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Hospital receipt format for Quality Assurance

thank you all for coming today for the gibbon lecture it's my great honor to introduce the american college of surgeons clinical congress 2018 john h gibbon junior lecturer dr richard a jonas the gibbon lecture was established in 1971 to honor the pioneering cardiothoracic surgeon dr gibbon in the spirit of dr gibbons accomplishments the given lecture is someone who has made an undeniable impact on the cardiothoracic surgical specialty as well as the house of surgery as a whole dr jonas is indeed that individual at the children's national medical center in washington dc he serves as the chief of cardiovascular surgery the co-director of the children's heart institute and the cohen finger professor of cardiac surgery originally hailing from adelaide south australia and obtaining zim deep in the university of adelaide and university of adelaide does have a twitter account and i tweeted them this event today so we'll we'll hope to hear from your your your alumni association dr jonas undertook his general surgical training at the royal melbourne hospital in melbourne australia and subsequently his ct surgical training at the royal children's hospital in melbourne and green lane hospital in auckland new zealand after fellowships at the brigham and women's hospital and children's hospital here in boston he joined a surgical faculty at children's hospital in 1984 and then only 10 years later dr jonas was appointed to the william e ladd chair of surgery at harvard medical school and became the cardiovascular surgeon in chief at boston children's dr jonas embodies the surgeon giant he's a trailblazer in congenial cardiac surgery helping to define and evolve the specialty and he contributes scientifically with the nih supported laboratory research program and has authored over 400 peer-reviewed publications and two textbooks he has disseminated that knowledge globally through project hope for more than 25 years in establishing a pediatric heart surgery program in shanghai china as well as helping with the design and development of the shanghai children's medical center i present to you dr richard a jonas [Applause] well thank you very much uh dr cook it's certainly a great pleasure to be back in uh chile boston that's one aspect of boston that i don't miss it's uh a little bit warmer 500 miles south so it's certainly a great honor to have been invited to present this 2018 john h gibbon jr lecture as you can see the title of my talk if we can move on to the next slide i don't have any uh disclosures so the title of my talk is early hospital mortality a misleading metric for quality assurance in the new era of hybrid palliation of congenital heart disease but before we get on to that i wanted to tell you a little bit about dr john h gibbon jr dr gibbon lived for 70 years between 1903 and 1973. he was the son of dr john h gibbon who was the professor of surgery at jefferson medical school in philadelphia john jr attended princeton university and jefferson medical college before interning at the pennsylvania hospital between 1927 and 29 in 1930 he shifted from philadelphia to boston to undertake a research fellowship in surgery at harvard medical school as with many important discoveries in the field of medicine gibbons passion for developing a workable heart lung machine was derived from a deeply moving experience that occurred when he was a research fellow in boston while working under edward churchill given cared for a patient with a massive pulmonary embolus from 3 pm one day to 8 a.m the next day on october 31st he writes during that long night watching helplessly the patient's struggle for life as her blood became darker and her veins more distended the idea naturally occurred to me that if it were possible to remove some of the blue blood from the patient's swollen veins put oxygen into that blood and allow carbon dioxide to escape from it and then inject continuously the now red blood back into the patient's arteries we might have saved her life gibbon returned to philadelphia but then came back to boston to undertake a second research fellowship under churchill at mass general between 33 and 34. he worked on a number of different ideas but eventually was able to use a rotating cylindrical oxygenator to maintain the circulation in a cat for three hours in 1935 his devoted research assistant mary hopkinson spent many hours in the laboratory with gibbon and eventually became his wife gibbons research was interrupted by the second world war and he spent time in the grueling pacific theater in the solomon islands as shown here following the end of the war gibbon partnered with ibm and together they built the gibbon model 1 heart lung machine which was further refined in late 1949 to have six rotating mesh screens rather than rotating cylinders his first clinical case in february 1952 was unsuccessful but the breakthrough came on may 6 1953 when he was able to successfully close a secundum asd in an 18 year old woman in the jefferson hospital in philadelphia this is one of the only photographs that captured that landmark operation that opened the new field of open-heart surgery using cardiopulmonary bypass although gibbon's success was celebrated his subsequent patients did not survive and he abandoned clinical cardiac surgery fortunately for the field of cardiac surgery the ibm oxygenator was adopted by dr john kirkland at the mayo clinic in rochester minnesota where many landmark operations were undertaken during the 1950s dr kirkland will emerge as an important figure later in my presentation 90 miles away from rochester dr walt little high and the team at the university of minnesota worked with a much less complex oxygenator that bubbled