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Editors Selection IGR 9-4

Surgery: Quality of surgery

Comment by George Spaeth on:

19466 The relation of volume and outcome in trabeculectomy, Wu G; Hildreth T; Phelan PS et al., Eye, 2007; 21: 921-924

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It seems self-evident that the more frequently a particular procedure is done the better it was done, whether that involves playing the piano, scoring on a penalty shot in a sport such as hockey or soccer, or performing a particular type of surgery, such as trabeculectomy. Incompetent pianists are not likely to be hired, and players who consistently miss penalty shots are not likely to play in many more games. However, the economic system which underpins most medical care programs appears to be based on the belief that the quality of surgery does not vary depending upon who performs it. A trabeculectomy in the United States is reimbursed the same regardless of the experience (or the competence) of the operating surgeon. It is a strange fact that this practice of reimbursing physicians on the basis of the diagnosis or the type of procedure is so widespread, especially in bastions of capitalism and entrepreneurialism such as the United States.

The economic system which underpins most medical care programs appears to be based on the belief that the quality of surgery does not vary depending upon who performs it

One wonders how such 'egalitarianism' in reimbursement can exist in communities such as England (where the current study was performed) and the United States, where reimbursement is so typically tied to quality of performance. The player who sits on the bench may barely earn a living wage, whereas the star of the team typically earns millions of pounds or dollars. The fact is, that the medical profession has at least partially brought this deplorable situation on itself. It is presumed that on graduating from an ophthalmology residency training program the physician is competent to practice as an ophthalmologist. Fortunately, that is usually the case. However, the stretch from that conclusion to a belief that all practitioners are equally competent is beyond understanding. Nevertheless, the medical profession has not merely acquiesced but has been strong in supporting the idea that physicians should receive the same fee for the same service. There have been several attempts to change from this tragically oversimplified system, including the recent 'pay-for-performance' policy being initiated in the United States. Unfortunately, these projects have been universal failures, as will pay-for-performance, because of an inability to evaluate honestly and meaningfully the value of the service to the patient. Something as apparently simple as a shallow anterior chamber is in fact not simple at all. As soon as surgeons having fewer shallow anterior chambers following trabeculectomies are reimbursed at a higher rate than those having a greater number of 'shallow anterior chambers', the definition of shallow anterior chamber will change. It will change most dramatically for those who are most prone to dishonesty and those most easily seduced. Because independent evaluations will not be made, there will be no way to determine whether the data submitted are valid or not.

The study by Wu et al. (1149) was carefully done. They were meticulous at including only 'garden variety' trabeculectomies. Nevertheless, if one adds the percentage of complications that occurred in the cases performed by surgeons performing more than ten cases a year, the result is 52 percent over five years, or approximately ten percent a year. In contrast to the complication rate in trabeculectomy where surgeons performed fewer than eight cases a year, and where the complication rate was 105 percent over five years or an average of over 20 percent. That is, the likelihood of complication was twice as great when the surgery was performed by those performing few surgeries. There are clearly justifiable reasons why surgery should occasionally be performed by those who are 'occasional surgeons'. It is sometimes difficult or impossible for patients to have surgery in a center where there is a specialist. However, as has been demonstrated frequently, there is a threshold below which surgeons are not likely to perform as competently as when the threshold is met. Such a fact should be taken into account by all those involved in healthcare policy and finance.

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