Outcome Data

Time is of the essence: delays and waits need urgent action for cardiovascular care

NICOR are delighted to share their 2023 National Cardiac Audit Programme (NCAP) Annual Report, the annual summary report for patients, carers and the public and the six clinical domain summary reports.

2023 National Cardiac Audit Programme (NCAP) Annual Report

Annual summary report for patients, carers and the public

National Adult Cardiac Surgery Audit (NACSA) 2023 Summary Report

The Appendix to the National Audit Cardiac Surgery Audit (NACSA) 2023 Summary Report

The annual report covers the 12 months from 1 April 2021 to 31 March 2022, during the second year of the COVID-19 pandemic and records the initial recovery of NHS hospital services for patients with cardiovascular heart disease.

The NHS continues to face huge challenges two years after the onset of the first wave of the COVID-19 pandemic. Across all NHS services, patients are experiencing long delays and waits to access treatment, which is having a detrimental effect on patients, staff and the families and/or carers of patients.

The NCAP analyses combined with inputs from our clinical colleagues, patients, and carers, have allowed us to share experiences during that time as well as highlighting lessons to be learned for service recovery and quality improvement.

To read each report including the clinical domain reports, please visit the NICOR website and the NACSA website.

All operations carry a certain risk. We try and calculate this risk for each patient based on various information before the operation takes place. There are two categories of information (or factors) that make the risk for an individual: patient and operation factors.

1. The Patient – people that have a higher risk with heart surgery have factors that make them ‘riskier’ to undergo major heart surgery such as older age, high blood pressure, diabetes, heart failure, asthma, kidney failure etc.
2. The Operation – some operations/procedures are ‘riskier’ than others. For example, a coronary artery bypass operation alone is less risky than coronary artery bypass grafts and replacement of two heart valves.

There have been many attempts to try and calculate the exact risks with heart surgery based on the patient and operation factors and a number of different models exist to try and estimate the risk for an individual - although no model is ‘perfect’.

Here are two commonly used complex calculators for approximate risk in an individual:

• EuroSCORE2
• STS Score

It is also important to reflect on the fact that surgical results have improved over time. If we measured the results of a set patient and set operation in 2020, they would be considerably better than those same patients and operations in the 1990’s. The risks are therefore lower now and so the mathematical models have changed over time to try and measure the most contemporaneous (up to date) risks for patients.

The overall objective is to provide information to enable those who receive healthcare (patients), deliver healthcare (surgeons and hospitals) and commission healthcare to measure and improve services.

Patients need reassurance that their surgeon or hospital has had their results reviewed recently and that the results fall into a ‘safe’ category. In other words, they are both competent and safe to perform the heart operation. It can be difficult to measure the performance of a surgeon or hospital, and therefore a ‘risk adjustment’ is made when calculating what a safe.

’Risk adjustment’ is a sophisticated statistical process that takes into account the riskiness of a operation or procedure when calculating clinical outcomes, like survival. Risk adjustment is based on the presence of certain patient risk factors, like high blood pressure and diabetes. Whether risk factors are present in each patient is reported by hospitals along with other national clinical audit data.

Collection of these risk factors is important as outlined in the following example:

An experienced surgeon who is very competent may be referred the patients with the higher risks for surgery. These patients may be older with more risk factors (less healthy) and require more complex heart operations – they will have a lower chance of survival (lower predictive survival)

A newly qualified surgeon, who has less experience, may be referred lower risk patients (healthier) who require more straightforward operations they will have a higher chance of survival (higher predictive survival).

It would not be fair to compare the operative results of these surgeons (actual survival) as you would expect the experienced surgeon to have worse results as predicted. Therefore, a mathematical adjustment is made (called a risk adjustment) from all the risk factors that have been collected.

The SCTS (Society for Cardiothoracic Surgery in UK and Ireland) provides specialist clinical knowledge and clinical leadership of the collected data. The overall objective of the NICOR cardiac audits is to provide information to enable those who receive, deliver and commission healthcare to measure and improve services.

The National Adult Cardiac Surgery Audit (NACSA) collects data on all major heart operations carried out on NHS patients in the UK. The audit is managed by NICOR, with clinical direction and strategy provided by the Society for Cardiothoracic Surgeons (SCTS) and the Project Board.

The NACSA is part of the National Clinical Audit Patient Outcomes Programme (NCAPOP), which is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England.

The National Adult Cardiac Surgery Audit (NACSA) collects consecutive operation data from all NHS hospitals in the UK that carry out adult heart surgery. A number of Irish and UK private surgical units also voluntarily submit data.

The project, which has been running since 1977, enables secure collection and analysis of cardiac surgery data, as well as long-term tracking of mortality. Participation in the audit is mandatory for relevant English and Welsh hospitals as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP).

The project aims to improve the clinical outcomes for cardiac surgery patients by making publicly available comparisons of local hospital and consultant surgeon results against national benchmarks.

Analysis of NACSA data is reported to participating hospitals, Cardiac Networks, NHS regulatory bodies such as the CQC) and the public. This drives the development of cardiac surgery services by encouraging shared learning and the improvement of identified poor performance. The audit is also designed to enhance understanding of clinical trends and develop risk adjustment models for outcome measures, such as mortality.

A consultant cardiothoracic surgeon with specialist clinical knowledge and clinical leadership for NACSA is provided by the Society for Cardiothoracic Surgeons (SCTS) and the audit Project Board.

NACSA is managed by NICOR with specialist clinical knowledge and clinical leadership provided by the Society for Cardiothoracic Surgeons (SCTS) and assisted by the audit steering group.

This graph shows the “in hospital” survival rate of patients who are operated on by the individual surgeon/unit you have selected for the period 2016-2019. “In hospital” means time the patient is in the hospital where they have had their operation. It does not include any time that patients may have spent in other hospitals, either before or after their heart operation.

The data has been through a complex methodology (risk adjusted), including the variations in patient risk factors in order to give you a comparative base from which to work from. This means that the survival rates take into account the type and risk of patients being operated on for each surgeon/unit and the complexity of the operation. This is known as risk adjusted survival.

The vertical axis shows the GMC number of the surgeon or the Hospital identifier. In brackets is the total number of patients operated on by the surgeon/unit and the percentage of patients for whom the survival is known.
The horizontal axis is the percentage survival.
The dashed vertical line shows the risk adjusted survival rate for the UK as a whole.
The solid black horizontal line represents the surgeon/unit.

What is important here is that the horizontal line crosses the vertical dashed line. If this occurs, it means that the surgeon/unit are within the expected outcomes given the case-mix and risk factors of the patients they operate on.

The icons that sit on the horizontal line should give you more information about your surgeon/team.

For example:
The open square is the survival rate with no risk adjustments – (observed survival):
The X is the predicted survival with adjustments – (adjusted predicted survival)
The solid dot is the survival probability after the methodology has been applied.

• If the solid dot is red it means survival is worse than expected
• If the solid dot is black it means that it is within limits
• If the solid dot is green it means that there is significantly higher survival than expected

There is a lot of information on these plots, but the takeaway message is that if the solid black line crosses the dashed vertical line and then the survival rate for the surgeon/unit is within expectations and that there is no reason for any concern.