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Quality and appropriateness of surgical care
J Oral Maxillofac Surg 47:730.732,1989
Quality and Appropriateness of Surgical Care PAUL A. EBERT, MD, FACS care, in particular, have brought about a reexamination of the ways in which quality has been defined and measured. Most notable has been the emphasis on the public disclosure of quality-related information, such as mortality statistics. The surgical profession, and rightly so, has raised key questions concerning the validity of such mortality statistics in truly helping the patient to determine where bettcr care can be received. Obviously, mortality data alone, without some stratification of the patient population, have essentially no meaning. As we all know, many times our best surgeons have a higher mortality rate because many patients are referred to them by other surgeons because they are considered to be more likely to obtain a good result in a high-risk patient. The Health Care Financing Agency (HCFA) has suffered greatly from its own data base, which was never intended to provide medical care information. Thus, one is able to obtain from the Medicare claims data such information as sex, age, and length of hospital stay, but no real information regarding the specific risk to each individual patient. It is true that HCFA is making major attempts to remedy this inability but, as yet, part A and B claims have not been able to be compared. This would certainly assist in the stratification of patients regarding risk. There also have been numerous papers in the recent past regarding the appropriateness of decisions to offer patients certain treatments. One of the most notable articles is that published in the March 24, 1988 issue of the New England Journal ofMedicine, regarding carotid endarterectomy. This study was undertaken on Veterans Administration patients by the Rand Corporation, and it showed that 32% of patients underwent carotid endarterectomy for "inappropriate reasons" and another 32% for "equivocal reasons." When the Delphi technique, as used by the Rand Corporation, is applied, the selection of panel members becomes most important. A review of the Rand data by seven individuals performing vascular surgery showed that in their view only 20% of the operations were inappropriate. Now, this is still a significant amount and cannot be discounted, but one must take into consideration that when review of any subject is undertaken, it most
I believe that all of us have always been concerned about the quality and appropriateness of surgical care. Clearly, therefore, it would be presumptious of me to come before you and attempt to tell you what is and is not appropriate in the field of oral and maxillofacial surgery. Your organization has been in the forefront in determining the indications for many of your services, and now you should be complimented for moving these efforts to an actual testing phase. Appropriate services have always seemed to be something we've taken for granted. The profession, per se, has learned from its seniors the pros and cons of one therapy versus another, and surgeons have selected what, in their view, has been the best and safest procedure to perform for each specific patient. There are, however, only a small number of experienced investigators in health care outcomes and a very limited amount of actual information in the literature to document what most of us have always assumed to be correct-that what we do is appropriate and hopefully performed to the best of our abilities. There is little question that concerns about health care spending have prompted much of the enthusiasm and emphasis about the words appropriateness, effectiveness, and quality. At the same time, there have been changes in the financing of healthcare, most notably, the implementation of Medicare's Hospital Prospective Payment System, and the risk-based health maintenance organization program. These changes have resulted in some redistribution of services from the inpatient to the outpatient setting, and have raised concerns that the quality of care may be compromised by efforts to reduce costs. Heightened concerns about quality of
* Director, American College of Surgeons, Chicago. Dr Ebert was the 1989Distinguished Lecturer, presenting this address at the AAOMS Clinical Congress, Palm Desert, California, January 28, 1989. Address correspondence and reprint requests to Dr Ebert: Director, American College of Surgeons, 55 EErie St, Chicago, IL 60611. © 1989 American Association of Oral and Maxillofacial Surgeons 0278-2391/89/4707-0013$3.00/0
730
PAUL A. EBERT
likely should have two separate reviews. One should be by a panel most familiar with the patient selection and indications for the procedure, and the other by a group that is not as speciality specific. I believe that only then will one be able to obtain a reasonable and realistic interpretation of what is appropriate. Whereas the peer review organization (PRO) program under Medicare has examined the care received by Medicare beneficiaries in the inpatient hospital setting, it has been much more difficult to identify and evaluate practice in the office. It is likely that HCFA may consider releasing information regarding physicians' specific mortality and morbidity data because this same information is currently available on a hospital-wide basis. