making judgements in this context.
Hospitals are expected to cluster around the average mortality on the plots. As the number of procedures increases the variation of the points should
decrease. This is because higher numbers of procedures decreases the likelihood of the mortality rate being high due to chance alone. Similarly, as the
number of procedures decrease there will be an increased variation (wider spread) due to sampling variability. The increased clustering around the mean
line as procedure numbers grow is what gives the chart its funnel shape.
Using only an ‘average’ line for the standard makes it difficult to tell whether units that are plotted away from it are within accepted limits (as there will
always be some variation between hospitals and surgeons due to biological variability). For this reason, the graphs also show control limits, which are
represented by red and green dotted lines.
Control limits represent the expected range of values based on the mean. If a hospital or surgeon's risk adjusted mortality rate lies underneath the red
control limit, it should be understood as being an ‘expected’ mortality rate. If the risk adjusted mortality rate falls above the red line it means that it is
higher than expected, and this may mean a number of things including issues with data quality, abnormal case mix which is not accounted for by the risk
adjustment, a chance finding, or poor quality of care.
It is important to remember that the consultant surgeons whose mortality rates are included on this report work as part of a larger clinical team; consisting
of anaesthetists, junior medical staff, nurses, perfusionists, pharmacists, and physiotherapists. All of these team members may affect patient outcomes,
along with a hospital's facilities.
Adult Cardiac Surgery – Trust Wide
Cardiac Surgery Casemix (1st April 2009 - 31st March 2012)
Cardiac Surgery Risk-Adjusted Mortality Rates (1st April 2009 – 31st March 2012)
Adult Cardiac Surgery - Consultant Level
Cardiac Surgery Risk-Adjusted Mortality Rates (1st April 2009 – 31st March 2012)
Mr Bhabra
Mr Billing
Cardiac Surgery Risk-Adjusted Mortality Rates (1st April 2009 – 31st March 2012)
Mr Luckraz
Mr Matuszewski
Cardiac Surgery Risk-Adjusted Mortality Rates (1st April 2009 – 31st March 2012)
Mr Morgan
Mr Yiu
Colorectal
This data focuses on the operation for a major resection of the bowel (this is when a patient has cancer and the diseased part of the bowel is removed).
The data is organised by NHS Hospital Trusts in England. It gives the total number of patients who underwent a planned (non- emergency) operation for
bowel cancer and the number of these patients who died within 90 days of their operation. In addition, the same information is presented for individual
surgeons who performed more than 10 operations for bowel cancer at The Royal Wolverhampton NHS Trust.
Nationally not all surgeons who operate on bowel cancer are included in this information. There are a number of reasons for this. Many will not have
performed enough operations to be able to calculate a survival figure. Some surgeons are colorectal surgeons who specialise in other diseases of the bowel
rather than colorectal cancer. Some surgeons only operate on emergency cases, which were excluded from this analysis.
There is wide variation in both numbers of operations undertaken and the mortality rate (death of the patient within 90 days) between surgeons. What can
be said is that on average, just over 1 in 30 patients undergoing elective surgery for large bowel cancer die within 90 days from the operation. The vast
majority of surgeons have mortality figures that lie within the expected range. Whilst some surgeons may appear to have a high mortality rate, this could
be have arisen by chance alone because of the low number of patients included in the audit. However, there are a few surgeons whose mortality figures
are higher than expected. These surgeons are examining their results and identifying reasons for this result. There are no surgeons at RWT whose
mortality rates are classed as an outlier.
This can be down to one of a number of factors. It has already been stated that the accuracy of the data varies from surgeon to surgeon. Some surgeons
may take high risk patients or those whose cancer is advanced, and this means that they may have higher death rates than other surgeons. Some surgeons
will have had a few deaths clustered together in this time period by chance alone. Their own data on a much larger number of patients show that overall
their results are acceptable. In future it is hoped to use data collected over five years which will reduce the variation and clustering effects.
To look at the operation alone is not the whole picture in recovery. Many other specialists are involved in the care of a patient with bowel cancer, both
before and after the operation and during the 90-day period after surgery. This will include such people as anaesthetists, critical care specialists and nurses.
They are all vital members of a team which works for the survival of the patient after the operation, and their good recovery.
All patients are different. Some patients will have a much greater chance of survival while others will have a greater risk of dying. This may be because they
are overweight, they have another serious illness, or they are older. The data has been adjusted to take into account the greater risk in some patients, but
working out the risk for an individual patient remains very difficult.
The “funnel plot” below compares the 90-day mortality after a planned removal of a bowel cancer in The Royal Wolverhampton NHS Trust with the
mortality of the other NHS Trusts in England. The mortality result of RWT is highlighted in red whereas the result of the other Trusts are presented in blue.
On the same page, there is another funnel plot that compares the results of all surgeons. The results of the surgeons working in RWT are highlighted in red.
In addition, there is a Table with the names of the surgeons working at RWT, the numbers of their operations that were included, and the adjusted
mortality in the first 90 days.
