Random Thoughts from a Restless Mind

Transparency is the new buzzword in medicine. Systems should be transparent with regard to prices, if not costs. Doctors and other providers of healthcare services should publish their costs and fees, too. Various ratings and measurements have been developed in an attempt to measure that nebulous and elusive entity “Quality”. Calls have been made for transparency here as well; hospitals, doctors, and others are browbeaten to release any and all manner of quality measurements so that we might create something one could call an “informed patient”.

The first, and therefore most important challenge in the quest to measure quality is to agree on a definition of just what quality is. Like all rational discussions the first order of business is to agree on terms and the terms of engagement.

Let’s take the question of evaluating the quality of an individual surgeon. What are the salient metrics? Are we concerned with only outcomes? You know, success rates, complication rates, stuff like that. Is there more to the measurement? Should we be concerned with EFFICIENCY, the ability to obtain high quality outcomes in a more timely manner? How about VALUE, the soft and difficult to measure combination of quality and COST? In this day and age of “economic credentialing” in which doctors, hospitals, and other providers are held responsible for the cost of care, not only on an individual basis but also a societal one, it seems as if value is an inescapable aspect of quality, at least in the eyes of our government and the people who actually pay for healthcare.

Quality measures will be different for surgeons of different stripes; we will want to evaluate different complications and their rate of occurrence for an ophthalmologist versus, say, a cardiothoracic surgeon. Even similar adverse events like infection rates will have a different meaning across specialties. One classic example of a surgical complication is post-op infections. From my limited reading about heart and chest surgery it appears that the post-op infection rate is around 1-2%. This would be scandalous in eye surgery where the post-op infection rate is 100X lower, closer to .01-.02%. Stuff like this should be fairly easy to uncover, or at least you’d like to think so. It turns out that even this metric is rather hard to come by since multiple doctors will participate in the treatment of post-op infections, and literally no one offers up these stats uncompelled. Similar issues apply to specialty-specific complications (vitreous loss, graft leak) for similar reasons.

Right away the difficulty of measuring quality is obvious: even the simple quality measures appear to be something other than simple to discover right now.

Outcome measures are even trickier. Since I know eye surgery best let me stay in that arena and use cataract surgery as my example. For our discussion let’s assume that we have magically been granted unfettered access to every eye surgeon’s charts (and that they are all legible, and that they all contain the same basic information). It should be a rather simple proposition to draft meaningful criteria–let’s say “how well do the patients see after cataract surgery.?”  Would that it were so. The answer to that very simple question–how well do you see after surgery–depends on several variables, and further varies if you ask the question slightly differently. How much improvement did the patient achieve compared with pre-op? How fast did the improvement come? How well does the patient see without eyeglasses?  Is the patient more or less dependent on eyeglasses following surgery? What level of vision constitutes a success? Does the surgeon get the same results with complex cases?

I imagine these issues are not specific to ophthalmology. I can see the same types of questions and complexities in orthopedic surgery, for example. Think about hip replacement–along with cataract surgery and cardiac bypass surgery, hip replacement is arguably one of the most significant medical developments when we think about the quality of life enjoyed by an older person. What defines success in hip replacement? How long do you allow for success to occur for it to be deemed one for the  “win” column? Do we give bonus points for speed in the OR, both from a patient’s standpoint and an economic one? How about a surgeon’s ability to achieve the same level of success in a thin 70 year old tennis player and an obese, cart-riding smoker?

Seriously, if docs can’t come to an agreement about what constitutes “quality”, how can we in good faith measure it? Furthermore, if we WON’T define it we have no one but ourselves to blame when some nameless, faceless 30 year old sociology major in D.C. does it for us.

Nobody asked me (again), but as long as I’m here let me offer up a 3-part proposal to measure and promote quality using surgeons as a theoretical template. Let’s start with a thought exercise borrowed from CrossFit. Fitness training using the CrossFit methodology involves high intensity exercise while trying to maintain near-perfect movement and form. One is shown three targets from a shooting range. The first has random bullet holes all around the bullseye, the second has every shot dead-on perfect, and the third has 95% of the shots within the center bullseye and 5% on-target but not perfect. Which one represents the most desirable CrossFit training strategy?

In CrossFit the answer is “C”, 95% accuracy with the misses still close because this represents the optimal combination of form (accuracy) and intensity (speed). Is this directly applicable to surgery? Well, that depends on how far outside the bullseye the misses land, doesn’t it? And in surgery I think we also need a more accurate measurement of intensity; we need a clock. Speed matters, from both a medical standpoint and a financial one. The shorter a surgery lasts while still hitting the target, the less physically and mentally taxing it is for the patient, and the fewer costly resources (OR time, staff time, doctor time, supplies, etc.)  you are consuming during surgery. All things being equal, the surgeon who achieves the desired outcome faster without increasing her complication rate is the better surgeon.

Put surgeons on the clock.

A successful outcome must be explicitly defined for each common surgical procedure. Pre-operative factors that reduce the likelihood of success should certainly be taken into account (e.g. a morbidly obese cart-riding smoker and hip replacement), but care needs to be taken so that a measurement can’t be gamed (two guttata do not constitute a corneal dystrophy and increased likelihood of swelling) in order to work with a lower standard. Surgical societies should show some spine and make a call, define what constitutes a high-quality outcome, regardless of the howling that will emanate from the mediocre and the incompetent. It’s gonna happen anyway, and physicians making the call would be orders of magnitude better than MBA’s and philosophy majors.

Lastly, quality should be measured, publicized and praised, and those surgeons (and other doctors) should be explicitly rewarded with as many cases as they can (or wish to) handle. They should also be paid more. Once we decide what constitutes quality we can measure it and publish the data. People will understand this, just like they understand the data in a box score. Why is it so OK for the baseball player with the highest batting average or lowest ERA to be paid more based on his success, yet somehow the most efficient surgeon who has the best outcomes is labeled a “money grubber” who must somehow be doing something wrong if he is also very busy? We want that high batting average guy at the plate in the 9th inning of a tight ballgame, and we pay him more because of his higher quality outcomes. Why aren’t we doing the same thing with surgeons? The very least we can do is stop accusing surgeons of being successful!

It’s time that we apply basic theories about quality to medicine in general and surgery in particular. Indeed, it should be easier to do it with surgeons. Make a call–define a successful outcome. Pull out a stopwatch. Faster, more efficient surgery is less expensive and generally less taxing physically for patients. Once the data is available be transparent and publish the results. I know what Miguel Cabrera is batting this year; my patients (and potential patients) should know my “batting average” in the OR. While I hold out little hope of being heard on this last point, uncountable articles support the benefit of the carrot at the expense of the stick when it comes to promoting excellence. Higher quality should beget higher pay. At the very least we should stop with the assumption that the busy surgeon is somehow “getting over”, guilty of somehow gaming the system (eg. doing unnecessary surgery) until and unless proven innocent.

She may just be better.