Measuring quality care in surgery

We live in an age where transparency and accountability have become central values of public life. It is possible to measure and compare organisations and individuals in a manner that was inconceivable a few decades ago. Schools, businesses, governments, and sports teams are analysed in minute detail.

Doctors and hospitals have been an important target of this trend. Patients want to be sure that they are receiving quality care and healthcare funders want to ensure that they are getting good value for the money they are paying healthcare providers.

But what is quality care? Is it a doctor who is kind and holds your hand? Is it a hospital with free high-speed Wi-Fi? How do we measure quality?

Robert McNamara was the United States Secretary of Defence during the Vietnam War. He believed that America was winning the war based on his quantification of success (the enemy body count) while ignoring other variables. The ‘McNamara fallacy’ bears his name and says that we end up measuring what can easily be measured and we disregard what cannot be measured. Things that aren’t measured end up being ignored as unimportant. In healthcare there are many things that are easy to measure and these end up being used as the yardstick by which we judge the quality of medical care – regardless of whether they are useful metrics or not.

Surgery is at the centre of this discussion. Surgical care involves inherent risks that can lead to major complications for the patient and significant costs for healthcare funders. A simple operation to remove a gallbladder that ordinarily involves just an overnight stay in hospital can end up with major complications that keep a patient in hospital for months and months.

Every patient undergoing an operation should ask themselves (and their surgeon) the following questions:

• Is the operation necessary?
• Has all the right testing and preparation been done before the operation?
• Is the right surgeon doing the operation?
• Is the hospital appropriate for the procedure?

John Birkmeyer is a surgeon in the United States of America and he has published a number of academic papers on the relationship between volume and outcome. He has clearly demonstrated that surgeons and hospitals that do higher numbers of complex operations have significantly better outcomes for those patients. Recently, Birkmeyer stirred controversy by saying that "Low-volume hobbyists are bad for patients and we have to stop them”. He instituted a low-volume pledge at his hospital group where surgeons voluntarily refrained from doing a certain kind of operation if their yearly numbers were too low to maintain proficiency.

Every surgeon aims to do their best for each patient with every operation. It is essential for surgeons and hospitals to audit their outcomes regularly.

After major cancer surgery, it is more important to measure quality of life and long-term survival, but it is often easier to measure the cost of care and length of stay in hospital – metrics that are perhaps less relevant to the patient in the long term.

There has been a strong move internationally to create centres of excellence where patients are directed to regional hospitals for major surgery. In a country such as South Africa it may be socioeconomically difficult to get a patient to travel for two hours to such a centre. The costs of travel and accommodation are prohibitive to a fairly large proportion of South Africans. A patient may be torn between the convenience of the local hospital and the expertise of travelling to a high-volume centre. Michael Porter, a healthcare economist at Harvard Business School said, "The only true measures of quality are the outcomes that matter to patients.”

A number of initiatives exist to try to incentivise doctors. A ‘pay for performance’ model is attractive but it may steer a doctor away from taking care of higher risk patients that might ruin their score. Discovery Health is partnering with a number of medical specialist organisations in a ‘pay for participation’ model. Doctors allow themselves to be audited by their peers and are remunerated by Discovery for participating in this process. The doctors themselves decide what should be measured and are given regular feedback about their performance relative to their peers.

Clinicians need to lead the audit and quality control process. Creating the infrastructure to do this is costly and resource intensive and there is a natural partner to do this in the medical scheme industry. It is difficult to measure quality and the raw data available is often quite weak.

We hope that the various societies that represent the various specialties will continue to grow, engage clinicians, and facilitate the audit process so that our patients can be sure that they are receiving quality care for a good price.

- Dr Dean Lutrin, Surgeon