The mortality figures were from the National Bowel Cancer Audit run by the Association of Coloproctology of Great Britain and Ireland (ACPGBI). They are
for 90-day postoperative mortality after planned surgery to remove colorectal adenocarcinomas diagnosed between April 2010 and March 2012. The
outcomes for equally major surgery done for other types of large bowel cancer and for benign diseases of the large bowel have not been reported. The
average annual colorectal cancer workload for colorectal surgeons in England is between 20 and 40, so case-numbers from a two-year audit will not reach a
statistically significant threshold for the vast majority of surgeons.
At RWT, 260 patients were reported: (3.1%) died within 90 days of surgery. The mortality rates for the five colorectal surgeons ranged from 0-8.3 % - none
of these is a statistical outlier from the national average of 3.06%.
The mortality for the following surgeon listed at this trust contains procedures performed at >1 trust:
Youssef, Haney
Name
Procedures
Deaths
Adj. 90-day mortality rate
ACP member *
Badger, Ian
49
2
3.34
Yes
Elgaddal, Sanaa
86
1
0.96
Yes
Soulsby, Ruth
52
0
0
Yes
Williams, Graham
57
4
8.27
Yes
Youssef, Haney
16
1
5
Yes
Head & Neck
Head and Neck cancer is an umbrella term encompassing several different diseases, including cancers of the larynx, oral cavity, oropharynx,
hypopharynx, nasopharynx and major salivary glands. Each of these require different forms of treatment that include surgical, and
non-surgical interventions such as chemotherapy or radiotherapy.
The publication of this information follows a commitment from NHS England to present consultant level data for 10 different surgical and
clinical specialties as part of a drive within the NHS to improve the transparency of information available to the public. Surgeons whose data
are presented here have agreed to publication of their patients’ outcomes and by doing so contributed to this important process.
The knowledge and guidance of the British Association of Head and Neck Oncologists (BAHNO) has been central to determining how this
release of information can be presented in the most meaningful way for head and neck surgery for cancer.
This data also relates to the same time period as the established National Head and Neck Cancer Audit (DAHNO) in order to help build an
even broader, joined up picture of head and neck cancer care in England. This means it is possible to consider surgeon level data alongside
information about, for example, patient treatments and multi professional care delivery along the patient pathway over the same time period.
Although surgeon level information within this report is limited in scope, with short timescales for data validation and issues with the ease of
data collection, it represents the first step in the journey of ensuring consultant level data can be collected, analysed and published in a way
that is as complete and accurate as possible and is meaningful to the public, patients and clinical communities. It is important therefore that
the development of this information involves these groups and we welcome their feedback.
This report presents surgeon level data about new cases of head and neck cancer recorded between 1 November 2011 and 31 October 2012,
where surgery was recorded as the first treatment received by the patient. Data presented is for those patients included in the eighth annual
report from the National Head and Neck Audit (DAHNO), published on 26 July 2013, in order to help build an even broader, joined up picture
of head and neck cancer care in England.
As the Audit was not originally designed to report at surgeon level, a new system was developed to allow individual surgeons to assign activity
to themselves and validate the data included in the eighth annual audit report, which included 7,195 procedures for 3,200 patients in total.
Surgeons, who were given seven weeks to update data onto the system, supplemented information for just under half of these procedures
(3,409 of 7,195 - or 47%). Some organisations had difficulties or were unable to supplement data about their activity. This should be taken into
account when interpreting the data.
In addition to the number of procedures and mortalities requested to be published by NHS England, information has also been presented about
other aspects of head and neck cancer patients’ care that are seen as key markers towards effective treatment. Much of the data presented has
been collected for the first time and is not fully complete, which should be considered when reading the report.
The surgical procedures and related outcomes in this report represent only part of a head and neck surgeon’s workload. This report does not
consider, for example, diagnostic procedures for head and neck malignancy, surgery for benign disease, recurrent disease or surgical treatment
after initial non-surgical therapies such as radiotherapy and chemotherapy. It is anticipated that more of a surgeons workload will be reported on
at consultant level in the future, as this new process develops and evolves.
Data presented and initial findings
• Major surgical procedures performed by surgeon
This is the count of cases with major procedures identified as being performed solely by an individual surgeon, or in combination with other
surgeons. A wide range of procedures are performed by head and neck cancer surgeons and vary in complexity and frequency. More complex
procedures are performed by teams of surgeons working together, which means treatment of the same patient may therefore be recorded for several
different surgeons.
- Of the 7,195 procedures included in the 2011-12 audit 6,311 (87.7%) were assigned a surgeon GMC code (which identifies the individual surgeon).
• Number of cases reported by surgeon that during the same hospital admission required an unplanned return to the operating theatre
Major head and neck surgery consists of a complex set of procedures, which carry a risk of complications. The complications are varied and will differ
both in nature and in expected frequency with the specific procedure. Unplanned return to theatre is a proxy measure to reflect the likely occurrence
of a significant complication during the hospital stay. This information has been obtained by surgeons entering data for each case where known.
- Of the 3,200 major surgery cases 1,444 (45.1%) had an unplanned return to theatre status recorded.