oxygen directly into the blood and did not rely on meshes or screens like john kirkland little high made enormous breakthroughs in the field of congenital cardiac surgery but it was john h gibbon jr whose courage and persistence his methodical and meticulous surgical research in the laboratory set the stage for the opening of the new field of congenital open-heart surgery using cardiopulmonary bypass now of course those of us who trained in boston at boston children's were well aware that the field of surgery for congenital heart disease was already 15 years old by the time gibbons successfully applied the heart lung machine in 1938 at boston children's robert gross had undertaken the first closed heart surgery procedure when he successfully ligated a patent ductus arteriosus seven years later in 1945 dr gross also successfully undertook repair of coarctation at boston children's following the lead of clarence crawford in sweden earlier that same year like gibbon gross had undertaken exhaustive studies of aortic anastomosis in young pigs in the laboratory because he was very concerned about the potential growth of aortic anastomoses in young patients and these studies led him to conclude that repair of coarctation early was inadvisable gross wrote in his landmark textbook entitled the surgery of infancy and childhood from laboratory observations on aortic anastomosis and growing pigs it's been found that it is possible for the lumen to enlarge reasonably well with the increase in the size of the growing animal but in some instances it lags behind somewhat hence in a human baby we generally prefer to carry along the treatment by medical means and then to perform aortic resection and anastomosis later in childhood when there is more reasonable promise that the pathway will be large enough to be adequate during adult life now today we wouldn't dream of delaying co-octation repair simply because of the small risk of growth-related anastomotic stenosis my own textbook comprehensive surgical management of congenital heart disease the first edition of which was written when i was in the same professorship in boston as gross begins with a chapter entitled why early primary repair over the last 30 years there's been a gradual acceptance around the world that complete repair in the newborn period or early infancy is the correct approach to the management of most congenital heart problems but recently that has begun to change today i'm going to examine with you a number of factors that are coalescing that threaten the continuing application of early primary repair but first what's the evidence that supports an approach of early repair when i was working in new zealand in the early 1980s before i came to boston pat clarkson who was a highly respected senior cardiologist at green lane was examining the very long term outcomes of coachation repair over the previous 25 years working with sir brian barrett boys here is the paper that resulted from that study that documented the high risk of late hypertension when calactation repair is delayed into later childhood in addition developments in microvascular techniques for arterial surgery as well as the advent of balloon angioplasty are additional factors why early primary repair of coactation has become routine and is unquestioned things become a little more complicated when open heart surgery is required the development of bypass by gibbon produced a number of new reasons in addition to growth why surgeons in the early years of surgery for congenital heart disease recommended delaying surgery usually until a specific age and weight had been attained that varied from unit to unit early hot lung machines had multiple deleterious effects that were particularly dangerous for the young infant the priming volume for early circuits was usually several leaders exposing infants to effectively a massive blood transfusion anesthesia for babies was in its infancy and intensive care units appropriate for young babies didn't exist the diagnosis of heart disease was dependent on invasive cardiac catheterization so for all these very valid reasons every attempt was made to manage the child medically and to defer the open heart procedure until the child was considered better able to withstand the stresses of surgery for the child who could not be managed medically a number of palliative surgical procedures were developed beginning with the ingenious technical innovation that we know today is the blaylock shunt but just as delay in the repair of coactation is negative consequences so too do palliative procedures result in ongoing deleterious consequences of an abnormal circulation in addition the palliative procedures themselves carry a risk of mortality and morbidity no matter how skilled and experienced the surgical team the advantages of early primary repair were in fact apparent from the earliest years of open heart surgery in 1954 and 1955 which you'll recall is actually after gibbons successful application of the heart lung machine walt little high undertook cross circulation operations which demonstrated that infants could undergo correction of a number of congenital anomalies with remarkably low morbidity and mortality and excellent long-term results by using the parent as an oxygenator but following the introduction of the heart lung machine with its attendant morbidity the two-stage palliative approach became firmly entrenched and during the 1950s and 1960s was the standard of care in 1972 brian barrett boys astounded the world with his reports of successful primary repair and infancy of a wide range of congenital cardiac anomalies both he and eldercastenator in boston were able to achieve remarkable results in spite of the still primitive state of cardiopulmonary bypass what they did was to minimize exposure