Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Challenges no surgeon would refuse
- Richard G Fiddian-Green (11 July 2003)
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Complexity of case load
- James C Hurley (14 July 2003)
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Preventable or Predicted lobectomy mortality: A calculated or down right callous risk?
- Joseph F. KHALIL-MARZOUK (23 July 2003)
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Making the Excellence more infectious.
- Mangesh, A Thorat (2 August 2003)
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Richard G Fiddian-Green, None None
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It is essential to monitor outcomes from surgical operation if outcomes are to be improved and not allowed to regress. Far from being a dis-incentive auditing should provide an incentive for surgeons to take on increasingly high-risk cases because these are the most discriminating of their skills and because in the private sector these cases can have the greatest potential for lucrative remuneration. In cardiovascular surgery the risk of adverse outcome in elderly patients is no different from that in young patients provided they do not develop shock, defined as a low gastric intramucosal pH, during or immediately after surgery (1). In those that develop shock, however, the outcome is far worse in the elderly patients than in the younger patients. The same applies to patients with high and low cardiac indices, a measure of myocardial function in patients having coronary artery bypass grafts. It also applies to patients having other forms of surgery notably emergencies in general surgery and trauma. High-risk patients are simply less forgiving of deficiences in technique or perioperative management. The better the surgeon and his/her team the less likely high-risk patients will have adverse outcomes or cost the hospital excessive amounts of money. By paying surgeons and hospitals a fixed amount for an operation, an amount possible determined by a refinement of the diagnosis related groups (DRGs) used in the US, it should be possible to build in an incentive to get better results at an affordable price and take on increasingly high- risk patients. One might, for example, reimburse the surgeon/hospital 50% at the conclusion of the operation, an additional 10% thirty days after surgery, yet another 10% six months after surgery and the remaining 30% five years after surgery or use a variation of this theme. The amount reimbursed at thirty days, six months and five years should be determined by current standards so that performances better than expected would be rewarded and those worse than expected penalised. The 50% would be equivalent to the amounts currently being reimbursed in the private sector so that existing budgetary expectations would be met. This amount that rarely if ever rewards better short-term and longer -term outcomes. It can be seen from the estimates of the long-term costs of the failures of carotid endarterectomy that there is ample opportunity for building in some very attractive incentives both for staff and for hospitals to achieve lower morbidities and mortlaities especially in high- risk patients (2). There are two things a surgeon will not turn down. The first is a challenge to demonstrate his superior skills by getting better results than those expected in the DRG determinations. The second is an opportunity to make money from his superior skills. There are just two obstacles. The refusal of the government to give patients private insurance and of the NHS to pay one surgeon much more than another let alone pay them more than physicians many of whose treatments have never been shown to have a measurable effect upon either short-term or longer- term outcome. 1. Fiddian-Green RG. Gut mucosal ischemia during cardiac surgery. Semin Thorac Cardiovasc Surg. 1990 Oct;2(4):389-99. 2. High cost of surgical failure Richard G Fiddian-Green bmj.com/cgi/eletters/326/7394/832#31438, 22 Apr 2003 Competing interests: None declared |
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James C Hurley, Physician Ballarat Health Services, 3350 Australia
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Interesting article. The perenial question that comes to mind is whether surgeons who perform more surgery are referred the more complex and higher risk patients. Competing interests: None declared |
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Joseph F. KHALIL-MARZOUK, Consultant Thoracic Surgeon Birmingham Heartlands Hospital, B9 5SS
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Editor.-Treasure et al declared that the current system is 'open to dishonesty' and concluded with a prediction that there is a 'likelihood of surgeons refusing to operate on high risk cases'. I cannot disagree more on both counts, because we should have a system of reporting that should be open, transparent, robust, audited and validated. Then and only then there will not be a place for such dishonesty or for dodging high risk cases. It must be acknowledged that the only guarantee to abolish operative mortality is to avoid surgery, which will deny the majority of patients who benefit for the sake of the minority that do not survive. There should be a built-in mechanism to identify 'honest' predictable mortality, in order to proceed with surgery after an 'informed consent' of the patient and the full knowledge of the legal next of kin. Having identified my contribution in this paper to be the third from the right in figs 1 and 2, I know the circumstances of the 3 cases (2.1% mortality) that died. I could have easily declined to operate on all 3 patients and had the best results ever, but they would not have stood a chance not only to potentially cure them from operable cancer but also improve their paraneoplastic symptoms. All 3 cases were presented and sanctioned by multidisciplinary discussions. Hind sight is a 20/20 vision but please also consider that there were twice this number of patients who survived with equally high risk among the remaining 135 cases. In my experience with 61 to 83 cases per annum (average of 66 cases) and a total of 792 lobectomy for primary lung cancer since 1992, and 19 deaths i.e. 2.4% I believe I am qualified enough to identify the 'Calculated' risks and will never consider it 'Callous' to offer proceed with what might be considered an avoidable deaths from surgery but a certain death from the pathology neoplastic or otherwise. Competing interests: None declared |
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Mangesh, A Thorat, Clinical Fellow, Dept. of Surgical oncology. Tata Memorial Hospital, Dr. E.Borges Marg, Parel, Mumbai-400012. Phone - +91 22 24177000 ext. 4259
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Authors agree that mortality from lobectomy for primary lung cancer is a poor means of measuring surgical performance. But this does not necessarily mean that surgical experience is not a prognostic factor, since they admit to the shortcomings of this retrospective data. Surgical skills, which develop with experience, are definitely one of the most important prognostic factors, mainly in complex surgeries. This has been observed before in studies relating to pancreatic cancer. Surgical excellence can not be substituted for. Excellence can be infectious. Development of excellence in one faculty can lead to development of excellence in other faculties. For example, development of thoracic surgical excellence can lead to better critical care in that hospital and this will definitely contribute in a major way to reduce mortality. First step in development of excellence is recognition. Recognising and creating new subspecialities will eventually lead to development of better skills through focussed training. Japanese have shown us the way. Earlier the other countries adopt it, better it is for the patients for whom decision-making will also get simplified apart from reduction in the mortality. NHS can start by recognising surgical oncology as a broad speciality. Competing interests: None declared |
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