A commentary, published in the Nov. 3 issue of the journal NEJM Catalyst Innovations in Care Delivery, highlights how defects in surgical care could be diminished or eliminated for the benefit of patients and to lower costs in American health care spending.
“While prior reports have commented on individual defects in surgical care, we believe that the current article is the first to summarize the opportunity to reduce defects in surgical care,” said author David W. Dietz, MD, Chief, Division of Colorectal Surgery, and Vice President of System Surgery Quality, University Hospitals Cleveland Medical Center.
Using colorectal surgery to provide examples and national estimates of the costs of defects in surgical care, the paper summarizes a holistic approach to eliminating defects in surgical care and offers a framework for centers of excellence for removing them.
“Defects in health care are common and can be defined as behaviors, based on known evidence, that needlessly reduce the quality of care and patient experience or add to the annual total costs of care,” said Dr. Dietz.
“We are now entering a new era in medicine and surgery in which the focus will be elevated from the quality of care to its value,” he said. “High-value health care is achieved when excellent outcomes, including patient experience, are achieved at reasonable costs. As surgery accounts for nearly half of all Medicare spending, surgeons will have a critical role in this journey.”
Co-author Peter Pronovost, MD, estimates the U.S. health care system spends $1.4 trillion annually—one-third of health care costs—on defects. At his own institution, University Hospitals in Cleveland, where he is the Chief Clinical Transformation Officer, he found that focused efforts to reveal and reduce defects improved quality and reduced Medicare costs by 9 percent. Dr. Pronovost is also Professor, Schools of Medicine, Nursing, and Management, Case Western Reserve University.
In their new paper, Drs. Dietz and Pronovost estimate that defects in colorectal surgery cost the American health care system more than $12 billion. The authors discuss eight areas (or domains) of defects that waste money and/or contribute to lower value in care for colorectal surgery patients.
“Given the abundance of opportunities presented, a ‘whack-a-mole’ approach to address them individually seems inefficient and overwhelming,” said Dr. Pronovost. “However, a holistic approach through the creation of Centers of Excellence (COEs), if well designed and well-executed, can address all of these defects”
Dr. Pronovost said, “COEs are a systematic attempt to design surgical care to eliminate all or most of these defects. In COEs, we provide frictionless access; we provide patient navigation; we use explicit appropriateness criteria to ensure patients will benefit from the procedure; we ensure the procedure is done at the highest value site of service by a surgeon and at a hospital that has high volume; we use standard protocols, yet personalize when needed to eliminate preventable harm; we ensure patients go home rather than to a post-acute facility when possible. As a result; quality and experience increase and cost decrease.” University Hospitals has created COEs, for example, for joint replacement surgery, spine surgery, and atrial fibrillation ablation, and is creating one for colorectal surgery.
“If we are to finally improve the value of surgical care in the U.S., we need to ensure that surgeons are engaged in the process and that principles for quality improvement are also applied to identify and eliminate all defects in value in surgical care,” he said.
Other authors of the paper are William V. Padula, Ph.D., MS, Assistant Professor, Department of Pharmaceutical & Health Economics, School of Pharmacy; Fellow, Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles; and Hanke Zheng, MS, Graduate Research Assistant, Department of Pharmaceutical & Health Economics, School of Pharmacy, University of Southern California, Los Angeles.