Australian And New Zealand Audit Of Surgical Mortality Research Articles

223. UNDERSTANDING POTENTIALLY PREVENTABLE MORTALITY FOLLOWING ESOPHAGO-GASTRIC CANCER SURGERY: ANALYSIS OF A NATIONAL AUDIT OF SURGICAL MORTALITY

Abstract Introduction At a national level, understanding preventable mortality after esophago-gastric cancer surgery can direct quality-improvement efforts. Here, we utilized the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database to 1) determine the causes of death following esophago-gastric cancer resections in Australia, 2) quantify the proportion of potentially preventable death, and 3) identify clinical management issues contributing to preventable mortality. Methods All in-hospital mortalities following esophago-gastric cancer surgery from 01/01/2010 to 31/12/2020 were analyzed from ANZASM data. Potentially preventable and non-preventable cases were compared. Thematic analysis was used classify clinical management issues. Overall, we reviewed 636 complications and 123 clinical management issues in 105 mortalities. Results The most common causes of death were cardio-respiratory in etiology. Forty-nine (46.7%) mortalities were potentially preventable. These cases were characterized by higher rates of sepsis (59.2% vs. 33.9%, p = 0.011), multiorgan dysfunction syndrome (40.8% vs. 25.0%, p = 0.042), reoperation (63.3% vs. 41.1%, p = 0.031), and other complications compared with non-preventable mortality. Potentially preventable mortalities also had more clinical management issues per patient [median (IQR): 2 (1–3) vs. 0 (0–1), p < 0.001), which adversely impacted preoperative (30.6% vs. 7.1%, p = 0.002), intraoperative (18.4% vs. 5.4%, p = 0.037), and postoperative (51.0% vs. 17.9%, p < 0.001) care. Thematic analysis highlighted recurrent areas of deficiency in patient management. Conclusions Almost 50% of deaths following esophago-gastric cancer resections were potentially preventable. These were characterized by higher complication rates and clinical management issues. We highlighted recurrent themes in patient management to improve future quality-of-care.

Understanding Potentially Preventable Mortality Following Oesophago-Gastric Cancer Surgery: Analysis of a National Audit of Surgical Mortality

IntroductionAt a national level, understanding preventable mortality after oesophago-gastric cancer surgery can direct quality-improvement efforts. Accordingly, utilizing the Australian and New Zealand Audit of Surgical Mortality (ANZASM), we aimed to: (1) determine the causes of death following oesophago-gastric cancer resections in Australia, (2) quantify the proportion of potentially preventable deaths, and (3) identify clinical management issues contributing to preventable mortality.MethodsAll in-hospital mortalities following oesophago-gastric cancer surgery from 1 January 2010 to 31 December 2020 were analysed using ANZASM data. Potentially preventable and non-preventable cases were compared. Thematic analysis with a data-driven approach was used to classify clinical management issues.ResultsOverall, 636 complications and 123 clinical management issues were identified in 105 mortalities. The most common causes of death were cardio-respiratory in aetiology. Forty-nine (46.7%) deaths were potentially preventable. These cases were characterized by higher rates of sepsis (59.2% vs 33.9%, p = 0.011), multiorgan dysfunction syndrome (40.8% vs 25.0%, p = 0.042), re-operation (63.3% vs 41.1%, p = 0.031) and other complications compared with non-preventable mortality. Potentially preventable mortalities also had more clinical management issues per patient [median (IQR): 2 (1–3) vs 0 (0–1), p < 0.001), which adversely impacted preoperative (30.6% vs 7.1%, p = 0.002), intraoperative (18.4% vs 5.4%, p = 0.037) and postoperative (51.0% vs 17.9%, p < 0.001) care. Thematic analysis highlighted recurrent areas of deficiency with preoperative, intraoperative and postoperative patient management.ConclusionsAlmost 50% of deaths following oesophago-gastric cancer resections were potentially preventable. These were characterized by higher complication rates and clinical management issues. We highlight recurrent themes in patient management to improve future quality of care.

