Analysis of the results of surgical interventions has always been central to the profession of surgery. Whether in the Morbidity and Mortality Conference or in scientific reviews of surgical outcomes, the concept of studying the outcomes of surgical procedures in hopes of improving them in the future has long been a tenet of surgical practice. Quality surgical care and the advancement of the science of surgery demand it. The past must inform the future. There is nothing to hide and such data should be public and inform public policy.
The Current Climate
The Centers for Medicare and Medicaid Services (CMS) has mandated the Physician Quality Reporting System (PQRS) to encourage physicians to participate in continuous quality improvement. CMS has also mandated adoption of the Electronic Health Record (EHR). Other recent legislation has focused on including a measure of quality into payment for medical and surgical treatments.
The American Board of Medical Specialties has defined part IV of Maintenance of Certification as "Practice Performance Assessment –They (physicians and surgeons) are evaluated in their clinical practice according to specialty-specific standards for patient care. They are asked to demonstrate that they can assess the quality of care they provide compared to peers and national benchmarks and then apply the best evidence or consensus recommendations to improve that care using follow-up assessments."
• Surgeons need access to outcomes data in order to improve themselves and the practice of surgery.
• Patients need access to outcomes data so that they may make decisions about treatment options.
• Health policymakers need access to outcomes data in order to shape public policy as it relates to the health care system.
• Payers want access to outcomes data so that they may calculate and compare value across providers.
Adequate analysis of outcomes, however, requires robust databases that adequately capture confounding variables and relevant co-variables. Outcomes data must be risk adjusted. It must include adequate follow-up. It must be seamlessly integrated into the EHR, and must be available to serve multiple requirements including, but not limited to those mandated by CMS, the various Boards of the ABMS, and various national, state, and local licensing and credentialing bodies.
All of these efforts are ultimately aimed at improving quality and decreasing costs, thus improving value. It must be explicitly stated that the purpose of this data is to improve quality, decrease costs, and improve value but NEVER to be used in a punitive manner. All these efforts demand access to high quality, risk adjusted data on surgical outcomes with adequate follow-up.
There may be unanticipated consequences of the reporting of such data. Practice patterns may change in both a positive and negative way and there must be a mechanism in place to study the outcomes of such public reporting in and of itself.
These various efforts must be aligned and coordinated for optimal implementation. It should be mandated that EHR’s be developed in such a way that they collect data that can be used for PQRS and that this data then qualify for MOC and eventually maintenance of licensure (MOL). The collection of this data must not be an unfunded mandate on the individual physician and surgeon, but instead should be built into the health care system in such a way that it serves the physician/surgeon, the patient, and the public alike. The EHR, linked to such systems as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) is probably the most effective way to achieve that objective and the development of these systems should proactively include the acquisition of ACS NSQIP data.
The American College of Surgeons believes strongly in the acquisition of high quality, risk adjusted surgical outcomes data and supports efforts to study, codify, and systematize the collection of such data.