of the child to the deleterious effects of bypass by employing the technique of deep hypothermic circulatory arrest so over the next 10 to 15 years controversy raged regarding whether primary repair should be the standard for care for all cardiac anomalies an important landmark occurred at the world the first world congress of pediatric cardiac surgery which was held in bergamo italy in 1988 dr john kirkland who as we noted earlier had undertaken pioneering operations using gibbons machine at the mayo clinic and was very well aware of the multiple deleterious effects of bypass in the young entitled his keynote address the movement of cardiac surgery to the very young by 1988 35 years after gibbons first success supported by specialized cardiac anesthesia and cardiac icu teams which had emerged as continuing improvements together with improvements in the hardware of caterpillar bypass non-invasive diagnosis by echocardiography together with operations conducted with improved surgical technique had resulted in a crossover point where the risks of a single corrective repair operation were no now less than the combined risks of a palliative operation a period of interim palliation with an abnormal circulation and the subsequent risks of a repair operation albeit in an older and larger child so there are a number of important advantages for the patient for the family and for society of undertaking early primary repair rather than an outdated two-stage approach with initial palliation such as a pulmonary artery band or a systemic to pulmonary artery shunt followed by an extended period of abnormal circulation both the fetus and the newborn infant are adapted to thrive in a hypoxic environment if this were not the case oxygen would not transfer across the placenta from the maternal circulation to the fetal circulation in addition to the adaptation of having fetal hemoglobin there are a number of my uh there are really multiple mitochondrial enzyme differences between the fetus and the mature individual and both and these adaptations are beneficial in tolerating the stresses of surgery but they're gradually lost over the first weeks and months of life there are advantages for the heart itself in early repair let's look at the example of the commonest cyanotic anomaly tetralogy of fellow as long as the vsd remains open the pressure within the right ventricle will remain at systemic pressure this results in progressive hypertrophy and fibrosis relative to the normal right ventricular myocardium which results in gradually worsening diastolic function as the weeks pass in early infancy and poor right ventricular function is the achilles heel of tetralogy repair the neonatal brain is ideally suited to withstand hypoxia and ischemia because it has limited synaptic development and limited myelin it's not that a newborn baby has to learn how to sit or walk the synaptic connections and myelinated axons to achieve these things simply don't exist in the newborn brain and therefore cannot be damaged if there happens to be a hypoxic ischemic event the advantages for the family of early primary repair are always readily appreciated by young residents and fellows during teaching sessions over the years i've regularly drawn the picture of a young couple with their first newborn being told there's a risk that their child will experience brain damage or possibly death if an acute cyanotic spell occurs i explain that cyanotic spells can be precipitated by a wet diaper or a hungry child our trainees who themselves are often in the early years of child rearing have no difficulty empathizing with the distressed and sleepless young parents in addition to the psychological health of the family unit there are financial advantages in early primary repair as my colleagues pranav sinhara murfred peer demonstrated in their publication in the annals of thoracic surgery in 2014 now this almost certainly wasn't true in the early days of neonatal repair of tetralogy when the majority of procedures were being done for babies who were prostate gland independent or who were spelling now that early primary repair is undertaken electively in the first weeks of life the most important factors that increase cost other than prematurity and important extra cardiac anomalies is undertaking repair as an emergency delaying surgery is more likely to result in the need for an emergency procedure so this is the main reason why repair at an older age say six months is actually more expensive than repair at two or three months furthermore many papers going back to the analysis of the costs of the palliative approach versus primary repair which were undertaken by ross ungerleite of many years ago have documented that the cost of an admission for a shunt procedure is usually equal to the cost of an admission for repair so the total cost is more than doubled by adopting a palliative approach particularly if you add the additional cost of managing the complications of shunts such as balloon angioplasties and the cost of medical care during the interim period so with all of these advantages why on earth would anyone consider an outmoded two-stage approach the reality is that there are a number of forces at play in the current environment that if unrecognized and left unchecked will push our specialty backwards in time when a two-stage palliative approach was a standard of care so let's examine what these factors are there are several threats to the continuing adoption of early primary repair but by far the most important is the use of early procedural mortality rather than patient survival is the key metric to judge the quality of congenital heart programs additional important factors are the increasing use of data analytics by hospital administrators as well as challenges in teaching the