Get better at anesthesia – or get out!

by
  • Chamberlin, Keith, MD, MBA
| Jan 31, 2017

Keith_ChamberlinExcuse me, doctor. Are you any good? I mean, are you any good at anesthesia stuff? If your answer is yes, how do you know, and why should I believe you? Have you collected any outcome data you can show me, or that you’ve published?

What? Who am I to question you?

I am the United States Government. No, wait. I am every insurance plan you deal with every day. Or I could be your hospital and your surgeons. No, no – I am far more important than that. I am your patient!   

What? Publish my results? Tell patients specifically how well I perform in the areas that matter to them the most? Who does that?

Exactly – virtually no one in anesthesiology is currently reporting quality metrics to the public. Yet heart surgeons, fertility centers, and kidney transplant programs (to cite a few examples) are required to do it. Alarmingly, the government already reports certain quality metrics for all of us.

Think for a moment. If you can’t say confidently to the world, “My success rate at performing blocks, preventing nausea, and managing acute pain is as good as anyone else’s in my group,” then maybe it’s time for a quality improvement project. We can all get better at what we do – we just need to know what targets to set for improvement!

We have outcome registries already for spine surgery and total joint surgery. Germany has outcome registries for prostate cancer treatment, including both surgical and non-surgical. We know where we should be in terms of outcomes for many of the things that we do, as the House of Medicine. We know about “never events.” We have data about topics including infection rates, take-back rates, and mortality based on ASA status.

More and more, this information is being made public to our patients. Take a look at Medicare’s “Physician Compare” website, https://www.medicare.gov/PhysicianCompare, as well the companion site for hospital information, “Hospital Compare” https://www.medicare.gov/hospitalcompare.

The information is out there, but much of it doesn’t seem to be accurate, nor do many people truly understand the definitions of risk categories. Nonetheless, some information about your practice is public, and you would be wise to check into it. To be clear, if we don’t start going public with our own outcome data, the government will. It’s better that we should do it, no?

The patient’s concept of anesthesia success

successWhat information matters most to patients? What outcomes are they interested in? Back in 1999, Alex Macario, MD, and his colleagues at Stanford University (Anesth Analg 1999 Sep;89(3):652-8), published an excellent study looking at what clinical outcomes patients want most to avoid. The list hasn’t changed substantially since then:

  • Vomiting
  • Gagging on the tracheal tube
  • Pain
  • Nausea
  • Recall without pain (“awareness”)
  • Residual weakness
  • Shivering
  • Sore throat
  • Somnolence

As an aside, there is always a cost component. For example, if you were to tell a patient, “I guarantee you will not vomit, but it will cost an additional $25,000 outside of your totally inadequate insurance,” then I’ll bet the patient would reply, “That’s ok, doc, I don’t mind throwing up a time or two…”

Where was “not surviving the surgery” on this list of things to avoid? That wasn’t an option in the study; the authors simply assumed that mortality is the number one outcome to avoid. But is it? Many of us have met patients who say, “I would rather die than live with this back pain.”  Or a lifelong Jehovah’s Witness who says, “I would rather die than have a blood transfusion.”  Think about that – what matters most to patients varies with the patient.

For most of our patients, I think we can agree that the above list is reasonably accurate. So now that we know the list of outcome statistics to publish, and the clients who want to know about them (patients/surgeons/hospitals/government/insurers) – how do we go about accomplishing the task?

Start with common problems

I would recommend starting with the most common issues that patients think about: postoperative nausea and vomiting (PONV), pain, and regional anesthesia success. Once you have that information, you can expand to the less common concerns.

collectFirst, you need to collect the data. You can do it yourself, or you can participate in the National Anesthesia Clinical Outcomes Registry (NACOR) by becoming a member of the Anesthesia Quality Institute (AQI). NACOR will provide you with peer-to-peer benchmarks as well as other quality measures.

How exactly do you collect this information? Most electronic health records (EHRs) have a module for this, but you can also extract it manually from handwritten charts. Honestly, this is information we all should know about our own practices – we owe it to our patients. Peter Drucker’s well known statement – “What you can’t measure, you cannot manage. What you can’t manage, you cannot change.” – applies to every specialty and every business. We are no different – we need to measure.

You need good outcome definitions so that everyone is on the same page. Nationally accepted outcome definitions can be found through NACOR: http://www.aqihq.org/files/AQI_NACOR_Outcome_Data_Elements-FINAL_103116.pdf  

Once you have the data collected and stratified for ASA category, type of surgery, etc., you start by reviewing your own outcomes as a group, blinded as to the names of individuals. Only you know who you are, and how your performance compares.

The next step is data verification, since physicians always think the data is wrong, followed by a period of time to allow group members the opportunity to improve their own practices. After the next round of data collection, show the data to your group unblinded. This is a big step, but consider the powerful motivation to improve quality that could result from saying:

“Here is where I sit, relative to my group, for rates of PONV, block success, pain relief, etc., and everyone in my group knows who I am and how I did.”

Think about the impact of that statement. Within your group, you are willing to examine your outcomes publicly, and rank yourself. That is a powerful incentive to improve quality, and that is how this should be viewed – as a quality improvement tool.

Publicize results with pride

Once everyone in your group is meeting or exceeding benchmarks, you take the data as a group to the surgeons and hospital. You give them something to tell their patients – look how great our anesthesiology group is! They are so good they are willing to publish their outcomes.

resultsThen you tell patients directly. But how? You can put it on a website – your group’s results versus the world’s. Everyone will know that if you do that, you have the data to support it, and that you have helped those physicians who might have started a bit behind the 8-ball to get better. 

Of course, you must carefully categorize your patient population and surgical cases. I hear all the time, “My patients are sicker and higher risk.” Please. That argument does not apply to a basic ASA 1 knee arthroscopy patient. We all have sick patients and we all have healthy routine patients, and the data must be stratified accordingly. Eventually you will arrive at an “all-comers” PONV rate, block success rate, etc., but for starters select the routine cases that you frequently perform for routine patients.

You can also post your group’s data on the hospital website, and the administration can use it as a marketing tool. Finally, we have a way to get people to come to the hospital BECAUSE of the anesthesiology group! We have a way to showcase our specialty, and your group, in a very positive light.  

This approach, while seemingly heretical, gets to the important questions very fast:

Are you any good, and if so, how do you know?

  • By comparison to your peers and to national benchmarks.

If you lag behind, what can be done to solve the problems?

  • Yes, you CAN learn new blocks.
  • Yes, you CAN learn ultrasound-guided techniques.
  • Yes, you CAN get help both from new partners and established partners.
  • Yes, everyone CAN reach and even exceed benchmark performance.

If every group were to publish its outcomes, one of two things would happen as a consequence:  individual physicians and groups would get better, or they would find other work to do. Either way, patients would benefit, which is the point.

The final reason for doing this kind of quality examination is that eventually it’s going to be required – and if you haven’t done it, someone is going to do it for you. I promise you they will not be as interested in helping you as you will be in helping yourselves. They will be interested only in results. Now is the time to start helping yourselves. Get better at your anesthesia practice, or get out!

Editor’s Note: Dr. Chamberlin presented on this topic at the recent ASA Practice Management Meeting in Grapevine, Texas.

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