| The information in this column is intended for | | | | stay after surgery also declined by a rather incredible |
| informational purposes only, and does not constitute | | | | 50 percent (from an average of 9 days, to 4 days). |
| medical advice or recommendations by the author. | | | | Needless to say, if the NSQIP results from these 132 |
| Please consult with your physician before making any | | | | VA hospitals were to be universally replicated in all of |
| lifestyle or medication changes, or if you have any | | | | the nearly 6,000 hospitals in the United States, the |
| other concerns regarding your health. | | | | potential for improvement in patient morbidity and |
| As a practicing cancer surgeon, complications | | | | mortality, and consequently in the cost of delivering |
| following surgery (including death, which can be | | | | high quality surgical care in the United States, would |
| considered the "ultimate" complication of surgery) are | | | | be enormous (currently, only 243 civilian hospitals are |
| of great concern to me. As federal and state | | | | listed as voluntary NSQIP participants by the |
| government officials continue to grapple with the | | | | program's steward, the American College of |
| tremendously complex and seemingly insoluble | | | | Surgeons). |
| deficiencies in our current health care system here in | | | | As surgeons finally begin to move from their long |
| the United States, one area that has been receiving | | | | tradition of well-intentioned but seriously flawed |
| increased attention, lately, has been patient | | | | retrospective analysis of postoperative complications, |
| outcomes following surgery. | | | | and into the dawning era of prospective data |
| Traditionally, surgeons have reviewed and analyzed | | | | collection and analysis, a detailed evaluation of the |
| their complications during regular morbidity and | | | | data from programs such as NSQIP will continue to |
| mortality ("M&M") conferences. Each surgical | | | | yield important new insights into the causes of |
| complication is presented by the operating surgeon | | | | preventable surgical complications and deaths. Indeed, |
| during such conferences, and the surgeon, and his or | | | | a newly published study in the prestigious New |
| her peers, then analyze the patient's clinical course. A | | | | England Journal of Medicine, from the University of |
| consensus is then, hopefully, reached as to the | | | | Michigan, evaluated NSQIP data collected on 84,730 |
| proximate causes of the patient's complications. | | | | surgical patients between 2005 and 2007. Unlike most |
| Therefore, the goal of M&M conferences is to | | | | prior studies that have used NSQIP data to assess |
| retrospectively identify patient risk factors for | | | | the potential causes of preventable surgical |
| complications, as well as to examine the quality of | | | | complications and mortality, the authors of this |
| care that patients have received, in an effort to | | | | research study were particularly interested in the role |
| identify areas where patient care can potentially be | | | | of patient management in preventing postoperative |
| improved, and complications, perhaps, prevented. | | | | deaths once complications had, in fact, already |
| Unfortunately, there are several obvious weaknesses | | | | occurred. |
| associated with this approach to quality improvement | | | | The authors of this important clinical study ranked |
| in patient care. The first and perhaps greatest | | | | the NSQIP-participating hospitals according to their |
| weakness of M&M conferences is their | | | | overall death rates for patients undergoing inpatient |
| retrospective nature. A great deal of subjectivity is | | | | surgery, and divided them into five different groups, |
| injected into the analysis of specific patient care | | | | based upon their mortality rankings. The researchers |
| factors when the operating surgeon reviews his or | | | | then evaluated and compared the extensive NSQIP |
| her own patient complications, in hindsight, and then | | | | data in each of these five groups of hospitals. The |
| presents selected patients to other surgeons | | | | results of this analysis were both intriguing and, |
| participating in the M&M conference. Whether by | | | | seemingly, rather counterintuitive. |
| accident or by intention, important lapses in diagnosis | | | | The first important finding of this study was that the |
| and/or treatment are commonly withheld during such | | | | actual incidence of complications following surgery did |
| conferences, which often leads to an incomplete | | | | not significantly vary among the hospitals studied. |
| picture of the events leading up to patient | | | | The second illuminating finding of this study is that, |
| complications and deaths. | | | | unlike complication rates, death rates following |
| Another pitfall of M&M conferences is directly | | | | surgery did significantly vary among these same |
| related to the interpersonal and professional dynamics | | | | hospitals (from 3.5 percent among the best |
| between surgeons participating in such conferences. | | | | performing hospitals, to 6.9 percent among the |
| Some medical centers' M&M conferences have a | | | | poorest performing hospitals). |
| justly earned reputation for being ruthlessly | | | | A comprehensive review of the NSQIP data for |
| aggressive in holding individual surgeons accountable | | | | these nearly 85,000 surgical patients confirmed that |
