A recent study of surgeons credentialed to perform bariatric surgery suggests that current hospital methods for assessing competence in new and complex procedures are inadequate.
The study was conducted by lead author John Birkmeyer, MD, now a professor of surgery at the Dartmouth Institute in Hanover, NH, and colleagues. They focused on bariatric surgery because it is a complex procedure requiring a new set of skills, and one that is growing in popularity and profitable for hospitals. They studied 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. (The study is available online at http://tinyurl.com/osn63zb.)
Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass. Each videotape was rated in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon, the researchers write.
Mean summary ratings of technical skill ranged from 2.6 to 4.8 across the 20 surgeons. That variability was troubling, says Robert Wachter, MD, interim chairman of the Department of Medicine and chief of the Division of Hospital Medicine at the University of California, San Francisco.
“That was the first lesson, that not everyone was well versed in the skill and has the technical ability,” Wachter explains.
Then the researchers assessed variables such as readmission rates, return to the OR, surgical infection rates, and mortality rates, correlating those with the technical scores of the surgeons. They assessed relationships between these skill ratings and risk-adjusted complication rates, using data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients.
They found that the bottom quartile of surgical skill, as compared with the top quartile, was associated with higher complication rates (14.5% vs. 5.2%) and higher mortality (0.26% vs. 0.05%). The lowest quartile of skill was also associated with longer operations (137 minutes vs. 98 minutes) and higher rates of reoperation (3.4% vs. 1.6%) and readmission (6.3% vs. 2.7%).
“The technical skill of practicing bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department,” the researchers concluded. The findings suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon’s proficiency, they said.
“It was staggering. Major, major differences in mortality, return to OR, many factors,” Wachter says. “We credential proceduralists with no knowledge of any of that. We let them tell us that they’re trained in the new procedure without any expert review of their skills, as was done in this study.”
