Monitoring the quality of cardiac surgery based on three or more surgical outcomes using a new variable life-adjusted display
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Fah Fatt Gan1, Xu Tang1, Yexin Zhu1
1Department of Statistics and Applied Probability, National University of Singapore, 6 Science Drive 2, 117546, Republic of Singapore.
Insights
A new Variable Life-Adjusted Display (VLAD) uses more detailed surgical outcomes, improving accuracy in assessing surgeon performance and surgical quality monitoring.
Area of Science:
- Medical Statistics
- Surgical Quality Improvement
- Health Informatics
Background:
- Traditional Variable Life-Adjusted Displays (VLAD) use binary outcomes (death or survival), leading to significant information loss.
- Current quality monitoring procedures based on binary outcomes may lack sensitivity in detecting performance variations.
Purpose of the Study:
- To develop and evaluate a novel VLAD that incorporates more than two surgical outcome categories.
- To enhance the accuracy and fairness of surgical performance assessment.
Main Methods:
- A likelihood ratio method was employed to create a penalty-reward scoring system for multiple surgical outcomes.
- The new VLAD accumulates a statistic (W-W¯R) to estimate surgeon performance against a historical dataset.
- Implementation involved comparing traditional binary-outcome VLADs with the new multi-outcome VLAD.
Main Results:
- Illustrations demonstrated the impact of partial recovery outcomes on surgical results.
- A reversal in the relative performance of surgeons was observed when using the new VLAD compared to the traditional one.
- The new VLAD effectively displayed surgical results for multiple surgeons based on detailed outcome data.
Conclusions:
- Classifying surgical outcomes into more than two categories, rather than a simple binary, significantly reduces information loss.
- The refined VLAD provides a more accurate and equitable assessment of surgical outcomes and surgeon performance.
- This improved method enhances the sensitivity of quality monitoring procedures in healthcare.
Quality Problem Or Issue:
The traditional variable life-adjusted display (VLAD) is a graphical display of the difference between expected and actual cumulative deaths. The VLAD assumes binary outcomes: death within 30 days of an operation or survival beyond 30 days. Full recovery and bedridden for life, for example, are considered the same outcome. This binary classification results in a great loss of information.
Initial Assessment:
Although there are many grades of survival, the binary outcomes are commonly used to classify surgical outcomes. Consequently, quality monitoring procedures are developed based on binary outcomes. With a more refined set of outcomes, the sensitivities of these procedures can be expected to improve.
Choice Of Solution:
A likelihood ratio method is used to define a penalty-reward scoring system based on three or more surgical outcomes for the new VLAD. The likelihood ratio statistic W is based on testing the odds ratio of cumulative probabilities of recovery R. Two methods of implementing the new VLAD are proposed.
Implementation:
We accumulate the statistic W-W¯R to estimate the performance of a surgeon where W¯R is the average of the W's of a historical data set. The accumulated sum will be zero based on the historical data set. This ensures that if a new VLAD is plotted for a future surgeon of performance similar to this average performance, the plot will exhibit a horizontal trend.
Evaluation:
For illustration of the new VLAD, we consider 3-outcome surgical results: death within 30 days, partial and full recoveries. In our first illustration, we show the effect of partial recoveries on surgical results of a surgeon. In our second and third illustrations, the surgical results of two surgeons are compared using both the traditional VLAD based on binary-outcome data and the new VLAD based on 3-outcome data. A reversal in relative performance of surgeons is observed when the new VLAD is used. In our final illustration, we display the surgical results of four surgeons using the new VLAD based completely on 3-outcome data.
Lessons Learned:
Full recovery and bedridden for life are two completely different outcomes. There is a great loss of information when different grades of 'successful' operations are naively classified as survival. When surgical outcomes are classified more accurately into more than two categories, the resulting new VLAD will reveal more accurately and fairly the surgical results.
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