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is focusing on the use of outcomes as a way of monitoring the quality of care being rendered. At the moment, the JCAHO is pilot testing an outcomes approach in 17 hospitals. This clearly has future implications nationwide. There are also many other attempts being made to identify indications and necessity for service. The American College of Physicians has developed a clinical assessment project to evaluate certain medical technologies. The Rand Corporation, in cooperation with UCLA, is developing "indications for selected medical and surgical procedures." The American Medical Association in 1988 established an office of quality assurance, which in cooperation with researchers at the Rand Corporation will'work to develop parameters of care. It is obvious that only a small percentage of HCFA's total budget has been directed toward research in health care outcomes. They have, however, begun an effectiveness initiative whose goal is to produce better information to guide the decisions of physicians and patients. In this effort, HCFA plans to make use of data from both Medicare claims and professional review organizations. In addition, HCFA is supporting a project to analyze data on the use of hospital services and provide feedback to practitioners about observed variations in use rates. Obviously, the attempt of this effort will be to influence the medical community to consider changes in their individual practice patterns by comparing its pattern with a regional or national "standard of practice." A more in-depth attempt to evaluate outpatient services will begin in 1989. All physicians' claims will have to include diagnosis codes, which would certainly enhance the value of Medicare claims data. As of now, office visits are essentially gauged by size, intensity, and length of time, but there is no real identification of specific diseases being treated.
731
This is in contradistinction to information that is easily available from hospital discharge data. The Physician Payment Review Commission is also devoting a great deal of attention to medical necessity, volume, and quality-of-care issues. The Commission has sponsored a conference to explore the issue of practice guidelines and to begin formulating a strategy for the development of such guidelines. A footnote from the Commission's previous report expressed the view that it now seems appropriate to develop national guidelines, but to apply them with recognition of local factors. This certainly is an important consideration because it is obvious that the style of medical practice may differ from region to region, even though it is very difficult to determine particular significant variations in outcome. Thus, two or more treatments may offer the same end result, but this is also difficult to include in guideline preparations. Clearly, with so many agencies, groups, and commissions working on the problem of medical guidelines, as well as on the issues of quality and effectiveness, it is easy to decide that these are not simple or straightforward issues. Certain observations would appear more important to discuss in consideration of these questions. It would seem reasonable that the PRO system might look at a physicians' or surgeons' longitudinal practice pattern rather than doing simple case-by-case review. It has always seemed to me that a physician who repeatedly performs services or operations for borderline or infrequent indications is more deserving of review than a physician or surgeon who has a single bad outcome in a particular case. One needs to look at the entire performance record and treatment patterns of this surgeon in order to draw any significant conclusions about his skills and abilities. A single case can often be very misleading. Likewise, when guidelines are established, the indications for an operation should be accompanied by a frequency of need. It is obvious that there are many indications for a particular operation, but the majority of them may be encountered very infrequently. Thus, if an individual practitioner is to be evaluated on a longitudinal basis, one needs to know what the indications were for the procedures he applied over a spectrum of patients and if the frequencies were in the same distribution as what one might anticipate, or if some operations were performed for very infrequent and questionable indications. It is obvious that we do not have enough qualified people actively involved in health outcome research. There needs to be better scientific training in the methods that one requires to do such sound, basic research. Too often our scientific journals are more interested in the content and possible impact
732
of a health care outcome article rather than on whether sound scientific methods were used . On a final note, one must remember that as more emphasis is put on appropriateness and effectiveness of a specific treatment, if the goal is truly cost containment, the savings will be based essentially on the frequency and number of inappropriate services. Once these are eliminated, it is unlikely that there will be significant future cost reductions. One must be certain that delays in treatment because of borderline indications do not result in more costly therapies being provided at a later time. This is why
QUALITY AND APPROPRIATENESS OF SURGICAL CARE
good health outcome research must follow patients in the inappropriate group, if they are denied service , for a long enough time to be certain that the indications themselves were truly correct, and that they were able to identify a segment of the population in which that particular operation was inappropriate for the indications presented. Otherwise, we may see a short-term reduction in health expenditure produced by these methods of review, but possibly a greater cost in the long term if the techniques and methodologies used to reduce services are not accurately field tested and reliability substantiated.
