Over the past year, we’ve seen more and more articles about operating room integration appear in medical journals and healthcare publications, an exciting sign that attitudes are shifting toward a broader understanding that digitally integrated O.R.s could be the new ‘gold standard’ of the surgical theater to help drive increased workflow efficiency and improve clinical outcomes.
But what about surgical outcome variability? Why is it that, in spite of the increased implementation of digitally-integrated workflows, not all surgeries are created equal?
This was the focus of a recent study conducted at the University of Michigan which addressed variability of surgical outcomes following minimally-invasive Laparoscopic Colectomy (LC). In it, variability of complication rates following LC was found to be two times higher among surgeons than it was for the same surgeons conducting Open Colectomy (OC), despite the increased risk profile and generally higher rate of complication for OC. Taken a step further, a second study published in the Journal of Gastrointestinal Surgery compared outcome variability following LC performed by 276 surgeons at 44 hospitals. Accordingly, outcomes varied by 30% across surgeons, compared with only 18.2% across hospitals.
There are several implications in these findings. One would be to challenge the assumption that Laparoscopic Colectomy, by merit of its minimally-invasive application, is an inherently less variable surgery relative to Open Colectomy. On the contrary, the variability of outcome pertains less to the elected surgery itself, and more to the surgeon's application of the chosen technique.
Thus, the quality gap revealed by these studies indicates the need for a more “surgeon-centric” approach to quality improvement.
It’s not that the authors aim to lay blame on the qualification or preparedness of the surgeon; laparoscopic surgeons receive extensive LC-specific training throughout residency and fellowship, and traditionally, participate in continuing education via surgical society meetings, cadaveric courses, and other MIS training forums. In this manner, the majority of laparoscopic surgeons arrive to the OR well-trained and knowledgeable of the latest techniques.
However, the next (and arguably most crucial) step is often skipped: quality review and proctoring. Without adequate case volume or experienced guidance, a surgeon recently trained in the latest LC techniques is unlikely to optimally apply their newly acquired skills in the surgical setting. And without access to the means of procedural assessment, the surgeon lacks the resources to self-improve – thus, the heightened potential for variability of outcomes.
These conditions suggest the need for video-based assessment, including both formal proctoring as well as self-evaluation. The potential for success in this application is high, as was recently demonstrated in a study of digitally-captured bariatric surgeries published in The New England Journal Of Medicine. According to the study, skill levels vary widely amongst fully-trained and equally qualified surgeons, indicating a steep "learning curve" post-training. More importantly, surgical skill was found to be strongly correlated to clinical outcome. In this context, peer review and rating of each surgeon’s application of laparoscopic techniques was proven as an effective method to assess proficiency and drive skills improvement.
Together with more formalized and ongoing proctoring, video-based assessment could be a key tool for narrowing the gap in surgical quality.
And clearly, there are far more stakeholders who will benefit from video-based surgical assessment besides surgeons and patients. As the healthcare pendulum swings toward a more value-based care system, O.R. managers and hospital administrators will need to embrace surgical quality management as a pivotal strategic differentiator. Driving this type of large-scale transformational change at large organizations (especially hospitals) can be difficult, and early adoption can be cumbersome. But implementing video-based surgical assessment can lead to key procedural discoveries, and the first incremental wins required to create positive momentum around new skills-assessment protocols, and ultimately, the standardization of tried-and-true best practices across the surgical team.
Healy MA, Regenbogen SE, Kanters AE, Suwanabol PA, Varban OA, Campbell DA, Dimick JB, Byrn JC. Surgeon Variation in Complications With Minimally Invasive and Open Colectomy Results From the Michigan Surgical Quality Collaborative. JAMA Surg. Published online June 14, 2017. doi:10.1001/jamasurg.2017.1527
Xu T, Makary MA, Al Kazzi E, Zhou M, Pawlik TM, Hutfless SM. Surgeon-level variation in postoperative complications. J Gastrointest Surg. 2016;20(7):1393-1399.
Birkmeyer JD, Finks JF, O’Reilly A, et al; Michigan Bariatric Surgery Collaborative. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013