| for their complications, in an effort to improve the | | | | the two-fold difference in death rates that was |
| quality of patient care. At the same time, in many | | | | observed between the best performing and worst |
| other medical centers, M&M conferences are | | | | performing hospitals appeared to be directly related |
| relatively benign and quasi-social affairs among collegial | | | | to the way that patients with major complications |
| groups of surgeons, and a critical evaluation of | | | | were managed once the complications occurred, and |
| surgeons' care of their patients is, instead, substituted | | | | not due to any underlying difference in the actual |
| with an affable and superficial review of patient | | | | incidence of complications among the various |
| complications and deaths that, too often, fails to drill | | | | hospitals. Thus, the authors concluded that our |
| down to specific potential patient care deficiencies. | | | | attention must not only continue to focus on |
| Both extremes in approaches to surgeon morbidity | | | | preventing complications, but that we should also |
| and mortality conferences tend to obscure the true | | | | more aggressively concentrate on our actual |
| causes and events associated with patient | | | | management of complications following surgery, once |
| complications and unexpected deaths following | | | | they occur, in our ongoing efforts to reduce the |
| surgery, due to the many biases that are injected | | | | incidence of preventable postoperative deaths. |
| into purely retrospective M&M conferences. | | | | In view of the landmark Veterans Administration |
| In an attempt to overcome the intrinsic biases and | | | | NSQIP findings linking the prevention of complications |
| limitations associated with a purely retrospective | | | | with a decrease in postoperative death rates, it may |
| assessment of surgical complications, most surgeons | | | | seem counterintuitive that the two-fold difference in |
| at morbidity and mortality conferences present clinical | | | | postoperative death rates observed in this new |
| research studies, published in peer-reviewed medical | | | | study appeared to be unrelated to the actual |
| journals, in an effort to inject some scientific | | | | incidence of complications among the hospitals |
| objectivity into the discussion. However, once again, | | | | studied. However, it is important to remember that |
| personal biases still often arise despite attempts to | | | | these same hospitals had already previously |
| present published clinical data relevant to the | | | | demonstrated their strong commitment to reducing |
| complication being discussed, as it is almost always | | | | preventable postoperative complications through their |
| possible to find a couple of published papers that | | | | voluntary participation in the NSQIP program. |
| appear to support the decisions that were made by | | | | Therefore, the finding of this study that complication |
| the operating surgeon. | | | | rates did not vary considerably among these |
| In response to growing concerns regarding the quality | | | | particular hospitals may not be applicable to the vast |
| of surgical care at Veterans Administration hospitals in | | | | majority of hospitals that have not yet adopted |
| the United States, a paradigm-shifting approach to | | | | NSQIP guidelines (or other comparable, prospective |
| the analysis of surgical complications was initiated by | | | | surgical quality improvement programs). |
| the Veterans Administration (VA) in 1991. Out of an | | | | The results of this study clearly show that, while the |
| abundance of concern over the high rate of | | | | implementation of the NSQIP program is helping |
| postoperative complications and deaths at several | | | | participating hospitals to make significant progress in |
| VA medical centers, the National Surgical Quality | | | | reducing the incidence of complications following |
| Improvement Program (NSQIP) was born. Between | | | | surgery, we still have much work to do in devising |
| 1991 and 2001, VA medical centers prospectively | | | | and implementing evidence-based clinical pathways for |
| collected data encompassing multiple patient risk | | | | managing those complications that, despite our best |
| factors, as well as data related to 30-day | | | | efforts, still continue to occur. Based upon the results |
| postoperative morbidity (complications) rates, and | | | | of this important clinical research study, it appears |
| 30-day postoperative mortality (death) rates. Using | | | | that we can further and dramatically reduce the |
| this prospectively collected data to improve surgical | | | | incidence of unnecessary deaths following surgery |
| care at all of the VA's 132 medical centers that | | | | while, at the same time, significantly reducing the |
| perform surgery, the VA was able to subsequently | | | | already excessive cost of delivering quality health |
| demonstrate some striking improvements in patient | | | | care in the United States. |
| outcomes. Specifically, between 1991 and 2001, | | | | Disclaimer: As always, my advice to readers is to |
| 30-day death rates following surgery decreased by | | | | seek the advice of your physician before making any |
| 27 percent, while postoperative complications | | | | significant changes in medications, diet, or level of |
| occurring within 30 days of surgery were decreased | | | | physical activity. |
| by a whopping 45 percent. The average length of | | | | |