Quality and Appropriateness of Surgical Care PAUL A. EBERT, MD, FACS care, in particular, have brought about a reexamination of the ways in which quality has been defined and measured. Most notable has been the emphasis on the public disclosure of quality-related information, such as mortality statistics. The surgical profession, and rightly so, has raised key questions concerning the validity of such mortality statistics in truly helping the patient to determine where bettcr care can be received. Obviously, mortality data alone, without some stratification of the patient population, have essentially no meaning. As we all know, many times our best surgeons have a higher mortality rate because many patients are referred to them by other surgeons because they are considered to be more likely to obtain a good result in a high-risk patient. The Health Care Financing Agency (HCFA) has suffered greatly from its own data base, which was never intended to provide medical care information. Thus, one is able to obtain from the Medicare claims data such information as sex, age, and length of hospital stay, but no real information regarding the specific risk to each individual patient. It is true that HCFA is making major attempts to remedy this inability but, as yet, part A and B claims have not been able to be compared. This would certainly assist in the stratification of patients regarding risk. There also have been numerous papers in the recent past regarding the appropriateness of decisions to offer patients certain treatments. One of the most notable articles is that published in the March 24, 1988 issue of the New England Journal ofMedicine, regarding carotid endarterectomy. This study was undertaken on Veterans Administration patients by the Rand Corporation, and it showed that 32% of patients underwent carotid endarterectomy for "inappropriate reasons" and another 32% for "equivocal reasons." When the Delphi technique, as used by the Rand Corporation, is applied, the selection of panel members becomes most important. A review of the Rand data by seven individuals performing vascular surgery showed that in their view only 20% of the operations were inappropriate. Now, this is still a significant amount and cannot be discounted, but one must take into consideration that when review of any subject is undertaken, it most
I believe that all of us have always been concerned about the quality and appropriateness of surgical care. Clearly, therefore, it would be presumptious of me to come before you and attempt to tell you what is and is not appropriate in the field of oral and maxillofacial surgery. Your organization has been in the forefront in determining the indications for many of your services, and now you should be complimented for moving these efforts to an actual testing phase. Appropriate services have always seemed to be something we've taken for granted. The profession, per se, has learned from its seniors the pros and cons of one therapy versus another, and surgeons have selected what, in their view, has been the best and safest procedure to perform for each specific patient. There are, however, only a small number of experienced investigators in health care outcomes and a very limited amount of actual information in the literature to document what most of us have always assumed to be correct-that what we do is appropriate and hopefully performed to the best of our abilities. There is little question that concerns about health care spending have prompted much of the enthusiasm and emphasis about the words appropriateness, effectiveness, and quality. At the same time, there have been changes in the financing of healthcare, most notably, the implementation of Medicare's Hospital Prospective Payment System, and the risk-based health maintenance organization program. These changes have resulted in some redistribution of services from the inpatient to the outpatient setting, and have raised concerns that the quality of care may be compromised by efforts to reduce costs. Heightened concerns about quality of
* Director, American College of Surgeons, Chicago. Dr Ebert was the 1989Distinguished Lecturer, presenting this address at the AAOMS Clinical Congress, Palm Desert, California, January 28, 1989. Address correspondence and reprint requests to Dr Ebert: Director, American College of Surgeons, 55 EErie St, Chicago, IL 60611. © 1989 American Association of Oral and Maxillofacial Surgeons 0278-2391/89/4707-0013$3.00/0
730
PAUL A. EBERT
likely should have two separate reviews. One should be by a panel most familiar with the patient selection and indications for the procedure, and the other by a group that is not as speciality specific. I believe that only then will one be able to obtain a reasonable and realistic interpretation of what is appropriate. Whereas the peer review organization (PRO) program under Medicare has examined the care received by Medicare beneficiaries in the inpatient hospital setting, it has been much more difficult to identify and evaluate practice in the office. It is likely that HCFA may consider releasing information regarding physicians' specific mortality and morbidity data because this same information is currently available on a hospital-wide basis. