ajog.org
Editorial Measuring what matters: quality in gynecologic surgery Jason D. Wright, MD
T
he measurement of quality has become a central focus of medicine in the United States. Although there is a pressing need to improve the quality of care in women’s health, gynecology has lagged behind other procedural specialties in defining appropriate measures of quality. Quality metrics can be broadly divided into 3 basic domains: structural, process, and outcomes measures. Structural measures reflect the underlying contextual factors in which care is delivered, process measures reflect the care a patient actually receives, and outcomes measures are a direct assessment of the outcomes of care.1 Surgical quality improvement often relies on an admixture of all 3 types of measures.1 The association between surgical volume and outcome has long been recognized and procedural volume is now a commonly used structural metric for high-risk surgical procedures.2,3 Process measures, such as use of perioperative antibiotics and venous thromboembolism prophylaxis, are strongly associated with outcomes and have been validated in randomized trials and, as such, are routinely collected data points. Finally, direct outcome measures, such as morbidity and mortality, are readily quantifiable and are the ultimate endpoints of interest for most patients. For many general surgical procedures, components of these measures are not only publicly reported and tied to reimbursement but also have been directly used to drive policies that have improved the quality of surgical care patients receive.4 For most gynecological surgical procedures, the ideal quality measurement schema remains more elusive. For all but the highest risk procedures, significant morbidity and mortality are too infrequent to provide the discriminatory power needed to be a meaningful metric. Similarly, although procedural volume is associated with outcomes for gynecological procedures, the magnitude of the association is modest compared with higher-risk oncological and cardiovascular procedures.5 Lastly, although there is substantial variation in use of thromboprophylaxis and perioperative antibiotics and these measures are promising, data correlating adherence with From the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, NY. Received Sept. 29, 2014; accepted Oct. 10, 2014. Corresponding author: Jason D. Wright, MD. [email protected] 0002-9378/free ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.10.019
See related article, page 304
outcomes are less robust for many gynecological operations compared to general surgical procedures.6,7 There is clearly a need to define what we consider high-quality gynecological surgery and develop a consensus on how we measure it. In this issue of the Journal, Corona et al8 asked an important question, that is, how often are recommended alternatives to hysterectomy utilized prior to the performance of hysterectomy in women with benign gynecological disease? The authors collected data on more than 6000 women who underwent hysterectomy at 1 of 52 hospitals in Michigan that participated in a statewide quality collaborative. Indications for surgery included endometriosis, chronic pelvic pain, abnormal uterine bleeding, or fibroids. The authors first analyzed the frequency in which a trial of conservative management (either medical management or a less invasive surgical intervention) was utilized prior to hysterectomy. The study noted that 38% of women did not receive any type of alternative treatment prior to hysterectomy. Alternative treatments, in those who received them, included medical therapy in only 29%, whereas 24% had other minor surgical procedures prior to the hysterectomy. The investigators then went on to examine how often the pathological findings from the hysterectomy did not support an indication for surgery. Surprisingly, nearly 1 in 5 women had pathological findings that did not justify the performance of a hysterectomy. The authors concluded that alternatives to hysterectomy were underutilized and evidence-based recommendations for treatment were often circumvented.8 These data add to a growing body of literature that has noted widespread variation in utilization of procedures and interventions, often in the absence of clear indications. Perhaps even more importantly, numerous studies have demonstrated that high-intensity use of procedures and increased spending often are not associated with quantifiable improvements in outcomes.9 This variation, particularly for elective procedures, is coming under increasing scrutiny. As an illustration, a recent report of nearly 2 million elderly fee-for-service Medicare beneficiaries found that 32% of patients underwent inpatient surgery in the year before death, whereas 18% underwent a procedure in the last month of life and 8% had an operation in the last week of life. Like many prior studies of surgical interventions, there was substantial regional variation in practice patterns.10 Although judging the appropriateness of surgical procedures is often not straightforward, prior work in gynecology has also shown that hysterectomy is frequently performed in scenarios of questionable value.11 Corona et al8 appropriately recognized a number of limitations in their analysis. Most importantly, they were unable to link surgical data to outpatient medical records, and thus, there may have been some undercapture of alternative therapy use. MARCH 2015 American Journal of Obstetrics & Gynecology
257
Editorial However, even if a small number of women who received alternative treatments were not captured, their findings remain stark, in that such a large percentage of women did not receive medical treatments prior to surgery. The high rate of elective hysterectomy prior to use of other therapies was noted despite the fact that national recommendations defining appropriate indications for hysterectomy for benign gynecological conditions have long been in place.12 Although quality in gynecological surgery has focused on care after a procedure, the findings of Corona et al8 suggest that appropriateness of surgery could serve as an important quality metric in gynecology. Although optimization of postoperative care will undoubtedly improve outcomes, reducing the number of procedures performed in women who may not necessarily require the procedure in the first place has the potential to have an even more meaningful impact in reducing adverse outcomes and cost. As reimbursement policies shift, appropriateness of surgery will likely become an even greater imperative from patients and payors. At present, initiatives to ensure adherence to recommendations for nonsurgical alternatives to hysterectomy prior to definitive surgery can help reduce variation in gynecological surgery, and, ultimately, improve quality and outcomes. REFERENCES 1. Birkmeyer JD, Dimick JB, Birkmeyer NJ. Measuring the quality of surgical care: structure, process, or outcomes? J Am Coll Surg 2004;198:626-32.
