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Quality and outcome assessment ESA Jubilee

PRESS RELEASE - Zurich, November 21, 2023

As the outcome assessment of medical procedures remains poor worldwide, the 2 most prestigious surgical societies, the European Surgical Association (ESA) and American Surgical Association (ASA), took the task to identify the best parameters to consider. They based their recommendations on the recently published Jury-based consensus conference on how to assess the quality of surgical interventions, which took place in June 2022 in Zurich and whose results were published in Nature Medicine. Novel was the main focus on the perspective of patients, and on appropriate benchmarking for comparisons among surgeons, centers or various therapies.

In 2008, the World Health Organization (WHO) recognized that postoperative complications account for a large proportion of preventable medical injuries and deaths and deemed them «a global public health issue». But a lack of standardized and universal surgical endpoints has led to inconsistent, arbitrary, and often clinically irrelevant outcome assessments. This led to biased interpretations and finally hindered the improvement of health care quality.

The European Surgical Association (ESA) and American Surgical Association (ASA) have convened a symposium meeting for their special 2023 Jubilee meeting hold in Bordeaux, France, (Past Meetings | ESA ( to discuss what quality in surgery means and how outcomes of surgical procedures should be assessed. Experts in the field of quality and outcome in surgery were invited to debate and the conclusion was to put a special emphasis on the perspective of patients. Although being the most important stakeholder, this focus was somewhat new. Another focus was on appropriate benchmarking to enable credible comparisons among centers or various therapies.

Prof. Clavien presenting the Outcome4Medicine Consensus Conference The lack of standardized and universal surgical endpoints motivated Prof. Pierre-Alain Clavien (Zurich) and Prof. Milo Puhan (Zurich) to organize the Outcome4Medicine Consensus Conference, which took place in Zurich in June 2022. The aim was to produce internationally valid recommendations, which consider the perspectives of many stakeholders, including patients, health care providers, as well as payers or governments. The conclusions, published in the prestigious journal Nature Medicine (Nature Medicine 2023; 29: 811-822), were exclusively drawn by an independent Jury. A significant credit was given to the Zurich team in the assessment of the postoperative course including comprehensive complication index (CCI®) developed through a unique collaboration between the Department of epidemiology and Surgery at the University of Zurich ( This unique index captures the cumulative morbidity for a single patient with the CCI®, ranging from the value 0 (no complication) to 100 (death of the patient). This is currently the only available and validated metric to captures the entire postoperative morbidity of a patients. The complication grading developed also in Zurich and the CCI® are now uses in all procedures and worldwide.

Prof. Laurence Chiche (Bordeaux, France) presented the perspective of the patients, the most important stakeholder, which have been regrettably forgotten until the consensus conference hold in 2022 in Zurich. Patients define quality of care through novel criteria including their functional status postoperatively or criteria related to nonmedical services such as food quality. Therefore, to assess the quality of surgery, standardized assessment of outcomes from the patient’s perspective including patient-reported outcome or experience measures (PROMs and PREMs, respectively) must be developed to become an integral part of any surgical outcome assessment. PROMs and PREMs allow evaluating the real impact of surgery on a patient’s life and people’s satisfaction, and before full implementation must be validated according to a rigorous methodology. In practice, PROMs and PREMs are questionnaires completed by patients, without professional interference, typically using electronic applications. By using these measures, doctors can assess the benefit of the surgery in terms of quality of life and social consequences, better understand postoperative symptoms and their severity. Away from the role as background artist: Of further importance is that patients should move away from their role as «background artist» and take an active role in choosing their care. Patient education and empowerment are novel key elements to support patients in taking responsibility for their care, rather than to be passive secondary players.

Prof. Han-Kwang Yang, from Seoul, Korea, talked about quality improvement with benchmarking. Approaches like benchmarking, which compares performances to «the best», are central for quality assessment leading to improvement. While benchmarking originally comes from the fields of economy, it is now widely adopted in medicine. «The best» relates to the fact, that benchmark values for a specific surgical procedure are based on the outcomes of low-risk patients treated in international high-volume reference centers. Since 2016, such benchmark values have already been determined for more than 15 procedures by numerous groups in various fields of surgery. The implementation of proper benchmarking in all institutions would enable trustworthy comparisons, as any health care providers must strive to reach «the best» outcomes. Comparisons of outcomes translate the quality of care among individual therapies, physicians, hospitals, or even health care systems. Such high-level symposia are of utmost importance in our currently rapidly changing world facing economic crisis and uncontrollable heath care costs. Any actions to control or minimize cost escalation must secure that quality of care remains acceptable. This conjoint effort from the 2 most prominent academic surgical societies are therefore timely and should be understood from all stakeholders including the general public.

About Privatklinik Bethanien: Privatklinik Bethanien in Zurich is one of the leading private clinics in Switzerland. It has 105 beds. Around 360 attending physicians and 250 employees offer patients first-class medical care in a personal atmosphere and pleasant surroundings. The most important medical specialties include general internal medicine, gynaecology and obstetrics, ear, nose and throat medicine (ENT), orthopaedic surgery and traumatology of the musculoskeletal system, urology and visceral surgery. Around 500 children are born in the family department every year. Founded in 1912, the clinic is a member of Swiss Leading Hospitals (SLH) and since 2010 has been part of the Swiss Medical Network, to which a total of 21 clinics belong.

Contact: Prof. Dr. med. Pierre-Alain Clavien Privatklinik Bethanien University of Zurich Wyss Translational Center


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