Perioperative databases: from data to improvement of outcome.

A NESTHESIA and surgery have a prominent role in health care, and during the last decade major innovations in anesthesia, surgical technology, and perioperative care have occurred with documented benefits on early and late postoperative outcomes. However, with a continuous increase in healthcare costs attributable to the growing elderly population with comorbidities and the development of expensive new procedures, there is agreement that outcome data must be available such as those provided by anesthesia and surgical perioperative databases. In this context, major advances in the design of large surgical databases have been documented, especially by well-defined risk scoring to allow comparison between institutions such as those used in the National Surgical Quality Improvement Program. Such databases represent a prerequisite to assess organizational aspects and new treatment principles in relation to outcomes and health economics. Another advantage of large databases is to uncover relatively uncommon complications with subsequent focus on patient-centered outcome. In addition, local databases may provide important data when results are compared and adjusted to updated, best-available evidence of care. However, the main question to be asked is how to take the next step with such data to actually achieve an improved outcome; another question to answer is how do we get beyond the fact that major surgery is still a risky affair for the high-risk surgical patient. History has shown that despite the availability of data and evidence-based guidelines, the translation of evidence into clinical practice often is slow, including in the provision of perioperative care. Although various checklists have been proposed to improve surgical quality, they often have not been based on updated evidence or included the most important care or treatment principles. Thus, the way forward should be based on data-driven discussions and include the important caregivers, such as anesthesiologists, surgeons, surgical nurses, physiotherapists, and primary caregivers, together with hospital administrators. These discussions should include an analysis of procedure-specific risk factors, the relevant perioperative pathophysiology, and whether the provided care was in accordance with existing evidence. The multidisciplinary discussions on pathogenic mechanisms of the morbidity in question should be based on the simple question “Why is the high-risk surgical patient still at risk? ” Such discussions probably represent the most effective way forward, as shown, for instance, in the Danish Hernia Database Collaboration with two annual meetings and outcome data presentation and discussion, including those of anesthesiologists and surgeons. This process has led to major improvements on a nationwide basis. In addition, the multidisciplinary approach is argued from the diversity of factors and care principles that must be adjusted to current evidence if major progress on early postoperative outcomes is to be achieved. This has been illustrated especially in colonic surgery with documented improved outcomes. However, such procedure-specific multidisciplinary discussions are relatively easy to perform in smaller regions such as Scandinavia, but more difficult in large countries where the approach must be organized on a reasonable population-based regional Photo/image: J. P. Rathmell.