Keeping score: tracking complications and side effects of surgery improves results

Women having hysterectomies for benign conditions do so in the main because after suffering heavy periods, pelvic pain or prolapse over many months, they want to improve their quality of life.

That makes it particularly important that they understand the side effects and potential complications of this common surgical procedure - by the age of 60 one in three women in the US and one in five women in the UK have had a hysterectomy.

Haemorrhage, infection, early menopause and damage to the bladder and urinary system are among the complications associated with the procedure. While new, non-surgical treatments are gradually reducing the number of hysterectomies for less serious uterine conditions, it remains difficult for patients and doctors to decide when a hysterectomy is the most appropriate course.

The biggest problem is the absence of clear-cut information on the incidence of complications said Meghana Pandit, chief medical officer and deputy CEO of University Hospital Coventry and Warwickshire (UHCW) NHS Trust.

“As a gynaecologist, I have a strong interest in hysterectomies and this, coupled with my passion for safer healthcare and better patient experiences, inspired me to take action,” she said.

More than mortality

What Pandit found was a glaring data gap: most of the available information tracks mortality rates, rather than recording and publishing details of patients’ quality of life and experience of complications.

“It is important to focus on mortality but we don’t place enough emphasis on morbidity,” says Pandit. “The reason people come to see a gynaecologist [for benign conditions] is that they ultimately want an improvement in their quality of life. But if we don’t measure outcomes we have no idea whether we are delivering what patients want.”

Greater transparency about outcomes might reduce the number of patients having hysterectomies to alleviate heavy periods – a condition for which there are less radical alternatives. “Hysterectomy is the correct option for some women,” says Pandit, “but for others it is not: [there is] the operation itself, the delayed return to work, the need for care in hospital and recovery at home.”

By setting out the pros and cons of surgery and risks associated with different operations - while 53 per cent of hysterectomies are performed abdominally by open surgery, the trend in recent years has been for more vaginal and laparoscopic procedures, which are less invasive and typically have a much shorter length of stay in hospital and faster recovery times - patients can make an informed decision.

This empowers patients, sets accurate expectations and reduces the number of patient complaints and medico-legal claims.

Benchmarking study

Pandit led a benchmarking study tracking hysterectomy outcomes of 32,000 operations in the UK, US and Australia. This led to the development of a surgical scorecard recording everything from length of stay and readmission rates, to post-operative haemorrhage and wound infection for each of the three types of procedure.

The scorecard has proved so valuable that it has been adopted for all other surgical specialities at UHCW. Each speciality has its own set of parameters to be tracked, in addition to some outcome measures common to all surgeries.

Starting with colorectal surgery, the performance and programme management office team selected basic data to be collected, including haemorrhage rates, recovery time, embolism risk, hospital readmission rates, and wound infection rates.

“With Meghana and other clinicians, we established a set of fifteen indicators across all surgical specialties, which aimed to demonstrate the prevalence of postoperative problems or conditions,” said Kathryn Pearce, programme analytics specialist at the hospital. “Our team created the web-based scorecard containing data for these measures for a number of financial years allowing trends in activity to be highlighted.”

Pandit said these generic primary indicators are for “everyone who wields a scalpel” and can be enhanced with other bespoke indices for different surgical specialities over time.

The scorecard can be viewed by clinical leaders in all surgical specialities at the hospital and reviewed during regular quality and safety meetings.

“The more data we collected, the more powerful it became because we were able to look for trends,” said Pandit. “If there was a problem we could see whether the same team had a high rate of blood transfusions, for example, or if certain categories of patients suffer higher complication rates.”

The data is recorded in the hospital intelligence system but the names of individual surgeons are only visible to Pandit and the clinical director of each department. This was to allay doctors’ fears that they might be ranked against their peers.

Most doctors have embraced the system but, as with any major change, there is hesitation in some quarters. “It’s a big change and requires a new way of thinking about what we do as surgeons,” says Pandit. “The main purpose is learning and to change practice where needed to improve safety – nothing more than that.”

After introducing the scorecard a year ago, it has now been rolled out to all specialities and is subject to continuous refinement. The next step is to build patient input into the scorecard and to find the right way to share the results with new patients.

“Ultimately, we want each surgeon to be able to share surgical outcomes with their patients,” says Pandit. “We will be better able to identify the right procedure for the right patient.”

How surgeons view the scorecard

Abigail Tomlins, consultant surgeon at UHCW says surgeons have long acknowledged the importance of open discussion of morbidity and mortality in improving outcomes. However, developing a formal system for morbidity data collection is a step forward.

“There are robust systems for recording and discussing mortality but morbidity data has historically been collected on a more ad-hoc basis,” she said. “The scorecards, used alongside the other trust and group scorecards, are proving to be useful clinically. They generally show a reassuring picture of low morbidity across most specialties, whilst highlighting areas that may be improved.”

The data is regularly scrutinised at meetings on quality improvement and patient safety and can be used to direct resources to areas where improvement is needed.

“In my own sub-specialty of breast surgery, I can at a glance see that our average length of stay is below national average with a low readmission rate, haemorrhage rate and no recorded venous thromboembolism,” Tomlins said. “If there were to be a change in trend it would be easily visible to me, and I know how to access more detailed data so that I could investigate early whether or not action is required.”

The power of the scorecards would be further enhanced if adopted by other hospitals, Pandit said. “This would enable direct comparison with national specialty-specific data, encouraging sharing of good practice.”