- Of these 1,444 cases, 92 (6.4%) had an unplanned return to theatre
• Number of cases where surgical pathology results were discussed at an MDT
Discussion of the pathological findings after surgery at a multidisciplinary team meeting is considered an important standard of care, and all
cases undergoing major re-sective surgery should be discussed. Head and Neck surgeons are part of this wider team which includes ear nose and throat,
maxillo-facial and plastic surgeons, clinical oncologists, radiologists, pathologists, restorative dentists, specialist nurses, dietitians, and speech and language
therapists. The MDT is responsible for the development of a comprehensive treatment plan for each patient. This is why we have presented information
about the number of cases discussed at MDT in this report, with further information also presented in the eighth annual audit report.
- Of the 3,192 cases having a re-sective procedure 2,748 (86.1%) had surgical pathology discussed at MDT status recorded.
- Of these cases, 2,215 (80.6%) were discussed by an MDT
• Margin status of surgical cases
In removing a cancer, the intent is to remove both the cancer and a “safety margin” of tissue to try to obtain complete local excision. Previous
research has identified that surgical margins are one of the factors that influence long term outcome and that good practice where practicable
is to obtain clear margins. The width of the margin reported will vary with the surgical technique used, the anatomic site of the cancer and its
extent. In some cases it is not practicable to obtain clear margins as this could put vital structures (such as major blood vessels) at risk. Only
cases having surgery applicable for the assessment of margins have been included in this measure.
- Of the 1,962 cases having surgery applicable for the assessment of margins 941 (48%) had margin status recorded.
- Of these 941 cases, 844 (89.7%) had a clear margin recorded
The Expert Panel (a group of consultant head and neck surgeons from hospitals in England) have considered the findings from this report and do
not feel that this indicator is a useful reflection of surgical practice. Resection margins are influenced by a wide variety of factors – by tumour
stage (more likely to be positive with increasing tumour size), by surgical site (tongue cancers are more likely to be positive), by cancer type,
by the need to spare essential structures, and where planned serial excision is performed to obtain clearance. Laboratory reporting is not aligned
to the purposes of this audit and therefore may contribute to variation. It is therefore not planned to collect and report on these items in future.
For the purposes of transparency however they have been included in the results this year.
• Count of reported cases who died from any cause within 30 days of major head and neck surgery
The data confirms that major head and neck surgery in England and Wales is safe, with a low known mortality. According to the eighth National Head
and Neck Cancer Audit annual report, 98.7% of patients survived surgical intervention. Many patients with head and neck cancer have other serious
illnesses. Some patients may die shortly after their operation due to the complexity of surgery and complications from other conditions.
Where multiple surgeons have been involved in an operation, the outcome will be attributed to each of them.
- No individual surgeon had more than two deaths attributed to them.
Due to the relatively low number of these specific procedures undertaken by each surgeon an increase in one or two deaths can have a large
impact on the surgeon’s mortality rate. To understand whether this variation is within the levels we would expect to see through natural variation
statistical control limits have been applied to the data and examination of any cases which fall outside these limits has been undertaken. ‘Outliers’ are
identified when we would only see the results as a result of random variation one in twenty times (p>0.95).
- No individual surgeon was recorded as an ‘outlier’ – meaning no individual surgeon had a higher than expected number of deaths attributed to them.
The data comes from the National head and Neck Audit for new cases of cancer diagnosed between 1st November 2011 and 31st October 2012 and the
report is the 30-day mortality rate for the five surgeons at RWT who conduct this sort of surgery. The RWT mortality was 0%.
Trust/Surgeon
Number of
patients having
surgical
procedure (A)
Unplanned
return to
theatre (B)
Surgical
pathology
discussed at
MDT (C)
Clear (D)
Involved
(D)
Not
Recorded
(D)
Not
Applicable
(D)
Mortality
(E)
18 (100%)
0
0
20
1
0
14 (100%)
12
1
0
1
0
6 (100%)
0
0
5
1
0
C4105480 N Grew
21
C4170680 N Pigadas
14
C6073102 K Rehman
6
C4015790 L Liew
4
<_2
4 (100%)
3
0
0
1
0
C4457125 A Spinou
3
<_2
3 (100%)
1
0
0
2
0
<_2
Interventional Cardiology
This data is from a new part of the British Cardiovascular Intervention Society (BCIS) web site and is dedicated to providing information for patients about
percutaneous coronary intervention (PCI) as a treatment for heart disease. The web pages provide some background about coronary heart disease and
treatment by interventional techniques. There is also information about the way in which patients can assess the quality of PCI care being provided.
For many years the BCIS audit program has published information about the practice of interventional cardiology based on assessment of each hospital’s
activity and performance.
For the first time, BCIS are now publishing an analysis based on each individual consultant PCI operator’s activity and outcomes. The aim is to become even
more open about the way in which patients are treated, and is part of a NHS wide increase in the transparency of reporting the way patients are treated
and the outcomes they might expect from a high quality service. BCIS strongly supports this endeavour.
