To the Editor: The conclusion in the article by Bridgewater et al¹ that mandatory reporting and public scrutiny have not resulted in risk-averse behaviour but rather have improved surgeons’ performance is simply wishful thinking not supported by data from other quality-driven states such as New York.² A more likely explanation for their findings is that public scrutiny increased the pressure to assign higher EuroSCORES, so despite the fact that they operated on patients at lower risk (as shown by the lower mortality), the predicted mortality was higher. A better marker of risk-averse behaviour is the operative risk of patients who the surgeons are turning down, and those dying while waiting for surgery, but these data are not available.

EuroSCORE overestimates operative risk by around double, perhaps because of improved practice but more likely …