Surgical interhospital transfer mortality: national analysis.

Interhospital transfers of surgical patients are an independent risk factor for mortality. The Australian and New Zealand Audit of Surgical Mortality (ANZASM) aims to improve surgical care through assessment of all cases of surgical mortality. This study aimed to describe common clinical management issues that contributed to interhospital transfer patient mortality. Data for all surgical patient mortality in Australia (except New South Wales) that underwent interhospital transfer between 1 January 2010 and 31 December 2019 were extracted from ANZASM. The surgeons' reports and assessors' evaluations were examined to identify clinical management issues. Thematic analysis was performed to develop pertinent themes and subthemes. Some 8679 patients were identified over the 10-year period. Of these, 2171 (25.0 per cent) had 3259 clinical management issues identified. Prominent themes were operative design (n = 466, 14.3 per cent), decision to operate (n = 425, 13.0 per cent), medical conditions (n = 344, 10.6 per cent), diagnosis (n = 326, 10 per cent), transfer (n = 293, 10.0 per cent), intraoperative issues (n = 278, 8.5 per cent), inadequate assessment (n = 238, 7.3 per cent), communication (n = 224, 6.9 per cent), delay in recognizing complications (n = 180, 5.5 per cent), coagulopathy (n = 151, 4.6 per cent), insufficient monitoring (n = 127, 3.9 per cent), infection (n = 107, 3.3 per cent), and hospital resources (n = 100, 3.1 per cent). Assessors considered 58.4 per cent of clinical management issues (n = 1903) probably or definitely preventable. This study identified 13 themes of potentially avoidable management issues present in surgical mortality following interhospital transfers. Quality-improvement initiatives targeting these areas may improve surgical patient outcomes.

Unexpected deaths after endocrine surgery: learning from rare events using a national audit of surgical mortality.

The mortality rate is low in endocrine surgery, making it a difficult outcome to use for quality improvement in individual units. Lessons from population data sets are of value in improving outcomes. Data from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) were used here to understand and elucidate potential systems issues that may contribute to preventable deaths. ANZASM data relating to 30-day mortality after thyroidectomy, parathyroidectomy, and adrenalectomy from 2009 to 2020 were reviewed. Mortality rates were calculated using billing data. Thematic analysis of independent assessor reports was conducted to produce a coding framework. A total of 67 deaths were reported, with an estimated mortality rate of 0.03-0.07 per cent (38 for thyroidectomy (0.03-0.06 per cent), 16 for parathyroidectomy (0.03-0.06 per cent), 13 for adrenalectomy (0.15-0.33 per cent)). Twenty-seven deaths (40 per cent) were precipitated by clinically significant adverse events, and 18 (27 per cent) were judged to be preventable by independent ANZASM assessors. Recurrent themes included inadequate preoperative assessment, lack of anticipation of intraoperative pitfalls, and failure to recognize and effectively address postoperative complications. Several novel themes were reiterated, such as occult ischaemic heart disease associated with death after parathyroid surgery, unexpected intraoperative difficulties from adrenal metastasis, and complications due to anticoagulation therapy after thyroid surgery. This study represents a large-scale national report of deaths after endocrine surgery and provides insights into these rare events. Although the overall mortality rate is low, 27 per cent of deaths involved systems issues that were preventable following independent peer review.

Elective abdominal wall hernia repair surgical mortality-A systematic review of the literature and peer review of mortality in Australia.