Because this is the first year of operator outcome reporting, it has been necessary to introduce a number of changes in the way data about PCI procedures
are collected and analysed. Great strides have been made within very tight deadlines by a large number of people including cardiology consultants,
statisticians, project managers and audit staff across the country to try to get everything ready in time. While there will inevitably be some gaps in the data
on this, the first public report of operator activity and outcomes, this is just the start of an important journey. The completeness, complexity and quality of
reporting will become more sophisticated every year.
All PCI procedures performed in the calendar year 2012 are included in the analysis. Only data reported to NICOR can be analysed. Almost all UK NHS
hospitals have uploaded data, but not all private hospitals have sent data.
There are several possible reasons why operators may be recorded with low procedural volumes. It may genuinely reflect their practice. They may have
only been appointed as a consultant part way through the year in question (and so only a subset of their cases will be included). They may have suspended
their work due to pregnancy, or a sabbatical. In some cases an operator may have retired part way through the data collection period. There may be an
error with data submitted, with missing procedures, or missing consultant GMC numbers associated with procedures
If an operator has worked on multiple sites, then all data from those sites will be ascribed to that one operator. However some private hospitals have not
submitted data electronically to NICOR, and these cases will not be included.
It is also important that though the information here is presented according to the consultant who was responsible for the overall care of the patient during
their PCI procedure, they represent part of a larger clinical team consisting of paramedics, emergency medicine doctors, nurses, radiographers and
technicians, and the way this teams works together along with the hospital facilities available to them may have an impact on the quality of care that can be
provided.
One of the most important and worrying aspects of the public reporting of PCI outcomes is the potential for it to generate ‘risk averse behaviour’. Very sick
patients will always be at higher risk of not surviving whether they have a PCI or not, and yet they are those who stand to gain the most from treatment by
PCI. If it is felt that the risk model that is used to try to adjust for these patient factors does not work, then there is the potential for a PCI operator to be
reluctant to treat the sickest patient who has the most to gain, in case it makes them look as if they have poorer outcomes in spite of them actually
providing an excellent quality of PCI. Thus the models for risk adjustment are pivotal to optimising patient care, not only to allow assessment of quality of
PCI practice but also to avoid the possibility of risk averse behaviour.
The current risk model being used in this analysis is the North West Quality Improvement Program (NWQIP) model (see section on data preparation). While
it has been very valuable, it was generated at a time when PCI practice was rather different from that used currently and so is becoming out of date. It
relies on outcome data that is self-reported by operators. We know that it is sometimes difficult to track adverse outcomes after PCI. Take the example of
a patient who is transferred to another hospital the same day as their PCI, the PCI centre may not know about later events. Also, paradoxically, an operator
who is very assiduous at collecting data on all the patients he or she treats may appear to have a higher complication rate than an operator whose practice
is less good and misses or fails to record adverse events. The responsibility for recording adverse events rests with the PCI operators, the data collection
staff and clinical governance teams at the PCI hospital. These data cannot be validated by BCIS, so they are reliant on the operators for the accuracy of data
collection. A new model is being developed which can use independently tracked mortality data and if it performs well on mathematical testing, BCIS plan
to use it next year.
With those caveats in mind, the data are presented as the MACCE experienced by a PCI operator’s patients up to the time of their discharge from hospital,
compared with what would have been expected on the basis of the patient case mix, and the statistical limits of chance variation at the 2 standard
deviation level.
Provided the observed level is lower than this modelled 95% upper limit then there is no concern about the observed MACCE rates. If an operator has high
observed MACCE rates, but is within the 95% limit, that implies that the patients being treated by that operator are high risk, sicker patients. It is important
to note that you cannot use these data to compare one operator with another in any meaningful way.
If an operator falls outside the expected range, there are several possible explanations. If an operator has event rates higher than expected, then it may be
that the operator and their team are genuinely performing less well than the model would predict. Other potential explanations include errors in data
provision, incomplete data, and failure of the risk model to adequately reflect the case mix being treated.
During the time that these data were collected there were 10 consultant operators undertaking PCI in our Centre. In each case the annual volume of
procedures undertaken by each operator was, in all but one case, at or well above the national average. This is to be expected in a high volume unit such as
ours. The one instance we have of a relatively low volume operator was at a time when this individual was embarking on independent and unsupervised
consultant practice and thus his caseload comprised largely stable cases and with good outcomes.
It can be seen from the data that elective PCI forms a small proportion of our practice and in the modern era of interventional cardiology the majority of
cases are non-elective being either urgent (usually as a result of an Acute Coronary Syndrome or ACS) and scheduled for the next available list, or
emergency (usually in patients in the throes of a heart attack - or STEMI - and therefore requiring immediate treatment).
In a high volume centre such as ours and with experienced operators undertaking large volumes of cases one would expect that individual outcomes should
be acceptable and indeed the data in all cases confirms this.
In the introductory paragraphs and amongst the data themselves the term MACCE is referred to; this stands for Major Adverse Cardiac or Cerebral Events
and is self-reported by operators in terms of whether patients sustain a heart attack, stroke or death related to the PCI procedure.