258 American Journal of Obstetrics & Gynecology MARCH 2015
ajog.org 2. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346: 1128-37. 3. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117-27. 4. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011;364: 2128-37. 5. Rogo-Gupta LJ, Lewin SN, Kim JH, et al. The effect of surgeon volume on outcomes and resource use for vaginal hysterectomy. Obstet Gynecol 2010;116:1341-7. 6. Wright JD, Hershman DL, Shah M, et al. Quality of perioperative venous thromboembolism prophylaxis in gynecologic surgery. Obstet Gynecol 2011;118:978-86. 7. Wright JD, Hassan K, Ananth CV, et al. Use of guideline-based antibiotic prophylaxis in women undergoing gynecologic surgery. Obstet Gynecol 2013;122:1145-53. 8. Corona LE, Swenson CW, Sheetz KH, et al. Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. Am J Obstet Gynecol 2015;212:304.e1-7. 9. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003;138: 288-98. 10. Kwok AC, Semel ME, Lipsitz SR, et al. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet 2011;378:1408-13. 11. Broder MS, Kanouse DE, Mittman BS, Bernstein SJ. The appropriateness of recommendations for hysterectomy. Obstet Gynecol 2000;95: 199-205. 12. American College of Obstetricians and Gynecologists. Management of abnormal uterine bleeding associated with ovulatory dysfunction. ACOG Practice bulletin no. 136. Obstet Gynecol 2013;122:176-85.
Editorial Measuring what matters: quality in gynecologic surgery Jason D. Wright, MD
T
he measurement of quality has become a central focus of medicine in the United States. Although there is a pressing need to improve the quality of care in women’s health, gynecology has lagged behind other procedural specialties in defining appropriate measures of quality. Quality metrics can be broadly divided into 3 basic domains: structural, process, and outcomes measures. Structural measures reflect the underlying contextual factors in which care is delivered, process measures reflect the care a patient actually receives, and outcomes measures are a direct assessment of the outcomes of care.1 Surgical quality improvement often relies on an admixture of all 3 types of measures.1 The association between surgical volume and outcome has long been recognized and procedural volume is now a commonly used structural metric for high-risk surgical procedures.2,3 Process measures, such as use of perioperative antibiotics and venous thromboembolism prophylaxis, are strongly associated with outcomes and have been validated in randomized trials and, as such, are routinely collected data points. Finally, direct outcome measures, such as morbidity and mortality, are readily quantifiable and are the ultimate endpoints of interest for most patients. For many general surgical procedures, components of these measures are not only publicly reported and tied to reimbursement but also have been directly used to drive policies that have improved the quality of surgical care patients receive.4 For most gynecological surgical procedures, the ideal quality measurement schema remains more elusive. For all but the highest risk procedures, significant morbidity and mortality are too infrequent to provide the discriminatory power needed to be a meaningful metric. Similarly, although procedural volume is associated with outcomes for gynecological procedures, the magnitude of the association is modest compared with higher-risk oncological and cardiovascular procedures.5 Lastly, although there is substantial variation in use of thromboprophylaxis and perioperative antibiotics and these measures are promising, data correlating adherence with From the Department of Obstetrics and Gynecology and Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, NY. Received Sept. 29, 2014; accepted Oct. 10, 2014. Corresponding author: Jason D. Wright, MD. [email protected] 0002-9378/free ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.10.019
See related article, page 304
outcomes are less robust for many gynecological operations compared to general surgical procedures.6,7 There is clearly a need to define what we consider high-quality gynecological surgery and develop a consensus on how we measure it. In this issue of the Journal, Corona et al8 asked an important question, that is, how often are recommended alternatives to hysterectomy utilized prior to the performance of hysterectomy in women with benign gynecological disease? The authors collected data on more than 6000 women who underwent hysterectomy at 1 of 52 hospitals in Michigan that participated in a statewide quality collaborative. Indications for surgery included endometriosis, chronic pelvic pain, abnormal uterine bleeding, or fibroids. The authors first analyzed the frequency in which a trial of conservative management (either medical management or a less invasive surgical intervention) was utilized prior to hysterectomy. The study noted that 38% of women