This study systematically reviewed the literature regarding perioperative mortality in human adults undergoing elective surgical abdominal wall hernia repair, including an audit of the Royal Australasian College of Surgeons (RACS) Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. A systematic review was conducted in accordance with PRISMA guidelines for the reporting of systematic reviews and meta-analysis of observational studies. Cochrane Library, PubMed, MEDLINE and Embase database searches and data extraction were conducted from June 1979 to October 2019. Statistical analysis was undertaken utilising denominator values for elective hernia procedures derived from the Australian Institute of Health and Welfare (AIHW) data. Risk-adjusted perioperative mortality rates for the relevant procedures were also produced, using a binary logistic regression for the risk adjustment. Through systematic review of the literature, it was established that the overall reported perioperative mortality in human adults undergoing elective surgical abdominal wall hernia repair was low (0.1%-0.5%). Using ANZASM and AIHW data, the calculated risk-adjusted mortality rate for Australian patients was found to be significantly lower (0.04%-0.06%, p< 0.001). The risk-adjusted mortality rate for elective abdominal wall hernia surgery in Australia is very low and compares favourably to international cohorts. Despite low absolute numbers, the factors which were most significantly associated with increased perioperative mortality in patients undergoing elective surgical abdominal wall hernia repair were increased age, cardiorespiratory co-morbidity and incisional hernia repair.

Peri-operative Mortality Following Cholecystectomy in Australia: Potential Preventability of Adverse Events.

Cholecystectomy is a commonly performed procedure; however, it is not without risks. It is crucial to constantly audit surgical outcomes in order to improve quality of care. The aim of this retrospective population-based cohort study is to identify preventable issues of clinical management associated with adverse occurrences in order to reduce mortality of cholecystectomy patients. Data were obtained from the Australian and New Zealand Audit of Surgical Mortality (ANZASM). It encompasses peer-reviewed first and second line assessments of management of cholecystectomy patients who died from 2005 to 2015 in Australia. Clinical Management Issues (CMIs) were identified from text in assessments and grouped into communication failures, pre-operative, intra-operative and post-operative categories. These were further classified into subthemes using thematic analysis with a data-driven approach. There were 359 deaths in the study period. CMIs were present in 71 cases, with a reported total of 124 concerns or adverse events. Post-operative CMIs were the most prevalent issue [50% (62/124)], with the most common theme being delay to recognise complications (19/124). Pre-operative concerns were the second most common (n = 34). Decision to operate was questioned in 14 cases, and delay to surgery was reported in 12 cases. ANZASM analysis has allowed us to identify modifiable adverse occurrences. This audit shows that delay to recognise complications is the most common assessment recorded. Preventive measures should be taken to improve outcomes and reduce peri-operative mortality, with an emphasis on post-operative management and enhancing communication between members of the multidisciplinary team.

Urinary tract stone deaths: data from the Australian and New Zealand Audits of Surgical Mortality

To analyse all mortalities related to surgery for urinary tract calculi in Australia from 1 January 2009 to 31 December 2018, and identify common causes, clinical management issues (CMIs), and areas for improvement. All urological-related deaths reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) from 2009 to 2017 were analysed. The Bi-National Audit of Surgical Mortality (BAS) database was interrogated for any involvement with renal, ureteric or bladder stones and all relevant associated data analysed. Any CMIs documented by the peer reviewers were recorded and compared to those in urology and all of surgery ANZASM data. Of 1034 total urological deaths, 100 (9.7%) were related to stones. The mean (range) age of patients was 74.4(21-97)years; 95% of the patients underwent at least one procedure, with 45 (47.4%) of these being elective. Urinary sepsis was responsible for 49.5% of the deaths, with 20% dying of cardiac events. In all, 39% (37/95) of deaths were associated with CMIs, the most common considerations being delays in diagnosis or treatment, perioperative management and inadequate preoperative evaluation. This is a considerably higher percentage than the 26% recorded for the general urology and all surgery national data. Ureterorenoscopy at 54% (12/22) had the highest rate of CMIs. Death related to stone surgery represents only a small proportion of all urological surgical deaths, but generates more CMIs amongst ANZASM peer assessors. Results could be improved with more rapid diagnosis and treatment. Careful case selection and access to all treatment options are recommended.

