Editorial
Variability in Surgical Practice. An Unresolved Problem
Variabilidad en la práctica quirúrgica. Un problema por resolver
Miguel Pera@
Servicio de Cirugía General y Digestiva, Hospital del Mar, Barcelona, Spain
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The expression of tissue factor and the binding of antibodies to Gal and nonGal antigens in the neonatal porcine islets leads to activation of the complement and the coagulation cascade. Clot formation and direct damage of the cell membrane is generated through the membrane attack complex (MAC), as well as recruitment of macrophages and monocytes through chemoattractants C3a and C5a. TF: tissue factor.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana María Aristizabal, Luis Armando Caicedo, Juan Manuel Martínez, Manuel Moreno, Gabriel J. Echeverri" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Ana María" "apellidos" => "Aristizabal" ] 1 => array:2 [ "nombre" => "Luis Armando" "apellidos" => "Caicedo" ] 2 => array:2 [ "nombre" => "Juan Manuel" "apellidos" => "Martínez" ] 3 => array:2 [ "nombre" => "Manuel" "apellidos" => "Moreno" ] 4 => array:2 [ "nombre" => "Gabriel J." "apellidos" => "Echeverri" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0009739X16302214" "doi" => "10.1016/j.ciresp.2016.12.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0009739X16302214?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507717300297?idApp=UINPBA00004N" "url" => "/21735077/0000009500000002/v1_201703300040/S2173507717300297/v1_201703300040/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Variability in Surgical Practice. An Unresolved Problem" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "59" "paginaFinal" => "61" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Miguel Pera" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Miguel" "apellidos" => "Pera" "email" => array:1 [ 0 => "mpera@hospitaldelmar.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">@</span>" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía General y Digestiva, Hospital del Mar, Barcelona, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Variabilidad en la práctica quirúrgica. Un problema por resolver" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The issue of variability in surgery has been the object of debate for decades, especially following the publication of papers by Wennberg and Gittelsohn showing important differences in tonsillectomy and hysterectomy rates (between 8% and 70%) as well as dissimilarities among other procedures conducted in adjacent geographic areas of the states of Maine and Vermont.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> Although years have passed, the variability in surgical practice is still an unresolved problem. These variations occur not only in the rates of certain surgical interventions but throughout the entire healthcare process. In colorectal surgery, for example, there are currently very important variations in the percentages of use of neoadjuvant chemoradiotherapy in patients with rectal cancer,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> minimally invasive surgery<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> or mechanical bowel preparation.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> In addition, the differences in the care we provide our patients occur not only among different geographic areas and hospitals but also among surgeons within the same surgical service.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The participation of the patient in decision-making after considering the risks and benefits of the various therapeutic options may the cause of a certain variability, which has been defined as positive variability,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> but its influence on the variations of surgical practice is still minimum in our setting. On the other hand, what are responsible for variations that in most cases are inexplicable and unjustified include factors dependent on the population, structure, services offered and, especially, surgeon-related factors.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> This variability has a negative impact and is associated with problems in terms of effectiveness, less efficient use of resources, and problems of accessibility and equality. In short, the outcome is a loss of value in the care we provide our patients.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> In this context, important variations in the surgical practice consequently lead to important variations in the results. Hence, great variability has been observed in the rates of surgical site infection,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a> readmissions<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a> and 30-day mortality,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> among other outcome indicators, following colorectal cancer surgery.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Variability in surgical practice may be due to the uncertain value of different therapeutic options, as occurs with the surgical treatment of hemorrhoids, in keeping with the example of colorectal surgery.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a> Sometimes, even though there is sufficient evidence on the best form of treatment, the lack of knowledge limits its application; such is the case of fast-track protocols for perioperative care.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a> Finally, lack of training or technical skills may also explain variations in surgical results among hospitals and among surgeons. Although the influence of surgeons on variability has been researched much less, several studies have demonstrated significant differences in the percentages of anastomotic dehiscence, definitive stomata and tumor recurrence after colorectal cancer surgery among surgeons of the same service.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Different strategies have been proposed to reduce unwarranted variability in surgical practice and its negative consequences.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> First, the creation, dissemination and application of clinical practice guidelines and protocols, which is compatible with the necessary participation of patients in decision making. Secondly, it is necessary to measure, analyze and publish the results and related variations. The Atlas of Variations in Medical Practice is a good example.