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is focusing on the use of outcomes as a way of monitoring the quality of care being rendered. At the moment, the JCAHO is pilot testing an outcomes approach in 17 hospitals. This clearly has future implications nationwide. There are also many other attempts being made to identify indications and necessity for service. The American College of Physicians has developed a clinical assessment project to evaluate certain medical technologies. The Rand Corporation, in cooperation with UCLA, is developing "indications for selected medical and surgical procedures." The American Medical Association in 1988 established an office of quality assurance, which in cooperation with researchers at the Rand Corporation will'work to develop parameters of care. It is obvious that only a small percentage of HCFA's total budget has been directed toward research in health care outcomes. They have, however, begun an effectiveness initiative whose goal is to produce better information to guide the decisions of physicians and patients. In this effort, HCFA plans to make use of data from both Medicare claims and professional review organizations. In addition, HCFA is supporting a project to analyze data on the use of hospital services and provide feedback to practitioners about observed variations in use rates. Obviously, the attempt of this effort will be to influence the medical community to consider changes in their individual practice patterns by comparing its pattern with a regional or national "standard of practice." A more in-depth attempt to evaluate outpatient services will begin in 1989. All physicians' claims will have to include diagnosis codes, which would certainly enhance the value of Medicare claims data. As of now, office visits are essentially gauged by size, intensity, and length of time, but there is no real identification of specific diseases being treated.
731
This is in contradistinction to information that is easily available from hospital discharge data. The Physician Payment Review Commission is also devoting a great deal of attention to medical necessity, volume, and quality-of-care issues. The Commission has sponsored a conference to explore the issue of practice guidelines and to begin formulating a strategy for the development of such guidelines. A footnote from the Commission's previous report expressed the view that it now seems appropriate to develop national guidelines, but to apply them with recognition of local factors. This certainly is an important consideration because it is obvious that the style of medical practice may differ from region to region, even though it is very difficult to determine particular significant variations in outcome. Thus, two or more treatments may offer the same end result, but this is also difficult to include in guideline preparations. Clearly, with so many agencies, groups, and commissions working on the problem of medical guidelines, as well as on the issues of quality and effectiveness, it is easy to decide that these are not simple or straightforward issues. Certain observations would appear more important to discuss in consideration of these questions. It would seem reasonable that the PRO system might look at a physicians' or surgeons' longitudinal practice pattern rather than doing simple case-by-case review. It has always seemed to me that a physician who repeatedly performs services or operations for borderline or infrequent indications is more deserving of review than a physician or surgeon who has a single bad outcome in a particular case. One needs to look at the entire performance record and treatment patterns of this surgeon in order to draw any significant conclusions about his skills and abilities. A single case can often be very misleading. Likewise, when guidelines are established, the indications for an operation should be accompanied by a frequency of need. It is obvious that there are many indications for a particular operation, but the majority of them may be encountered very infrequently. Thus, if an individual practitioner is to be evaluated on a longitudinal basis, one needs to know what the indications were for the procedures he applied over a spectrum of patients and if the frequencies were in the same distribution as what one might anticipate, or if some operations were performed for very infrequent and questionable indications. It is obvious that we do not have enough qualified people actively involved in health outcome research. There needs to be better scientific training in the methods that one requires to do such sound, basic research. Too often our scientific journals are more interested in the content and possible impact
732
of a health care outcome article rather than on whether sound scientific methods were used . On a final note, one must remember that as more emphasis is put on appropriateness and effectiveness of a specific treatment, if the goal is truly cost containment, the savings will be based essentially on the frequency and number of inappropriate services. Once these are eliminated, it is unlikely that there will be significant future cost reductions. One must be certain that delays in treatment because of borderline indications do not result in more costly therapies being provided at a later time. This is why
QUALITY AND APPROPRIATENESS OF SURGICAL CARE
good health outcome research must follow patients in the inappropriate group, if they are denied service , for a long enough time to be certain that the indications themselves were truly correct, and that they were able to identify a segment of the population in which that particular operation was inappropriate for the indications presented. Otherwise, we may see a short-term reduction in health expenditure produced by these methods of review, but possibly a greater cost in the long term if the techniques and methodologies used to reduce services are not accurately field tested and reliability substantiated.