Peer review of mortality after hepatectomy in Australia

BackgroundThe data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after hepatectomy can provide greater insight into how deaths can be prevented. The objective of this study was to determine the reasons for patient deaths post-hepatectomy in Australia. MethodsANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following hepatectomy were selected for analysis. Assessors determinations of whether management could have been improved were reviewed, and then classified into groups of significant clinical events using thematic analysis with a data driven approach. ResultsThe study included 88 deaths reported to ANZASM after hepatectomy. The assessors questioned the decision to operate in 23/88 (25%) patients with a further nine (10%) patients insufficiently investigated prior to resection. ANZASM assessors determined that there was a delay in recognising a significant complication in 16/88 (18%) patients. ConclusionMulti-disciplinary decision making is strongly recommended when deciding which patients to treat with hepatic resection. Optimal care post-hepatectomy includes early recognition of complications and enactment of an adequate rescue plan.

Peer review of mortality after pancreaticoduodenectomy in Australia

BackgroundThe data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after pancreaticoduodenectomy (PD) can provide greater insight into how deaths can be prevented. MethodsANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following PD were selected for analysis. Assessor's determination of whether management could have been improved were reviewed and classified into groups of significant clinical events using thematic analysis with a data driven approach. ResultsThe study included 87 deaths reported to ANZASM after PD. Forty-two major complications were considered significant clinical events in 29/84 (35%) of patients. The assessor determined that there was a delay in recognising a significant complication in 18/84 (21%) of patients. In 14/84 (17%) of patients, ANZASM assessment questioned the decision to operate. ConclusionMulti-disciplinary decision making is strongly recommended when deciding which patients to treat with PD. Late recognition, and therefore delayed action to treat complications, in almost a quarter of deaths is a significant finding that warrants consideration for clinicians involved in the postoperative care of PD patients.

Rural centres do not have a higher prevalence of post‐operative complications than urban centres: a retrospective analysis of a mortality audit

The trend towards centralization of surgical care from rural to high-volume centres is based on studies showing better outcomes for patients requiring complex surgical procedures. However, evidence that this also applies to less complex procedures is lacking. This study therefore aimed to determine whether there was a relationship between geographic location (rural versus urban) of surgical procedures of varying complexity and post-operative complications. This was a retrospective cohort study examining all in-hospital deaths reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) between 2009 and 2016. Multivariable logistic regression was used to ascertain interactive effects of location and complexity of surgical procedures on post-operative complications, adjusted for potential confounders. There was no interactive effect of hospital location and operation complexity on the occurrence of post-operative complications. Post-operative complications were reported in 2160 of 6963 (31%) patients who died post-surgery. Patients operated on in rural centres had lower risk profiles: younger, with lower American Society of Anesthesiologists grades and less likely to present with injury and circulatory diseases. Nonetheless, risk of post-operative complications did not differ between procedures performed in rural compared with urban hospitals. Results of this study suggest that a wide range of procedures may be safely performed in rural centres. Further prospective studies of unfiltered cohorts are warranted to validate these findings.

Peer review of mortality after pancreaticoduodenectomy in Australia

Introduction: The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. ANZASM considers all deaths following a surgical admission in Australia. Consideration of the factors contributing to mortality after pancreaticoduodenectomy (PD) can provide greater insight into how deaths can be prevented. Method: ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following PD were selected for analysis. As a part of the audit process, assessors determine significant clinical events relevant to the patient’s care and classify these into a level of seriousness. Assessor’s determination of whether management could have been improved were reviewed and classified into groups of significant clinical events using thematic analysis with a data driven approach. Result: The study included 87 deaths reported to ANZASM after PD. A return to theatre was reported in 58% of patients. Major complications such as post operative haemorrhage and intraoperative vascular injury occured in 20% and 10% of patients respectively. The assessor determined that there was a delay in recognising a significant complication in 21% of patients. In 17% of patients, ANZASM assessment questioned the decision to operate. Conclusion: This study sought to summarise the significant clinical events leading to mortality after PD in Australia. The large proportion of patients where the decision to operate or proceed was questioned by assessors was a concerning feature. Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with PD. The finding of nearly a quarter of deaths being assessed to be associated with late recognition of complications warrants consideration for surgeons involved in PD.

