EMILY R. WINSLOW, MD
Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
Although the critical assessment of randomized controlled trials follows fairly well-accepted principles, the analysis of the quality of an observational study is the subject of much debate. Novel methodologies are now being applied to surgical fields and are beginning to allow more meaningful conclusions to emerge from observational trials. Two such methods for accounting for bias in observational data sets include propensity score analysis and instrumental variable analysis. Propensity score analysis attempts to control for the nonrandom choices made in clinical care by matching subjects who got the treatment under study with those who did not. The second method, instrumental variable analysis, attempts to correct the data for unmeasured confounders. Central to this methodology is the identification of an appropriate “instrument”—an unbiased variable that differentially impacts the subjects with respect to the exposure but is not related to the outcome of interest.
JUSTIN B. DIMICK, MD, MPH
Center for Healthcare Outcomes and Policy, Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
The landscape of existing quality measures is rapidly changing. A relatively new evaluation of quality measurement, using surgical videos to assess skill and technique, will very likely be translated into broader use in the next few years. Findings suggest that peer ratings of operative videos could be an entirely new type of quality metric—one that can be targeted for improvement. Surgical videos could be used to measure both technique (how the procedure was done) and skill (how well the procedure was done). This field is currently in its infancy but will no doubt dramatically change how we think about surgical quality measurement and improvement (e.g., surgical coaching) over the next decade.
MARK A. HEALY, MD
NANCY J.O. BIRKMEYER, PHD
University of Michigan Health System, Ann Arbor, MI
A review of characteristics of different strategies for improving surgical quality shows advantages and disadvantages for each. Outcomes measurement and feedback programs can motivate local quality improvement efforts among hospitals with poor performance. Regional collaborative quality improvement programs may accelerate improvement, but can be expensive and complex to implement. Pay for performance programs and selective referral strategies are shown to be effective in a more limited scope. New strategies, such as video-based feedback and coaching programs and incorporation of surgical quality improvement into postgraduate residency training, have the potential for substantial surgeon-level effects in improving overall quality. As a combined effort of the Accreditation Council for Graduate Medical Education and the American Board of Surgery, the general surgery milestone project identifies educational competencies expected of all general surgery resident trainees.
ZARA COOPER, MD, MSc, FACS
Brigham and Women’s Hospital, Boston, MA
ANNE MOSENTHAL, MD, FACS
Rutgers New Jersey Medical School, Newark, NJ
Using time-limited trials for life-prolonging treatments can reduce the use of nonbeneficial treatments in intensive care unit patients and help make the transition to care directed solely toward comfort…. When well selected, patients who undergo palliative procedures have acceptable rates of achieving symptom relief and improved survival…. However, a critical aspect of patient selection is frank (and well-documented) discussions between patient, family members, and surgeon about the patient’s overall prognosis, expected outcomes of surgery, and the likelihood of addressing the patient’s complaints.
Figure of the Month: The Figure of the Month for March is entitled Latent and Active System Failures Contribute to Injury. (Figure 1 from Patient Safety in Surgical Care).