Quality metrics: hard to develop, hard to validate

In this issue of the British Journal of Anaesthesia, Epstein and colleagues¹ report their findings surrounding the proposed use of intraoperative hypotension as a quality metric for comparison of anaesthetists. The authors analysed a retrospective data set derived from 10 yr of data from their anaesthesia information management system, focusing specifically on a cohort of patients undergoing surgery at an increased risk of postoperative myocardial injury. The availability of electronic health records has enabled big data approaches for quality improvement and outcomes research in anaesthesia.²³ Anaesthetists performing these procedures were compared based on the time-weighted area under the curve for postinduction hypotension (defined as a mean arterial pressure of <65 mm Hg) over 2 month intervals. Recent evidence reviewed by Epstein and colleagues¹ has implicated intraoperative hypotension in adverse outcomes after cardiac and non-cardiac surgery, and additional relevant studies will appear in the British Journal of Anaesthesia.⁴⁵ The authors showed, convincingly, that because of the wide distribution of hypotension across providers and time epochs, intraoperative hypotension cannot be used alone as a quality metric to compare anaesthetists.

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