Measuring Outcomes of Clinical Care: Victorian Emergency Laparotomy Audit Using Quality Investigator.

The Australian and New Zealand Audit of Surgical Mortality (ANZASM) National Report 2015 found that within the cohort of audited deaths, 85% were emergencies with acute life-threatening conditions, and by far, the most common procedures were laparotomy and colorectal procedures. Emergency laparotomy outcomes have shown improvement through audit and reporting in the UK. The purpose of this study was to determine the outcome of emergency laparotomy in the state of Victoria, Australia. The Dr Foster Quality Investigator (DFQI) database was interrogated for a set of Australian Classification of Health Intervention (ACHI) codes defined by the authors as representing an emergency laparotomy. The dataset included patients who underwent emergency laparotomy from July 2007 to July 2016 in all Victorian hospitals. There were 23,115 emergency laparotomies conducted over 9years in 66 hospitals. Inpatient mortality was 2036/23,115 (8.8%). Mortality in the adult population increased with age and reached 18.1% in those patients that were 80years or older. 51.3% were females, and there was no significant difference in survival between genders. Patients with no recorded comorbidities had a mortality of 4.3%, whereas those with >5 comorbidities had 19.3% mortality. Administrative data accessed via a tool such as DFQI can provide useful population data to guide further evidence-based improvement strategies. The mortality for emergency laparotomy within Victorian hospitals is comparable, if not better than that seen in overseas studies. There is a need to continue routine audit of mortality rates and implement systems improvement where necessary.

Perioperative Mortality Rates in Australian Public Hospitals: The Influence of Age, Gender and Urgency.

A decline in surgical deaths has been observed in Australia since the introduction of the Australian and New Zealand Audit of Surgical Mortality (ANZASM). The current study was conducted to determine whether the perioperative mortality rate (POMR) has also declined. This study is a retrospective review of the POMR for surgical procedures in Australian public hospitals between July 2009 and June 2013, using data obtained from the Australian Institute of Health and Welfare. Operative procedures contained in the Australian Refined Diagnosis Related Groups were selected and the POMR was modelled using urgency of admission, age and gender as explanatory covariates. The POMR in Australian public hospitals reduced by 15.4% over the 4-year period. The emergency admissions POMR dropped from 1.40 to 1.12%, and the elective admissions POMR from 0.09 to 0.08%. The binary logistic regression model used to predict patient mortality showed emergency admissions to have a higher POMR than elective, being more evident at older ages. For emergency admissions, the difference in POMR between females and males increased with age, from about 55years onwards, with females being lower. For elective surgeries, the difference between males and females was of little practical importance across ages. The reduction in the POMR in Australia confirms the reduction in surgical deaths reported to ANZASM. Continuing to monitor POMR will be important to ensure the safest surgery in Australia. Further investigations into case-mix will allow better risk adjustment and comparison between regions and time-periods, to facilitate continuous quality improvement.

Analysis of deficiencies in care following cholecystectomy

Failure To Rescue was first defined in patients who died due to a complication following (open) cholecystectomy but research into the relevant factors has been scarce. This study was designed to determine a chronological sequence of deficiencies in care. Adult patients who died under the care of a surgeon following cholecystectomy in Queensland were identified from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. Not unexpectedly, this is a high-risk patient population: median age of the 48 patients was 74.5 years and the median number of comorbidities and American Society of Anesthesiologists class was 4. Death occurred on postoperative day 6. Most deaths occurred at the end of the week. Over 80% of deaths followed emergency cholecystectomy. In almost half the patients, there were no deficiencies in care. Most common deficiency was during postoperative management (i.e. Failure To Rescue), however, significant deficiencies also arose prior to surgical admission; choice and timing of intervention as well as intraoperative decision-making. Surgeons who perform cholecystectomy need to be aware of the levels at which deficiencies arise given that many may be preventable.