next generation of congenital surgeons the skills required to undertake successful neonatal corrective surgery but let's start with an example that illustrates precisely what the main problem is the misleading metric early hospital mortality when bill nord and aldo castaneda introduced the primary neonatal arterial switch procedure in 1983 when i was fortunate to be chief resident of boston children's it was very hotly debated by surgeons and cardiologists around the country around the world and certainly within boston children's whether it was ethically acceptable to start doing this new procedure the controversy arose from the fact that the early procedural mortality for the established atrial level procedures like the mustard and sanding operation was extremely low at that time while the procedural mortality for the arterial switch was somewhat higher the theoretical advantage that there would be long-term benefits did not in the minds of many justify a higher early mortality now fortunately for our specialty dr castaneda and nord as well as dr john kirkland at uab understood that procedural early mortality could be misleading they understood that what was required was a study that looked at the entire population of newborns admitted to an institution with transposition and the overall survival of patients at one year so this led to the organization of the first multi-institutional study organized by the congenital heart surgeons society which is meeting today actually in chicago the study published in 1988 confirmed that the mustard and sending procedures could indeed be done with a lower procedural early mortality than the arterial switch but the total number of survivors at one year was greater with the arterial switch the metric early mortality had failed to capture the deaths that occurred in the interim period between an initial balloon septostomy and later atrial level procedure early procedural mortality was heavily biased for this reason against the early primary repair procedure in this case the arterial switch in contrast to the atrial repairs where surgery is delayed to several months for the arterial switch all comers undergo this surgical procedure in the newborn period and every death counts against the procedure even though there may be more survivors overall it was this study that convinced dr kirkland to title his landmark paper in bergamo the movement of cardiac surgery to the very young so if we want to measure patient survival we have to measure how many patients enter our hospital for treatment of congenital heart disease and not the number of procedures let's examine how the inherent problem of using early hospital mortality which can also be called procedural mortality is even further magnified than the example we just looked at by trying to compare a two-stage palliative approach versus early primary repair so let's compare two institutions hospital a skeleton neonatal surgery hospital b last experience with neonatal surgery hospital admits 10 neonates with prostate gland independent tetralogy all patients undergo neonatal repair one stage early primary repair one patient weighing 1500 grams dies at two months from necrotizing colitis leaving nine patients alive at one year the preemie never left hospital both the early mortality and the mortality for the index operation which in this case is repair of tetralogy is high it's 10 percent so hospital b also emits 10 patients with prostaglandin dependent tetralogy the surgeons place outflow p patches in five patients on bypass this was the operation that jimmy kimmel's baby had for example five patients at hospital b have blaylock shunts and there's one death following discharge two of the outflow patients die from heart failure because they have an open vsd and excessive pulmonary blood flow of the seven surviving patients all undergo the index operation repair of tetralogy with no mortality the hospital proudly announces that their survival for repair of tetralogy is one hundred percent even though seven patients are alive at one year furthermore their early mortality is six percent because they have increased the denominator representing the number of procedures they have 17 operations with one early procedural death thus the overall early hospital mortality the benchmark that is currently being used is six percent and once again their index operation has a zero percent mortality another benchmark metric that is frequently cited so would you choose to send a complex neonate not just a straightforward tetralogy to hospital a or hospital b u.s news and world report would strongly recommend that you go to hospital b unfortunately those of us within the specialty and i count myself among them have failed until relatively recently to appreciate the importance of this impact and the fact that it cannot in any way be risk corrected there is fundamentally no way that early procedural mortality even with the best statisticians in the world can be corrected to deal with this fundamental and inherent failure of procedural mortality to measure quality outcomes in congenital heart programs the danger of relying on early procedural mortality as a quality metric has come into focus because of its heavy weighting in publicly reported rankings of children's hospitals and cardiac programs the topic of public reporting has been eloquently explored in this excellent book that i strongly recommend to you entitled the naked surgeon by samia najaf who's an adult cardiac surgeon at papworth in cambridge uk now dr najaf and the whole uk cardiac surgery healthcare system has been strongly committed to public transparency and cardiac surgical outcomes in the uk for many years pre-dating efforts in the us however as the cover of this book displays there's not only power but there's