Thursday, October 25, 2007

A Monkey Wrench in the Ratings Machine

Interesting things, facts. Stubborn at times, when they are reviewed, and apt to make most reasonable people change their minds about subjects if they are studied and accepted. Of course, they often tend to be ignored --- unfortunately, in the wonderful world of Modern American Medicine™, the latter situation often prevails.

A case in point is the headlong rush to rate physicians' quality of care almost solely upon the volume of a specific procedure they happen to perform. It's a simple concept, really --- it would seem to make sense that the more frequently a surgeon performs a given procedure, the better their outcomes should be. That case has been frequently made, particularly on the part of large academic medical centers, for a whole variety of procedures -- sort of a Good Housekeeping Seal for surgery. These include pancreatic resection, esophagectomy, coronary bypass surgery, laparoscopic gastric bypass surgery, and carotid endarterectomy. There is a push for "centers of excellence" to be created for these procedures, with gastric bypass surgery centers of excellence already established. There are reasonable statistics to back up this idea, but very little investigation has been undertaken to evaluate the opposite proposition ---- what if some surgeons actually have good outcomes with a given procedure, despite performing that procedure at a low volume than has been arbitrarily picked as a threshold?

I would like to give kudos to a few surgeons at the University of Vermont who have decided to buck the trend and look a bit differently at their own data. Their study, entitled Credentialling for Laparoscopic Bowel Operation: There Is No Substitute for Knowing the Outcomes was published in the October edition of the JACS. Basically, they acknowledge that case volume has been utilized as a reasonable estimate for granting surgical privileges --- a point that I agree with completely --- but that it also has the potential to prevent some surgeons for gaining privileges. Bowel resections performed by four surgeons at their institution were reviewed; one of the surgeons had completed fellowship training in advanced laparoscopy, and a second had recently completed a colorectal surgical fellowship --- so, each had a large amount of laparoscopic bowel surgical experience in their training. Let's call them the Young Turks. The other two had completed colorectal surgical training prior to the advent of advanced laparoscopic training; we'll call them the Old Farts. Out of a total of 112 laparoscopic bowel resections performed, the Old Farts held their own, despite lower volumes and the obvious difference in training:

Six hundred twenty-four bowel resections were performed during the study period, of which 112 were performed laparoscopically. Of the four study surgeons, the percentage of laparoscopic versus open cases ranged from 8% to 56%. Individual surgeon complication rates varied from 9% to 47%. Surgical volume and training had no notable relationship to incidence of complications (19% high volume/fellowship training versus 10% low volume/no fellowship, p = 0.25). An inflammatory indication was a strong predictor of technical complications on univariate (p = 0.02) and multivariate (p = 0.01) analysis.
Well, looky there. The Old Farts actually had fewer complications than the Young Turks, though statistical significance was not established. Wouldn't you have liked to be sitting in on the faculty conference when this data was presented!

Well, what does this teach us? The most important take-home lesson for surgeons in the present-day world where hospitals, insurance corporations, health-rating companies, and Uncle Sam (or Aunt Hillary) want to rate, regulate, and limit surgical privileges based upon volume is:
Unfortunately, that's kind of hard --- it is time consuming, requires a lot of data collection and entry, and I can tell you from personal experience is not easily accomplished with presently available programs (including the one offered by the American College of Surgeons).

What this also may tell us is that there is something to be said for experience. I feel, and I pray that I am right, that I am a better clinician and a better surgeon today than when I first came out of training ---- despite the fact that that training was long, intensive, included a laparoscopic fellowship, and involved a whole lotta operating. Maybe we could say that physicians, like musicians, get better with age, experience, and practice. Don't believe me? Well, who would you rather see in concert:
this guy
or this one?

I know how I would answer that question, but I am an Old Fart, with an emphasis on the "Old" part of the description. Pharmaceutical enhancements aside, I think anyone who listens to the young Clapton and compares him to today's version understands that the man has learned a few tricks along the way.

Lest I be condemned for advocating continued practice by surgeons far beyond their prime in reasoning and physical skill, I admit that there is a point beyond which a physician loses skills necessary to good practice. It is impossible to tell when exactly that happens, and in the ideal world every surgeon would be able to recognize a diminution in his or her ability to adequately care for patients, and back off. And once again, we can turn to the world of music for a comparison. Who would you rather hear play:

this guy, on top of his game

or this over the hill, ridden-hard-and-put-away-wet guitarist who can't remember the notes?

I guess the trick for patients is to not let Keith Richards operate on you.