10 Jul Surgeons Need To Document Why Patient Care May Fall Outside Standard Guidelines
Medical Research: What is the background for this study? What are the main findings?
Dr. Tjoe: Numerous national health organizations have confirmed minimally invasive breast biopsy (MIBB), which uses a percutaneous core needle as opposed to open surgical techniques, as the biopsy procedure of choice when a patient’s diagnostic test reveals a breast lesion suggestive of malignancy. Unfortunately, despite the overwhelming evidence supporting use of MIBB, open breast biopsy rates in the United States remain as high as 24-39%. Our study was designed to determine if measuring individual practice patterns and providing subsequent feedback to surgeons across a large, multihospital healthcare system would improve their adherence to the quality metric of using minimally invasive breast biopsy to diagnose indeterminate breast lesions.
We found that the proportion of studied surgeons (n=46) appropriately adhering to the MIBB quality metric in every instance (i.e. those who achieved 100% adherence) significantly improved from 80.4% to 95.7% (p=0.0196) after receiving feedback on not only their own practice patterns, but those of their blinded peers. As might be expected, the handful of breast-dedicated surgeons (n=4) who cared for nearly half of the analyzed patient population achieved perfect adherence throughout the study, but interestingly, the gains made in total adherence were driven by the general surgeons (n=42), showing that the study’s direct educational efforts were effective in changing practice patterns for the better. These efforts included sending letters describing adherence to the quality metric to individual surgeons and organizational leadership.
Medical Research: What should clinicians and patients take away from your report?
Dr. Tjoe: Research on quality metrics can be used for quality improvement, accountability, payment incentives/penalties, patient steerage and public transparency. However, poorly designed studies that inappropriately measure quality metric adherence and then use the results for accountability have the potential to create risk for surgeons and healthcare systems if substandard outcomes are attributed to the surgeon rather than, for example, radiographic or patient anatomic limitations, patient comorbidities or compliance, or the actions taken by a prior surgeon before transfer of care to the accepting accountable surgeon. For every defined quality metric, there are “nonquality” and “quality” reasons for physician adherence/compliance, and responsible reporting of this influential data should take both into consideration. It is absolutely critical to define and record these appropriate exceptions, and herein lies the strength of our institutional review compared to those of national databases: our granular data distinguishes appropriateness of nonadherence by abstracting from each patient chart the surgeon’s reason for not performing minimally invasive breast biopsy. While doing this is resource-intensive and time-consuming, it nevertheless is essential to responsible and fair reporting of quality metric adherence data.
As healthcare institutions move toward the growing trend of mining databases to identify practice trends, it is in surgeons’ best interests to personally review data accredited to them to determine proper interpretation and attribution of quality metrics. Surgeons themselves should take the important and necessary step of documenting their reasons for why an individual patient’s care may fall outside standard guidelines, as recommended by the Commission on Cancer. Such instances do not demonstrate willful defiance, but rather exemplify sound judgment and understanding that every particular patient is an individual with a unique set of circumstances influencing his/her disease. Surgeons and/or their institutions should not be penalized for selecting treatment options outside of standard guidelines if it is necessary or appropriate in a particular situation.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Tjoe: While our study did not find significant differences between male and female surgeons in quality metric adherence following internal performance feedback, there was a notable difference between surgeons under age 55 compared to those 55 and older, even after accounting for acceptable scenarios for nonadherence to minimally invasive breast biopsy. It would be interesting to determine if external motivating factors (e.g., financial incentives or disincentives) versus internal motivating factors (e.g., innate perfectionism or intense sense of responsibility that often characterizes the surgeon personality) affect younger and older generations of surgeons’ responses to performance feedback differently.
Quality Metric Adherence in a Multihospital Health System: Educating Surgeons on Minimally Invasive Breast Biopsy
Tjoe, Judy A. et al.
Journal of the American College of Surgeons
Abstract presented at the American College of Surgeons Clinical Congress, San Francisco, CA, October 2014.
Judy A. Tjoe, MD, FACS Breast Oncology Surgeon (2015). Surgeons Need To Document Why Patient Care May Fall Outside Standard Guidelines