This type of data reporting, and the public access to it, is clearly in its infancy and in the years ahead the quality of data presented and the risk models used
to calibrate them will be continuously refined. Nevertheless this is a major step forward in interventional practice and transparency.
Dr Abdal Al-Allaf
Dr Matthew Banks
Dr James Cotton
Dr Michael Cusack
Dr Ram Ghasil
Dr Rumi Jaumdally
Dr Saib Khogali
Dr Jose Martins
Dr Michael Norell
Dr Anthony Scriven
Orthopaedics
National Joint Registry (NJR) Surgeon and Hospital Profile provides information about surgeons who carry out hip and knee replacements, and hospitals
where hip and knee replacements are carried out. Information is taken from the National Joint Registry, following a process to collect the consent of
individual consultants.
Surgeons should not be ranked by their mortality rate as there is a risk that they will be wrongly criticised and patients misled. The mortality rate after hip
and knee replacement surgery is influenced by many factors outside the control of the operating surgeon. Case-mix adjustment is a useful tool but as with
any methodological approach it cannot account for all differences including those that may be due to random events.
Information in report is the first phase of publication covering surgeons who have performed NHS-funded hip or knee replacement surgery in England in
2012 as Consultant in Charge of the operation. Other surgeons with hip or knee activity recorded on the NJR are also included, where they have opted-in to
publication.
Nationally a small number of surgeons have declined to publish their data at this time. The fact that a surgeon has declined to publish data does not
necessarily imply that the surgeon’s results are bad. It may reflect a concern with the relevance of published data requested this year or the methods of
preparation of the data. A list of the surgeons who have declined to publish their data, and the reason they have given for this (where provided) is available
on the NHS Choices website. No RWT surgeons have declined to publish data.
This report data is delivered in partnership with the British Orthopaedic Association, the British Hip Society and the British Association for Surgery of the
Knee.
The orthopaedic figures were 90-day mortality rates for only hip and knee replacements taken from the National Joint Register. These operations have an
average of 0.6% and 0.4% 90-day mortality in England. The SMR for RWT surgeons was between 0.5 and 1.5 with no outliers. Mortality as an outcome
measure for orthopaedic surgery gives no indication of the true quality of the surgical team.
Orthopaedics – RWT Trust Wide
Operation Type
Hip Primary
Hip Revision
Knee Primary
Knee Primary
Knee Primary
Knee Revision
Total
Operation Subcategory
Patello-Femoral Replacement
Total knee replacement
Unicondylar Knee Replacement
-
Procedures Recorded for this Hospital
357
32
7
417
30
25
868
National Average
174
31
4
184
18
19
430
Orthopaedics – RWT Trust Wide
Operation Type
Hip Primary
Hip Revision
Knee Primary
Knee Primary
Knee Primary
Knee Revision
Total
Operation Subcategory
Patello-Femoral Replacement
Total knee replacement
Unicondylar Knee Replacement
-
Procedures Recorded for this Hospital
907
94
34
1127
95
62
2319
National Average
455
73
10
495
43
45
1121
RWT Trust Wide - Hips
The graph above shows the 90 day mortality rate following hip surgery for The Royal Wolverhampton NHS Trust, based on the type of patients that RWT
has seen. The national average 90 day mortality rate following primary hip replacement surgery is approximately 0.6%.
The Royal Wolverhampton NHS Trust data is highlighted as a black triangle. Progression along the x (horizontal) axis means that the hospital has done more
cases and/or cases at a higher mortality risk such as older patients. Progression along the y (vertical) axis means the hospital has had more deaths. The y
axis figures are presented as a ratio. This means the values do not represent percentages of patients who have died, but they represent the proportion of
deaths compared to the average.
Hospitals on the central (green) horizontal line (at a figure of 1) have had exactly the average expected mortality taking into
account their case mix and number of cases.
Hospitals either side of the central green line but below the upper red line have had a level of mortality (when taking into account
their case mix and number of cases) that is within the expected range.
Any hospitals that appear above the top red line (which represents a '99.8% Confidence Limit line') have a mortality rate that is
higher than expected
The data is ‘risk adjusted’ to take account of the fact that different hospitals may operate on more higher-risk or lower-risk patients (e.g. because of
demographics in the patient population they work with).
Mr Ali – Hips
Mr Chugh - Hips
Mr Damany – Hips
Mr Deshpande - Hips
Mr Hart – Hips
Mr Isbister - Hips
Mr Marino – Hips
Mr Mughal - Hips
Mr Rajkumar – Hips
Mr Shrivastava - Hips
Mr Simpson – Hips
Mr Thomas - Hips
Trust Wide - Knees
The graph above shows the 90 day mortality rate following knee surgery for The Royal Wolverhampton NHS Trust, based on the type of patients this
hospital has seen. The national average 90 day mortality rate following primary knee replacement surgery is approximately 0.4%.
