Ethical Issues Confronting Outcomes Analysis and Quality Assurance

  • Constantine D. Mavroudis
  • Jeffrey P. Jacobs
  • Allison Siegel
  • Constantine Mavroudis


The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) has served as the primary, externally validated source for outcomes from its many participating centers. Because participation is voluntary and data are not publically reported, there exists a fundamental conflict with the overwhelming trend toward public reporting in both medicine and cardiac surgery. The ethical issues surrounding this conflict, as well as those involved in public reporting of complex congenital heart disease in general are described herein. The process by which adult cardiac surgery has come to initiate public reporting, while an important model for future directions in outcome reporting, does not adequately address the unique challenges that are faced by the reporting of congenital heart surgical outcomes. If these ethical issues are addressed and public reporting can be done in a responsible manner, then it should be undertaken by the leadership of physician-based groups such as the Society of Thoracic Surgeons.


Congenital heart surgery Database Public reporting 


  1. 1.
    Jacobs JP, Mavroudis C, Jacobs ML, Maruszewski B, Tchervenkov CI, Lacour-Gayet FG, Clarke DR, Gaynor JW, Spray TL, Kurosawa H, Stellin G, Ebels T, Bacha EA, Walters 3rd HL, Elliott MJ. Nomenclature and databases – the past, the present, and the future: a primer for the congenital heart surgeon. Pediatr Cardiol. 2007;28(2):105–15.PubMedCrossRefGoogle Scholar
  2. 2.
    Jacobs ML, Jacobs JP, Franklin RC, Mavroudis C, Lacour-Gayet F, Tchervenkov CI, Walters H, Bacha EA, Clarke DR, William Gaynor J, Spray TL, Stellin G, Ebels T, Maruszewski B, Tobota Z, Kurosawa H, Elliott M. Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease – the perspective of cardiac surgery. Cardiol Young. 2008;18 Suppl 2:101–15.PubMedCrossRefGoogle Scholar
  3. 3.
    Jacobs JP, Lacour-Gayet FG, Jacobs ML, Clarke DR, Tchervenkov CI, Gaynor JW, Spray TL, Maruszewski B, Stellin G, Gould J, Dokholyan RS, Peterson ED, Elliott MJ, Mavroudis C. Initial application in the STS congenital database of complexity adjustment to evaluate surgical case mix and results. Ann Thorac Surg. 2005;79:1635–49.PubMedCrossRefGoogle Scholar
  4. 4.
    Jacobs ML, O’Brien SM, Jacobs JP, Mavroudis C, Lacour-Gayet F, Pasquali SK, Welke K, Pizarro C, Tsai F, Clarke DR. An empirically based tool for analyzing morbidity associated with operations for congenital heart disease. J Thorac Cardiovasc Surg. 2013;145(4):1046–57.PubMedCrossRefGoogle Scholar
  5. 5.
    Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med. 2008;148:111–23.PubMedCrossRefGoogle Scholar
  6. 6.
    Zinman D. State takes docs’ list to heart. New York Newsday. December 18, 1991:A7.Google Scholar
  7. 7.
    Coronary artery bypass graft surgery in New York State 1989–1991. Albany: New York State Department of Health; 1992.Google Scholar
  8. 8.
    Hannan EL, Kilburn Jr H, Racz M, Shields E, Chassin MR. Improving the outcomes of coronary artery bypass surgery in New York State. JAMA. 1994;271:761–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Hannan EL, Siu AL, Kumar D, Kilburn Jr H, Chassin MR. The decline in coronary artery bypass graft surgery mortality in New York State: the role of surgeon volume. JAMA. 1995;273:209–13.PubMedCrossRefGoogle Scholar
  10. 10.
    Topol EJ, Califf RM. Scorecard cardiovascular medicine. Its impact and future directions. Ann Intern Med. 1994;120:65–70.PubMedCrossRefGoogle Scholar
  11. 11.
    Green J. Problems in the use of outcome statistics to compare health care providers. Brooklyn Law Rev. 1992;58:55–73.Google Scholar
  12. 12.
    Green J, Wintfeld N. Report cards on cardiac surgeons. Assessing New York State’s approach. N Engl J Med. 1995;332:1229–32.PubMedCrossRefGoogle Scholar
  13. 13.
    Omoigui N, Annan K, Brown K, Miller D, Cosgrove D, Loop F. Potential explanation for decreased CABG related mortality in New York State: outmigration to Ohio. Circulation. 1994;90:I-93 (abstract).Google Scholar
  14. 14.
    Grossi EA, Green J, Galloway AC, et al. Surgical evaluation of high risk cases in the era of statewide cardiac surgery data reporting. Presented at the 20th meeting of the Western Society for Thoracic Surgery, Olympic Valley, 22–25 June 1994 (abstract).Google Scholar
  15. 15.
    Byer MJ. Faint hearts. New York Times. March 21, 1992:A23.Google Scholar
  16. 16.