did not receive any type of alternative treatment prior to hysterectomy. Alternative treatments, in those who received them, included medical therapy in only 29%, whereas 24% had other minor surgical procedures prior to the hysterectomy. The investigators then went on to examine how often the pathological findings from the hysterectomy did not support an indication for surgery. Surprisingly, nearly 1 in 5 women had pathological findings that did not justify the performance of a hysterectomy. The authors concluded that alternatives to hysterectomy were underutilized and evidence-based recommendations for treatment were often circumvented.8 These data add to a growing body of literature that has noted widespread variation in utilization of procedures and interventions, often in the absence of clear indications. Perhaps even more importantly, numerous studies have demonstrated that high-intensity use of procedures and increased spending often are not associated with quantifiable improvements in outcomes.9 This variation, particularly for elective procedures, is coming under increasing scrutiny. As an illustration, a recent report of nearly 2 million elderly fee-for-service Medicare beneficiaries found that 32% of patients underwent inpatient surgery in the year before death, whereas 18% underwent a procedure in the last month of life and 8% had an operation in the last week of life. Like many prior studies of surgical interventions, there was substantial regional variation in practice patterns.10 Although judging the appropriateness of surgical procedures is often not straightforward, prior work in gynecology has also shown that hysterectomy is frequently performed in scenarios of questionable value.11 Corona et al8 appropriately recognized a number of limitations in their analysis. Most importantly, they were unable to link surgical data to outpatient medical records, and thus, there may have been some undercapture of alternative therapy use. MARCH 2015 American Journal of Obstetrics & Gynecology
257
Editorial However, even if a small number of women who received alternative treatments were not captured, their findings remain stark, in that such a large percentage of women did not receive medical treatments prior to surgery. The high rate of elective hysterectomy prior to use of other therapies was noted despite the fact that national recommendations defining appropriate indications for hysterectomy for benign gynecological conditions have long been in place.12 Although quality in gynecological surgery has focused on care after a procedure, the findings of Corona et al8 suggest that appropriateness of surgery could serve as an important quality metric in gynecology. Although optimization of postoperative care will undoubtedly improve outcomes, reducing the number of procedures performed in women who may not necessarily require the procedure in the first place has the potential to have an even more meaningful impact in reducing adverse outcomes and cost. As reimbursement policies shift, appropriateness of surgery will likely become an even greater imperative from patients and payors. At present, initiatives to ensure adherence to recommendations for nonsurgical alternatives to hysterectomy prior to definitive surgery can help reduce variation in gynecological surgery, and, ultimately, improve quality and outcomes. REFERENCES 1. Birkmeyer JD, Dimick JB, Birkmeyer NJ. Measuring the quality of surgical care: structure, process, or outcomes? J Am Coll Surg 2004;198:626-32.
258 American Journal of Obstetrics & Gynecology MARCH 2015
ajog.org 2. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346: 1128-37. 3. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117-27. 4. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011;364: 2128-37. 5. Rogo-Gupta LJ, Lewin SN, Kim JH, et al. The effect of surgeon volume on outcomes and resource use for vaginal hysterectomy. Obstet Gynecol 2010;116:1341-7. 6. Wright JD, Hershman DL, Shah M, et al. Quality of perioperative venous thromboembolism prophylaxis in gynecologic surgery. Obstet Gynecol 2011;118:978-86. 7. Wright JD, Hassan K, Ananth CV, et al. Use of guideline-based antibiotic prophylaxis in women undergoing gynecologic surgery. Obstet Gynecol 2013;122:1145-53. 8. Corona LE, Swenson CW, Sheetz KH, et al. Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. Am J Obstet Gynecol 2015;212:304.e1-7. 9. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003;138: 288-98. 10. Kwok AC, Semel ME, Lipsitz SR, et al. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet 2011;378:1408-13. 11. Broder MS, Kanouse DE, Mittman BS, Bernstein SJ. The appropriateness of recommendations for hysterectomy. Obstet Gynecol 2000;95: 199-205. 12. American College of Obstetricians and Gynecologists. Management of abnormal uterine bleeding associated with ovulatory dysfunction. ACOG Practice bulletin no. 136. Obstet Gynecol 2013;122:176-85.
