Abstract

BackgroundThe recent push for the publication of individual surgeon outcomes underpins public interest in safer surgery. Conventional, retrospective assessment of surgical performance without continuous monitoring may lead to delays in identifying poor performance or recognition of practices that lead to be better than expected performance.DiscussionThe variable life adjusted display (VLAD) is not new, yet is not widely utilised in General Surgery. Its construction is simple and if caveats are appreciated the interpretation is straightforward, allowing for continuous surveillance of surgical performance.SummaryWhile limitations in the detection of variations in performance are appreciated, the VLAD could represent a more useful tool for monitoring performance.

Highlights

  • The recent push for the publication of individual surgeon outcomes underpins public interest in safer surgery

  • Conventional, retrospective assessment of surgical performance without continuous monitoring may lead to delays in identifying poor performance or recognition of practices that lead to be better than expected performance

  • A variable life adjusted display (VLAD) for a mortality rate that is equal to what is expected will end at zero, while a VLAD for a mortality rate above what is expected is seen as a falling line, and vice versa

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Summary

Discussion

VLAD The VLAD was established by Lovegrove et al [1] to demonstrate the difference between observed and expected mortality over a specified period of time in Cardiac Surgery. At case 100, the actual mortality rate changes to a higher level, but this new “change point” is not detected given the wider control limits at this time These figures can be explored further using the aforementioned webapplication (http://www.datasurg.net/vlad). One method to prevent good runs masking subsequent poor performance is to prevent the VLAD from becoming positive so that only runs of worsening outcome are examined but this may lead to excess triggering and unneeded reviews of performance [5] Alternative plots such as the risk-adjusted CuSum and risk-adjusted exponentially weighted moving average overcome these limitations but may be more complex to construct.

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