There Is a Critical Relationship between Large-scale Clinical Data Registries, Analysis of Clinical Practice Variation, and Outcomes Improvement
The phenomenon of large differences in treatment, cost, and outcomes in contemporary medical practice is well-known to the general public, business, and medical communities, and is generally associated in some indistinct fashion with medical quality.*1
However, to relate these differences more precisely to the concept of medical quality, it is important to reach a consensus on what medical quality actually is, or should be. The concept of “quality” originated in industry with efforts to decrease variation in manufactured products, principally initiated by Walter Shewhart's concept of statistical process control.3
Similar efforts to decrease variation in medical practice outcomes are likewise critical to the concept of medical quality, but have been hampered by (1) a lack of understanding of the fundamental link between outcomes variation and medical quality improvement, (2) physicians practicing with an individualistic, artisan-like approach in a fragmented medical practice environment, and (3) individual physicians and individual institutions relying on their own practice outcomes data for quality improvement.4–6
The Society of Thoracic Surgeons National Database, the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP), and the American Society of Anesthesiologists Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry (NACOR) exemplify the efforts of organized medicine to approach quality improvement through the use of large-scale data registries, and recent editorials in this journal have highlighted the importance of using clinical data registries, including analysis of clinical care variation, for the purpose of improving clinical outcomes.7
“Accomplished soloists must transition into members of a well-orchestrated symphony.”
We Are Increasingly All on the Same Team
As healthcare systems consider opportunities for cost containment and quality improvement, the lowest-hanging fruit is often related to the delivery of surgical services, principally through decreasing surgical length of stay, incidence and severity of perioperative complications, and rate of readmission. However, meaningful performance improvement in these areas is dependent upon surgical team
practice and an institutional systems
approach, rather than on autonomous physician practice.9–11
Accomplished soloists must transition into members of a well-orchestrated symphony. Although systems-based team practice has been the norm for many years in a few institutions, such as the Mayo Clinic and the Cleveland Clinic, the current, rapid evolution of U.S. surgical practice into physician teams practicing in integrated healthcare delivery systems is driven by three factors: the growing preference of young physicians to work as employees of large medical group practices or healthcare systems, the coalescence of individual healthcare institutions into large, integrated healthcare systems, and the emphasis of the Patient Protection and Affordable Care Act on accountable care organizations and bundled care payments in preference to traditional fee-for-service care.†12
Ideally, surgical outcomes registries should reflect these changes in the delivery of surgical services by placing emphasis upon the outcomes of surgical teams practicing in integrated healthcare systems, rather than on the results of individual physicians or individual medical specialties. A national health information network, combining clinical and administrative data, may facilitate more comprehensive quality analysis.14
The Michigan Surgical Quality Collaborative and its patient outcomes registry is an example of physicians, hospitals, and a commercial health insurance payer working successfully together to improve surgical care.15
In addition, the concept of the surgical home promoted by the American Society of Anesthesiologists provides an ideal template for the role of anesthesiologists in the future of surgical and procedural services delivery.16
How Do We Unlock Additional Value in Anesthesia Services?
As early as 2005, the American Society of Anesthesiologists' Task Force on Future Paradigms of Anesthesia Practice recognized the rapid evolution of surgical care, urging our specialty to acknowledge and adapt to these changes and avoid the inevitable consequences of becoming trapped in a professional status quo
ANESTHESIOLOGY has selected four peer-reviewed editorials to highlight opportunities and threats to our specialty as we deliberate a transition from a predominant emphasis upon operating room anesthesia care to a more expansive approach in assuming leadership and management of invasive procedural services delivery in integrated healthcare delivery systems—the surgical home concept. These editorials provide compelling impetus for anesthesiology's leaders in clinical practice, education, and research to drive the transition of our specialty into the future of surgical and invasive procedural care delivery.
David C. Mackey, M.D., Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas. email@example.com
* Carey J: Medical guesswork: From heart surgery to prostate care, the health industry knows little about which common treatments work. May 29, 2006. http://www.businessweek.com/print/magazine/content/06_22/b3986001.htm?chan=gl
. Accessed March 10, 2012. Cited Here...
1. Gawande A: The cost conundrum. What a Texas town can teach us about health care. The New Yorker, , 2009
2. Ghaferi AA, Birkmeyer JD, Dimick JB: Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009; 361:1368–75
3. Shewhart WA: The application of statistics as an aid in maintaining quality of a manufactured product. J Am Statistical Assoc 1925; 20:546–8
4. Batalden PB, Buchanan ED: Industrial models of quality improvement, Providing Quality Care. The Challenge to Clinicians, 1st Edition. Edited by Goldfield N, Nash DB. Philadelphia, American College of Physicians, 1989
5. Jensen NF, Tinker JH: Quality in anesthesia care: Lessons from industry and a proposal for valid measurement and improvement. Clin Perform Qual Health Care 1993; 1:138–51
6. Fasting S, Gisvold SE: Statistical process control methods allow the analysis and improvement of anesthesia care. Can J Anesth 2003; 50:767–74
7. Lanier WL: Using database research to affect the science and art of medicine. ANESTHESIOLOGY 2010; 113:268–70
8. Kheterpal S: Random clinical variation. Identifying variation in perioperative care. ANESTHESIOLOGY 2012; 116:3–5
9. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP: Enhanced recovery pathways optimize health outcomes and resource utilization: A meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011; 149:830–40
10. Kehlet H, Wilmore DW: Surgical care – how can new evidence be applied to clinical practice? Colorectal Dis 2010; 12:2–4
11. Kehlet H, Mythen M: Why is the surgical high-risk patient still at risk? Br J Anaesth 2011; 106:289–91
12. Less than 30% of physicians now in solo, partner practice. Daily Briefing. The Advisory Board Company, , 2010, Washington, D.C.
13. Abelson R: Hospital groups will get bigger, Moody's predicts. NY Times , 2012
14. Glance LG, Neuman M, Martinez EA, Pauker KY, Dutton RP: Performance measurement at a “tipping point.” Anesth Analg 2011; 112:958–66
15. Share DA, Campbell DA, Birkmeyer N, Prager RL, Gurm HS, Moscucci M, Udow-Phillips M, Birkmeyer JD: How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care. Health Aff 2011; 30:1–10
16. The Perioperative or Surgical Home. An Emerging Draft Proposal for Pilot Innovation Demonstration Projects. American Society of Anesthesiologists, 2011
17. Miller RD: Report from the Task Force on Future Paradigms of Anesthesia Practice. American Society of Anesthesiologists Newsletter 2005; 69:20–3
© 2012 American Society of Anesthesiologists, Inc.