Early experience with clinical indicators in surgery

Background: In 1997 a set of 53 clinical indicators developed by the Royal Australasian College of Surgeons (RACS) and the Australian Council on Healt hcare Standards (ACHS) Care Evaluation Programme (CEP), was introduced into the ACHS Evaluation and Quality Improvement Programme (EQuIP). The clinica l indicators covered 20 different conditions or procedures for eight specia lty groups and were designed to act as flags to possible problems in surgic al care. Methods: The development process took several years and included a literatu re review, field testing, and revision of the indicators prior to approval by the College council. In their first year 155 health-care organizations ( HCO) addressed the indicators and this rose to 210 in 1998. Data were recei ved from all states and both public and private facilities. Results: The collected data for 1997 and 1998 for some of the indicators re vealed rates which were comparable with those reported in the international literature. For example, the rates of bile duct injury in laparoscopic cho lecystectomy were 0.7 and 0.53%. respectively; the mortality rates for coro nary artery graft surgery were 2.5 and 2.1%, respectively; the mortality ra tes after elective abdominal aortic aneurysm repair were 2.5 and 3.7%, resp ectively; and the post-tonsillectomy reactionary haemorrhage rates were 0.9 and 1.3%, respectively. Results for some indicators differed appreciably f rom other reports, flagging the need fur further investigation; for example , the negative histology rates for appendectomy in children were 18.6 and 2 1.2%, respectively, and the rates for completeness of excision of malignant skin tumours were 90.7 and 90%, respectively. The significance of these fi gures, however, depends upon validation of the data and their reliability a nd reproducibility. Because reliability can be finally determined only at t he hospital level they are of limited value for broader comparison. Conclusion: The process of review established for the indicator set has led to refinement of some indicators through improvement of definitions, and t o a considerable reduction in the number of indicators to 29 (covering 18 p rocedures), for the second version of the indicators (which was introduced for use from January 1999). The clinical indicator programme, as it has wit h other disciplines, hopefully will provide a stimulus to the modification and improvement of surgical practice. Clinician ownership should enhance th e collection of reliable data and hence their usefulness.