Tuesday, August 24, 2010

A Stroll Down Future Memories Lane

You may not know this, but I have a hidden talent. I can predict the future. No, this doesn’t involve a crystal ball, Ouija board, or looking at the entrails of a freshly slaughtered surgical intern. I can see the future that is written out, plain as day, in medical journals. While this will not allow me to get rich in the stock market, predict the next presidential election result, or find out exactly when Monica Bellucci is planning to leave what’s-his-name and realize that she was meant for me, my limited skill gives me a little insight into how general surgeons will be treated --- and, more importantly, how they will respond to such treatment --- in the next few years.

A good example is the ongoing, relatively one-sided discussion regarding who should be doing certain procedures. Sounds relatively simple --- look at a variety of measurable outcomes for certain surgical procedures, and compare the results between “high volume” and “low volume” facilities and surgeons. This data is then often used to argue that across the board, we should as a matter of public policy push to shepherd certain types of patients to “high volume” facilities to achieve the best possible results. I have written about this a bit before, and certainly the freight train pushing certain types of procedures (pancreatectomy, esophagectomy, cardiac surgery, etc.) towards higher volume centers has been rolling down the track for so long that it is essentially unstoppable.

But what about procedures that are considered to be less complex? Should the same type of spotlight be placed upon cholecystectomy? Colectomy? Appendectomy? Hernia repair? And what if the data from such an evaluation reveals a contradictory result; should that instigate a reevaluation of prior “low versus high volume” studies? That’s good question, and one that is partially addressed by a study published in the July edition of the Journal of the American College of Surgeons --- Predictors of Major Complications after Laparoscopic Cholecystectomy: Surgeon, Hospital, or Patient?

From the abstract:

  • Using the Nationwide Inpatient Sample for patients undergoing laparoscopic cholecystectomy, major complications including acute myocardial infarction, pulmonary compromise, postoperative infection, deep vein thrombosis, pulmonary embolism, hemorrhage, and reoperation were assessed.
  • A total of 1,102,071 patients' records were available for this retrospective 1998-2006 study, with a complication rate of 6.8%.
  • Univariate analyses showed that advanced age, male gender, and higher Charlson Comorbidity Score were associated with higher complication rates
  • Higher surgeon volume and higher hospital volume were associated with fewer complications (6.7% versus 7.0%, 6.4% versus 7.0%, respectively)
  • Multivariable analysis showed that advanced age (65 years or older versus younger than 65 years), male gender, and comorbidities (Charlson Comorbidity Score 2 versus 0) were associated with complications
  • Neither surgeon nor hospital volume was independently associated with increased risk of complications.
Conclusions -- Major in-hospital complications after LC are associated with individual patient characteristics rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures might be unnecessary. Rather, careful patient selection and preoperative preparation can diminish overall complication rates.
Uh, what did they just say? Let me repeat it --- “Major in-hospital complications after laparoscopic cholecystectomy are associated with individual patient characteristics rather than surgeon or hospital operative volumes.” In other words, we are not a bunch of rubes out here away from the miracle centers. On average, the general surgeons of this country are competent and well trained. “Rather, careful patient selection and preoperative preparation can diminish overall complication rates.”

Time for a little futurama. I have no doubt whatsoever that the push for regionalization of a whole swath of surgical procedures will continue unabated, especially in the current political environment. To an extent, I will benefit from such a push --- I am a high volume general surgeon working in a tertiary referral center, albeit not in the largest city in my state --- and would anticipate an increase in surgical volume over time if such proposals come to fruition. It would be very reasonable to also expect that the types of patients sent up the road will be sicker to a pretty substantial degree, with simpler, elective procedures being done on healthy patients being retained in lower volume facilities.

Look at it this way. Let’s say you are a well-trained and salty seasoned surgeon in a small-to-medium sized city. An hour away is a miracle center, and they have actively pushed to make sure that, for example, colon resections should only be done in high volume centers by high volume surgeons. And let’s say that at 1AM you get a call to the ED to see a 62 year old, 280# diabetic man with hypertension and coronary artery disease who has perforated diverticulitis. Peering into the future, I predict the response of most physicians put into that difficult position will be “Gee, if I am not considered good enough to do elective colon surgery during daylight hours, I certainly am not good enough to do something more complex and emergent on a someone who has had no careful patient selection and preoperative preparation in the middle of the night. Call the miracle center and arrange transport.”

Patient wants to stay in town? Too bad.
Patient is pretty darn sick? Give him antibiotics, load and go.
Patient has given googobs of cash to the hospital? Cue Lindsey Buckingham. Call the hospital CEO to hold his hand during transport.
ED really, really wants you to take care of the patient? Wouldn't be prudent. I can hear the attorney's question when I get sued for a complication: "Doctor, when was the last time you performed one of these operations electively?"

This sort of begs the question, is this a good thing for the patient, or a bad thing? I'm sure you can tell that I come down a bit on the side of "bad thing," but some might argue the opposite. The difficulty is that all hospitals cannot be staffed with high volume surgeons for every possible procedure. It's a Pollyannish idea, sort of like how the schoolkids in Lake Wobegon are all above average.

Please understand, I am not arguing that we should be avoiding progress; obviously, I don't think it's ethical to turn away a patient in need. But progress in medical care has generally come from striving for excellence in training and disseminating information about how to best care for patients. If there is a concern that surgeons performing a lower volume of certain common procedures need a little buffing up, first prove it.....and then I would humbly suggest that the way we have been going about steadily improving care in this country has worked extremely well over the past century. I have yet to see strong evidence that radically changing this system will be beneficial to patients in the long run.