The aim of the Society of Cardiothoracic Surgeons National Adult Cardiac Surgery Database is to improve quality of care for cardiac patients by allowing appropriate comparison of clinical performance with national and international standards, and to provide useful data on changing trends within the speciality. We have been actively collecting, analysing and benchmarking data since as early as 1977, and we are widely recognised as international leaders in the field, having published data down to individual surgeon level since 2005.
Blue Book Online
You can also look at national trends and hospital procedure numbers over time on our dynamic website, the Blue Book Online.
Blue Book for Patients
The ‘Blue Books’ have been a series of large documents for people who work in healthcare. This edition of the Blue book is designed especially for patients, to explain what they can expect from their heart surgeon.
To increase its accessibility, this publication is available as both a downloadable PDF document and an iBook.
• UK Heart Surgery: What patients can expect from their surgeons (downloadable PDF)
• UK Heart Surgery: What patients can expect from their surgeons (iBook via SCTS website):
Acting as a ‘window’ into National Adult Cardiac Surgery Audit (NACSA) data, the SCTS iData app allows users to place filters on different types of surgery to generate a report showing analysis of all heart surgery in the UK over the last five years. Reports provide a running total of procedures as you add each filter, with the option to generate a report at any time.
The SCTS iData app is available for free in two formats:
• Web application accessible via www.idata.scts.org (N.B. if using Internet Explorer this application does not work with version 9 or earlier)
• Apple iOS application, which can be downloaded by searching ‘SCTS iData’ in the Apple App Store
Where does the data come from?
All of the data shown on these websites and applications is based on the National Adult Cardiac Surgery Audit (NACSA). This project, which collects information about all heart surgery carried out in the UK, is managed by the National Institute for Cardiovascular Outcomes Research (NICOR) and commissioned by the Healthcare Quality Improvement partnership.
• The National Adult Cardiac Surgery Audit (website)
Maintaining patient's trust
The SCTS believes that we, in partnership with other organisations, have a responsibility to monitor and publish the outcomes of our surgery. By doing this, we aim to ensure that the trust placed in the medical profession by our patients is well deserved. You can find out more information about how we do this in our book, Maintaining Patients’ Trust’, which can be viewed online, downloaded and printed.
• Maintaining Patients’ Trust (downloadable pdf)
Monitoring individual and team outcomes and supporting early action in response to divergence in performance in adult cardiac surgery
Our current programme consists of the following
1. Systematic collection of an agreed minimum dataset at each contributing centre on all patients undergoing surgery.
2. Aggregation and validation of the data
3. Analysis and development of risk stratification models for outcome measures
4. Regular feedback of risk adjusted clinical outcomes to contributing centres
5. Continuous evaluation of performance and changing practice and the influence of risk factors.
6. Intermittent governance analyses to look for surgeons or hospitals whose mortality rates are higher than expected
7. Publication of named surgeon and hospital mortality rates for patients and the public.
8. Intermittent comprehensive reports of trends and outcomes in cardiac surgery (The Blue Books). The most recent Blue Book (Demonstrating Quality) was published in 2009.
The SCTS adult cardiac surgery database programme was awarded the prestigious BMJ award for best quality improvement programme in 2010.
More recently we have started to explore what we see as the wider cultural benefits that are derived for the medical profession from programmes to collect and publish clinical outcomes. We have reported these thought in our recent publication ‘Maintaining Patients’ Trust‘.
Funding: Funding for collation and online analyses of the data for the adult cardiac surgery database project in England and Wales comes from the Healthcare Quality Improvement Partnership. This grant is awarded to UCL, London and the central cardiac audit database (CCAD) data collection infrastructure has recently migrated from the NHS Information Centre to the National Institute for Cardiovascular Outcomes Research (NICOR) at UCL. NICOR is now responsible for running all the cardiac national audits in conjunction with the associated professional societies (http://www.ucl.ac.uk/nicor/). Since September 2011 we are also in grateful receipt of a grant from the Heart Research UK which funds an analyst who works on the SCTS database project at Manchester University.
Dataset: The first agreed dataset was finalised in June 1996 and remained unchanged until 2003. This dataset was updated in and ran until April 2011. We have now made further modifications to the dataset, to bring it in line with current clinical practice.
Data Collection: Data is collected in all the centres and returned to a central source at the CCAD. All patient identifiers are anonymised in compliance with data protection legislation, but this is done in a way that allows long-term mortality to be tracked. The recent report ‘demonstrating quality’ contains 5 year CABG mortality rates on over 88,000 patients.