The Royal Wolverhampton NHS Trust data is highlighted as a black triangle. Progression along the x (horizontal) axis means that the hospital has done more
cases and/or cases at a higher mortality risk such as older patients. Progression along the y (vertical) axis means the hospital has had more deaths. The y
axis figures are presented as a ratio. This means the values do not represent percentages of patients who have died, but they represent the proportion of
deaths compared to the average.
Hospitals on the central (green) horizontal line (at a figure of 1) have had exactly the average expected mortality taking into
account their case mix and number of cases.
Hospitals either side of the central green line but below the upper red line have had a level of mortality (when taking into account
their case mix and number of cases) that is within the expected range.
Any hospitals that appear above the top red line (which represents a '99.8% Confidence Limit line') have a mortality rate that is
higher than expected.
The data is ‘risk adjusted’ to take account of the fact that different hospital may operate on more higher-risk or lower-risk patients (e.g. because of
demographics in the patient population they work with).
Mr Ali – Knees
Mr Chugh - Knees
Mr Damany – Knees
Mr Deshpande - Knees
Mr Hart – Knees
Mr Isbister - Knees
Mr Marino – Knees
Mr Mughal - Knees
Mr Rajkumar – Knees
Mr Shrivastava - Knees
Mr Simpson – Knees
Mr Thomas - Knees
Upper GI
The information on surgeon outcomes was derived from data on patients diagnosed between 1 April 2011 and 31 March 2012. The information presented
is for the surgeon based at RWT, however, the report reflects the outcomes of the multidisciplinary teams at the Specialist Cancer Centre based at
University Hospital North Staffordshire . The information by surgeon describes the results for the Consultant in Charge of the operation, even though the
operation may have been performed by two consultants.
In total, 163 surgeons from 40 specialist stomach and oesophageal cancer centres contributed data from 2,381 patients. The median annual hospital
volume was 56 operations (range 19-141). The annual surgeon volume ranged from 1 to 39 operations per year, with a median of 14 operations.
For surgeons, the number of operations and number of postoperative deaths are reported. The Association of Upper Gastrointestinal Surgeons has
reported the number of deaths and not a rate because the single year of data collection meant the analysis was based on a small number of operations for
most surgeons. When the number of operations is low, rates are often unreliable due to the influence of random events. Moreover, the observed rates
cannot represent a low underlying risk precisely. For example, although the underlying risk of an operation may be 2%, surgeons who perform just 10
operations could equally have observed mortality rates of 0%, 10%, etc. Therefore, report outcomes for surgeons that performed less than five procedures
in the reporting period have not been included in this data. Nevertheless, all surgeons performed within expected range.
To ensure accuracy, the Audit used mortality data reported by the surgeons and from the Office for National Statistics. The figures reported were reviewed
and verified by both NHS trusts and individual surgeons prior to publication.
Considerable care should be taken in making comparisons between surgeons on the basis of the data reported here, as outcomes may vary due to random
variation, case-mix or data quality.
The mortality figures were derived from the National Oesophago-gastric Cancer Audit and are 30-day mortality rates after resection for patients diagnosed
with gastric or oesophageal cancer diagnosed between April 1st 2011 and March 31st 2012. Wolverhampton patients undergo resectional surgery in Stoke
for these cancers. Only one RWT surgeon operates there on those patients, and his mortality was 10%, which lies below the expected upper limit for this
type of surgery (16%).
Upper GI – Mr Curran
Vascular Surgery
The information contained in this report has been drawn from data collected by the National Vascular Database and the UK Carotid Interventions Audit.
These projects have been used by vascular surgical services in the UK to monitor their practice and outcomes since 2005, and have been part of a broad
quality improvement programme undertaken by the Vascular Society in collaboration with other organisations. A part of this programme was the
Abdominal Aortic Aneurysm Quality Improvement Programme funded by the Health Foundation (an independent charity) which ran from 2008 until 2013.
During this time, the mortality rate following elective abdominal aortic aneurysm (AAA) repair in the United Kingdom fell from 7% to 2.4%.
This improvement in care has coincided with a move from the traditional “surgical firm” structure to a more open, multi-disciplinary team structure.
Surgeons are seeing the value of working in a team to provide high quality outcomes, and the role of anaesthetists and radiologists in providing specialist
care are more established. Specialist nurses are acting as a clear focus for communication and are a critical part of a successful team.
This report describes outcomes following carotid and elective abdominal aortic aneurysm surgery. It provides a measure of the safety of the procedure.
This is a fundamental aspect of care but it only reflects one part of the spectrum of outcomes that are important to patients.
For AAA repair, this report gives the proportion of patients who died in hospital after surgery for those patients who had an elective repair of an infra-renal
abdominal aortic aneurysm. Patients undergoing an emergency repair of their AAA or whose AAA was above the kidneys are not included in this analysis.
The figures include both open and endovascular repairs analysed together because most surgeons do not undertake sufficient numbers of either procedure
to produce reliable outcome figures for them individually.
