Do any of these situations sound familiar?
When complications are evaluated on an individual basis, it can be difficult to know if they are isolated instances, or if they are part of a broader problem. After all, complications can occur even when care is stellar. When conducting external peer review, MDReview’s expert reviewers assess whether patient selection, technical skill, and overall clinical judgment were appropriate. Typically, informed consent has been appropriately obtained, and the complications under review are virtually always known, if infrequent, described events. If consent has been appropriate, and the record contains no evidence of errors in surgical technique or inappropriate patient selection, reviewers may conclude that despite the unfortunate or uncommon complication, treatment nevertheless fell within standard of care.
Sometimes a reviewer has the opportunity to review multiple cases from a single provider or institution, and series of cases can yield deeper insight than a single case. Recently, a hospital requested evaluation of a cardiothoracic surgeon because of a concern about high complication rates during minimally invasive direct coronary artery bypass (MIDCAB) surgery. Multiple cases had a similar complication. Based on a single case review, we may have reasonably concluded that it was an unfortunate rare occurrence in which there was no evidence of a deviation from standard of care. When our reviewer found the same complication had occurred in a third of the provider’s MIDCAB patients, it became clear there was a problem. Nothing in the operative reports described a specific surgical error, but the high rate of this rare complication clearly indicated some technical challenges.
At this point, the natural question was, how big was this problem? Did this represent a complication rate that was slightly higher than average or more worrisome? Without knowing the surgeon’s overall volume of cases, the reviewer recommended that the hospital track the provider’s procedures and compare his surgical complication rate with the national benchmarks.
He wrote: “An isolated complication may not represent a deviation from standard of care. However, regular or frequent occurrence of such complications within a short time period does raise the question of the operator’s technical proficiency with the MIDCAB procedure. Trending the overall frequency of complications, whether common or unusual, is not within the scope of this review but may be appropriate. It would be useful to compare the provider’s outcomes with the national complication rate published in the literature.”
Tracking outcomes is a critical step in identifying any areas of recurring problems; without clear data, it is not possible to measure quality and quality improvements. MDReview strongly encourages medical executive staff to internally track their surgical outcomes and participate in national databases such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).
As the case above illustrates, the relatively small sample size of a peer review can present limitations. “When performing peer review, we do our best to identify sources of unexpected bad outcomes,” says Don Lefkowits, MD, Medical Director at MDReview. In many cases, peer review can provide invaluable insight into a provider’s clinical judgment, documentation practices, and appropriateness of care. “But sometimes we can’t tell from a single case. Trending outcomes over a volume of cases may point to a problem that is fixable.” If trending suggests a problem, the next step may be to consider a Focused Professional Practice Evaluation (FPPE), which will include concentrated reviews on a larger sample of a provider’s cases.
As is the case with most things in life, balance and perspective are key. When it comes to identifying and addressing potential quality issues, external peer review provides the opportunity to closely examine the details of select cases, while tracking outcomes can shed broader light on problematic trends that warrant further study. Used together, they provide hospitals a solid foundation for monitoring and continually improving quality measures.
1. American College of Surgeons. About ACS NSQIP. Accessed at https://www.facs.org/quality-programs/acsnsqip/about