Check, Please

This is about one of those surgical papers that makes me scratch my head. Or shake it, or press on it from both sides. Can it really be true? If so, why?

It reminds me of another one, a few years back, that touted using a laser in performing a mastectomy. Since we started doing it, the authors said without evident embarrassment, our transfusion rate decreased from four units per case to two, and our hospital stays went from nine to five days. Wow. At the time I'd done several outpatient mastectomies (at the patients' request, may I add); rarely did any of my patients need or want to stay in the hospital longer than a day or two; and I never even ordered blood for the operation, much less used it. Who the hell were those guys, and what the hell kind of surgeons were they?

It's with that in mind that I mention a recent and much talked-about report which shows an impressive and universal (throughout the study hospitals) lessening of surgical deaths and complications by the use of a simple checklist before and after the operation. I certainly don't disapprove of such checklists; variations thereon are more or less universal in American operating rooms nowadays. Where I come up a little short, understanding/explanation-wise, is here: first, the "major complication" rate before the study was 11%, and death rate was 1.5%. With the checklist, they diminished to 7% and .8%. Still pretty high, if you ask me: if I'd had numbers like the pre-study ones in my practice, I'd have been kicked off staff. Summarily. With the post-study ones, I might be on probation. Second, the checklist is so rudimentary that I'm at a loss to understand why it works. And, like some, I question whether it's even true. But there it is.

Without doubt, taking care to eliminate wrong operation or wrong-sided surgery is essential (even though the incidence is very low.) Counting sponges and instruments at the end of a case is routine, and has been approximately forever. (The second link indicates that compliance before the study was only 34%; even more remarkably, during the study it was only 57%! Once again: who are these people?) Similarly, if the anesthesia personnel aren't making sure they have what they need ahead of time, and if the surgeon hasn't thought about whether s/he needs blood available or antibiotics administered, there's something wrong. But there's nothing wrong with checking to be sure.

In the first link, one can watch (not-particularly-gripping) video. It provides some clues. Part of the routine is to introduce the members of the team to one another, which hardly seems protective of anything, per se, but suggests a group of people not used to working together. And the surgeon mentions that the operation, a routine hernia, will probably be under an hour. Probably? How about fifteen or twenty minutes? Both of those factors suggest a training program, where there's typically no continuity of personnel, and where operations take longer than "normal." Each of those contributes to increased complication rates. As does the fact that in teaching settings there are usually two or three extraneous people scrubbed in, peering into the hole, scratching their asses, etc.

You'd think that in taking a right turn from my usual targets, I'd have some sort of wisdom to impart at this point (although, one might ask, why start now?); I really don't. I applaud all attempts to improve the quality of health-care delivery; it's just that this particular approach puzzles me. Comparably, it's as if all a pilot were required to do before take-off is to make sure the crew knew each other, confirmed the destination and that the doors were shut.

If that makes a difference, we're in bigger trouble than I thought.

Or maybe I'm missing something.

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Heartless

Riding my indoor bike in front of the TV, working on my own heart, I saw that the owner of the Carolina Panthers, age 72, is awaiting a heart transplant. I'm sure he's a nice guy.

Until we have so many extra hearts that they're being thrown away, seventy-two year olds ought not be getting them. Football team owners are among the very wealthy, so I assume he can and/or would pay every nickel himself. Even so, it's not right. Whereas it brings up that age-old question about whether the wealthy ought to get better medical care than the not-so, and whereas I'm not entirely unsympathetic on one level (the level that says rich people get better cars and bigger houses), medical resources are finite, and getting finiter. No matter if he plans to leave a big tip: unless everyone under fifty already has one, he shouldn't get a heart. That's not just rationing: it's morality.

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To Our Health!

"Now, some may ask how, at this moment of economic challenge, we can afford to invest in reforming our health care system. Well, I ask a different question – I ask how we can afford not to." [Barack Obama, today.]

On the occasion of Barack Obama's rollout of his health policy team, and given that, according to a couple of pieces of paper I have around here somewhere, I'm a doctor, this seems a good time to spout off -- yet again -- on the state of health care in the US. What it really boils down to is this: we need to reduce cost and raise quality. As long as the discussion is only about paperwork, ie, single payer vs current insurers, electronic vs paper records; and as long as the only real efforts to control costs are in reducing payments to providers, we'll be getting nowhere. As usual.

