|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Originally published as JCO Early Release 10.1200/JCO.2004.02.044 on June 15 2004 © 2004 American Society of Clinical Oncology.
Understanding Surgeon Performance and Improving Patient OutcomesDepartment of Surgery, University of Michigan, Ann Arbor, MI Some surgeons have better outcomes than others. Although the implications of this assertion make clinicians uncomfortable, there should be little doubt that it is true. For example, O'Connor et al1 demonstrated more than a decade ago, a six-fold variation in operative mortality rates among surgeons performing coronary artery bypass surgery in northern New England, despite adjusting for illness severity and other patient characteristics. Variation in performance is related to several surgeon characteristics, including how often they perform a given procedure (volume), subspecialty certification, and the hospital setting in which they operate.2-4 Although evidence linking these characteristics to operative mortality is particularly strong, surgeon factors also predict rates of postoperative complications and even cancer outcomes after selected surgical procedures.5,6 In this issue of the Journal Of Clinical Oncology, Herr et al7 add to the literature, suggesting that subspecialty surgeons have better outcomes. In the context of a randomized, cooperative group trial assessing the effectiveness of neoadjuvant chemotherapy, the investigators studied late outcomes in patients undergoing radical cystectomy and the role of surgeon-related factors. In a subgroup analysis, patients who underwent surgery by urologic oncologists had substantially lower rates of local tumor recurrence than those who were operated on by general urologists (6% v 23%, respectively; P = .06). They also had higher 5-year survival rates (58% v 48%, respectively; P = .053). Although not quite statistically significant, the magnitudes of these differences are clinically compelling. No oncologist would dismiss a new chemotherapy regimen or radiation treatment that produced a 10% absolute gain in long-term survival. One obvious response to such data is evidence-based referral—direct more patients to surgeons or hospitals likely to achieve the best outcomes (eg, subspecialists, high-volume surgeons or hospitals). This could occur simply by providing patients or their referring physicians with more information to guide their decisions about where and by whom to undergo surgery. Although most sites do not currently provide data on surgical treatment for bladder cancer, numerous Internet sites, including http://www.healthgrades.com, provide hospital-specific data about mortality rates and procedures volumes with many other operations. Evidence-based referral can also be leveraged by payers. For example, the Leapfrog Group, a large coalition of public and private employers covering more than 40 million patients, is using a variety of financial and other incentives to steer patients to high-quality hospitals for coronary artery bypass surgery, percutaneous coronary interventions, elective aortic aneurysm repair, esophagectomy, and pancreatic resection.8 Although such efforts may be the right place to start, evidence-based referral is ultimately limited in its ability to improve surgical outcomes. First, our ability to correctly identify high-quality surgeons or hospitals is suspect. With the notable exception of cardiac surgery, adequately precise, risk-adjusted, and publicly available provider-specific outcome data remain scarce for most procedures. Indirect measures of quality, including surgeon volume or subspecialty certification, may be better than no information at all. However, such measures often poorly predict the performance of individual surgeons or hospitals. Second, even if quality could be reliably assessed, the likelihood of redirecting all patients to the highest quality providers is remote. Unlike Canada's single-payer, government-run system, the US health care system is fractured and decentralized, such that no payer group or regulatory body has sufficient leverage to implement such far-reaching policies. Given patient preferences, geography, capacity at tertiary care centers, provider financial incentives, and other factors, many patients will undoubtedly continue to receive their care from surgeons or hospitals with suboptimal outcomes. Under this reality, strategies for improving the quality of surgical care delivered by all surgeons and hospitals must be considered. For this to occur, we must first understand why some surgeons have better outcomes than others. With radical cystectomy, Herr et al found that achievement of negative margins, and excision of at least 10 lymph nodes, were each associated with substantially lower recurrence rates, and higher late survival. Although other reasons cannot be excluded, urologic oncologists seemed to have better outcomes in large part because they were more successful with these two aspects of care than their generalist counterparts. Once processes of care underlying better outcomes are identified, such practices can then be implemented by other surgeons. The potential for process improvement to improve surgical outcomes is perhaps best illustrated in rectal cancer. Local recurrence and late survival rates after surgical resection