This timely book analyses and evaluates ethical and social implications of recent developments in reporting surgeon performance. It contains chapters by leading international specialists in philosophy, bioethics, epidemiology, medical administration, surgery, and law, demonstrating the diversity and complexity of debates about this topic, raising considerations of patient autonomy, accountability, justice, and the quality and safety of medical services. Performance information on individual cardiac surgeons has been publicly available in parts of the US for over a decade. Survival rates for individual cardiac surgeons in the UK have recently been released to the public. This trend is being driven by various factors, including concerns about accountability, patients' rights, quality and safety of medical care, and the need to avoid scandals in medical care. This trend is likely to extend to other countries, to other clinicians, and to professions beyond health care, making this text an essential addition to the literature available.
Author(s): Steve Clarke, Justin Oakley
Edition: 1
Publisher: Cambridge University Press
Year: 2007
Language: English
Pages: 318
Cover......Page 1
Half-title......Page 3
Title......Page 5
Copyright......Page 6
Contents......Page 7
Contributors......Page 10
Acknowledgements......Page 13
Reference......Page 14
Introduction: Accountability, informed consent and clinician performance information......Page 15
Ethical arguments for reporting clinician performance information......Page 17
Historical background to surgical outcomes reporting......Page 20
Modern developments......Page 22
Further issues in reporting surgeon performance information......Page 25
Notes......Page 30
References......Page 32
Part I Accountability......Page 37
Accountability......Page 39
References......Page 40
Evidence-based patient choice......Page 41
The widening circle of evidence......Page 42
Ethical justifications for the widening circle of evidence–based patient choice......Page 43
Main arguments against the use of report cards......Page 45
Greater patient choice?......Page 47
Will the standard of care actually rise if data is published?......Page 48
Justice and fairness......Page 49
Threshold guarantees......Page 50
The training of health professionals: a test case......Page 51
Conclusions......Page 52
References......Page 54
2 Report cards for institutions, not individuals......Page 55
Adverse consequences of the Clarke–Oakley proposal......Page 56
An institution-focused alternative......Page 59
The patient–surgeon relationship......Page 61
References......Page 64
3 Safety, accountability, and ‘choice’ after the Bristol Inquiry......Page 66
I......Page 68
II......Page 71
III......Page 73
IV......Page 76
References......Page 77
A system not designed for patient choice......Page 79
Presentation of data......Page 80
Evidence about harm......Page 81
Role of regulation......Page 82
Complex environment......Page 83
A new role for patients......Page 84
Notes......Page 86
References......Page 87
Introduction......Page 90
Why disclosure?......Page 91
Ethical rationale for disclosure......Page 92
Benefits for the patient......Page 93
Benefits for the clinician......Page 94
Physician report cards......Page 95
Benefits for the healthcare organization......Page 96
The risks and costs of disclosure......Page 97
Drawbacks for the clinician......Page 98
Drawbacks for the healthcare organization......Page 99
Duty-based ethics......Page 100
References......Page 101
Introduction......Page 105
Is there a need for report cards and performance monitoring?......Page 106
Do report cards or performance monitoring reduce complications for patients?......Page 108
Are report cards or performance monitoring harmful to patients?......Page 110
What are the necessary features of report cards and performance monitoring?......Page 111
What are the barriers to enhanced performance reporting?......Page 112
Conclusions......Page 114
References......Page 116
Part II Informed consent......Page 121
Informed consent......Page 123
References......Page 124
Risk and disclosure......Page 125
Recent institutional and legal developments......Page 129
Two objections......Page 132
The threshold objection......Page 133
Justice issues......Page 134
Practical considerations......Page 136
Notes......Page 141
References......Page 145
Requirements for informed consent and information about persons offering or performing interventions......Page 148
Informed decisions and information about risk......Page 149
Criticisms of informed consent......Page 150
The requirements for informed consent are an impossible goal......Page 151
Lack of understanding......Page 152
The difficulty in knowing what information is ‘material’......Page 154
Informed consent does not lead to better choices or good or palatable outcomes......Page 155
Information about a clinician’s ability to perform an intervention is necessary for meaningful consent......Page 156
Disclosing clinician performance information to patients may strengthen the doctor-patient relationship......Page 157
References......Page 159
9 Against the informed consent argument for surgeon report cards......Page 161
References......Page 169
Difficulties interpreting information......Page 171
Self-interest, trust and professionalism......Page 172
Trust and surgeons......Page 175
Managing risk......Page 176
The perspective of the trustee......Page 177
Trust and moral character......Page 178
Conclusions......Page 179
References......Page 180
Informed consent and surgeons’ performance information......Page 181
Heuristics, biases and dual–processing......Page 184
Responding to bias......Page 186
Presentation of data......Page 189
Notes......Page 190
References......Page 191
Introduction......Page 194
Market: what market?......Page 195
Information systems and consumer sovereignty justifications......Page 197
Markets as distributive mechanisms......Page 199
The transformation of our incentive structures......Page 201
Concluding remarks: informed consent as a fundamental value?......Page 203
References......Page 204
Part III Reporting performance information......Page 207
Reporting performance information......Page 209
Introduction......Page 211
Report cards on cardiac surgeons......Page 212
Report cards on cardiac surgeons in the United States of America and United Kingdom......Page 213
The status of cardiac surgery report cards in Australia......Page 214
Effects on surgeons......Page 215
Effects on patients......Page 217
Effects on the health system......Page 219
Who should present the information?......Page 220
Evaluation of report cards......Page 221
Conclusions......Page 222
References......Page 223
14 Examining the link between publicly reporting healthcare quality and quality improvement......Page 226
Selection of high–quality providers by patients......Page 227
Provider response to report cards......Page 229
Has public reporting of healthcare quality improved the quality of healthcare?......Page 231
Implications......Page 233
References......Page 235
Sources of data......Page 240
Data quality......Page 241
Variation......Page 244
Systematic unknown sources of variation......Page 245
Adjusting for case-mix......Page 246
Multiple statistical testing......Page 247
League tables......Page 248
Funnel plots......Page 249
Cumulative sum plots......Page 250
Investigating an alert......Page 251
Note......Page 252
References......Page 253
16 An ethical analysis of the defensive surgery objection to individual surgeon report cards......Page 257
What evidence is there of defensive surgery as a response to report cards?......Page 258
If report cards have led surgeons to adopt defensive practices, are report cards therefore ethically unjustified?......Page 262
Conclusions......Page 264
Notes......Page 265
References......Page 267
Surgeons’ anxiety......Page 269
Negative defensive medicine......Page 271
Defensive medicine......Page 272
Is surgeons’ anxiety groundless?......Page 273
Necessity of risk adjustments......Page 275
Notes......Page 277
References......Page 278
The learning curve......Page 280
Justification......Page 284
Distribution and coercion......Page 286
Report cards......Page 288
Notes......Page 290
References......Page 291
Introduction......Page 293
The United States......Page 294
Canada......Page 295
The United Kingdom......Page 296
Australia......Page 297
The environment within which report cards are emerging......Page 300
The legal status of report cards......Page 302
Forms and terms of report cards......Page 303
References......Page 306
Index......Page 308
