"All the surgeons I know think that while they may not be the best in the world at what they do, they are clearly above average (think Lake Wobegon, but as adults). Hence, it can be a little disconcerting when data is produced that suggests that at least half of us have room for improvement," writes Henry Rosevear, MD.
All the surgeons I know think that while they may not be the best in the world at what they do, they are clearly above average (think Lake Wobegon, but as adults). Hence, it can be a little disconcerting when data is produced that suggests that at least half of us have room for improvement.
Quality surgery, of course, can be defined in many ways. Two definitions come to mind immediately. The first and probably most important is medical. To my knowledge, in the world of urology, the only national database that compares surgical outcomes is published by ProPublica (https://projects.propublica.org/surgeons/). This database calculates death and complication rate for eight elective operations, two of which are urologic (prostate removal and prostate resection). The outcome is a simple bar graph that lists a surgeon’s complication rate as versus that of his peers.
This database does not have any information on medical outcomes such as positive margin status, making it somewhat incomplete. After all, what is the purpose of choosing a cancer surgeon with few complications if he also doesn’t get the job done? Further, when I query this database for prostate removal, one of the surgeons listed hasn’t done a case in over 3 years. So I question how up to date it is. Other specialties have more specific information, the best of which is probably the Society of Thoracic Surgeons, which publishes an online searchable data base on outcomes for various cardiac surgeries (http://publicreporting.sts.org). While this data is not complete, it is certainly useful information and I applaud the efforts of those who put it together.
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But that is not what this blog is about. Rather, this blog is to talk about the second definition of a good surgeon, which is surgical efficiency. What does that mean? Cost. Now, I realize some folks will immediately disagree with me or worse. I also am aware that some people believe the costs of surgery shouldn’t even enter a surgeon’s mind. But in a world of limited resources where the money on disposables spent on one patient limits what can be spent on another, this is a legitimate area of concern. Further, if two urologic surgeons can get the same outcome (stone gone, patient home safe with no issues) and one is spending twice the other on disposables, isn’t there something to be learned?
What prompted this? I recently learned that of the four urologists who routinely perform ureteroscopy at my hospital, the disposable costs vary significantly among them. While I don’t have any hard data on complication rate, as I take call on everyone’s patients, I can say that no one stands out. On the other hand, I do know that one of us tends to tackle larger, more complicated stones ureteroscopically and one certainly does not-a practice pattern that likely explains at least some of the cost variation. With that in mind, the hospital recently presented us with data showing that, compared to the average of the four of us and only looking at disposable costs (not OR time and certainly not case complexity or practice patterns), one of us is 40% below average, one is 7% above, one is 10% above, and one is 33% above.
Makes you wonder, doesn’t it?
This situation is not unique to urology. Similar cost variation among surgeons doing the same case is well documented. There are published examples in the orthopedics world(Orthop J Sports Med 2016; 4:2325967116677709), general surgery world(Surg Endosc 2016; 30:2679-84), and spine world(Bone Joint J 2015; 97-B:1102-5).
Next: What can we do about this?
What can we do about this? First, knowledge is power. Sometimes simply naming names is enough. A recently published paper showed that by simply providing surgeons with a monthly scorecard listing supply costs for each case they did, the intervention group was able to decrease costs by almost 10% with no changes in medical outcomes (JAMA Surg 2017; 152:284-91). And while that may work in some cases, given variations in case complexity, practice pattern, and the lack of granularity of billing data (ie, I bill a 52356 ureteroscopy laser lithotripsy with stent placement for both a 7-mm distal ureteral stone and a 2-cm renal pelvis stone), it is naïve to think that every case and every surgeon will have the same costs.
Correctly making tough intraoperative decisions is what surgeons are paid to do. With that in mind though, it is likely possible to cut some of the “fat” from the system. The general surgery article referenced above, which examined cost variation in laparoscopic cholecystectomy, provides one example. This group was able to identify the disposable equipment that produced the least costs without negatively impacting outcomes.
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While this may work in the academic setting, I question whether it will work in the private practice setting. Why? For no other reason than the outcomes of interest for a hospital and a surgeon are not aligned. The goal of the hospital is to provide medically safe surgery in a cost-efficient manner. The surgeon’s goal, in contrast, is only to achieve a good medical outcome. A surgeon takes home the same amount of money if he or she spends $1 on disposables or $1 million.
My group is taking this to heart and approaching one of the hospital systems in town about better aligning our goals. We are proposing to internally evaluate our use of disposable equipment while monitoring clinical outcomes with the understanding that any gains are shared between the hospital and the surgeons. I don’t know if this is going to work, but I don’t see how it can hurt. I’ll report back in a few months with an update on how this turns out for us.
Primum non nocere. And I would argue that we make an effort to do surgery efficiently. If anyone else has thought about this issue and has ideas on how to reduce costs while continuing to provide excellent care, please write me at firstname.lastname@example.org.
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