I've written about why I favor single-payer, and have acknowledged that among physicians I'm in a distinct minority. I've said pretty much all I know about that aspect of it. Moreover: as controversial as it is, it's really only nibbling around the edges. Solutions --REAL solutions -- will come from fundamentally changing the nature of care itself, and how we provide it. And if you think addressing insurance is complicated and daunting, you ain't seen nothin' yet! If we were ever to get to the nitty gritty, we'd hear screams of bloody murder from providers and patients alike!! If and when you hear the noise, you'll know we're almost there.

As I try to elucidate, two things might become apparent: 1) I can only talk about my personal "style" (for lack of a better word), and 2) I probably don't know what I'm talking about. Specifics, anyway. But I think I'm right, looking down from a few miles up.

Inevitably, quality of care delivered differs wildly from provider to provider. It should be no surprise, of course; there are good teachers and bad, competent lawyers and lousy ones (insert malpractice comment here), engineers and architects and scientists and machinists who vary greatly one from the other. To the extent that quality control and outcome assessment have been instituted, it's been pretty superficial. And pathetic. Surgeons, for example, (a subject with which I have particular familiarity) are "judged" on whether preoperative antibiotics are given within an hour of surgery cut-time. (The criterion used to be the opposite; or, at least, in days of yore I was taught that antibiotics should be given at least an hour before, in order to allow time for equilibration within tissues.) They're assessed for application of anti-clotting techniques (pressure devices and drugs), and for proper recording of various patient data, not the least of which is assurance that the operation and patient match up. Worthy and important, all of it, without doubt. But pennies on the dollar.

To save real money, it's necessary to get doctors to agree to practice evaluation. Or, at minimum, to be open to self-assessment based on data from others. Tough stuff. Here's the part where it becomes personal horn-tooting: practically every operation I did, I did faster and cheaper than my peers, with as good or better outcomes. And for those who might find taking my word for it a bit of a stretch, let's just assume it's true that one might be able to find ways to rank surgeons on those criteria. (I speak here of surgeons; but I have no doubt it can and must be applied to all specialties. Especially critical care!!) And having done so, that it could be possible to look at the "best" and find out what separates them from the "worst." Technically. Methodologically. Behaviorally. Finally, assuming such information could be amassed, imagine that surgeons could be "encouraged" to adopt the good methods and toss out the bad. It would require, since doctors are in many ways like humans, a combination of carrot and stick: rewards for adopting cost-effective methods, penalties for being out of range. And reasonable (easier said than done) criteria on which to make such assessments.

Over the objections of many surgeons, and until those voices eventually prevailed, a large insurer in my area used to publish data comparing average total hospital cost of a given operation among all the surgeons in the state. For every one listed, I was near or at the top (or is it bottom?) -- meaning my total costs were very low. It stemmed from being efficient in the OR, and from efforts that made the postoperative stay as short as possible. There's no point in going into detail here; but there are very specific items to which I could point: choice and conduct of operation, and things I did in the recovery period that affected length of stay. (Not the least of which was willingness to make hospital rounds two or more times a day!) (Nor, might I add, was I kicking people out before they were ready!!) For every operation there are specific choices and efforts to be made, the adoption of which would save gazillions of health care dollars.

It's not just doctors that would have to climb on board: patients would have to face reality as well. My favorite example: laparoscopic surgery. It's sexy, it's the latest thing, it's hyped like the newest iPod. But for many operations, it greatly increases cost, while adding nothing to outcome. (Here's where good data are needed: studies comparing, for example, laparoscopic colon resection to open techniques generally use numbers that are nothing like mine: my routine colon resection patients were in the hospital four days or less, whereas the numbers to which laparoscopy are compared are of patients in for closer to a week! Time in the OR -- very expensive, hourly -- is way less for a properly done open operation. Equipment cost differences: staggering!) Patients would have to accept the data as well.

Which gets us to the hardest part of all: when we're at the point of getting truly serious about health care costs, we'll have to bring the "R" word into the conversation.

Rationing.

Call it something else: prioritizing. But until we look at the enormous amounts of money spent in the final days of life, and until we're willing to make hard choices and take difficult -- maybe impossible -- stands on who gets what, and when, we'll just be dancing around the fire.


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