When Cases Individually Meet Standard of Care, But Collectively They Don’t
I am honored to serve as the Chief Medical Officer of NorthGauge. I was recently called upon to review 20% of a physician’s procedures over a six-month period, encompassing a spectrum of varying procedures the surgeon had performed. Although I had no knowledge as to how the cases were selected, I presumed that they were representative of the physician’s practice on some level. I assessed if the care met the standard and evaluated the level of concern, root cause issues, and the impact on the outcome related to any deviation. I was also asked to comment on the physician’s documentation and to answer specific client questions. Within each case, there was a complication, but one that by itself was understandable and a known potential complication for the procedure being performed. However, by the time I reviewed the fourth case, I became aware of a pattern. As I continued my review, the pattern became more concerning.
By the tenth case, it became clear to me that the overall volume of complications was too high. Considering that the ten cases I was asked to evaluate had all been performed within the same three-month period, I was concerned that this surgeon was causing avoidable injury to his patients. Standard of care was met for each case on its own, as known complications were handled appropriately and care management was adequate. However, collectively these cases did not meet the standard of care because the cumulative complication rate was far greater than what is expected. For example, if a certain procedure carries with it a 1% risk of wound infection, then an occasional wound infection is not surprising. Three wound infections in a two-month period, however, is a cause for alarm.
It is my obligation to draw conclusions based on the pattern identified throughout my review, not just on the individual cases. For this reason, NorthGauge provides a summary report whenever five or more cases for one physician are reviewed. In this case, the summary report provided an opportunity to outline my concerns regarding the technical skill and decision-making of the operator. Ultimately, this cumulative evaluation highlights the importance that hospitals must place on trending clinical outcomes, tracked and organized by the attending physician or surgeon. By monitoring longitudinally, patterns of deficiency in skill, knowledge, citizenship, etc. may be unearthed. When viewed in sum, several individually explainable complications might unearth a larger issue with a practitioner and avoid further harm to patients.
Peer review can be used for identifying trends, improving quality of care, and ultimately keeping patients safe. A robust cross section of cases for review is an important consideration when hospital leadership engages in focused peer review. Looking at a single case is akin to feeling an elephant’s tail in a dark room and assuming you know everything about the animal! While there is a time and place for single case review, a concerning pattern warrants review of a sufficient number of cases necessary to determine if there is cause for concern. –Robert Mordkin, MD