A new method has been developed at University Hospital Zurich to evaluate hospital quality for surgical procedures. In a large international study, a team headed by surgeon Pierre-Alain Clavien, Prof. MD, PhD, was able to demonstrate that the success of an operation depends not only on the experience of the surgeon or volume of patients, but more on the proportion of complex cases, which enhances the skills of the entire team in recognizing and early managing any adverse events.
A comparison of surgical quality and outcome is particularly difficult when cancer mortality is high and the chances of cure are slim – as is in patients with diagnosed pancreatic cancer.
Prof. Clavien, Director of Surgery and Transplantation at University Hospital Zurich, and his team set out to tackle precisely this hurdle. As part of an international collaboration with twenty-three pancreas centers from around the world, the team defined the medical parameters (e.g. mortality, serious complications, blood loss or cancer-specific factors) and set their reference values for this procedure. This made it possible for the researchers to determine what could be considered superior surgical performance by a center.
The quality of pancreatic surgery is considered of high standard if the mortality rate after the operation is below 1.6%, if serious complications occur in less than 35% of cases, and if more than 10% of the operated patients live for more than three years following the procedure. Patients with preoperative risk factors, such as old age or multimorbidity (patients suffering from multiple diseases) were excluded from the study to be able to assess the quality of the procedure itself as independently as possible.
Currently, these are the first surgical quality thresholds compiled in a standardized method based on data from multiple international high-volume centers, that would allow hospitals to measure the quality of their performance objectively.
The study further uncovered an important insight: Centers that treat mostly complex patients with a high surgical risk achieved better results. “Teams that often deal with complex cases get more practice in managing such patients. They recognize complications at an earlier stage and therefore, manage them more effectively,” explains Pierre-Alain Clavien. This takes a little weight off the shoulders of the surgeon, as the number of patients operated per year or individual surgeon is not the only parameter influencing the outcome of a procedure. Just as critical is the performance of the whole system, in other words, how well attuned the team of nurses, anesthesiologists, and surgeons is regarding the management of difficult cases and complications.
This new concept of quality control was applied to the surgical treatment of pancreatic cancer as it is one of the most fatal types of cancer. Only ten percent of people survive for more than five years after their diagnosis. It is also one of the few cancers with a continuous increase in newly diagnosed patients. “In the next twenty years, pancreatic cancer will likely be the most common cause of cancer-related deaths in the Western world,” predicts Pierre-Alain Clavien. Each year, 1,300 people in Switzerland develop pancreatic cancer, with over 92% of them dying from the condition. As for today, the only treatment that promises a chance of survival is the surgical removal of the tumor in combination with chemotherapy given prior to surgery.
Benchmarking involves comparing business processes and performance metrics with the best practices of economic leaders. Typical measures include quality, time, and costs. Pierre-Alain Clavien and his team adopted this concept to the field of surgery by defining thresholds of the best possible results for specific procedures. Such benchmarks have already been established for liver surgery and transplantations, esophagus resections, and obesity surgery. The hope is that the objective and anonymous comparison with the best possible result may improve patient outcomes by revealing areas of quality gaps and thus, ultimately lower surgical treatment costs.
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