Harrison Ewen M, Drake Thomas M, O'Neill Stephen, Shaw Catherine A, Garden O James, Wigmore Stephen J
Clinical Surgery, Surgical and Perioperative Health Research (SPHeRe), University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.
The Medical School, University of Sheffield, Sheffield, UK.
BMJ Open. 2016 Oct 31;6(10):e012471. doi: 10.1136/bmjopen-2016-012471.
There is controversy on the proposed benefits of publishing mortality rates for individual surgeons. In some procedures, analysis at the level of an individual surgeon may lack statistical power. The aim was to determine the likelihood that variation in surgeon performance will be detected using published outcome data.
A national analysis surgeon-level mortality rates to calculate the level of power for the reported mortality rate across multiple surgical procedures.
The UK from 2010 to 2014.
Surgeons who performed colon cancer resection, oesophagectomy or gastrectomy, elective aortic aneurysm repair, hip replacement, bariatric surgery or thyroidectomy.
The likelihood of detecting an individual with a 30-day, 90-day or in-patient mortality rate of up to 5 times the national mean or median (as available). This was represented using a novel heat-map approach.
Overall mortality rates for the procedures ranged from 0.07% to 4.5% and mean/median surgeon volume was between 23 and 75 cases. The national median case volume for colorectal (n=55) and upper gastrointestinal (n=23) cancer resections provides around 20% power to detect a mortality rate of 3 times the national median, while, for hip replacement, this is a rate 5 times the national average. At the mortality rates reported for thyroid (0.08%) and bariatric (0.07%) procedures, it is unlikely a surgeon would perform a sufficient number of procedures in his/her entire career to stand a good chance of detecting a mortality rate 5 times the national average.
At present, surgeons with increased mortality rates are unlikely to be detected. Performance within an expected mortality rate range cannot be considered reliable evidence of acceptable performance. Alternative approaches should focus on commonly occurring meaningful outcome measures, with infrequent events analysed predominately at the hospital level.
对于公布个体外科医生的死亡率所带来的潜在益处存在争议。在某些手术中，个体外科医生层面的分析可能缺乏统计学效力。本研究旨在确定利用已公布的结果数据检测外科医生手术表现差异的可能性。
一项全国性分析，分析外科医生层面的死亡率，以计算多种外科手术报告死亡率的效力水平。
2010年至2014年的英国。
实施结肠癌切除术、食管切除术或胃切除术、择期主动脉瘤修复术、髋关节置换术、减肥手术或甲状腺切除术的外科医生。
检测出30天、90天或住院死亡率高达全国平均或中位数（如适用）5倍的个体的可能性。这采用了一种新颖的热图方法来呈现。
这些手术的总体死亡率在0.07%至4.5%之间，外科医生的平均/中位数手术量在23至75例之间。结直肠癌（n = 55）和上消化道癌（n = 23）切除术的全国中位数手术量提供了约20%的效力来检测死亡率为全国中位数3倍的情况，而对于髋关节置换术，这一比例是全国平均水平的5倍。对于甲状腺手术（0.08%）和减肥手术（0.07%）报告的死亡率而言，外科医生在其整个职业生涯中不太可能实施足够数量的手术，从而有很大机会检测出死亡率为全国平均水平5倍的情况。
目前，不太可能检测出死亡率较高的外科医生。在预期死亡率范围内的表现不能被视为可接受表现的可靠证据。替代方法应侧重于常见的有意义的结果指标，罕见事件主要在医院层面进行分析。
