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April #UROJC: The Surgeon Scorecard – Merits of Publicly Reported Surgical Outcomes

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The April 2016 International Urology Journal Club on Twitter (#urojc) hosted a discussion on our paper, “Comparing Publicly Reported Surgical Outcomes with Quality Measures from a Statewide Improvement Collaborative”. Published in JAMA Surgery on March 16, 2016, the paper was authored by Gregory Auffenberg MD, David Miller MD, Khurshid Ghani, Zaojun Ye, Apoorv Dhir, Yoquing Gao. I contributed as a member of MUSIC.

It was an honor to have the paper selected for a #urojc discussion, and the authors would like to thank JAMA Surgery for providing open access during the discussion period. This post serves as an overview, and the entire #urojc transcript is available for reading courtesy of Symplur

For those not familiar, the #urojc Twitter chat is a 48-hour asynchronous conversation amongst urologists around the world on Twitter on a selected journal paper, taking place on the first Sunday/Monday of every month.

 

The ProPublica Surgeon Scorecard

The subject of our research centered on the online U.S. surgeon ratings compiled for ProPublica’s Surgeon Scorecard. ProPublica is an investigative journalism organization that was given exclusive access to U.S. Medicare data for the years 2009 to 2013.

“Reporters Olga Pierce and Marshall Allen studied almost 75 million hospital visits billed to Medicare looking for eight common, elective surgeries. They then looked to see whether the same person returned to the hospital for what appeared to be complications from the surgery. Their full methodology is spelled out here.”

 

The Michigan Urological Surgery Improvement Collective

Specifically, our research paper looked at ProPublica’s ratings for only one procedure – results on radical prostatectomy (RP) for prostate cancer – and correlation to reporting by MUSIC, the Michigan Urological Surgery Improvement Collaborative. MUSIC is a state-specific quality initiative in the U.S. in which I am a participating surgeon. Participation in MUSIC is voluntary, over 85 percent of urologists in the State of Michigan participate in the collaborative.

 

 

April #UROJC

As our paper states, the recent release of the Surgeon Scorecard accelerated debate around the merits of publicly reporting surgical outcomes. Surgical outcomes assessment is not a new concept, even dating back to 1860 as this tweet by @mattbultitude surfaced.


What does our community of urologists think about public reporting? Does greater transparency correlate with better outcomes? What are the benefits of a collaborative method like MUSIC? What methods are used in other parts of the world?

 

The #urojc discussion found that many urologists outside the U.S. were not familiar with the ProPublica ratings or debate. Some were not surprised that we did not find a correlation between our MUSIC outcomes data and the ProPublica data, thereby validating the need for quality outcomes data.

 

 

If the Surgeon Scorecard is flawed, what needs to be done to create an acceptable public reporting system?

 

Is public reporting of surgical outcomes taking place in Australia, UK, Canada & elsewhere?

 

 

How are ‘outliers’ identified by this study handled by MUSIC?

 

Do ratings lead to cherry-picking of patients?

 

According to New York cardiologist, Sandeep Jauhar, MD via Medscape, 63 percent of cardiac surgeons acknowledged accepting only relatively healthy patients for heart bypass surgery owing to report cards in New York State.

 

Moving Surgical Outcomes Forward 

On behalf of the authors of the paper and the entire MUSIC collaborative, I would like to thank our #urojc colleagues around the world for their thoughts, insights, criticisms and questions about the paper.

The ProPublica Surgeon Scorecard has generated significant and serious discussion in the U.S. about the challenges and merits of the public reporting of surgical outcomes. In an increasingly connected world, it’s difficult to imagine how this can remain simply an American debate.

Urologists by their very nature are leaders. Personally, I see this debate as yet another opportunity for us to develop and implement systems and strategies that reassure the public and advance patient care.

MUSIC JAMA Paper

 

Are you ready to go to prison on a manslaughter charge?

