An archetypal scene that resonates with every surgeon is where the doctor finds him/herself in a tribal village tending to the wounds of the chief's child. The surgeon knows that it is not only the child's life that hangs in the balance.
Today a modern version of that tribal hut is emerging with profound consequences to the practice of oral and maxillofacial surgery. Good results of the care we provide have always been an essential goal of our clinical practice. Traditionally, we seek excellence in clinical care out of our moral obligation to our patients.
In the past decades, other influences have propelled clinical practice toward a skewed and some might say grotesque quest for quality. Some examples: 1) The emergence of the third party payment system has evolved from a mission to simply pay for necessary health services to a for-profit goal of subscriber and provider silence at the lowest cost, cloaked in the claim of highest quality. 2) The professional liability system has its cadre of plaintiffs' teams who claim to be responsible for improved treatment outcomes as they punish presumed deviations from good care. 3) The marketing of practices of specialties and of ABMS/CODA-recognized board certification in a competitive environment has also driven claims of improved surgical outcomes.
All of these are now time-honored, though not concordant, centers of critical assessment of our treatment outcomes.
While the past has produced enormous changes in our assessment of surgical outcomes, it is but a prologue to the changes, and the stakes, yet to unfold. Emerging technologies such as the electronic medical record, standardized diagnostic and treatment codes, and vast databases of clinical diagnoses linked to treatment records have allowed the outcome information attached to those databases to be referable to institutions and to individuals.
Our institutional reputations, our individual reputations, hospital credentialing of surgeons, and even doctor reimbursement now depend directly upon the outcomes of the care we provide. Our livelihoods are also tightly linked to the quality of the care we provide as it is measured by others with goals that might not match our own.
Information Technology's Effect on Measuring Treatment Outcomes
As a recent example (with details not revealed to respect confidentiality), our credentials committee received a letter of concern from a physician who claimed that another service was performing a procedure with inferior outcomes compared to those achieved by the physician's own service. After the critical outcomes of the procedure were identified, a spreadsheet revealed 4 services and 17 physicians performing the procedure with complication rates from 2% to 14%. Patient comorbidities, age-adjusted risk, surgeon case load, overall complications, number of admissions, etc, were revealed in complete detail on every physician. Interestingly, the complaining physician also discovered (to his amazement) his individual profile for this procedural outcome. Importantly, the committee was able to see the power of the database software in revealing true detail on treatment outcomes in concurrent review. Since the case load for this procedure could have been accommodated by fewer physicians, the obvious question for the committee was whether to take any action, eg, limit the number of physicians treating the condition, select the best service to treat the condition, prescribe continuing education, proctor procedures, or determine other means to improve quality. Other than to reveal the unhappy surprise of the complaining physician, it will be left to the reader to ponder what the committee decided.
Clinical Technology's Effect on Measuring Treatment Outcomes
Emerging new technology can precisely depict outcomes of oral and maxillofacial surgery. While postoperative imaging has become the norm for fracture management, computer-based navigation and intraoperative CT imaging provide real-time assessment of clinical movements of facial structure. Whether the outcome assessed is a reduction of a zygomatico-orbital fracture, reconstruction of a mandible, ramus osteotomy, sleep apnea surgery, or dental implant placement, precise visual and quantitative assessment of the surgeon's skill is now available. In this month's JOMS, Pohlenz et al assess the utility of intraoperative imaging for facial reconstruction of zygoma fractures with results that will drive improved outcomes of care.1 If intraoperative CT and precise postreduction measurement of orbital volume is widely available, it will not only improve the quality of care but it will raise the bar for acceptable treatment outcomes for zygomatico-orbital fractures. It will also provide fodder for all of the constituencies that measure clinical outcomes.
In another example, continuous multimodal anesthesia recordings that now include visual recordings have become akin to flight recorders in assessing adverse anesthesia events. Continuous measurement of EEG-evoked potentials (by spectral index) can assess anesthetic stage while electronic entry of drugs and doses is becoming the norm. Alerts formerly notable only for changes in patient status now can provide real-time feedback on deviation from threshold standards for drug doses and fluids, while assessing the effect of each dose. The anesthetic delivery environment is better able to inform the surgical team regarding the elements of quality than ever before. The task for our specialty is how to best incorporate available technology into the oral and maxillofacial surgery ambulatory anesthesia environment.
The Future Impact of the Assessment of Surgical Outcomes
Even further regulatory consequences of clinical outcomes assessment are stirring in the conversations of decision-makers in health care. Some of these might progress to fruition while others may be rejected due to societal or economic pressure. It is unlikely that any will be rejected due to a lack of technologic capability.
Here are some arenas in which measurement of surgical outcomes might affect the practice of oral and maxillofacial surgery in the future.
Patient-Based Assessment of Outcomes
Check out your scores on the Internet. You and your hospital are assessed by your patients on numerous Web sites. Just search Google, “How good is my doctor/hospital?” or similar to read comments. These are likely to congeal into a more centralized approach to “scoring” doctors.
Outcomes-Based Hospital Credentialing
Your hospital can compare you with normative values; your volume, your surgical technique (for example, the number of lymph nodes removed during ablative cancer procedures), recurrence rates, hours of operating time, readmissions, and “red flag” risk management issues. The reappointment process can link specific privileges to this outcome information.
Outcomes-Based Licensure
State licensing boards now require individual practitioner information on adverse outcomes be reported by their hospital. In the case of individuals in private offices, a condition of licensure in many states is the mandatory reporting of adverse outcomes including for example wrong tooth extraction. Federal, state, and institutional data bank submissions are becoming further linked by statute.
Outcomes-Based Reimbursement
Third party payers have begun the practice of not paying for the complications of treatment. For example, Medicare recently announced withdrawal of payment to hospitals for the consequences of nosocomial infection.
Outcomes-Based Funding of Health Science Education
Federal funding of health science education that produces the best outcomes at the lowest cost is becoming the norm. Watch for measurements of quality of intermediate level providers of oral health care, such as the Alaska dental health therapists program. Surgical specialties benefit tremendously from federal support of graduate medical education. The recognition of these specialties for federal reimbursement will depend upon their ability to produce improved health outcomes.
Our society is just a big tribal village and the hospital is beginning to resemble that hut.
Reference
1. 1Pohlenz P, Blake F, Blessmann M, et al.Intraoperative cone-beam computed tomography in oral and maxillofacial surgery using a C-arm prototype: First clinical experiences after treatment of zygomaticomaxilary complex fractures. J Oral Maxillofac Surg. 2009;67:515. Abstract | Full Text |
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