CUSUM analysis is a useful tool for surgical quality monitoring
Because it was designed for quality control, this methodology is most suitable when it is applied to assess a surgeon’s progress toward (or away from) proficiency, rather than to assign a representative number to classify a surgeon as proficient. By tracking a surgeon’s particular successes or failures with a procedure, CUSUM analysis can identify problems in an individual’s surgical quality.
If complication rates are tracking near, or cross, the unacceptable control limit using the standard method, or if they trend upward, away from the predicted complication rate with the risk-adjusted method, this fact should arouse concern so that the problem can be identified before patient safety is compromised.
Potential problems contributing to increased complications
Identifiable contributors to an increased complication rate could be intrinsic to the surgeon, such as:
- inadequate training
- low surgical volume
- sleep deprivation
- other personal issues.
Problems extrinsic to the surgeon also could be identified, such as:
- new policy changes in the surgical suite
- new staff assistance during cases
- excessive trainee involvement in surgery.
Ideally, both the standard and risk-adjusted CUSUM methods would be based on institution-specific complication rates and patient risk factors to make them internally valid. In this scenario, CUSUM analysis provides an opportunity for intervention to improve surgical quality and patient outcomes not only in robotic hysterectomy but also in any surgical procedure.
A surgeon’s proficiency waxes and wanes
At its most fundamental level, a learning curve for robotic surgery should be considered an individual continuum. A surgeon’s proficiency will wax and wane throughout his or her career, depending on any number of variables, including surgical volume, case complexity, practice setting, and personal attributes.
Although our findings suggest that a gynecologist, on average, will require 91 cases to become proficient in robotic hysterectomy, an overall benefit of robotic hysterectomy over abdominal hysterectomy was observed after completion of 21 and 14 cases by our two surgeons. We do not believe that credentialing bodies should mandate that 91 robotic hysterectomies be required of a surgeon. That approach would be too simplistic and obfuscates many of the true implications of our study—most importantly, that learning a new procedure is an individual process that must be compared with an acceptable outcome to determine proficiency and maintain patient safety.
INSTANT POLL
After reading the Editorial on proficiency in robotic hysterectomy, tell us:
- How do you and/or your institution measure surgical proficiency?
- Do you agree that a surgeon’s proficiency with the robot should be considered an individual continuum? Why? Why not?
Write to us at rbarbieri@frontlinemedcom.com, or click here. Include your name and city and state, and we’ll consider publishing your comments in an upcoming issue of OBG Management.