By Cheryl Clark, for HealthLeaders Media, August 23, 2013
For the first time, surgeons have a sophisticated risk calculator said to accurately predict the chance of death or a number of other bad outcomes, such as renal failure or infection, for nearly any surgical procedure done in a U.S. hospital.
"The old way we were assessing risk was very simple and it only applied to three or four operations, and only gave three outcomes," says Karl Bilimoria, MD, director of Surgical Outcomes and Quality Improvement Center at Northwestern University who developed the calculator with the American College of Surgeons.
"This one applies to more than 1,500 operations, and provides nine or 10 outcomes. It's considerably better."
"There's clear excitement among surgeons about having this available and I think they will use it," although initially, he says, it may take time to explain the online tool to their patients. "I think setting their patients' realistic expectations from the beginning may save them time in the long run."
In some cases, he says, the risk calculator may prompt a doctor to change a recommendation about whether a patient should have surgery. With the calculator, the procedure may appear less risky than originally perceived, but in some cases more so.
Bilimoria acknowledges that today, many surgeons don't really know how to assess patients' risk for most procedures, so many provide reassurance with generalities. For example, should the patient ask about a doctor's surgical track record, the surgeon may respond that his complication rates are low, or that the patient shouldn't worry because the doctor is experienced at doing that operation.
Surgical Risk, Quantified
"That may still be the case," Bilimoria says. "But the beauty of this risk calculator is that it takes into account the individual patient's risk factors, the type of operation they're going to have, and then generates their personalized risk factors."
The 23-question web page can be quickly filled out online by the doctor with the patient, or even by the patient alone if he or she knows the name of the surgery or appropriate CPT code. Risk factors such as age, height and weight, whether the patient is ventilator-dependent or has had a previous cardiac event, are all factored into the algorithm.
The calculator shows the probability of death or any complication, and the probability of a host of specific potential complications as well as the predicted length of hospital stay. It also calculates whether the adverse event risk for that patient is below average, average, or above average.
Tool Won't Reduce Surgeries by Much
As more patients are exposed to the risk calculator, Bilimoria says, it could mean fewer surgeries, especially when risks clearly outweigh benefits. Patients may choose to avoid potential harm that seems more likely when the bar on the online chart shows higher risk.
But he says that it won't reduce surgeries by much. What it will do is help doctors do a better job of giving patients realistic expectations, so they are not surprised if the surgery doesn't go as planned.
The reasons for developing such a calculator are many, Bilimoria says. Obviously, patients have a right to realistically know the chance a surgical procedure will be successful and give informed consent in a shared decision-making process.
Even if the procedure is risky, and a patient decides to proceed, and there's a complication, "it sets up more realistic expectations if a complication does occur," he explains.
The tool is designed for surgeons to use during an office visit with their patients, who can see "very quickly if they have a higher risk because the bar turns red, and gives the percentage. It really draws your attention," he says.
Medicare Reimbursement May Come Into Play
But there's another important reason for such a risk calculator. The Centers for Medicare & Medicaid Services in a proposed rule earlier this year, said that such a risk calculator might be an optional alternative to generate reimbursement under the Physician Quality Reporting System, through which physicians who report quality data can earn 2 or 3% more when taking care of Medicare beneficiaries.
Bilimoria said he's been working with CMS to include the calculator in the final rule, which is expected sometime next month.
"CMS realizes the importance of providing patients with empirical data-driven risk factors. They're going to incentivize surgeons who want to use this by letting it meet a PQRS requirement."
The new risk calculator is based on the ACS's National Surgical Quality Improvement Program (NSQIP) program, through which hundreds of hospitals are participating in confidential quality improvement programs for certain kinds of surgical care.
Participants share best practices and help other surgeons in their own hospitals as well as across the country, learn ways to improve outcomes. The calculator's formula was generated from outcomes from about 1.4 million patient procedures at nearly 400 participating NSQIP hospitals between Jan. 1, 2009 and June 30, 2012.
A paper detailing how the risk calculator was created is due to be published in the Journal of the American College of Surgeons in the near future. It is already posted online.