for rectal cancer have long been known to vary widely across both hospitals and surgeons.4,5,9 Subsequent research has demonstrated that surgeons vary widely in how often they achieve adequate node clearance and circumferential margins at the tumor site—two variables strongly related to late prognosis.10 Such observations have prompted numerous quality improvement initiatives aimed at training nonspecialist surgeons in the techniques of total mesorectal excision. Many of these initiatives have been remarkably successful, particularly in Europe. According to data from a national registry in Norway, for example, the use of total mesorectal excision, once performed infrequently, increased to 96% of patients by 1998.11 Although other improvements may have also contributed to better outcomes, local recurrence rates in Norway fell from 28% in 1988 to only 8% by 1998. Late survival rates improved similarly. Achieving better outcomes through process improvement assumes that high-leverage processes of care can be both identified and widely implemented. Neither of these assumptions is completely safe. For most procedures, processes of care that determine patient outcomes may be numerous and difficult to isolate. Different processes may also determine different types of outcomes. For example, techniques related to surgical margins and node excision may be important determinants of late oncologic outcomes after radical cystectomy, but it is unlikely that these factors explain the wide variation in operative mortality rates observed with this procedure.3 Simply identifying important processes of care may not always be sufficient. In other words, awareness that negative surgical margins are important does not mean that all urologists will be able to achieve them with the same regularity. For some procedures, technical proficiency may depend on subspecialty training and sufficient ongoing experience with that procedure (volume), which may not be easily transferred. For example, also in this issue of the Journal of Clinical Oncology, Sano et al12 demonstrate that highly experienced surgeons can achieve remarkably low mortality rates (0.8%) with D2, and even more aggressive resections for gastric cancer.12 In contrast, in a randomized clinical trial involving a broader cross-section of surgeons, D2 resection was accomplished only with significantly higher mortality than with simpler D1 resection (10% v 4%, respectively; P = .004).13 The relative merits of evidence-based referral and process improvement for different procedures will no doubt continue to be debated. Although neither is likely to completely eliminate variation in surgeon performance, either approach seems better accepting the variable care and variable outcomes of the status quo. Author's Disclosures of Potential Conflicts of Interest The following author or their immediate family members have indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. Acted as a consultant within the last 2 years: John D. Birkmeyer, Leapfrog Group. REFERENCES 1. O'Connor GT, Plume SK, Olmstead EM, et al: A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. JAMA 266:803-809, 1991[Abstract]
2. Birkmeyer JD, Siewers AE, Finlayson EVA, et al: Hospital volume and surgical mortality in the United States. N Engl J Med 346:1128-1137, 2002
3. Birkmeyer JD, Stukel TA, Siewers AS, et al: Surgeon volume and operative mortality in the United States. N Engl J Med 349:2117-2127, 2003 4. Porter GA, Soskolne CL, Yakimets WW, et al: Surgeon-related factors and outcome in rectal cancer. Ann Surg 227:157-167, 1998[CrossRef][Medline]
5. Hillner BE, Smith TJ, Desch CE: Hospital and physician volume or specialization and outcomes in cancer treatment: Importance in quality of cancer care. J Clin Oncol 18:2327-2340, 2000
6. Begg CB, Reidel ER, Bach PB, et al: Variations in morbidity after radical prostatectomy. N Engl J Med 346:1138-1144, 2002
7. Herr HW, Faulkner JR, Grossman HB, et al: Surgical factors impact bladder cancer outcomes: A cooperative group report. J Clin Oncol 22: 2781-2789, 2004 8. Leapfrog Group: Patient safety: Setting standards. Last accessed January 26, 2004. http://www.leapfroggroup.org 9. Kapiteijn E, Marijnen CAM, Colenbrander AC, et al: Local recurrence in patients with rectal cancer diagnosed between 1988 and 1992: a population based study in the west Netherlands. Eur J Surg Oncol 24:528-535, 1998[CrossRef][Medline] 10. Quirke P: Training and quality assurance for rectal cancer: 20 years of data is enough. Lancet Oncol 4:695-702, 2003[Medline] 11. Wibe A, Eriksen MT, Syse A, et al: Total mesorectal excison for rectal cancer: What can be achieved by a national audit? Colorectal Dis 5:471-477, 2003[CrossRef][Medline]
12. Sano T, Sasako M, Yamamoto S, et al: Gastric cancer surgery: Morbidity and mortality results from a prospective randomized controlled trial (JCOG 9501) comparing D2 and extended para-aortic lymphadenectomy—The Gastric Cancer Surgical Study Group of Japan Clinical Oncology Group. J Clin Oncol 22:2767-2773, 2004
13. Bonenkamp JJ, Hermans J, Sasako M, et al: Extended lymph-node dissection for gastric cancer. Dutch Gastric Cancer Group. N Engl J Med 340:908-914, 1999 Related Editorials
Related Articles
This article has been cited by other articles:
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
