Editorial comment: Quality measurement in adult cardiac surgery: a challenge.

Does the choice of risk-adjustment model influence the outcome of surgeon-specific mortality analysis? A retrospective analysis of 14637 patients under 31 surgeons. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting. sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2.579 consecutive operative procedures. wound infection after coronary artery bypass graft surgery: validation of existing risk scores. Quality measurement in adult cardiac surgery: a challenge The manuscript presented by Hartrumpf et al. concerns a current but sensitive topic [1]. In contrast with others reporting and promoting quality assessment at unit level [2—4], the article highlights the surgeon's individual performance, expressed by the Surgeon Performance Index (SPI). In this respect, the article is progressive, presenting public data, good and bad, without distinction. The authors thus take up a vulnerable position, which takes courage. However, despite the efforts and the good intention, the article contains several pitfalls. It is important to recognize these pitfalls, especially in the case of quality control. Otherwise, misuse of articles such as this will undermine the importance and power of quality assessment. The authors use early mortality, early rethoracotomy for bleeding, sternal rewiring for instability and mediastinitis as variables for their assessment and use the EuroSCORE for risk adjustment [5]. Firstly, why not use variables which have an accepted association with quality of care, as presented by several quality improvement organizations [2—4]? Secondly, the used variables differ from the definitions given in internationally used systems, thus making benchmarking impossible. Moreover, the used definitions are free to interpretation. Sternum instability is defined as visible movement of sternal edges, necessitating sternum rewiring. This definition contains two weak points. For one, 'visible movement', while everybody knows patients with a sternal dehiscence without visible movements. Secondly, 'necessi-tating sternum rewiring' which is not an event but a therapeutic decision. Therefore it is biased. The same goes for early rethoracotomy. As defined by the authors, it is a therapeutic decision, but what about patients, with minimal blood loss undergoing a rethoracotomy for cardiac tamponade? 2. Mortality It is important that when mortality is used, theoretically, the whole early phase, about 6 months postoperative, must be considered [6]. This means that an active follow-up is necessary [6]. Because of difficulties with follow-up, most centers use their hospital mortality. With the early discharge policy most patients leave the cardiac surgical center within 10 days postoperative. …