Health Policy$ense

Surgeon Scorecard: Are Surgeons Operating in a Health Care Team?

Broader Quality Metrics Needed

Twitter has been abuzz with commentary about ProPublica’s Surgeon Scorecard, which reports on how individual surgeons perform on in-hospital mortality and readmission (complication) rates for eight common elective procedures. Amidst the pointed criticisms of the Scorecard, there exists moderate agreement that it provides some value in helping consumers select a surgeon. And while choosing the right surgeon is certainly important; the Scorecard tells us little about how well surgeons operate as part of a health care team.

One visit to the hospital is often enough to convince most people that nurses make a difference in patient care. Indeed, two decades of empirical research points to the critical role of registered nurses in reducing mortality, readmissions, and other health outcomes, like satisfaction.

My recently-completed study of Medicare patients undergoing elective total hip and knee replacements demonstrates that patients cared for in hospitals with more favorable nurse staffing ratios and more supportive nurse work environments are less likely to be readmitted within 30 days. Nurses are integral to the delivery of medical care prescribed by surgeons, and nurse-directed nursing care. Nurses affect every aspect of a patient’s hospitalization. They administer pre-operative antibiotics, help patients safely recover from anesthesia, manage pain, monitor for signs of complication, prepare patients to safely transition home, and much more. And while the Surgeon Scorecard is a laudable first effort at measuring individual surgeon performance, it does not reflect an important attribute of quality – how well the surgeon operates as part of a team.

A close look at the methodology reveals that the readmission measure is based not on all-cause or unplanned readmissions (like the Hospital Readmission Reduction Program), but readmissions considered by a group of surgeons to be directly related to a surgical complication. Less than half of all readmissions were considered complications of surgery; and codes for conditions such as pneumonia were determined by a group of surgeons not to be a complication of the surgery. Designing a measure of quality whereby surgeons pick and choose what constitutes a complication of the surgery, not only goes against the American College of Surgeons’ frequently cited Statement of Principles that states surgeons are responsible for “the patient’s safety through the preoperative, operative and postoperative period,” but perhaps more importantly, it minimizes the importance of the contributions of the care team and the ability of the surgeon to work within that care team, to ensure the safest possible outcomes for every patient. 

For example, postoperative pneumonia can result from a number of health care delivery errors, including improperly administering anesthesia, poor management of antibiotics, or inadequate mobilization of patients in the postoperative period. Indeed, developing pneumonia is not contingent on having undergone surgery. However, the experience of pneumonia and rehospitalization should undoubtedly reflect room for improvement on the part of all health care providers. From a consumer perspective – whether a negative experience is attributed to the surgeon, the nurse, or any other provider, is trivial. Consumer-based quality metrics should reflect the fact that health care is delivered by a team. And while the individual assessment of surgeon performance provides reasonable value to consumers, it would benefit from assessing a broader range of care complications that more accurately reflect how health care is delivered and who delivers it.