|
OB/GYN Editorial DECEMBER 2004
You Are a Statistic (but Probably Don't Know It!)
Thomas E. Nolan, MD, MBA
 |
The Society of Gynecologic Surgeons and the American Urogynecologic Society had a joint meeting in San Diego this past July. One of the keynote speakers was Shukri F. Khuri, MD, a professor of surgery at Harvard University who has been instrumental in working with the Department of Veterans Affairs (VA) hospital system to assess and improve surgical quality and outcomes. The need for this meeting was to address problems that were reported in the national press on surgical outcomes in the VA system. The task of these individuals was to set up databases and statistics to compare outcomes among surgeons operating in the VA system, and to evaluate the physical environment ("systemic problems") and surgical outcomes. They also were charged with finding metrics that could be applied to improvement outcomes, primarily in cardiovascular surgery. Over the ensuing years, they have established criteria to evaluate surgeons and various aspects of medical care that can be data-driven.
After hearing this talk, I spoke with one of my colleagues from a well-known multispecialty clinic in the United States. At his particular institution, some of the surgeons on staff were evaluated for outcome using various tools on patients under their care. Interestingly, they were able to establish criteria that showed a definite relationship between the skill of the surgeon and patient outcome. Even though we did not discuss what the particular independent variables were, it was interesting to me that institutions are beginning to look closely at, and apply measures to, care outcome.
One of the more interesting things that I have been involved in over the past 2 years is serving as medical staff president at Charity Hospital in New Orleans (if you do a good job, it lasts for 2 years; if you do a bad job, it lasts for 3 years!). This job includes acting as chairman of the Credentials Committee. In this role, I find that there is a tremendous amount of pressure coming from various outside regulatory agencies, primarily from the Joint Commission on Accreditation of Healthcare Organizations, to measure physician skill sets. Currently, these measurements are rather primitive (eg, length of stay, cost of medications ordered, etc). However, it is not outside the realm of possibilities that in the next 5 years, review of surgical times, material usage (suture, laparotomy pads, trocar usage and complications), pathology reports, blood loss, and length of stay will be used more and more in the credentialing process. In some form, this is already occurring. The current issue is whether a physician is (a) showing competency in requested credentials; and (b) maintaining that competency. When I was in the navy back in the mid to late 80s, there was a movement afoot in which a physician applying for any procedure had to demonstrate, in reliable measurements, that he had performed the procedure successfully in the past credentialing cycle.
And this does not just pertain to surgeons and surgical subspecialties. The ACP Observer recently published an article on tiered networks that explains how data on cost-effectiveness of physician care is being used as a discriminator when determining who is allowed to join a network.1 This article reports that two dozen health care plans in 12 different markets are using these criteria. The decision to accept or reject a physician may be based on as few as 10 episodes of care over a 2-year period. Physicians are measured on volume, clinical performance, cost-efficiency, and network efficiency. Care is measured from initial hospitalization through postoperative care. For example, a surgeon who takes on few complex cases may have skewed data when submitting claims. Providers in multiple specialties will be compared with each other in the network.
Therefore, I think it's imperative that physicians understand they will be undergoing a great deal of scrutiny. Practitioners who deliver a large number of babies with low Apgar scores or excessive blood loss during or after cesarean delivery, and increased numbers of bad outcomes will undergo even more scrutiny. A significant problem is the denominator and mode of practice. What the medical profession does with close observation and interpretation of data is an open question. The Federation of State Medical Boards is having a difficult time trying to determine which physicians need to be evaluated, how to evaluate them, how to ascertain maintenance of proficiency, and what to do with physicians who need retraining or evaluation. There are very limited opportunities for structured, reliable retraining in the United States.
At my institution, we are beginning to work on surgical simulators. The use of these is becoming more and more widespread across the United States. As with anything new, there are not a lot of data driving the tools that are being used. We all remember the days of the laparoscopic simulators tying knots on gloves and putting balls in cups with various laparoscopic tools. In the near future, we will have to perform laparoscopic hysterectomies and various other procedures with a surgical simulator before we will be able to perform them on actual human beings. Remember the word haptic, which is defined as "of or relating to the sense of touch; tactile." Currently, the simulators I have used have little tactile "feeling," but this problem will soon be addressed. The days of introducing new technology with the weekend animal course for "credentialing" is over.
Therefore, it is important that physicians understand the future is already here. You are a statistic, and you are becoming more of a statistic as far as your hospital and medical staff are concerned. Be aware that various surgical and other misadventures will be looked at categorically and may require you to drop certain procedures and/or undergo retraining. Whether this will satisfy the public's need for greater safety is unknown at this time; however, it will not be long before these measures are applied universally. I foresee the day when all surgeons will be periodically required to "prove" their ability to perform surgery, with "re-credentialing" every 5 years.
Thomas E. Nolan, MD, MBA
Editor-In-Chief
References
- Darves B. Tiered physician networks spark controversy. ACP Observer. 2004;24(7):1-7. Available at: http:// www.acponline.org/journals/news/sep04/tiered.htm. Accessed November 10, 2004.
back
to top
|