also peril in transparency in medicine and he provides a number of examples of the way in which adult cardiac surgeons in the uk have gained the system in other words modified their practice in order to improve publicly reported outcomes and for example in the uk it is apparently still valid i realize it's not within the sts database but adding a few sutures to perform an aortoplasty excludes patients in their system from being registered as an index procedure of uncomplicated coronary artery bypass grafting and the decision to add the procedure can actually be made intraoperatively when it becomes apparent after coming off bypass that the patient's not likely to survive the procedure but the problem of gaming the system is far more insidious with congenital heart surgery and is leading to a drift backwards away from early primary repair another fact contributing to the shift backwards from early primary repair back to palliation and delayed repair is the increasing use of data analytics and very appropriately talking baseball in boston as the world series is about to begin i missed the days when the bill when the boston red sox won world series i was here in 1986. but taking the lead of the baseball industry is popularized in the book and movie entitled moneyball which described the rise of the oakland a's as they embraced a strategy of data analytics hospital administrators are increasingly using data analytics to confirm that their cardiac team is performing well so two of the numbers that are regularly reviewed by the c and governing boards the total volume of cardiac surgical procedures and the relative value units of productivity of individual surgeons so let's look at the example of tetralogy that we've already reviewed hospital b appears to be the more successful program the surgeons are busier they're generating a greater number of rvus per surgeon with their 17 procedures the total case volume for the year will be inflated by the initial palliative procedures the additional work effort of the cardiologists who might undertake frequent outpatient checks and additional echocardiograms for their patient in the interim period between palliative procedure and repair will also reflect well on the cardiology team but of course this is precisely the reason why early primary repair is more efficient and effective as we examine among the advantages of early primary repair the total cost is considerably less now this isn't a number that's currently measured or for that matter is easily measured namely the efficiency with which a program manages all patients admitted to their program with a diagnosis of tetralogy and of course neither is the total number of admitted patients ever related to the total number of survivors at one year a third major difficulty in maintaining an approach of early primary repair are the challenges involved in teaching the next generation of cardiac surgeons to be successful neonatal surgeons trainees and junior attendings today are under a microscope like never before the falling number of general cardiothoracic graduates is going to restrict the recruitment ultimately of outstanding young trainees who are prepared to meet the challenges in pro imposed by the current difficult environment in congenital heart surgery training hours have been shortened increasing nationalism and limitations on international movement of surgeons has reduced the number of young u.s surgeons acquiring international experience if you look around the u.s at senior surgeons running major programs over the last 10 to 20 years the majority have international experience today virtually no junior trainees in their early attending years go to international programs to acquire experience at places like great ormond street in london data analytics have resulted in increasing scrutiny of operating room time resource use and morbidity by administrators who are unfamiliar with patient complexities and finally there's actually been an increase in the complexity and challenges of our patient population one of the most important factors responsible for the increasing difficulty of the current patient population has been the increasing rate of prematurity and low birth weight for example this slide illustrates the risk factors for the report on costs associated with tetralogy of children's national you can see that 23 of our patients were less than 2.5 kilograms birth weight in less than 36 weeks gestation as a young attending surgeon in boston i didn't know how lucky i was to be faced with so few patients less than two and a half kilograms in weight and very few patients who had not had excellent prenatal care i'm often off what are the factors that are increasing the number of babies coming to our cardiac icus with very low birth weights under 1.5 to 2 kilos these include delayed childbearing and the impact of widespread fertility treatments resulting in multiple births fetal diagnosis is actually another important factor because very high risk complex babies are monitored very closely and in many cases are delivered early because of concerns by the obstetric team regarding fetal distress in association with a complex congenital problem so the question that's hotly debated today in our circles is where the complex and very small premature babies should be offered in early repair or whether repair should be delayed one option that sometimes is used is simply to place these babies in the corner of the intensive care unit on a prostaglandin infusion until some goal weight has been achieved every article that i've been able to find that's been published to date including all of these shown here suggests that simply delaying repair results in a higher mortality than moving ahead with early primary repair that's not to say that prematurity won't have