THCB

Surgical Complication Rates and the New Data Perspective

jordan shlain

In an age where the importance of data, statistics and predictive modeling win big games for baseball teams and make fat money for high-frequency traders, we are at the dawn of a new age of transparency in healthcare  It behooves every actor, in every sector, to use this new perspective to constructively illuminate best practices and design an infrastructure for true operational, clinical and logistic efficiencies at large scale and the local level – all in the spirit of getting the patient the best outcome.   

Every modern industry uses ‘big data’ to understand  the dynamics of their market landscape. This in turn, enables them to make decisions and develop strategies for gaining market share and building their brands. Fortress medicine has received a shot over the bow regarding the power of this new data perspective and needs to craft visionary, courageous yet mindful strategies that includes the bright light of outcomes into their private practices, clinics and large institutions. Propublica, in a seminal article, Making the Cut, shows us the power of transparency in complications rates during surgery. Doctors and their patients, since the dawn of medicine, have existed in a world without clarity around outcomes – there was not way to meaningfully collect it and analyze it. What Yelp has done for small business and Zagat has done for fine restaurants, CMS just did for the medical profession….and it just might be a needed dose of datacillin to start an honest conversation about what this all means.

Medicine has always grappled with complications, death and disability, in the private halls of hospitals. These are called “M & m” rounds – and they occur on a regular basis. The goal of these rounds is to dissect major mistakes (mortality – capital ‘M’) and minor ones too (morbidity, little ‘m’). 

These meetings are among peers and colleagues, in strict confidence, to share mistakes as a mechanism of improving. The Institute of Medicine in their acclaimed report, To Err is Human, highlights that many mistakes and death are human error. To be clear, they highlighted all forms of error; including nurses and pharmacists entering the wrong dose into the computers – not solely surgical complications. The point is that errors happen too frequently and people wind up dead or disabled as a result.  

I have personally attended my own father leading an M & m rounds to discuss an accidentally cut bile duct in a routine laparoscopic gall bladder removal. He was bummed out but not ashamed; rather he wanted to share his experience regarding variant anatomies (and we are mostly all different) that can lead to peril if specific maneuvers and procedures are not artfully choreographed. Sadly for the patient, a bad outcome occurred, yet in the end, an entire surgical department learns from his ‘mistake’. Morbidity and mortality rounds are meant to disseminate learning’s, better practices and to highlight error in a constructive, albeit humbling way.  

What Making the Cut elucidates is a new world order in healthcare Everyone on a surgical team is now part of the statistical modeling; for better or worse. Was the surgeon responsible, was it the nurse, the anesthesiologist, the post-surgical care, the patient, the follow up care coordination process – who is ultimately responsible for a bad outcome that is not clear-cut…and in many cases may never be clear.

Some bad outcomes and complications are just plain bad luck…and hopefully the data isn’t conflating all complications with a specific ‘culprit’. We need to look carefully at how the CMS dataset was analyzed. The last thing we need is a publication bias to morph into lore.  

Transparency on a grand scale will create the space for everyone to start talking to each other; stitching together the balkanized fiefdoms of medicine into coherent units that all see and own the outcome of individual patients – together. We can no longer hide behind the opaque veil of complexity and complex systems when in fact, taking care of patients is not complex, nor complicated.  Just look at the orthopedist from small town Alabama with the best outcomes.  What’s his special sauce? It appears that he took personal interest in follow up care. Is follow up the best medicine? Seems like it plays a significant role. After all, once a diagnosis has been made and treatment is commenced; the only way to know if a complication is imminent is to stay connected with your patient. If warning signs should arise, action should be taken. Simple as that; not complex. Sadly, medical codes (any payment) do not really exist for follow up care…..The Centers for Medicare & Medicaid Services has made two significant moves in the past year. One is to start paying for the management of poly-chronic (think the sickest of the sick) care coordination. Crazy that the government had to come up with that idea…the private sector is myopic when it comes to long term solutions in the context of quarterly earnings. Furthermore, on July 13th CMS just released new guidelines that will basically create a warranty for surgical procedures; specifically hip and knee surgery. Furthermore, a critical element of payment will be complication rates. The new paradigm in payment: your income will be dependent on your outcomes. Incomes = outcomes.

The crazy thing is that doctors, and I am one, have historically not participated in the data collection game. This was just a artifact of geeky computer science engineers building crappy code that doctors hated using (and still, mostly do). RAND’s 2013 report on the state of physicians is summarized here.

Data will give us a new perspective, a data perspective. This new illuminating presence is an opportunity that presents itself once in a generation. We can now see things in a new light.  

This puts doctors into the precarious position of being in the “if you’re not at the table, you may be on the menu” paradigm. Physician data is currently collected by EMR vendors, insurance companies, laboratory and radiology companies, pharmacies, revenue cycle management companies and a host of other third parties – but not the doctor….or if they do, it’s the exception. I have a hard time believing that your friendly, local insurance company will happily supply doctors all they data they want. This data is expensive, comes at a premium and is viewed through the lens of market share; not necessarily patient care.

Doctors need step up and start collecting their own data. As of now, all data often pre-analyzed by statisticians with conclusions drawn. Physicians have been reluctant to play the data game for good reason; they have always been at an asymmetrical disadvantage when it comes to the computational power of large institutions and their ‘crunched’ data. The time is now for the physician community to wake up and realize that if we don’t collect own our own data, and publish it; they will – and they will likely do it for their advantage.

The Centers for Medicare & Medicaid Services data that powers the Propublica article is a blunt instrument; like the first scalpel design– not sharp, not precise, but effective in making it’s point known. Many will argue that they see a ‘sicker population’; they their patients are ‘more complex’, and while this may be true, the data scalpels will become more sophisticated over time and physicians should be designing these tools with every major stakeholder for the sole purpose of getting the best outcomes. After all, patients want the best outcome and they are the whole point of medicine.

As the world of transparency descends on the fuzzy humanity of medicine, we all need to recognize that we are dealing with variable human anatomy, variable human physiology and human emotion. Data holds a key; a very important one, however it does not hold the key. Participatory humanism plus data does. 

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venus666DrShlaindocdaileyJohn IrvineMunia Mitra Recent comment authors
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venus666
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Data does explain something, but how to ensure the data’s accuracy is another question.

docdailey
Member

Munia, I too wondered about the methodology, so I looked. The methodology is discussed here: https://www.propublica.org/article/surgeon-level-risk-short-methodology More in depth here: https://static.propublica.org/projects/patient-safety/methodology/surgeon-level-risk-methodology.pdf It looks pretty good to me. They made a good faith effort to make this data good. It is likely somewhat forgiving. They don’t just throw stuff at the wall to see what sticks. The key here to all the uniqueness questions… the same standards are applied equally to everyone. It is fairly primitive (immature, naive and pedestrian are a bit more inflammatory than my intent) to just question the data. Everyone is on an equal footing here so… Read more »

DrShlain
Member

the big concern is that if we don’t give some composite weight to the risk of the patients, surgeons will not operate on high risk patients. I’m hopeful that smart people will come together and prevail on a solution that helps doctors, patients and the system equally.

Munia Mitra
Guest

Jordan – While I’m encouraged by the idea of opening the curtain, I’m not at all I agree about the value of these numbers. I do not see the context you mention (re: assigning nurses, anesthesiologists, patients. From what I can see, the propublica model assumes the surgeon is the captain of the ship. If a patient dies in the ICU because of a medication error, two days after surgery, the surgeon is given a complication, not the pharmacist. If the patient has a heart attack while going through rehabilitation.) The authors claim to have “screened for” high-risk patients, but… Read more »