Simpler Surgeries, Complex Market

Elyas Bakhtiari, for HealthLeaders Magazine , May 11, 2009
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But surgeons are often skeptical about of outcomes-based improvement initiatives. It's not that they aren't concerned about quality. The problem is risk—surgeons sometimes go into operations where there is a low chance of survival and feel they get an unfair shake when the outcomes data doesn't account for patient acuity.

"The reality is, everyone thinks they've got the sickest patients," says Krummel.

Three years ago, the surgical department at Stanford Hospital and Clinics ranked in the top 30% of departments in the country in terms of quality—a respectable distinction, but not good enough for Krummel. After revamping the department's approach to quality, it now ranks in the top 1% of surgical programs in the United States, including the lowest mortality rate in the country for complex general abdominal surgery.

Krummel says the improvement has been part of a sustained effort to address quality on an ongoing basis through monthly teaching conferences, internal metric tracking, quality teams, and other common approaches. But the catalyst for the change was participation in the American College of Surgeons' National Surgical Quality Improvement Program; it allows hospitals to compare 30-day, risk-adjusted outcomes data. Stanford monitors pneumonia, bedsores, and other measures and heads off problems when the numbers start to slip, tracking both individualized and departmentwide metrics. Although the risk-adjusted data alone didn't turn things around, it did make surgeons more comfortable with quantitative comparisons and broke down some of the resistance to quality improvement.

"Risk stratification has convinced us," Krummel says. "In the old days, it was not adjusted for risk and so what you had was surgeons avoiding risky cases because they didn't want to be known as an underperformer."

Elyas Bakhtiari is an editor with HealthLeaders magazine. He can be reached at
A note about NOTES

Surgeons have already made great strides in reducing incisions from several inches to a few millimeters for many procedures. In the future, however, they may do very little cutting at all—at least nothing noticeable.

A handful of leading institutions are experimenting with natural orifice transluminal endoscopic surgery—NOTES—which involves removing or operating on organs via natural openings in the body, such as the mouth, vagina, or colon. Earlier this year, Northwestern Memorial Hospital in Chicago became the third hospital in the United States to successfully remove a woman's gallbladder through her vagina, and several successful kidney donations have also been done using the NOTES approach.

These "scarless" operations rely on internal incisions and a small camera inserted through the naval. Recovery time is much faster for these procedures than current minimally invasive methods.

But is NOTES ready for prime time? Robert Sewell, MD, president of the American Society of General Surgeons, doesn't think so. There's a lot of excitement surrounding the novelty and the promise of the technique, but surgeons are, by training, cautious about puncturing internal structures such as the vagina or colon, and it's not clear whether these procedures are safe enough for widespread adoption, he says.

"What bothers me a little is, before it's proven to be advantageous, we've got news crews in operating rooms making this big deal out of a gallbladder snatched out of a mouth. There's a sense, in my mind at least, that people want to be out in front of curve. At the same time we need to make sure that what we're doing is safe and reproducible," he says.

Yet NOTES seems like an inevitable next step in the evolution of surgical techniques, and initial literature suggests this method brings very little risk to the patient. Given the small sample sizes so far, surgeons remain cautious and are still developing the technique. But as the process becomes safer, organ removals could feasibly be performed on an outpatient basis.

And for patients, scars that serve as a reminder of a major operation may become a thing of the past.

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