The Australian and New Zealand Audit of Surgical Mortality—Birth, Deaths, and Carriage

This article outlines the formation of the Australian and New Zealand Audit of Surgical Mortality (ANZASM) and describes its objectives, governance, functioning and challenges. A nationwide audit of surgical mortality provides an overview of the leading causes of death in patients who require surgical care. It identifies system or process errors, trends in deficiency of care and helps develop strategies to reduce deaths in the surgical arena. A standardized tool is used to systematically collect data after every surgical death. Patient details are reviewed by a peer surgeon (and in certain cases a second) to identify issues with patient management and hospital processes. The treating surgeon is then offered confidential feedback and alternate views on patient management. From January 2009 to December 2012, 19,096 deaths were reported to the ANZASM. Eighty-six percent of the audited deaths occurred in patients requiring an emergency admission. Significant criticism of patient care was reported in 13% of cases with 16% of clinical issues perceived to be preventable. Western Australia, which first began the audit process, has shown a 30% reduction in surgical deaths. Nationwide mortality audits are a useful and worthwhile exercise. Recommendations identified in the audit reports direct educational workshops and seminars to address these issues. They allow Departments of Health to make informed decisions in their hospitals. Through this model, and the lessons learnt, we would encourage other countries planning to set up their own audits to follow a similar concept.

Increasing Number of Comorbidities is Related to Delay to Surgical Management of a Perforated Peptic Ulcer in Patients who Died

Introduction: The incidence of peptic ulcer disease has declined since the introduction of medical therapy, but the rate of perforated peptic ulcer and associated mortality has remained relatively constant. Delay to definitive treatment is known to adversely affect survival. Methods: The Australian and New Zealand Audit of Surgical Mortality (ANZASM) retrospectively collects data on patients who died following surgery. To determine which patient characteristics are associated with delayed (not on the day of admission) surgical treatment of a perforated peptic ulcer, all patients who died in Queensland were identified from the ANZASM database. Results: There were 39 deaths between 2007 and 2013 with a median age was 76 years. The median number of comorbidities was three and American Society of Anaesthesiologists (ASA) class Original Research Article Wysocki et al.; BJMMR, 8(10): 842-847, 2015; Article no.BJMMR.2015.514 843 was 4. Twenty nine patients had operative intervention on the day of admission and 10 underwent surgery later. Those with delayed surgery had a greater number of comorbidities (4 vs. 3; p = 0.016) but did not differ with respect to other demographics compared to those who underwent repair on the day of admission. The reviewing surgeon found no management issues in two thirds of patients. Conclusion: Queensland patients with an increasing number of comorbidities were more likely to have delayed surgical intervention for a perforated peptic ulcer. Surgical delay is a known determinant of survival in patients with a perforated peptic ulcer and surgeons must be especially vigilant in multiply comorbid patients in making the diagnosis and expediting repair.

Perioperative Care Related Events are Different Following Elective and Emergency Right Hemicolectomy

Introduction: Right hemicolectomy is frequently performed for malignancy but emergency surgery is associated with double the mortality rate of elective colonic resection. The study was designed to compare perioperative clinical incidents patients who died following elective and emergency right hemicolectomy. Methods: Adult patients who died under the care of a surgeon following elective and emergency right hemicolectomy in Queensland, Australia were identified from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. Demographic data, free text entries and surgeon reviewer conclusions were analysed. Results: The two groups had different indications for surgery but were of similar age and gender. Surgeon reviewers (first and second line) identified similar rates of untoward perioperative events in both groups however post operative events tended towards being more frequent after elective surgery while pre operative events were more frequent in the emergency group. Almost half of the incidents occurred post operatively and often related to delayed diagnosis and management of Original Research Article Wysocki et al.; BJMMR, 9(6): 1-6, 2015; Article no.BJMMR.19247 2 anastomotic leak. Conclusion: This analysis suggests more thorough pre operative medical work up may be required prior to right hemicolectomy and that greater attention should be focused on recognizing intra-abdominal sepsis predominantly following emergency surgery.