The rates of mortality after AAA repair are based on five years of data, and include patients who were admitted to hospital and had their surgery between 1
January 2008 and 31 December 2012. For carotid endarterectomy, the report describes the proportion of patients who had a stroke or died within 30 days
of the operation. These figures are based on three years of data, and include patients who underwent a carotid endarterectomy between 1 October 2009
and 30 September 2012. A different timescale was selected for carotid endarterectomies because the quality of the data submitted to the audit improved
significantly in late 2009 and this makes the outcome figures more reliable.
Also presented is the median delay from symptom to carotid endarterectomy by NHS trust for patients who underwent a carotid endarterectomy between
1 October 2011 and 30 September 2012 for moderate symptoms. This information is only reported by NHS trust for the following reasons.
1. Reporting by NHS trust more accurately reflects the practice within a hospital as the UK Carotid Endarterectomy Audit recommends that patients are
referred to the next available operating list rather than an individual surgeon.
2. There has been a considerable reduction in the median delay from symptom to carotid endarterectomy since 2009 and using older data could give a
misleading impression of times between symptom and surgery.
The report gives the names of surgeons with five or fewer cases but shows their results as an asterisk (*). This is to prevent individual patients from being
identified and is in line with guidance from the Office for National Statistics.
Some surgeons work in more than one NHS trust. The figures for surgeons were produced from all patients that they operated on, and cover all hospitals in
which they have worked. The figures for NHS trusts were produced from only those patients that were operated on in their hospitals. Consequently, the
total number of patients shown as being treated in an NHS trust may not be the same as the total number of operations performed by surgeons working in
an NHS trust.
Many surgeons now perform AAA surgery in pairs, operating together. This is not reflected in this report. Cases are reported against the surgeon with
primary responsibility for the care of the patient.
The data on these vascular procedures were collected using the National Vascular Database (NVD).
In this report, for The Royal Wolverhampton NHS Trust there are tables that contain
- the surgeon’s name
- the number of operations they did, and
- the outcome for the procedure reported.
For AAA repairs, the outcome is proportion of patients who died after the operation while in hospital. For carotid endarterectomy, the outcome is the
proportion of patients who had a stroke or died within 30 days of the operation.
It is not recommended that the surgeons in these tables are ranked by their mortality rate. Surgeons will always differ from the national average because
of random variation – some will be higher and some lower. This variation is not communicated when figures are ranked. Consequently, ranking these
surgeon figures would be misleading and it could make people draw the wrong conclusions about an individual surgeon’s performance.
No major vascular surgery is now done at RWT, but our surgeons provide a service at Russells Hall Hospital. The mortality data came from the National
Vascular Database and examined only two operations of the many that are performed in vascular surgery. The figures were the risk-adjusted in-hospital
mortality after elective repair of infra-renal abdominal aortic aneurysms between 1st January 2008 and 31st December 2012, and the risk adjusted combined
rates of death or stroke within 30 days of elective carotid endarterectomy performed between 1st October 2009 and 30th September 2012. For RWT
surgeons, there were 179 aneurysms over the 5 year period and 92 endarterectomies over 3 years: the outcome rates were 2.8% and 4.3% respectively
with ranges for the individual surgeons between 0 and 8.3% for aneurysms and 0 and 6.8% for carotids: all these figures lie within the expected ranges.
Individual surgeon outcomes for elective AAA repair
The following pages contain the surgical outcomes for consultant surgeons undertaking elective AAA repair for infra-renal abdominal aortic aneurysms at
The Royal Wolverhampton NHS Trust. The reported mortality rate by each surgeon is their overall rate, and reflects their individual practice and their mix
of open and EVAR procedures. It is not the risk-adjusted rate and should NOT be used to make comparisons across surgeons.
The status column indicates whether the surgeon had outcomes in the expected range given their level of activity () or was found to be an outlier (X) in
the assessment of their risk-adjusted outcomes. No surgeons were found to have outcomes that differed from the national average by more than would be
expected from random fluctuations alone. The comparative, risk-adjusted mortality rates of surgeons are shown in the funnel plot in Figure 1. All surgeons
are performing within the range expected.
Some surgeons work in more than one NHS trust. The figures for surgeons were produced from all patients that they operated on, and cover all hospitals in
which they have worked. The figures for NHS trusts were produced from only those patients that were operated on in their hospitals. Consequently, the
total number of patients shown as being treated in an NHS trust may not be the same as the total number of operations performed by surgeons working in
that NHS trust. NHS trust figures may also be larger than the total reported for individual surgeons because retired surgeons have not been included in this
report.
Figure 1. Funnel plot of risk-adjusted in-hospital mortality after elective AAA repair, with surgeon figures shown in comparison to the national
average rate of 2.2%
Name
GMC
AAA
Open
EVAR
Mortality
Status
Mr Lionello Coen
2468633
48
48
0
4.2%

Mr Teodor Gardecki
1613140
12
4
8
8.3%

Mr Andrew Garnham
3278790
67
19
48
0.0%

Mr Simon Hobbs
4502609
52
17
35
3.8%

156
79
77
2.6%
Royal Wolverhampton NHS
Trust
Individual surgeon outcomes for carotid endarterectomy
The following pages contain the surgical outcomes for consultant surgeons undertaking carotid endarterectomy. The tables organise the surgeons
at The Royal Wolverhampton NHS Trust. The reported rate of stroke or death within 30 days by each surgeon is their overall rate, and reflects their
individual practice. It is not the risk-adjusted rate and should NOT be used to make comparisons across surgeons.