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Which of us fancies ending their career with a spell in the clink? Being a surgeon in the UK has just become a whole lot riskier. We all know that in our job success can add extra years to our patients lives, by contrast, failure, can result in significant harm, or, in the worst circumstances, death. We all do our best, but sometimes things don’t work out. The sentence of two and a half years in prison for Mr David Sellu, who was referred a patient who developed peritonitis after an orthopaedic operation and subsequently died, smacks of injustice, and sends a shiver down the spine of all of us surgeons, who work hard on behalf of our patients, but who cannot always guarantee success.

The case is reported in detail in the latest bulletin of the Royal College of Surgeons (Ann R Coll Surg Engl (Suppl) 2014; 96: 112-113). It appears that the main problem was a delay in taking the patient to theatre because of the difficulty in finding an anaesthetist; a problem that cannot be reasonably be blamed upon the surgeon himself. If prosecutions for manslaughter become more frequent in circumstances similar to the Sellu case, we may all have to develop new defensive strategies. Madison Branson Lawyers are experts in the area of Proceeds of Crime and Confiscation Law.  The prospect of ending an otherwise unblemished career in a prison cell as a result of an unfortunate clinical mishap might deter many from entering the profession in the first place. How should we react to the very sad scenario?

Roger Kirby, The Prostate Centre, London

 

Article of the week: The survey says: surgeon preferences during robot-assisted radical prostatectomy

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

The European Association of Urology Robotic Urology Section (ERUS) survey of robot-assisted radical prostatectomy (RARP)

Vincenzo Ficarra1, Peter N. Wiklund2, Charles Henry Rochat3, Prokar Dasgupta4, Benjamin J. Challacombe4, Prasanna Sooriakumaran5, Stefan Siemer6, Nazareno Suardi7, Giacomo Novara1 and Alexandre Mottrie8

1Oncological and Surgical Sciences, Urology Clinic, University of Padua, Padua, Italy; 2Urology Laboratory, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; 3Multidisciplinary Centre of Robot-Assisted Laparoscopic Surgery, Générale-Beaulieu Clinic, Geneva, Switzerland; 4Department of Urology, Guy’s Hospital, London, UK; 5Department of Urology, Royal Surrey County Hospital, Guildford, UK; 6Department of Urology, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany; 7Department of Urology, Vita-Salute University San Raffaele, Milan, Italy; and 8Department of Urology O.L.V. Clinic Aalst, Aalst, Belgium; EAU Robotic Urologic Section (ERUS) Scientific Working Group

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OBJECTIVE

• To evaluate surgeons adherence to current clinical practice, with the available evidence, for robot-assisted radical prostatectomy (RARP) and offer a baseline assessment to measure the impact of the Pasadena recommendations. Recently, the European Association of Urology Robotic Urology Section (ERUS) supported the Pasadena Consensus Conference on best practices in RARP.

SUBJECTS AND METHODS

• This survey was performed in January 2012. A specific questionnaire was sent, by e-mail, to 145 robotic surgeons who were included in the mailing-list of ERUS members and working in different urological institutions.

• Participating surgeons were invited to answer a multiple-choice questionnaire including 24-items evaluating the main RARP surgical steps.

RESULTS

• In all, 116 (79.4%) invited surgeons answered the questionnaire and accepted to participate to the ERUS survey.

• In all, 47 (40.5%) surgeons performed >100 RARPs; 41 (35.3%) between 50 and 100, and 28 (24.1%) <50 yearly.

• The transperitoneal, antegrade technique was the preferred approach.

• Minimising bladder neck dissection and the use of athermal dissection of the neurovascular bundles (NVBs) were also popular.

• There was more heterogeneity in the use of energy for seminal vesicle dissection, the preservation of the tips of the seminal vesicle and the choice between intra- and interfascial planes during the antero-lateral dissection of the NVBs. There was also large variability in the posterior and/or anterior reconstruction steps.

CONCLUSIONS

• The present study is the first international survey evaluating surgeon preferences during RARP.

• Considering that the results were collected before the publication of the Pasadena recommendations, the data might be considered an important baseline evaluation to test the dissemination and effects of the Pasadena recommendations in subsequent years.