a very substantial impact on procedural mortality however it is true that many of the published studies predate greater familiarity with hybrid type procedures so these are palliative procedures that were originally described for complex single ventricle patients particularly those needing the nord procedure for babies with hypoplastic left heart syndrome hybrid palliation includes ductile stenting bilateral pulmonary bands and often dilation or stenting of an asd although these procedures were initially done together often in a hybrid cath lab or operating room today they are in fact usually sequenced most commonly beginning with application of bilateral pulmonary artery bands in the operating room but today a similar approach is being applied in high risk premature babies with not just one ventricle but also those with biventricular lesions allowing them to grow and for organ systems like the lungs and brains to mature before exposure to cardiopulmonary bypass there are no reports to date that compare this approach with simply moving ahead with early repair and premature babies and it is going to be important as we develop increasing familiarity with a hybrid approach for very small babies with a biventricular lesion to accurately compare outcomes with an approach of early primary repair to see if there is indeed a weight below which a palliative hybrid approach is in fact valid and does result in a greater number of survivors but to date the tendency has been simply to focus on the outcome of the index repair procedure the babies who are lost following their hybrid palliative procedure or in the interim period are simply not counted so this is the same inherent bias against early repair that we've already discussed so what are some possible solutions to our dilemma there's clearly no single simple solution that counteracting the reversal that is occurring of the move to repair congenital heart problems in the young that john kirkland identified 30 years ago this year in bergamo italy many if not most of the deaths of babies with congenital heart disease today occur in very small preemies with extra cardiac anomalies we need to carefully study the role of hybrid procedures in delaying repair surgery for the particularly small and premature baby as regards the training dilemma the only solution one of the solutions i can see is to at least allow greater mobility of surgeons globally all the cajoling and incentives in the world are not going to encourage bright young people to come into our field and face a long training period and uncertainty regarding a successful career in the long run countries where cardiac surgery is rapidly expanding like india and china are currently generating large numbers of incredibly talented young people who are thriving in the less threatening training environment that is currently present in the united states and most countries and that should be a two-way traffic imagine the opportunities for a young u.s attending to go to delhi india and do a hundred double switch procedures that he wouldn't accumulate in a hundred years working in the u.s so there are great opportunities overseas there are some great institutions overseas and there are many young surgeons who can benefit from coming and spending some time in the u.s regarding the problem of measuring the wrong outcomes both for our hospital administrators as well as for into institutional comparisons either with or without public transparency the only solution i see is to move to a database and a system of analysis that accepts and understands the problems that exist with our current system we need to measure what's important to parents and patience patient survival means measuring the number of patients who come to the hospital with uncorrected congenital heart disease and the number of those patients who are alive at least at one year of age with corrected heart disease and parents patients insurance companies government payers appreciate survival being achieved with fewer procedures and less time in hospital the current system is incentivizing more procedures and doesn't measure patient survival only procedural success databases that are managed by statisticians who deal primarily with adult cardiac surgery simply are not equipped to understand the problems in inherent in congenital heart surgery in the world society for pediatric and congenital heart disease in which i'm the immediate past president we have established a new database the world society database this totally new internet based global database is rapidly accumulating a large number of patients it's been developed through the efforts of john kirkland's son dr jim kirkland who's working with the highly respected data center at the university of alabama dr jim st louis from kansas city has also played a key role in the development and deployment of the database around the world we're in a unique position to use this database to correct the misconceptions that have arisen by attempting to adopt and update database systems that were established for adult cardiac surgery the database will be linked with the sds database so it avoids dual data entry the sds is going to continue to collect data at an incredibly detailed level that will facilitate what i saw because i was there at the first meetings as its original role which was to allow careful clinical research studies which would allow us to analyze our outcomes but it was not designed as a tool to judge quality performance and compare institutions regarding transparency transparency means that outcomes are made public experience in the uk strongly suggests institutional and individual surgeon outcomes should not be presented as a league table the greatest risk to the patient and the publication of league tables is that surgeons will