Cataract surgery: benchmarks for established and trainee surgeons

Abstract

Much attention is currently focused on surgical outcomes, with policy clearly in favour of the publication of individual results for consultant surgeons.1-3 Approximately a quarter of cataract surgery in the NHS is, however, undertaken by trainees at specialist registrar (SpR) level, 4 which amounts to around 75 000 operations annually in England alone. It is accepted that posterior capsule rupture (PCR) rates for learners are higher than those for experienced phacoemulsification surgeonsFan unsurprising finding. 5,6 With this number of procedures being undertaken in the NHS by trainees, it is a matter of public health relevance to know what complication rates should be expected for this group of training surgeons.A recent electronic audit of 55 567 cataract operations identified an overall PCR rate of 1.92% for 406 surgeons of all grades working in the English NHS.4 Analysis of risk factors for PCR revealed surgeon's grade to be an important determinant of complication risk. 7Trainees at SpR level were 65% more likely to have a complication than consultants, after adjustment for other risk factors. A major determinant of PCR risk was case complexity, patients with multiple risk factors being at a strikingly increased risk of a complication as predicted by the logistic regression model. A male patient aged above 90 years with diabetic retinopathy and a brunescent cataract, for example, would have a predicted probability of a PCR of 10% if operated on by a consultant, but around 16% if operated on by an SpR. This difference in predicted probability of a complication of 6% between the surgeons makes a strong case for such higher risk patients being operated on exclusively by consultants.In this issue Buchan and Cassels-Brown 8 have provided information on surgical opportunities, and surgical complication rates for trainees at SpR level in the Yorkshire region. Surgical opportunities appeared adequate in this sample of trainees, and assuming representativeness, the finding bodes well for the training opportunities of the next generation of consultant ophthalmologists. The overall PCR rate for the 19 participating trainees of 2.3% is also reassuring. Without information on surgical case mix, however, the full picture remains uncertain. If the case mix complexity of these trainee surgeons was such that they operated exclusively on the lowest risk patients, then from the logistic regression model noted above, 7

Mapping standard ophthalmic outcome sets to metrics currently reported in eight eye hospitals

“…Failure to adjust for such may discourage surgeons from treating high-risk patients and therefore deny high-risk patients the opportunity of benefiting from surgery, while appropriate risk adjustment can do much to allay these concerns. There has been reported reluctance of some cardiac surgeons to operate on high-risk patients for these reasons [ 38 , 39 ] and, without appropriate risk adjustment, unintended distortions of appropriate surgical care may thus arise to the ultimate detriment of the public [ 40 ].…”

The cataract national data set electronic multi-centre audit of 55 567 operations: case-mix adjusted surgeon's outcomes for posterior capsule rupture

“…5 Furthermore the grade of surgeon has an important influence on the likelihood of a complication arising. 9 Transparency of medical and surgical outcomes has become a matter of public concern, with the medical director of the NHS having indicated a clear expectation that in the future the clinical outcomes of individual surgeons will be placed in the public domain. 10,11 The issue is therefore no longer whether this will or will not occur, it is now a question of which form it should take.…”