 

Read Previous Articles of the Week

Editorial: Robot-assisted radical prostatectomy: getting your ducks in a row!

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Robot-assisted radical prostatectomy (RARP) has become the technique of choice for clinically localised prostate cancer. However, marked inter-surgeon heterogeneity and an obvious lack of standardisation exist for the indications and technique of the procedure. In this issue of the BJUI, Ficarra et al. conducted a multinational survey seeking opinion from 145 robotic surgeons about individual practices during RARP. These opinions can be compared against the benchmark set by the Pasadena Consensus and can help gauge the impact of its recommendations.

Responses from 116 (79.4%) invited surgeons were analysed. The authors acknowledge the limited participation of non-European surgeons (17.1%), which may limit validity and application of its results at a global level. Most surgeons were in consensus with the Pasadena recommendations for transperitoneal access (88%), antegrade approach (76%) and bladder neck preservation (77%). The opinions on cautery use for the seminal vesicle/vas deferens dissection (51% athermal; 21% bipolar), athermal nerve-sparing approach (90%) and the use of the running suture technique for urethrovesical anastomosis (96.6%) were also in agreement.

Despite wide surgeon and institutional variability regarding the definition of bladder neck preservation and its role in the return of urinary continence, most preferred to preserve the bladder neck. This may pose difficulty in the interpretation of the results in view of the ambiguity about the definition and technique adopted under the term ‘bladder neck preservation’ (Eur Urol, BJU Int).

Most of the participating surgeons were using anterolateral prostatic fascia dissection (Veil of Aphrodite) towards preserving the cavernous nerves by using an athermal approach. Over the last decade the evolution of robot-assisted surgery, with excellent three-dimensional visualisation, depth perception, and EndoWrist® technology has made working in the confines of the pelvis both ubiquitous and a desired skill.

The present study found that 33% of surgeons omitted the internal iliac lymph nodes (LNs) and removed only obturator, with or without the external iliac LNs. The Pasadena Consensus recommends a template that includes the internal iliac, external iliac and obturator LNs. Mattei et al. in an attempt to map primary prostatic lymphatic ‘landing’ zones found that after performing a standard limited LN dissection (dorsal to and along the external iliac vein; medially along the obturator nerve) only 38% of LNs were removed. They recommended a template that retrieves LNs extending up to the ureteric crossing of the common iliac vessels. Meanwhile, Menon et al. evaluated the role of only internal iliac LN dissection (limited) in patients with a low probability of nodal disease (Partin table prediction 0–1%), and surprisingly found positive LNs in the internal iliac/obturator region 13.7 times more often than in the external iliac/obturator region. One of the issues that could be addressed in future surveys would be to evaluate how surgeons view and adapt to changes in the proposed LN template. The Pasadena Consensus further recommends considering performing LN dissection for the low-risk category based on the D’Amico risk stratification. The surgeon’s indications for pelvic LN dissection were not addressed in this survey.

Despite significant studies, including two randomised controlled trials (RCTs), published in the peer-reviewed literature reporting minimal advantage for early recovery of urinary continence with posterior reconstruction, a significant number of the surveyed surgeons still preferred to perform it. Responses to other questions about the posterior/anterior reconstruction also showed marked variability reflecting the controversial opinion about the value of these surgical steps.

On the other hand, future surveys should gather opinions about the role of RARP for high-risk disease, standardised evaluation of surgical complications; while addressing continence and potency status along with methods of their measurement. These topics were already addressed in the Pasadena Consensus and obtaining opinions of surgeons will further provide insight as to how surgeons adapt to the ever-changing advances in this field.

Over the last decade RARP has gained acceptance despite the absence of high-quality RCTs in robot-assisted surgery. The Pasadena Consensus was meant to meet the need for uniformity and this study educates us on how the surgeons really perform ‘in the trenches’. Until further evidence is available, surgeon experience and institutional volume will remain the main force driving the use of these surgical techniques and their outcomes.

Ahmed A. Aboumohamed and Khurshid A. Guru
Department of Urology, Roswell Park Cancer Institute, Buffalo, NY, USA

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