avoid high risk surgery and that's bad news especially if you are such a patient of course tabloid newspapers in the uk have taken delight in publishing articles with league tables headlined worst surgeon in bit by in britain at the bottom of course the logical conclusion to such tables which can result in the delisting of the worst surgeon is that ultimately there will be only one surgeon left and he or she will be both the best and the worst an alternative is to report outcomes by hospital in alphabetical order confidence covenant symbols should be clearly presented so that statistically insignificant differences are understood in a system of accreditation of congenital heart programs should be developed to reassure parents and currently the sort of reporting that's going on is scaring families and causing them to travel long distances for no statistically significant reason so we need to reassure parents that their child is undergoing surgery in the center with acceptable standards and outcomes the variable life adjusted display that clearly illustrates surgical outcome versus risk in real time is a great tool for monitoring individual surgeon performance within institutions this system has been pioneered it's widely used in the uk it should be adopted globally it takes away the arbitrary demarcate time demarcations where you look at a surgeon's performance over one year and compare it with the previous year well what happens if all the deaths occurred in the first week of january so the variable life adjusted display overcomes that problem as sabres bruce keogh who many of you know who's an adult cardiac surgeon until recently was medical director of the nhs in the uk has said do we make what's important measurable or what's measurable important or as albert einstein put it he had a sign on his office well not everything that counts can be counted and not everything that can be counted counts ladies and gentlemen it's been a great honor presenting the 2018 john h gibbon jr lecture thank you very much i think we have time for maybe one or two questions and if you have uh questions i'd be delighted if somebody would point out some inherent floor in my argument i i've given this presentation to a lot of congenital groups and so far the consensus that seems to have emerged is well you're right but it's it's too difficult and we just have to keep using what we got dr grover yeah i appreciate you is he's on yeah yeah i appreciate your um comments it sounds to me like what for example in the sts what our congenital group needs to do is to take these concerns into account and try to develop some kind of ways where you can factor in these things as complex as it is it's obviously much more complex in the congenital area because of all the congenital anomalies the variations the combinations of them they were the birth weight all of those in different procedures that you do that doesn't mean that it's impossible and in regard but i would think the core group of your your special subspecialty needs to try to figure out a better way uh to do that the issue of public reporting is a tough thing right because there are a lot of databases out there that are publicly reporting and if our professional societies don't get into it at least with those of us that know the details and try to do it right somebody else will report it and really do it even you know worse so it's a tough issue but i i would suggest that you really need a good think tank in your sub specialty and and see if you can make some of the corrections i do think the the point of research uh from the database is very important and you could take some of the data even in from from these if you measure these different types of procedures for one disease and come up maybe with a risk model for that but thanks that's very important to point out that side of it there are two pros and cons on on the public reporting that's for sure and in fact the sts is moving in this direction they've just introduced just in the last few months a 12-month follow-up the key is really going to be to get the enrollment based on patient rather than procedure and in fact the new databases that are emerging there's a new icu database it's called the pc4 database that a number of congenital programs are enrolling in and because most babies in the u.s today are admitted as newborns the congenital heart problem is almost always detected either prenatally or shortly after birth so these kids are almost always admitted uh and detected early so we we just simply have to say okay we've had an admission of a patient with tetralogy uh at three days of age and then look at that patient's outcome at one year we've had the one year outcomes in the world society database which has been going now for about nearly getting on for two years we've already enrolled around about 12 13 000 patients many of them from china but uh we've actually demonstrated with that getting 12-month follow-ups is not difficult in kids uh you know perhaps longer than 12 months would be a problem but 12 months doesn't seem to be a problem dr shima well welcome back to boston for both of us thank you excellent lecture timely and important you started out by telling about giving and the development of the heartland machine so it was hard it took a long time so i would say don't get discouraged obviously data and outcomes have become well ingrained and has a certain level of sophistication and has become a business for many but that should not deter us from getting it right so i think the approach that you've taken to a globe or a global medicine point of view and not just focusing only on the united states and i would also encourage that good outcomes of transparency is a national movement and therefore the political agenda may be another way to