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Surgeons Leading Health Care Reform

James F. Burdick, MD
JAMA Surg. 2013;148(1):7-8. doi:10.1001/jamasurg.2013.620.
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Physicians have recently begun new initiatives for health care reform. But for this to live up to its promise, physicians must have a critical role in implementing quality guidelines, a task beyond the capacity of administrators without professional input. Politicians and the lay public trust their physicians, but they may be paradoxically suspicious of ceding national power to physicians, fearing a conflict of interest. Physicians from different specialties may be suspicious of each other. Moreover, many physicians are unwilling to take on national responsibility, figuring that running the system is someone else's job. None of these concerns is groundless, but reform is unstoppable and physicians are increasingly involved.

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Do patients have to share the responsibility for their own outcomes?
Posted on March 5, 2013
Mohan Mathew John
Department of Surgery, Bronx Lebanon Hospital Center
Conflict of Interest: No potential conflicts or relevant financial interests
I read with interest the article by Burdick on ‘Surgeons leading health care reform’. The Hospital Value Based Update program links healthcare payments with certain performance outcome measures. The measures that come into effect for the year 2013 are based on the ‘clinical process of care’ and ‘patient experience of care’. An additional set of measures relating to mortality, hospital acquired conditions, patient safety and inpatient quality are slated to be included in next year’s program. It is clear that field of outcomes research is gaining a more prominent role in healthcare management decisions. Historically, surgeons have always been at the forefront of outcomes research. These studies are intuitively a more practical alternative to randomized clinical trials. However, the heterogeneity of factors leading to outcome cannot be understated. Surgical results are a composite of surgical skill and experience, the quality of ancillary support staff and infrastructure, and patient-related factors. The patient-related factors can be summarily divided into modifiable and non-modifiable risk factors. The concept of modifiable risk factors presents as much a challenge to the healthcare system as it does to the patient. The entire onus of healthcare should not rest with the system that provides it. There are certain factors under the direct control of the patient - lifestyle choices, high-risk behaviors and adherence to medication, just to name a few. These are possible confounders when it comes to outcomes and patient surveys. However, they are not factored in when making a decision about payment for healthcare. Some of the patient-related factors are easy to measure. Glycosylated hemoglobin, for example, can be used as a marker for adherence to anti-diabetic medications. Halkos et al. reported that HbA1c was a powerful predictor of in-hospital death and morbidity after coronary artery bypass grafting. But how does one quantify the effect of non-adherence to psychiatric medications or missed clinic visits. Does an attitude of non-compliance in one area affect other areas, and ultimately - outcomes? As the reliance on outcomes data to increases, all possible variables will need to be taken into account to make an equitable evaluation of the quality of healthcare. The contribution of these patient-related factors to outcome has not been well studied and deserves consideration. The ‘empowered patient’ has the right to make his or her own decisions about healthcare and lifestyle choices; and consequently, share the responsibility for outcomes.References1. Burdick JF. Surgeons Leading Health Care Reform. JAMA Surg. 2013;148(1):7-8. 2. Centers for Medicare and Medicaid Services. The Official Website for the Medicare Hospital Value-based Purchasing Program. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing/, Accessed March 4, 2013. 3. Halkos ME, Lattouf OM, Puskas JD, Kilgo PC, William A, Morris CD, et al. Elevated Preoperative Hemoglobin A1c Level is Associated With Reduced Long-Term Survival After Coronary Artery Bypass Surgery. Ann Thorac Surg. 2008 86: 1431-1437.
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