The first person to examine this question was Ernest Codman 1869-1930), a surgeon at Harvard Medical School.
During Codman’s time, no well-defined program for training surgeons existed. Unhappy with what he perceived to be surgeon incompetence, Codman left Harvard to found the “ End Results Hospital”, where he systematically measured the outcomes of care for each patient treated. His methods were embraced by the American College of Surgeons soon after the founding of the College in 1913. Around that time, William S. Halsted, a surgeon at the Johns Hopkins Hospital, developed a formalized residency training program for young surgeons.
In 1951, the American College of Physicians, the American Hospital Association, and the American Medical Association united with the American College of Surgeons to create the Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission is a not-for-profit organization dedicated to improving the safety and quality of the nation’s health care.
Central questions in modern outcomes research include:
Quality measures in the 21 st century
In 1996, the Institute on Medicine (IOM) launched a concerted effort to assess and improve the nation’s quality of care. The findings of the first phase of this ongoing project were published in 1999. In their landmark report, “ To Err is Human: Building A Safer Health System”, the IOM reported that as many as 98,000 people die annually as the result of medical errors and called for a national effort to make health care safe. The IOM’s follow up report, “Crossing the Quality Chasm: A New Health System for the 21 st Century”, examines the reforms that must take place to bring existing practice up to higher standards in safety and quality.
Today, a number of national organizations dedicated to health systems improvement exist. These include:
Quality in Surgical Care
Given its high-risk nature, the field of surgery has been subject to intensive scrutiny in quality measures since the mid-1990s. Much of the early work in surgical outcomes arose from the United States Department of Veterans Affairs Health System, Dartmouth University, and the UCLA Center for Surgical Outcomes and Quality.
In two landmark studies published in the New England Journal of Medicine (1, 2), Birkmeyer and associates analyzed certain complex operations (cardiovascular procedures and cancer resections) and found that:
Since then, a multitude of studies have examined the relationship between volume and outcomes in surgery. Surgeon experience has been linked to favorable cancer-related endpoints (survival and disease-free status) as well as improved economic outcomes (length of hospitalization and cost of surgical care) (3, 4).
The volume-outcomes relationship in surgery has a certain “common sense” appeal: The more you do something, the better you are at it. However, this viewpoint has been criticized as inadequate, for several reasons:
Obtaining health care is a risky endeavor. In fact, quality advocates have reported that the risks associated with hospitalization are many times greater than those associated with commercial air travel.
Patients and their families should become engaged as active participants in their own care, and use all available resources to seek out both the best doctors and the best hospital setting for their particular problem. Though we are entering a new era of increased transparency with respect to quality measures, good information remains a challenge to find. Here are some places to start.
This material is exceptionally well-written, clear, and accurate. It is essential reading for all patients. Some articles of particular interest include:
Currently, publicly available hospital information is limited to rudimentary measures on topics such as heart attack, heart failure, pneumonia, and surgical care improvement. The tool allows for comparison between various hospitals as well as comparison to state and national benchmarks. Overall, it allows for a crude yet informative assessment of hospital quality.
Please be advised that the methodology behind such surveys has been criticized. Read about how the results are derived.
Conclusion: Tough questions, clear answers
At this point, you are probably wondering why detailed quality information on individual hospitals and doctors is not publicly available. Be patient, we are getting there. Information of this nature is obviously very sensitive, and significant barriers to self-reporting exist. It remains the patient’s responsibility to ask the right questions. One useful framework for these questions centers around the structure, process, and outcomes of care as described by Donabedian (7) . Some examples follow.
There are many ways to ask pointed questions such as these in a respectful yet deliberate manner. Do not be afraid to ask these specific questions when you speak to your doctors. Demand nothing less than direct, clear, preferably numeric answers. Remember, your health is at stake.
1. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346(15):1128-37.
2. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117-27.
3. Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg. 2007;94(2):145-61.
4. Martling A, Cedermark B, Johansson H, Rutqvist LE, Holm T. The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer. Br J Surg. 2002;89(8):1008-13.
5. Liu JH, Zingmond DS, McGory ML, et al. Disparities in the utilization of high-volume hospitals for complex surgery. Jama. 2006;296(16):1973-80.
6. Khuri SF, Henderson WG. The case against volume as a measure of quality of surgical care. World J Surg. 2005;29(10):1222-9.
7. Donabedian A. Twenty years of research on the quality of medical care: 1964-1984. Eval Health Prof. 1985;8(3):243-65.