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31-Jan-2013

Ahead of his keynote lecture at the President's Meeting on Friday 8 March, Michigan's Dr John Birkmeyer speaks to RCSEd about the opportunities and pitfalls of surgical outcomes

Dr BirkmeyerDr John Birkmeyer still remembers the catalyst 22 years ago, while working as a surgical intern, that sparked his career-long interest in outcomes: "I participated in a lecture by a renowned clinical epidemiologist, who was describing the extent to which mortality rates varied across open heart surgery. I was so intrigued by the fact that a patient's outcome was largely a function of which doctor they happened to see, and that nobody knew why some surgeons did better than others, that I decided to dedicate my career to that area."

He has spent much of the time since that seminal lecture identifying, comparing and assessing the many factors that contribute to variation in surgical outcomes.


As George D. Zuidema Professor of Surgery at the University of Michigan and one of the leading authorities on outcomes and health policy, it's hard to imagine a better keynote speaker for the RCSEd's President's Meeting in March.


He picks up on a theme he'll be addressing at the meeting - the relationship between volume and outcomes:  "There's no doubt that, for certain types of complex surgical care, particularly cancer care, centralising care to high-volume regional centres is associated with better outcomes.


"However, centralising is a blunt tool to the extent that the volume handled by the hospital or the surgeon simply works as a proxy for the true proficiency of the surgeon. Some of the data that I'll be sharing at the March meeting will make it clear that the more direct measures of a surgeon's skill have a much bigger effect on outcomes than the number of cases that they handle."


His second caveat is that, while volume matters for a small number of complex cases, the volume/outcome effect is comparatively weak for the majority of procedures. And he's keen to point out that there are limitations to how far centralisation alone can improve outcomes: "There are few national healthcare systems that have the capacity at high-volume centres to deal with every type of inpatient surgical care. At least in the US, such hospitals are already full and there's a limit to how far they can accommodate increasing volumes. So it behoves policy makers to pick their battles and focus on the conditions for which the benefits will be sufficiently large."


Not surprisingly, he warns against placing too much value on high-volume, specialist centres: "We run the risk of getting distracted by regionalising care, which may or may not need to be regionalised, at the expense of other types of intervention which could actually improve outcomes far more."


In a recent editorial for the BJS (2012, pages 1467-69), he described surgical morbidity and mortality as public health concerns. It may be surprising to hear of surgical risks described in those terms, but he makes a convincing case: "Well over 100,000 people die in the US each year as a direct consequence of surgery. Between 1 and 2 million people have a serious complication as a result of surgery. If you put that in the top 10 leading causes of death in the US, it falls around number seven or eight. In fact, more people in the US die as a consequence of surgery than die because of diabetes."


It is observations like this that have helped put a renewed focus on surgical outcomes, leading to patient safety programmes in many countries. But here too, where there is substantial evidence that such programmes lead to better results, he is careful not to overestimate their potential: "Some may disagree about the magnitude of the Hawthorne effect [the theory that the mere existence of a study changes the behaviour of those being studied], but most experts would agree that it's real. The only caution that I'd mention is that it tends to be transient and that it gets outcomes to a new point that doesn't necessarily equate to optimal care.


"So I think to make surgical care as safe as it can be we need to start with outcomes tracking and with performance feedback. But we need longitudinal data monitoring systems that not only tell surgeons how they are doing but also tells them how to get better. In March, I'll be discussing my own involvement in large-scale outcomes programmes in Michigan, which aim to do just that."


Many of those who will be listening to Dr Birkmeyer at the RCSEd in March will have a personal interest in exactly how individualised outcome data will be used in the UK's new system of revalidation. Here he believes that historical approaches of asking doctors to complete a certain number of CPD hours is "woefully inadequate", but the challenge is strengthening the "data infrastructure" on which assessment is based. He explains, "Because surgeons do so many different types of cases and perform only a finite number of any given type of case in any given year, there's a lot of statistical imprecision associated with individual outcomes.


"We also have very little data to assess the performance of a surgeon other than the likelihood of the patient dying after surgery, or the likelihood of a complication occurring. And for the majority of procedures, the true measure of a surgeon is driven by other types of outcome, like freedom from pain or functional ability."


He believes such a comprehensive system is still many years away, but thinks the next wave of thinking around how to assess performance may not be purely around outcomes, but will be based on peer judgement on operative skill.

A separate and perhaps more controversial issue is making surgical data available to the general public. Here, although he believes the general public have the right to make the same treatment choices as doctors would for themselves or their families, he has concerns about the quality of the data. He explains, "Because of myriad limitations in the outcomes data we do have, the type of data that we can provide is frequently more 'noise than signal'.

"It is also clear that, just from a public health perspective, that policy centred around accountability and publicly reporting outcomes data generates such a huge amount of controversy that it frequently distracts us from the types of activity that could be more meaningful in improving care."


The interview date with Dr Birkmeyer coincided with a news release from the American College of Surgeons, reporting a study which found no difference in outcomes between cases where the surgeon had been operating during the previous night and cases where the surgeon had a full night's sleep. Where do the less complex issues, such as tiredness, belong in the outcomes debate? Although he hadn't seen that particular news item, Dr Birkmeyer's reply is thorough, balanced and immediate: "On the one hand, it's certainly true that the alertness of the surgeon is only one of a range of factors that ultimately influence the risk of morbidity and mortality after surgery. To some extent, this study may reflect the fact that most hospitals have built-in compensatory mechanisms for ensuring the safety of surgical patients.


"On the other hand, the critics of the study's conclusions may point out two things: first, there's an incontrovertible body of literature showing that cognitive and motor skills deteriorate in doctors who are sleep deprived. The second relates to new data that I'll be sharing with the RCSEd in March, that the operative technical skill of surgeons is a huge factor in the overall risk of complications after surgery."


It seems that Dr Birkmeyer has considered every factor involved in surgical outcomes and it looks certain that delegates lucky enough to hear him speak at the RCSEd on 8 March won't be disappointed.

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