Letters to the Editor

Editor’s note: The following comments were received regarding recent articles published in the Bulletin.

Letters should be sent with the writer’s name, address, e-mail address, and daytime telephone number via e-mail to dschneidman@facs.org, or via mail to Diane Schneidman, Editor-in-Chief, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611.

Letters may be edited for length or clarity. Permission to publish letters is assumed unless the author indicates otherwise.

Reporting health care data

We read with interest the article “Public reporting of health care data: A new frontier in quality improvement” in the June 2012 issue of the Bulletin (Bull Am Coll Surg. 2012;97[6]:6-11). We maintain that administrative data can be used to improve “processes of care and clinical and patient outcomes in efforts to optimize quality” and thought your readers might be interested in how the state of Victoria in Australia has used administrative discharge coding data for this purpose.

In Victoria, the funding of public hospitals is based on a system related to the complexity of cases. For example, a simple hernia has one code, while a recurrent hernia has a different code reflecting a higher payment. Postoperative heart attacks, DVTs [deep venous thrombosis], wound infections, and other complications all qualify for increased funding and are coded separately, so it is in a hospital’s interests to code an admission fully to ensure maximum funding.

In 2001, the state government established the Victorian Surgical Consultative Council (VSCC) to scrutinize adverse events after surgery. Most VSCC members (80 percent) are practicing surgeons. In 2005, the VSCC became aware of the huge amount of data stored on the government computer system, which makes it possible to analyze data and compare hospital with hospital. VSCC decided to use this information to identify problems in the overall health system and in individual hospitals. The VSCC created the Surgical Outcomes Information Initiative (SOII) to fulfill this responsibility.

The SOII looks at data on select elected operations to compare the performance of de-identified health services with the state average. Feedback is provided confidentially to any hospital with apparently outlying performance, inviting its examination of the circumstances and affording the opportunity for it to tackle any problems. VSCC also advises others of the risks and remedies. Following one such study, the hospital’s own investigation prompted action to improve surgeons’ practice and patient safety in their day-surgery operating suite.

In 2010 the SOII subcommittee looked at the following procedures and complications:

  • Hemorrhage following dacryocystorhinostomy
  • Removal of wrong intraocular lens and replacement
  • Mortality following repair of subcapital fractured femur in 80+ year olds
  • Mortality following bariatric surgery
  • Orchidectomy following admission with torsion of the testis
  • Mortality, wound infection, and transfer to a different hospital after colectomy

This data has enabled the VSCC to identify the state mortality rate for each procedure as well as the mortality rate for each of the health services that have undertaken these procedures. For example, we know the state mortality rate for elective laparoscopic cholecystectomy is 1 in 2,047 (0.05 percent), for elective inguinal hernia repair (initial and recurrent) is 1 in 22,892 (0.004 percent), and for laparoscopic hernia repair is 0 in 4,829.

Initially, a few surgeons and hospitals were somewhat skeptical about the process, but as they realized that the whole process was de-identified, confidential, and educative rather than punitive they accepted it and were keen to help. Around the world, undoubtedly, many systems would benefit from this type of data analysis in an effort to improve patient care.

Peter L. Field, MD, FRACS,
chairman, Victorian Surgical Consultative Council
John P. Royle, OAM, FRACS, FACS,
member, Victorian Surgical Consultative Council


Back to basics

The July and August 2012 issues of the Bulletin represented a one-two punch for this recently retired general surgeon, starting with an article on surgery in the 21st century, which described the transition from the “sustaining technology” of open surgery to the “disruptive technology” of minimally invasive and endoscopic procedures (Bull Am Coll Surg. 2012;97(7):6-11).The next two articles in that issue centered on the electronic health record (Bull Am Coll Surg. 2012;97[7]:12-19) and the benefits of exposing surgical trainees to global surgery, respectively (Bull Am Coll Surg. 2012;97[7]:20-26).

The author of the article on modern-day surgery notes that a surgeon trained in the 1970s might have been able to complete a career without adapting to new technology with the implication that anyone training thereafter would not have that luxury. Along with many of my contemporaries, I did seek training in laparoscopic techniques in the 1990s and did my share of lap cholecystectomies before retiring in 2010. Since then, I have been told more than once that I retired at the right time, given the sea change of private practice disappearing while hospital employment becomes the norm. Likewise, I was delighted to depart [at a time] when the written chart that I could carry to the bedside while making rounds was being replaced by a computer requiring me to log on every time I arrived at a nursing station.