Governance: The programme to collect and publish adult cardiac surgery audit data is managed by the National Instititue for Cardiovascular Outcomes Research (NICOR) and commissioned on behalf of NHS England by the Healthcare Quality Improvement Partnership (HQIP). NICOR is part of University College London and it runs 6 national audits in conjunction with the associated professional societies. NICOR is a partnership of clinicians, IT experts, analysts, academics and managers. It provides project, technical and analytical support for all of its audits and registries. It has its own internal governance mechanisms as well as external governance imposed by UCL. The governance includes a professional liaison group which has membership from NICOR and all the professional socities involved in the audits. The governance arrangements for the adult national cardiac surgery audit involve 3 representatives from the SCTS who sit on the NICOR adult cardiac surgery audit steering group, including the honorary secretary, the chair of the adult surgery subgroup, the database lead and one other appointed representative, along with a trainee representative. The chair of this group reports to the executive and there are detailed discussions about the issues at the annual and BOR meetings. The minutes of the steering group meetings are given here. The management of the audit and the principles of the methodology used are taken from HQIP guidance, and the methodology used has been published through peer review. The specific analytical methodology used has also been subject to independent statistical review. As part of the process to publish data , the data is validated with the units by sending it back to surgeons for local validation and the units are asked to amend data to rectify any data completeness or accuracy issues.
Governance Analysis 2010-13
Version 3 (18th February 2014)
· Operations between 1 April 2010 and 31 March 2013.
· England, Wales, Scotland and NI only. (Newly submitted RoI data excluded.)
· If more than one record for an admission spell, only the first record retained; the others are excluded.
· Primary cardiac and pulmonary transplants excluded.
· Primary VAD surgery excluded.
· Records with preoperative ventilation recorded as ‘1. Yes’ are excluded.
· Records with pre-operative impeller device, VAD or other support device use are excluded.
· Leaves 99,642 records.
Private hospitals were excluded. This left 98,252 records.
Missing GMC numbers
Records with missing GMC numbers are recorded as “Unknown Hospital xxx” where “xxx” denotes the assigned hospital. There were 9 such records: 4 from BAL; 4 from BRI and 1 from NGS.
Missing discharge status
There were 31 such records with missing discharge status (dead or alive), including unresolvable conflicts were mapped to ‘Dead’: 18 from RVB; 10 from UHW; 2 from BAL; 1 from RSC. There were three surgeons with 5 missing records; 5 surgeons with 2 missing records; and 6 surgeons with 1 missing record each. Rebecca Cosgriff had RVB, UHW and BAL update the discharge status (30 records). RSC failed to respond, but it was quite clear that the patient died and that data cleaning algorithms failed due to a disparity in census date and discharge date. Of the 31 records, 4 were actual mortalities and 27 were survivors.
There were two late corrections in this analysis after two hospitals discovered errors in their data after the extraction deadline. WYT requested a record be deleted as it corresponded to a non-cardiac surgery procedure. RVB requested that a record have its gender and discharged status changed. These have been implemented. Hence, there are now 98,251 records in the analysis.
EuroSCORE and associated risk factors were calculated using available algorithms. Assumptions made included: if age was missing, it was replaced with the global database median. If a binary / categorical variable was missing, it was replaced with the reference level, equivalent to the risk factor being absent.
We tried a range of methods, including a complete model refit of the logistic EuroSCORE, which was reasonable. However, graphical examination of binned predictions and outcomes (i.e. mean observed mortality vs. mean predicted mortality in deciles or otherwise) indicated that a flexible model with the logistic EuroSCORE (transformed as log odds for linearity) included as a cubic polynomial with financial year entered as a categorical variable was a marked improvement.
This model was as follows:
logit(p) = a + (1 + b)*logit(ES) + c*logit(ES)2 + d*logit(ES)3 + f
· ES = logistic EuroSCORE (as a proportion/probability: a number between 0 and 1)
· logit = a function: logit(p) = log(p) – log(1-p)
· a = -1.417228
· b = -0.397055
· c = -0.044741
· d = 0.010715
· f = 0 if operation was between 1 April 2010 and 31 March 2011; -0.117386 if between 1 April 2011 and 31 March 2012; -0.168919 if between 1 April 2012 and 31 March 2013
The AUC was 0.786 and the calibration was acceptable, as shown in the figure below.
Further information: Further information about the National Adult Cardiac Surgery Audit is available on request from firstname.lastname@example.org . We also keep a number of up to date technical papers, details on the dataset, and records of analyses in progress. Please click here for more information. Request for data for research purposes can be made through a data sharing agreement with NICOR. Please visit http://www.ucl.ac.uk/nicor or contact email@example.com.