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BJC Arrhythmia Watch, Professor Pandit

Clinical Articles, Lead Article

Do anaesthetists affect cardiac surgery mortality? An anaesthetist speaks

There has been much interest in a feature in the last edition of BJC Arrhythmia Watch, which focused on a paper1 published on behalf of the Association of Cardiothoracic Anaesthetists (ACTA) which concluded that “anaesthetists did not appear to affect mortality”.

In this issue we asked Professor Jaideep J Pandit, Consultant Anaesthetist Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, to comment further on the paper:

The publication of cardiac surgeon outcome data has been the topic of much debate. On the one hand this has been welcomed as a sign of transparency and openness; on the other hand it has been suggested that these data might be very misleading. One of the reasons for this is that surgeons do not work alone, but in teams, and nowhere has the role of the wider team in influencing outcome been examined.

To address this Papachristofo et al.1 have studied the potential impact of the anaesthetist, over a sustained period of time on outcomes and robustly concluded that “anaesthetists did not appear to affect mortality”. They further noted that by far the greatest influence was of the patient, with a small influence of surgeon. Thus it seems that although cardiac surgeon ‘league tables’ may be informative, they are in fact focussing on just a small part of the factors affecting outcomes.

Professor Jaideep J Pandit (Oxford University Hospitals NHS Trust)

Professor Jaideep J Pandit (Oxford University Hospitals NHS Trust)

Does the fact that the ‘anaesthetist has no influence’ mean that it does not matter what sort of anaesthetic one gives (or indeed, what level of anaesthesia qualifications one needs) in context of cardiac surgery? Far from it. The paper, and the accompanying editorial by Alston,2 emphasise that such a result is only possible where there is rigorous standardisation of training and practice in cardiac anaesthesia – as there has been through the processes overseen by the NHS and by the specialist societies that help maintain standards. It would be interesting to see if these results are paralleled in other countries where there is less rigorous standardisation of anaesthesia, or those that include nurse anaesthetists in the service delivery providers.

Quite rightly, Alston writes that this paper may be one of the most important in the field of cardiac surgery/anaesthesia in the last 30 years, as it widens the debate to one that deals with the role of performance tables and how they should be best analysed to provide useful information. However, the results do pose a challenge to anaesthesia. If practice is so standardised and so effective, how (if at all) can it be improved? Or is this really as good as it gets?”

References

1. Papachristofi O, Sharples LD, Mackay JH, Nashef SAM, Fletcher SN, Klein AA. The contribution of the anaesthetist to risk-adjusted mortality after cardiac surgery. Anaesthesia 2015;71:138–46. http://dx.doi.org/10.1111/anae.13291

2. Alston RP .Asked and answered: is the mortality associated with cardiac surgery related to the anaesthetist and should it be used to measure anaesthetic performance, Anaesthesia 2015;71:123–6. http://dx.doi.org/10.1111/anae.13315

Published on: January 14, 2016

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