Hospital mortality under surgical care

The article by Aziz et al reviews the use of the ‘hospital standardised mortality ratio’ (HSMR) in England as a measure of hospital performance as well as highlighting the inadequacies in its current form. A general surgeon’s data were used to evaluate accuracy of this system. Alarmingly, the results showed that at least 30% of cases were incorrectly attributed to the surgeon, that none of the surgeon’s cases were externally peer reviewed, that there was no clear evidence of adverse events being possibly attributed to the mortality to see if they could have been avoided and that there were so many missing data regarding co-morbidities. Clinical quality registries play an increasingly important role to improve the quality of healthcare in Australia. The 2009 Australian Institute of Health and Welfare report on the proposed national quality indicators emphasised the importance of having national registries, particularly in high cost areas of medicine.1 Indicator 36 (independent peer review of surgical deaths) stated that the original template of the Scottish Audit of Surgical Mortality (SASM) should be adapted for use in Australia. It recommended that these data sources be reported nationally, ensuring standardisation of reporting methods across all states and territories in Australia. We can report that this is now the case with the Australian and New Zealand Audit of Surgical Mortality (ANZASM) being set up in 2006. Aziz et al further pointed out that the HSMR cases are not reviewed externally and that the public could therefore be misinformed by seeing these crude mortality data (the validity and accuracy of the data being in question), especially when in many cases the risk of death is high in this group of patients. In our 2009 national report, the surgeon considered the risk of death to be expected in 11% of cases, considerable in 40% and moderate in a further 19%.2 Co-morbidity was another signifcantly important factor in the study by Aziz et al, with 94% of cases recorded as having an ASA (American Society of Anesthesiologists) grade >1. The Western Australian Audit of Surgical Mortality (WAASM), the Tasmanian Audit of Surgical Mortality (TASM) and SASM reported co-morbidity as 86–99%.3–5 In the 2009 Australian national report, 91% of cases reported at least one co-morbidity and 75% had at least two co-morbidities while only 6% were ASA grade 1 or 2.2 These levels of data and statistical analysis can only come from full surgical participation and a robust surgical case form applied across all states and territories. ANZASM agrees that the UK HSMR methodology looks at hospital mortality in isolation rather than from a regional or national perspective and is therefore open to faws in interpretation in its analysis of data, as Aziz et al clearly point out. Aziz et al go on to say that they consider HSMRs to be inadequate and suggest surgeons participate in large audits similar to SASM, WAASM and TASM. The Royal Australasian College of Surgeons (RACS) and Australian state and territory Departments of Health have committed to the national audit of surgical mortality. To reinforce the importance of the activity, participation in ANZASM was deemed a mandatory part of the Continuing Professional Development (CPD) programme (Category 1 – Surgical Audit and Peer Review) in January 2010. The ethos for this was to ensure complete participation by fellows in the audit process. There is tremendous beneft in having a common surgical case form questionnaire and being able to collect the same data set over a wide spectrum of surgical interventions (and therefore reducing variation in the levels of accuracy in the reporting methodology). Having this national system in Australia across all states and territories, encompassing surgeon reporting and peer review, enables accurate data collection, surgeon refection and general education by sharing de-identifed cases in case note reviews. This can only be a benefcial process to all concerned. The RACS fully encourages the audit programme as it is fully owned by the surgeons with the understanding for the need to have partnerships with governments and other bodies. Surgeon participation in an independent peer review mortality audit process would therefore be an ideal way to better inform the college, as well as the general public, in terms of its accountability in the profession of providing quality care to its patients.