Changing Regional Surgical Practice to Improve Quality and Efficiency of Care

Abstracts from the Kaiser Permanente2018 National Quality Conference


Charles Meltzer, MD

From Colorado, Hawaii, Northern California, Northwest, Southern California

Background: Customary referral patterns did not distinguish between higher- and lower-volume surgeons. In 2008-2013, 63% of patients underwent thyroid procedures by low-volume (< 10 cases per year) surgeons, who had significantly higher rates of complications and 30-day readmissions—and who performed many fewer surgeries on an outpatient basis than higher-volume surgeons: 3% vs. 13% for total thyroidectomies and 29% vs. 46% for hemithyroidectomies. When appropriate, outpatient surgery is both more efficient and preferred by many patients.
Methods: Population: Patients with thyroid nodules or primary hyperparathyroidism being considered for surgery. Intervention: A multidisciplinary group (Head and Neck Surgery, General Surgery, Endocrinology, Medical Imaging, and Pathology) developed workflows identifying patient management steps, responsible providers, and key metrics. Group members became specialty champions. Published analyses of Kaiser Permanente data demonstrated the need for change. Lower volume surgeons could opt out of performing procedures or increase case volumes. A patient education pamphlet was created to support outpatient procedures. Surgeon-level quarterly reports track metrics. Comparison: 2008-2013. Outcome measures: Proportions of low-volume surgeons performing thyroid/parathyroid surgery and outpatient procedures and complication rates.
Results: In 2014-2017, the proportion of low-volume surgeons (< 10 cases/y) performing thyroid surgery decreased from 56% to 34%, the proportion of total thyroidectomies performed by low-volume surgeons decreased from 12% to 6%, and the proportion of same-day outpatient procedures increased from 42% to 73%. Among patients undergoing total thyroidectomy, the rate of 30-day all-cause readmissions decreased from 3.5% in 2014 to 2.6% in 2015-2016. The rate of hematomas decreased from 0.3% in 2014 to 0.1% in 2015-2016, and the rate of transient hypocalcemia decreased from 7.8% in 2014 to 6.2% in 2015-2016. In 2016, Lokahi funding supported spread to Colorado Permanente Medical Group (June), Northwest Permanente (August), Hawaii Permanente Medical Group (October), and Southern California Permanente Medical Group (December). Data on interregional spread will also be presented.
Discussion: Changing surgical practice to improve quality is possible with organization-specific data demonstrating the need for change, multidisciplinary champions building workflows that follow clinical practice guidelines and define provider responsibilities, development of provider-level reporting to assure quality outcomes and process adherence, and strong leadership support. Accelerating spread across Regions requires vertical and horizontal alignment of improvement priorities at national, regional, and local levels, executive support, streamlined access to analytic resources and expertise. Taking down the silos across the program to promote active collaboration on an ongoing basis fosters clinical leaders who are adept at both evidence-based care and ongoing performance improvement.

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