The status column indicates whether the surgeon had outcomes in the expected range given their level of activity () or was found to be an outlier (X) in
the assessment of their risk-adjusted outcomes. No surgeons were found to have outcomes that differed from the national average by more than would be
expected from random fluctuations alone. The comparative, risk-adjusted mortality rates of surgeons are shown in the funnel plot in Figure 2.
Some surgeons work in more than one NHS trust. The figures for surgeons were produced from all patients that they operated on, and cover all hospitals in
which they have worked. The figures for NHS trusts were produced from only those patients that were operated on in their hospitals. Consequently, the
total number of patients shown as being treated in an NHS trust may not be the same as the total number of operations performed by surgeons working in
that NHS trust. NHS trust figures may also be larger than the total reported for individual surgeons because retired surgeons have not been included in this
report.
Figure 2. This Funnel plot of risk-adjusted rate of stroke/death within 30 days of a carotid endarterectomy, with surgeon figures shown in
comparison to the national average rate of 2.4%
Name
GMC
CEAs
Total CEAs with
% Stroke and/or
outcomes
Death
Status
Mr Lionello Coen
2468633
16
15
6.7%

Mr Teodor Gardecki
1613140
*
*
*

Mr Andrew Garnham
3278790
32
31
0.0%

Mr Simon Hobbs
4502609
44
44
6.8%

95
92
5.4%
Royal Wolverhampton NHS
Trust
Median (IQR)
11(7, 20)
Urology
The British Associate of Urological Surgeons has included all the data returned in the overall analysis but, when presenting the individual surgeons' results,
they have excluded those surgeons who returned less than 5 cases for the year because any statistical analysis of such low numbers would be invalid.
Patients vary by age, sex and the number of other illnesses they have (known as co-morbidities). Some surgeons may have many patients with complex
problems, others may have far fewer. This is known as the patient casemix and needs to be taken into account when considering figures such as those
shown, because higher risk patients are more likely to have complications. In addition, some procedures are inherently riskier than others. This needs to
be taken into account, too and is termed "risk adjustment".
It is important to note that risk adjustment of patients in this dataset, originally set up in 2001 to evaluate the (then) new technique of laparoscopic
nephrectomy, was never planned, so the predictive accuracy (and hence the ability to risk adjust every patient) is bound to be imperfect.
There will be a number of additional questions added to the dataset to help improve this process for future years (e.g. Charlson co-morbidity index, BMI,
whether the procedure was performed as part of a more major operation etc).
The data collection period was from 1 Jan 2012 to 31 Dec 2012
Figures for England: 5,449 procedures from 283 consultants at 119 centres, including 125 private patients from 34 consultants.
Hospital Episode Statistics (HES) for 2011 indicate that there were 6,766 nephrectomies undertaken by urologists in 2011. Assuming a similar number of
cases were undertaken in 2012, it is estimated that data has been captured on almost 80% of the nephrectomies undertaken by urologists in England during
2012.
93.3% of the cases were entered by hand, as opposed to being bulk-uploaded from datasets such as Somerset Cancer Registry.
Median number of cases per consultant: 14 (range 1 – 107)
Median number of cases per centre: 37 (range 1 – 231)
The Urology mortality data was compiled by the British Association of Urological Surgeons from a prospective audit of nephrectomies, a procedure that is
done by only 40% of English Urologists. They reported 30 day mortality after surgery performed during 2012 – there were no deaths in the 46 procedures
done at RWT during that time period, and rates of blood transfusion and complications following surgery lay within the expected ranges.
RWT - Trust Wide
Nephrectomy Casemix - 1st January 2012 to 31st December 2012
These two graphs show the number of times nephrectomy (removal of the kidney) has been performed by a hospital trust or surgeon over a year, so you
can see if a particular surgeon carries out such surgery regularly or rarely. They are sub-divided by the particular procedure, whether it was performed
laparoscopically (including hand assisted and robotic) or as an open operation and if it was being performed for a cancer (malignant) or benign reasons.
RWT - Trust Wide
Nephrectomy Morbidity and Stay Length – 1st January 2012 to 31st December 2012
This illustration shows the risk-adjusted morbidity (complications including deaths), transfusion rate and length of stay.
Ms Boddy
Nephrectomy Casemix - 1st Jan 12 to 31st Dec 12
Nephrectomy Morbidity and Stay Length – 1st Jan 12 to 31st Dec 12
Mr Cooke
Nephrectomy Casemix - 1st Jan 12 to 31st Dec 12
Nephrectomy Morbidity and Stay Length – 1st Jan 12 to 31st Dec 12
Urology – Mr Waymont
Nephrectomy Casemix - 1st Jan 12 to 31st Dec 12
Nephrectomy Morbidity and Stay Length – 1st Jan 12 to 31st Dec 12