Mortality as an indicator of quality of neurosurgical care in England: a retrospective cohort study

Abstract

ObjectivesPostoperative mortality is a widely used quality indicator, but it may be unreliable when procedure numbers and/or mortality rates are low, due to insufficient statistical power. The objective was to investigate the statistical validity of postoperative 30-day mortality as a quality metric for neurosurgical practice across healthcare providers.DesignRetrospective cohort study.SettingHospital Episode Statistics data from all neurosurgical units in England.ParticipantsPatients who underwent neurosurgical procedures between April 2013 and March 2018. Procedures were grouped using the National Neurosurgical Audit Programme classification.Outcomes measuredNational 30-day postoperative mortality rates were calculated for elective and non-elective neurosurgical procedural groups. The study estimated the proportion of neurosurgeons and NHS trusts in England that performed sufficient procedures in 3-year and 5-year periods to detect unusual performance (defined as double the national rate of mortality). The actual difference in mortality rates that could be reliably detected based on procedure volumes of neurosurgeons and units over a 5-year period was modelled.ResultsThe 30-day mortality rates for all elective and non-elective procedures were 0.4% and 6.1%, respectively. Only one neurosurgeon in England achieved the minimum sample size (n=2402) of elective cases in 5 years needed to detect if their mortality rate was double the national average. All neurosurgical units achieved the minimum sample sizes for both elective (n=2402) and non-elective (n=149) procedures. In several neurosurgical subspecialties, approximately 80% of units (or more) achieved the minimum sample sizes needed to detect if their mortality rate was double the national rate, including elective neuro-oncology (baseline mortality rate=2.3%), non-elective neuro-oncology (rate=5.7%), neurovascular (rate=6.7%) and trauma (rate=11%).ConclusionPostoperative mortality lacks statistical power as a measure of individual neurosurgeon performance. Neurosurgical units in England performed sufficient procedure numbers overall and in several subspecialty areas to support the use of mortality as a quality indicator.

Quality indicators and early adverse in surgery for atypical meningiomas: A 16-year single centre study and systematic review of the literature

“…Several studies have raised concerns regarding the reliable use of this rate as a quality measure ( Dimick et al., 2004 ; Wahba et al., 2022 ), due to the fact that low procedure numbers might impede the detection of poor performance and the corresponding lack of statistical power. The department's caseload must be high enough to detect raising in mortality rates ( Dimick et al., 2004 ), this remains difficult when focusing only on certain subdiagnoses, e.g.…”

Perioperative quality indicators among neurosurgery patients: A retrospective cohort study of 1142 cases at a tertiary center

“…Advancing the efficiency of healthcare delivery by improving patient outcomes relative to costs not only benefits patients but also increases the economic sustainability of healthcare systems [1]. Accordingly, parameters assessing patient outcomes, such as the length of hospital stay (LOS), readmission rate, reoperation rate, adverse event rate, and mortality rate, are increasingly used as quality metrics [2][3][4][5][6][7][8].…”

Benchmarking short-term postoperative mortality across neurosurgery units: is hospital administrative data good enough for risk-adjustment?

“…Administrative hospital datasets (like the English Hospital Episode Statistics) have been used to produce effective risk adjustment models for short-term outcomes like 30-day post-operative mortality for various surgical procedures [ 5 ]. There is recent evidence supporting the use of administrative data to investigate comparative mortality rates in neurosurgery [ 35 ], but the performance of these type of risk adjustment models has not been evaluated for neurosurgical procedures. Such models are required for producing risk-adjusted organisation-level outcome indicators within the National Neurosurgical Audit Programme (NNAP) of the Society of British Neurological Surgeons (SBNS) [ 33 ].…”