Practice makes perfect

Where -- and to whom -- are you sending
your patients for surgery?

By Susan Usher

The tests are back. Your patient, 45-year-old builder Mario Labonte, is going to need a coronary artery bypass. Mario reads the papers, he knows all about the state of hospital delays in Canada. His first question is: "How long will I have to wait, doctor?"

Until recently that was a bit like asking how long's a piece of string. But now, at least in some provinces, you and your patients can find an answer to that question -- on the net. Quebec, Alberta and Saskatchewan have all recently launched waiting list websites that provide doctors and patients with information on the number of patients waiting for different surgeries. The idea is to reduce waiting times by farming out popular procedures to less busy centres.

Waiting times continue to preoccupy policy makers and the Canadian public. The Fraser Institute's annual waiting list survey found that the total waiting time across specialties from referral to treatment increased from 16.5 weeks in 2001/2002 to 17.7 weeks in 2003. Armed with knowledge about the dangers of waiting for some surgeries, your patients may come to you requesting to travel to Chicoutimi or Sherbrooke for their procedure because they've read that Montreal has longer waiting times. And the Health Ministries seem to be encouraging them by making the waiting information public. In some ways it is a PR exercise to make Canadians feel that the government is taking action. For instance, when the Fraser Institute fingered Saskatchewan as having the longest wait times, the province reacted by launching a new Surgical Patient Registry last July to coordinate services and spread out the load more evenly.

However, this policy comes up against a convincing and growing body of evidence that in many cases, volume contributes significantly to outcomes in surgeries. In other words, the more a surgeon performs a procedure, the better she gets. And what about Mario, your bypass patient? Well, maybe his second question should've been: "Who's going to cut me open?"

A study from the November issue of the New England Journal of Medicine casts doubt on the wisdom of spreading out patients to facilities and surgeons with little demand and consequently little volume, especially when it comes to complex surgeries. The study, led by Dr John Birkmeyer of the Dartmouth-Hitchcock Medical Center in New Hampshire, looked at mortality rates among 474,108 patients who had undergone one of eight cardiovascular or cancer surgeries. The researchers attempted to see how much of the established difference in surgical outcomes between high- and low-volume hospitals had to do with the sophistication of the facilities and how much had to do with the experience of the individual surgeon.

The study concludes that, for many procedures, the outcomes have more to do with the surgeon than the facilities. The experience of the individual surgeon was inversely related to operative mortality for all eight of the procedures examined, independent of hospital volume. The authors suggest that initiatives underway in the US to rate hospital volume for certain procedures would do well to develop standards based on surgeon volume as well.

"All these results are applicable to Canada," says Dr Therese Stukely, of the Toronto-based Institute for Clinical Evaluative Sciences and one of the other study leaders. But she points out that we lack the volume of surgeries to conduct as thorough an analysis. She lauds Ontario's regionalization of cardiac bypass surgery as a real step towards ensuring facility and surgeon experience in that area.

Do patients care?
Despite these findings, patients are not hunting out information in droves, even when it is available. Ontarians have had hospital-specific reports on heart care, including surgery, available since the early 1990s. The reports would permit a curious patient to find out which hospitals had the best survival rates and lowest readmission rates. But the Canadian Health Services Research Foundation (CHSRF), in a "mythbuster" report released in December 2003, found that very few patients actually use this information in deciding where to go for heart surgery. "Patient surveys show that people are looking at just about everything except published track records," the CHSRF report states. They care about proximity, about the opinion of family and friends, and about familiarity with the doctor or hospital. Surveys in the US have also found that neither patients nor the majority of doctors put much store in surgeon or hospital ratings when deciding on referrals for surgery.

Physicians are more likely to refer patients to surgeons they have an established relationship with. "I refer my patients to one or two surgeons I am comfortable with and who don't take too long to see my patients," says Dr George Burden, a family physician in Nova Scotia. "My referrals are more based on a relationship with the surgeon than on waiting times."

Striking a balance
Two questions beg response in light of these findings. The first is what balance needs to be struck between making care widely available and ensuring that each centre (and surgeon) has enough volume to ensure good results? The ability to control waiting times hangs in the balance here. Dr Birkmeyer, in another study published in the April 2003 issue of the Journal of the American Medical Association, looked at how much patient travel time would increase if their surgical procedures were done at a high-volume facility. He found that if volume standards were applied through a regionalization of certain surgeries, the travel burden would not increase dramatically.

The second question is what makes a surgeon good? This is a question Dr Birkmeyer's team wants to look into further, to try and define some of the benefits "practice" brings. Skill levels to date have been measured by experience or by similarly subjective methods. A paper published in the November 1 issue of the British Medical Journal proposes developing more objective assessments of dexterity and judgement by using virtual-reality systems such as those used to test a pilot's performance. Like pilots, surgeons take the lives of people in their hands every day, so why aren't they subject to the same regular performance reviews?

Additional research by Julia Cyboran