The Quality Dilemma

My sincere appreciation to Drs. Ban, Gunter, and Kanters for an outstanding volume on quality in colorectal surgery. At my current institution, the Cleveland Clinic, our CEO always preaches that everything starts and ends with ensuring the highest patient safety and quality outcomes. Patient experience is also critical, as are other factors such as systemness, uniformity of care, and value. However, safety and quality of care are paramount. So why are things so variable? Caregivers and medical institutions certainly do not want their patients to have poor outcomes. As a surgeon, I tell my patients that while I cannot guarantee they will not develop a complication, we will strive to do the right operation, for the right indication and ensure that we as a team will do everything we can to ensure the patients gets through the operation as best as possible. Further, outside of the patient and their immediate family and friends, the person they are looking at (i.e., me) is the person most vested in them achieving a safe and great outcome. Unfortunately, morbidity and mortality still occur. There are also differences in outcomes, individually and institutionally, that are widely disparate for similar patients undergoing the same procedure. More concerning, some of these outliers remain outside of the normal curve—even in poor outcomes—repeatedly. The dilemma then lies in what can or should we do about this discrepancy. The answer(s) are more nuanced than apparent at first glance.

First, these should be agreed upon standardized quality definitions and guidelines available for physicians caring for patients with colorectal disease.[1] These should be centered around preoperative, intraoperative, and postoperative management, and based on prior well-documented reviews, widely accepted standards and high-quality outcome studies to provide a unified consensus regarding the quality of optimal outcomes. To date, the definition of quality is not even uniform.[2] [3] The National Institute of Medicine in the United States defines it as the “degree to which health services for individual and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” The definition of quality measure by the Agency for Healthcare Research and Quality is “a mechanism that enables the user to quantify the quality of a selected aspect of care by comparing it to a criterion.” The Center for Medicare and Medicaid Services defines quality measures as “tools that measure or quantify healthcare processes that are associated with the ability to provide high-quality healthcare.” While you may agree with parts of each or the totality of all, the differences may lead to an inability to focus on efforts for both measuring and improving outcomes.

Second, there remains disagreement with what we should be actually measuring. Ultimately, the utilization of quality parameters should be as a framework to improve patient outcomes. It seems straightforward. Yet, a quality committee's evaluation can range from efficacy or resource utilization to perioperative metrics or patient satisfaction (e.g., HCAHPS). Further, variability in definitions and reporting can radically alter performance.[4] Think of a problem with a postoperative wound. Is it infected? Is it a seroma? Was it present on admission? Was the assessor blinded? This is one of the most basic situations we deal with as surgeons, and there is likely to be disagreement among various providers as to how they would independently classify that simple wound. More concerning, under or over-reporting is often tied to fears of retribution or even economic reimbursement; hence, these factors may subtly (or not so subtly) influence reporting results.

Intrainstitutional reporting of quality standards should also be as a means of feedback and improving care in a timely manner. Interinstitutional reporting can be a way of identification of areas or focus or sharing best practice. In this light, efforts should be made toward changing modifiable factors able to be improved (such as optimization or readmission rate). This information can also be used to guide perioperative discussions with patients as well as to provide information on expected outcomes. For example, it is one thing to know what the literature says for a colorectal anastomotic leak rate. It is completely different to know what your leak rate is, especially when stratified by risk and in comparison to colleagues.

Ultimately some may push for regionalization or further subspecialization for certain procedures. In Scandinavian countries, centers of excellence for rectal cancer have centered care where only certain providers and institutions can treat these patients.[5] While this certainly limits the scope of practice for many providers, it has dramatically improved quality outcomes, and has become the norm in those countries. While not mandatory, here in the United States, programs like the American College of Surgeons' National Accreditation Program for Rectal Cancer (NAPRC) have similarly aimed to raise the quality of care for rectal cancer patients. To date, 77 programs are accredited with several more in process. While there have been mixed results, in general, improvements have been demonstrated in compliance of quality standards as well as overall survival.[6] [7] Due to the mere size of the United States, paucity of specialists in vast areas, impact of payors, and other factors unique to this country and others, centralization may simply not be possible. Further, regionalization remains very controversial, and implementation may be difficult.

In summary, ensuring the best outcomes for our patients is the most important aspect of care and it should drive all the efforts. Yet, an in-depth look at how we define, record, track, and implement action items to improve quality is still needed. Only by collectively working together without hubris and fear we can likely achieve the desired state.

Publication History

Article published online:
16 April 2023

• References

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• 2 Patwardhan M, Fisher DA, Mantyh CR. et al. Assessing the quality of colorectal cancer care: do we have appropriate quality measures? (A systematic review of literature). J Eval Clin Pract 2007; 13 (06) 831-845
• 3 Galandiuk S, Rao MK, Heine MF, Scherm MJ, Polk Jr HC. Mutual reporting of process and outcomes enhances quality outcomes for colon and rectal resections. Surgery 2004; 136 (04) 833-841
• 4 McGory ML, Shekelle PG, Ko CY. Development of quality indicators for patients undergoing colorectal cancer surgery. J Natl Cancer Inst 2006; 98 (22) 1623-1633
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