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a> The positive effect of audits and results research has been extensively demonstrated. The national program for the implementation of total mesorectal excision, developed in Norway in the 1990s<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> and which served as a model for our later Viking Project,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">16</span></a> is an example of how the creation of a national registry with its corresponding audits, together with standardized surgical technique, is able to decrease variability and improve outcomes in the treatment of rectal cancer. In a more recent study, we have evaluated the results over time of a cohort of hospitals participating in the National Surgical Quality Improvement Program of the American College of Surgeons.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a> The participation of the hospitals is voluntary and their results are audited periodically. It has been observed that hospitals that commit to staying in the program for at least 3 years improve their surgical results and present progressive reductions in mortality, morbidity and infection of the surgical site.</p><p id="par0025" class="elsevierStylePara elsevierViewall">This evaluation of surgical practice and its results should be conducted not only in the hospital as a whole, but also individually. Recently, initial experiences have been published with the use of surgeon-specific outcome reports, which provide for individualized evaluation and corresponding feedback.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">18,19</span></a> Although they have some limitations, these reports, when adjusted for patient risk and confidential in nature, provide surgeons with benchmarking information on different quality indicators that can be used to improve individual outcomes and also reduce variability.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">It has been suggested that surgeons, when merely observed, improve their results. This concept is known as the Hawthorne effect, the name of the Chicago electric company where this phenomenon was first described during experiments conducted by sociologists.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a> However, many believe that the evaluation of results is not sufficient to stimulate improvement and that additional strategies are needed, such as the communication of best practices and positive deviance, which will likewise reduce variability.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a> The main idea of a positive deviance approach is that solutions to the problems faced by a group often originate within that group, and that certain members have knowledge and skills that can be generalized to improve the performance of the rest. In other words, there are individuals whose practices produce better results than those of their peers, and the implementation of these practices should be promoted through group discussion.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, although the variability in surgery related to patients’ preferences and their participation in decision making should be considered good, in most cases these variations in the care process are not justified and may reflect inappropriate practices. The application of strategies aimed at reducing such variability will not only improve efficiency and equality, but also the value of the care we provide our patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pera M. Variabilidad en la práctica quirúrgica. Un problema por resolver. Cir Esp. 2017;95:59–61.</p>" ] 1 => array:3 [ "etiqueta" => "@" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">@m_pera_roman.</p>" "identificador" => "fn0005" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0115" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Small area variations in health care delivery; a population-based health information system can guide planning and regulatory decision-making" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Wennberg" 1 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 9 | 2 | 11 |
| 2024 September | 28 | 5 | 33 |
| 2024 August | 15 | 2 | 17 |
| 2024 July | 12 | 2 | 14 |
| 2024 June | 29 | 6 | 35 |
| 2024 May | 18 | 4 | 22 |
| 2024 April | 30 | 10 | 40 |
| 2024 March | 33 | 7 | 40 |
| 2024 February | 23 | 6 | 29 |
| 2024 January | 19 | 2 | 21 |
| 2023 December | 13 | 3 | 16 |
| 2023 November | 27 | 6 | 33 |
| 2023 October | 60 | 7 | 67 |
| 2023 September | 31 | 3 | 34 |
| 2023 August | 45 | 0 | 45 |
| 2023 July | 34 | 3 | 37 |
| 2023 June | 30 | 7 | 37 |
| 2023 May | 60 | 1 | 61 |
| 2023 April | 51 | 2 | 53 |
| 2023 March | 34 | 6 | 40 |
| 2023 February | 21 | 8 | 29 |
| 2023 January | 22 | 6 | 28 |
| 2022 December | 31 | 4 | 35 |
| 2022 November | 44 | 9 | 53 |
| 2022 October | 31 | 13 | 44 |
| 2022 September | 31 | 12 | 43 |
| 2022 August | 32 | 7 | 39 |
| 2022 July | 18 | 9 | 27 |
| 2022 June | 20 | 12 | 32 |
| 2022 May | 36 | 9 | 45 |
| 2022 April | 25 | 9 | 34 |
| 2022 March | 26 | 13 | 39 |
| 2022 February | 23 | 9 | 32 |
| 2022 January | 42 | 13 | 55 |
| 2021 December | 32 | 15 | 47 |
| 2021 November | 35 | 10 | 45 |
| 2021 October | 25 | 15 | 40 |
| 2021 September | 38 | 12 | 50 |
| 2021 August | 37 | 8 | 45 |
| 2021 July | 16 | 16 | 32 |
| 2021 June | 25 | 13 | 38 |
| 2021 May | 30 | 14 | 44 |
| 2021 April | 80 | 25 | 105 |
| 2021 March | 40 | 8 | 48 |
| 2021 February | 29 | 11 | 40 |
| 2021 January | 34 | 13 | 47 |
| 2020 December | 22 | 12 | 34 |
| 2020 November | 42 | 2 | 44 |
| 2020 October | 7 | 10 | 17 |
| 2020 September | 14 | 7 | 21 |
| 2020 August | 22 | 10 | 32 |
| 2020 July | 21 | 13 | 34 |
| 2020 June | 14 | 9 | 23 |
| 2020 May | 25 | 9 | 34 |
| 2020 April | 13 | 5 | 18 |
| 2020 March | 12 | 4 | 16 |
| 2020 February | 13 | 2 | 15 |
| 2020 January | 16 | 9 | 25 |
| 2019 December | 23 | 11 | 34 |
| 2019 November | 17 | 10 | 27 |
| 2019 October | 22 | 4 | 26 |
| 2019 September | 13 | 2 | 15 |
| 2019 August | 12 | 5 | 17 |
| 2019 July | 21 | 26 | 47 |
| 2019 June | 33 | 20 | 53 |
| 2019 May | 114 | 37 | 151 |
| 2019 April | 37 | 4 | 41 |
| 2019 March | 6 | 5 | 11 |
| 2019 February | 9 | 6 | 15 |
| 2019 January | 2 | 4 | 6 |
| 2018 December | 1 | 3 | 4 |
| 2018 November | 3 | 2 | 5 |
| 2018 October | 7 | 3 | 10 |
| 2018 September | 6 | 6 | 12 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 6 | 0 | 6 |
| 2018 June | 6 | 1 | 7 |
| 2018 May | 4 | 0 | 4 |
| 2018 April | 6 | 1 | 7 |
| 2018 March | 5 | 0 | 5 |
| 2018 February | 8 | 1 | 9 |
| 2018 January | 2 | 0 | 2 |
| 2017 December | 4 | 0 | 4 |
| 2017 November | 2 | 0 | 2 |
| 2017 October | 14 | 0 | 14 |
| 2017 September | 4 | 9 | 13 |
| 2017 August | 6 | 11 | 17 |
| 2017 July | 14 | 2 | 16 |
| 2017 June | 14 | 2 | 16 |
| 2017 May | 12 | 3 | 15 |
| 2017 March | 2 | 3 | 5 |
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