In 2011, I spent a month in Africa’s Ivory Coast with Doctors Without Borders (DWB). I brought my stethoscope. The only lab tests available at L’Hôpital Général de Duekoue were for hemoglobin and malaria. The only X-ray machine was an old “wet-reading” unit. Medical records were scanty and virtually meaningless. Nonetheless, patients with perforated typhoid peritonitis, appendicitis, incarcerated and strangulated hernias, peripheral bullet wounds, long bone fractures, and emergency cesarean sections almost always did well. I kept wondering if newly trained surgical residents would be able to cope without CT [computed tomography] scans, surgical staplers, and laparoscopes. In a way, I felt that I was back in my 1970s residency, and it was thoroughly refreshing.

It was therefore gratifying to read the article about surgical training in limited resource countries. It was all the more impressive to learn that the American Board of Surgery will allow certain international electives to count toward board eligibility. If high-tech training trends in the U.S. continue, what other opportunity will there be for surgical residents to work in the open abdomen with needle and thread?

The capstone article was in the August issue and described a postgraduate fellowship in global surgery featuring general surgery procedures plus some plastics, gynecology, and orthopaedics as well as public health and surgical education (Bull Am Coll Surg. 2012;97[8]:46-50). This sort of training holds promise and would be even better if mid-career surgeons could participate as well. More recent articles in the Bulletin have discussed rural surgery in the U.S. There are clear parallels here with humanitarian surgery. It will be interesting to see if crossover training programs develop.

Late last year, I went on another mission with DWB, this time to Haiti. I only wish that I had done this sort of thing at intervals during my 33 years of practice. I believe global surgery will help us get back to basics while improving the lot of global citizens and am impressed with the strides the American College of Surgeons has made in this area through Operation Giving Back.

Edward Walworth, MD, FACS,
Lewiston, ME

End of life surgery

I wish to comment on the two essays dealing with end of life surgery that were published in the November 2012 Bulletin (Bull Am Coll Surg. 2012;91[11]:19-23). The articles did not clearly differentiate emergency from elective operations nor do many studies evaluate the experience of the operating surgeons, which I agree would be a formidable task. I presented a study of operations in more than 300 octogenarians at the papers session of the American College of Surgeons Clinical Congress more than 25 years ago. Clearly it’s almost impossible to predict the last year of life. All experienced surgeons can cite anecdotal material of survivals in the elderly, but withholding surgery (particularly elective procedures) can deprive patients of a chance at a reasonable survival.
We know there are differences in survival rates from major operations, such as pancreatectomy, related to hospital and surgeon experience. Factors such as choice of incision, judicious use of anesthesia and fluids, and use of local anesthesia in some procedures (biliary emergencies, surgical decompression, incarcerated hernias, and so on) may play a significant role in results. While certification in geriatric surgery may not be feasible, many referring physicians should be selective in their referrals. I am impressed daily by the number of persons older than age 75 in my local community who have undergone successful major operations.

We are loath to criticize the use of chemotherapy to achieve one or two months of increased survival (usually poor quality) and there is a readiness to criticize a 70 or 80 percent survival in acute emergency operation in the elderly. Obviously, distinguishing a hopeless operation is dependent upon experience, and I am not advocating this approach. I just wish to emphasize that operations in the elderly should not be approached negatively.

Bernard Gardner, MD, FACS,
Venice, FL

Murphy memories

I am proud to have been a Fellow of the American College of Surgeons since 1970. I write to commend you on your reprinted article on the dedication and inauguration of the John B. Murphy Memorial (Bull Am Coll Surg. 2013;98[1]:37-44). The article is, in itself, an excellent reminder of a time when surgeons were respected for their craft and knowledge and not relegated to a pro bono computer technician/stenographer, as many of us are today.

In reading the article, I was reminded of the beauty and elegance of the Murphy Memorial and of the many times I have attended meetings in that facility. I particularly remember the many postgraduate courses on fractures and other trauma, which John J. Fahey, MD, FACS, originated.

It occurs to me that having the College sponsor lecture courses for the younger surgeons and perhaps residents and fellows from time to time in the Murphy Auditorium would give these younger people some sense of the vanishing grandeur of our profession. I can still recall many stellar surgeons who have presented excellent papers within that auditorium, and I recall, 40 years later, the majesty of the surroundings after having long ago forgotten the specifics of the lecture.

Boone Brackett, MD, FACS,
Oak Park, IL

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