get the support and try to imprint that we've got to measure it right so in the world of adult cardiac surgery we're dealing with tavr and those of us who are looking at short-term outcomes and procedural mortality find is irrelevant and have also assumed that the concept that life and improved at one year is really the metric we should be striving for so my comment is excellent presentation timely don't be discouraged and look at the global and the political way to try to achieve the appropriate metrics to benchmark ourselves and look at quality improvement thank you very much for those comments and you know i think the danger is that the the public reporting aspects of this are sort of outstripping what we're able to achieve in having a valid metric and within the congenital arena parent support groups have become extremely vocal they're very influenced by what they read coming out of publications that focus only on early hospital mortality the press has taken this up there have been some extremely high profile cases where congenital programs have been shut down in the u.s basically by pressure from the press based on procedural mortality numbers without any appreciation of the imports of what i'm talking about so that that's the danger we're going to keep moving ahead but we've got the press and uh the parent support groups out there uh sort of pushing ahead uh in a in a dangerous sort of way yep hello thank you for your inspiring presentation i'm zainab from turkey cardiac surgery resident i want to ask something about um the new innovative approaches i have been in boston children for my cardiology rotation and cardiac surgery and i know that they are currently working on mitochondrial transplantation and my graduate thesis is based on this uh idea and we have found that cyanotics have mitochondrial dysfunction and a cyanotic no no dysfunction and on the basis of this research researches i think nations are important because if i live in united states it means something but i'm coming from the other side of the world so you need to prove something even if you do the uh same thing i just wonder that what do you think about these innovative uh promising um researches approaches even if it causes mortality like for example uh you you try something new but it can be okay or not but it should be done well yeah i mean that that experiment was done with the arterial switch for example and there have been many examples i mean the norwood operation for example began was published in the new england journal the same year that the arterial switch was published and i can assure you the high early procedural mortality generated a tremendous amount of controversy within boston children's and once again throughout the country and around the world in fact it was debated in many countries for the next 20 years or so before the nord procedure was accepted but in that case it was a little bit easy because it was very clear to everybody that the mortality without an operation was a hundred percent yeah that the patient survived without an operation was zero so in some ways that made it justifiable there was still lots of arguments against the number of resources that were required and so on but but you're right i mean it's it can be a difficult balance where you have a reasonable short-term with the procedure but there's a new procedure that potentially offers better long-term outcomes and perhaps long-term survival and it's up to the basic science researchers like the research you were doing to demonstrate that at least in a translational animal model that this is an effective method and then to start off with small trials and and to begin to develop some scientific evidence for your your theory okay thank you okay thank you my name is dwayne sands i'm a cardiac surgeon practicing in nassau bahamas and i want to thank you for an excellent talk as you formulate the way forward i'd like to just give you a slight uh different impact of this process as a single pediatric cardiac surgeon practitioner in the bahamas 30 percent of my patients have insurance and are attracted into the united states uh to go to centers where care can be provided at a high standard the other 70 percent who are uh economic refugees i have no choice but to operate and so either i operate on them or they don't make it it is a fascinating problem and i wonder if you could incorporate that into your your uh way forward uh because it speaks to the whole idea of the global approach uh to congenital heart surgery and uh as we consider how we get all of the patients sorted out it's not just people in the developed world but people in the developing world well i hope you'll consider joining the world society for pediatric and congenital heart surgery because if you look on the website you'll see that the mission of the society its fundamental rationale for being established was exactly what you're talking about which is we want to make sure that there is good quality congenital surgery available to children around the world and so through education research through quality outcomes analysis like the world society database we're going to be able to offer that but yeah you're right there's tremendous health disparities but you know we're relatively small community we all know each other all around the world very well as congenital heart surgeons and so it is allowing for improved educational opportunities for help with programs to develop their their standards of care through visiting teams and so on i mean we certainly have to get away from the days of big uh surgical tourism my mentor elder castaneda used to call up where a team drops in does a bunch of operations and flies out it has to be a long-term educational commitment but thank you for raising that important point [Applause]