    Society of Thoracic Surgeons. Welcome to the STS National Database. Available at: Accessed 15 May 2013.
  17. 17.
    O’Brien SM, Jacobs JP, Clarke DR, Maruszewski B, Jacobs ML, Walters 3rd HL, Tchervenkov CI, Welke KF, Tobota Z, Stellin G, Mavroudis C, Hamilton JR, Gaynor JW, Pozzi M, Lacour-Gayet FG. Accuracy of the Aristotle Basic Complexity Score for classifying the mortality and morbidity potential of congenital heart surgery operations. Ann Thorac Surg. 2007;84:2027–37.PubMedCrossRefGoogle Scholar
  18. 18.
    Welke KF, Shen I, Ungerleider RM. Current assessment of mortality rates in congenital cardiac surgery. Ann Thorac Surg. 2006;82:164–71.PubMedCrossRefGoogle Scholar
  19. 19.
    Shroyer AL, Coombs LP, Peterson ED, et al. The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg. 2003;75:1856–65.PubMedCrossRefGoogle Scholar
  20. 20.
    Jacobs ML, Jacobs JP, Jenkins KJ, Gauvreau K, Clarke DR, Lacour-Gayet F. Stratification of complexity: the Risk Adjustment for Congenital Heart Surgery-1 method and the Aristotle Complexity Score–past, present, and future. Cardiol Young. 2008;18 suppl 2:163–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Society of Thoracic Surgeons. STS reporting online. Available at: Accessed 15 May 2013.
  22. 22.
    Shahian DM, Edwards FH, Jacobs JP, Prager RL, Normand SL, Shewan CM, O’Brien SM, Peterson ED, Grover FL. Public reporting of cardiac surgery performance: part 1-history, rationale, consequences. Ann Thorac Surg. 2011;92(3 Suppl):S2–11.PubMedCrossRefGoogle Scholar
  23. 23.
    Shahian DM, Edwards FH, Jacobs JP, Prager RL, Normand SL, Shewan CM, O’Brien SM, Peterson ED, Grover FL. Public reporting of cardiac surgery performance: part 2-implementation. Ann Thorac Surg. 2011;92(3 Suppl):S12–23.PubMedCrossRefGoogle Scholar
  24. 24.
    Society of Thoracic Surgeons. Potential unintended consequences. Available at: Accessed 15 May 2013.
  25. 25.
    The Denver Post Editorial Board. At the heart of the problem. Denver Post. March 2, 2001.Google Scholar
  26. 26.
    Sherry A. Children’s Hospital cardiology chief told to resign. Denver Post. March 1, 2001.Google Scholar
  27. 27.
    Jacobs JP, Cerfolio RJ, Sade RM. The ethics of transparency: publication of cardiothoracic surgical outcomes in the lay press. Ann Thorac Surg. 2009;87:679–86.PubMedCrossRefGoogle Scholar
  28. 28.
    Cronk CE, Malloy ME, Pelech AN, et al. Completeness of state administrative databases for surveillance of congenital heart disease. Birth Defects Res A Clin Mol Teratol. 2003;67:597–603.PubMedCrossRefGoogle Scholar
  29. 29.
    Frohnert BK, Lussky RC, Alms MA, Mendelsohn NJ, Symonik DM, Falken MC. Validity of hospital discharge data for identifying infants with cardiac defects. J Perinatol. 2005;25(11):737–42.PubMedCrossRefGoogle Scholar
  30. 30.
    Strickland MJ, Riehle-Colarusso TJ, Jacobs JP, Reller MD, Mahle WT, Botto LD, Tolbert PE, Jacobs ML, Lacour-Gayet FG, Tchervenkov CI, Mavroudis C, Correa A. The importance of nomenclature for congenital cardiac disease: implications for research and evaluation. In: Jacobs JP, editor. 2008 Cardiology in the Young Supplement: Databases and The Assessment of Complications associated with The Treatment of Patients with Congenital Cardiac Disease. Prepared by: The Multi-Societal Database Committee for Pediatric and Congenital Heart Disease. Cardiology in the Young, vol. 18, issue S2 (Suppl 2), p. 92–100, December 9, 2008.Google Scholar
  31. 31.
    Pasquali SK, Peterson ED, Jacobs JP, He X, Li JS, Jacobs ML, Gaynor JW, Hirsch JC, Shah SS, Mayer JE. Differential case ascertainment in clinical registry versus administrative data and impact on outcomes assessment for pediatric cardiac operations. Ann Thorac Surg. 2013;95(1):197–203.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  • Constantine D. Mavroudis
    • 1
  • Jeffrey P. Jacobs
    • 2
    • 3
  • Allison Siegel
    • 4
  • Constantine Mavroudis
    • 4
  1. 1.Department of Cardiothoracic SurgeryHospital of the University of PennsylvaniaPhiladelphiaUSA
  2. 2.Division of Cardiac Surgery, Department of SurgeryJohns Hopkins All Children’s Heart Institute, All Children’s Hospital and Florida Hospital for Children, Johns Hopkins UniversityTampa and OrlandoUSA
  3. 3.Division of Cardiac Surgery, Department of SurgeryJohns Hopkins UniversityBaltimoreUSA
  4. 4.Department of SurgeryJohns Hopkins University School of Medicine Florida Hospital for Children, Johns Hopkins Children’s Heart SurgeryOrlandoUSA

Personalised recommendations