In the current era of health care reform, there has been a nationwide push to define and enhance the quality of health care. To be clear, it is difficult, if not impossible, to define fully the concept of “quality” in health care. While automobile manufacturing may characterize quality by acceleration, driving performance, need for repairs, costs, and customer satisfaction, the ideal metrics are not as clear in health care. The most common quality measures in health care relate to surgical complications, outcomes, costs, and customer satisfaction.
Numerous studies have demonstrated an association between health care quality measures and surgical volume, whether defined by the number of procedures performed by an individual surgeon or at an individual hospital. These studies have considered joint replacement surgery, various types of cancer surgery, bariatric surgery, and cardiac surgery. The first effort to understand the benefits of high-volume surgery was a Harvard Business School case study of the Shouldice Hernia Centre in Ontario, Canada, that specializes in surgical hernia repair. The case study examined the benefits of standardizing processes before, during, and after surgery and the careful and critical review of patient outcomes to identify best practices. These practices have been adopted at various centers, including at Brigham and Women’s Hospital, where Dr. R. John Wright has developed protocols encompassing the entire care team that have improved outcomes in knee replacement surgery.
The benefits of experience in lower risks of sleep apnea surgery
The January 2014 issue of The Laryngoscope included an evaluation of obstructive sleep apnea surgery performed in 2007, using the Health Cost and Utilization Project’s Nationwide Inpatient Sample database compiled specifically for studies of inpatient care in this country. The study showed that patients undergoing sleep apnea surgery performed by high-volume surgeons and in high-volume hospitals had more-favorable outcomes than those undergoing surgery performed by low-volume surgeons or in low-volume hospitals. The mortality rate for low-volume surgeons was 3 times as high as for high-volume surgeons, and the hospital stay was an extra one-third of a day. Hospital charges for the low-volume surgeons were also $1,000 higher. Patients undergoing surgery in low-volume hospitals also had greater risks of mortality and other in-hospital complications, longer length of hospital stay, and greater costs. Importantly, the database does not include other important factors like sleep study results or measures of sleepiness or fatigue that can measure surgery effectiveness by comparing other important outcomes that matter to patients.
As someone who specializes in the surgical treatment of obstructive sleep apnea and snoring, this study reinforces the practices that I have implemented in the care of my own patients, based on the simple desire for completeness and the experience that developing protocols reduces the chances of forgetting important details. For example, I used to ask my patients numerous questions about their snoring and sleep apnea and hope that they could provide answers while sitting in my office examination chair. Now I have developed fairly complete patient forms that ask these questions in a structured, systematic way. Although I have always thoroughly discussed the procedures that I am considering with patients and addressed the risks and benefits, I have now developed this website and direct patients to it in order to make sure they have the information about various procedures, as studies have shown that patients often do not recall everything they are told in a physician’s office. In the operating room, it can be difficult for the team to make sure we have every single instrument we need for a case, but I have tried to simplify the instrument requests by developing 3 sets of instruments that encompass the wide range of procedures that I perform. Following surgery, I would write the necessary orders, but in some cases it was difficult to remember every order. To minimize these omissions, I have now developed a clear set of postoperative orders that I use for all patients, making modifications as needed. Finally, I am fortunate to work with a dedicated team in the operating room that focuses on otolaryngology—head and neck surgery as well as a nursing team on the specific floor of the Keck Medical Center of USC where I send my patients. With this select team, everyone has become more familiar with taking care of sleep apnea surgery patients and the expected—and unexpected—events that can occur. I have recommended these types of changes to other physicians across many fields, as I have seen the benefits they have brought to me.