|Welcome back and Happy New Year! It is my pleasure this month to feature an interview with two of my favorite people in surgery, MISS Conference Hernia Program Co-Director Dr. Guy Voeller and Dr. Michael Rosen. This article focuses on the Americas Hernia Society Quality Collaborative (AHSQC), which is a quality collaborative for hernia surgeons that is free to join. These two phenomenal hernia surgeons are not only at the forefront of hernia surgery research and advancement, but have also been involved in and developed recent healthcare initiatives that aim to improve several aspects of hernia care: the position of surgeons in the current healthcare environment, hernia surgery education, patient outcomes, hernia care processes, real world research efforts, and product development. I learned about the AHSQC last year and found the concept intriguing because participation seemed to be such a win-win for all relevant stakeholders in surgery—including surgeons, hospitals, patients, insurance companies, and product developers. Each group stands to benefit from the creation and success of the AHSQC, and the existing and potential future benefits of it are tremendous. Delving more into it, I found out that the AHSQC is a 501c3 supported by unrestricted industry grants. Currently there are three levels of supporters, which are Platinum (Intuitive Surgical); Gold (Bard, LifeCell, and Medtronic); and Silver (W. L. Gore).|
Read on for some insights from Drs. Voeller and Rosen on this exciting effort. If you don’t know much about the AHSQC but practice hernia surgery, this interview is a must-read for you.
Enjoy the first article recommendations of 2017 from some thought leaders in minimally invasive surgery, and we hope to see you in Las Vegas for MISS next month!
What is the AHSQC?
Dr. Voeller: The definition of the AHSQC (www.ahsqc.org) is contained in its initials–Americas Hernia Society Quality Collaborative. It is a quality collaborative. That may sound simple but its purpose is to improve the quality of hernia repair by collaboration amongst surgeons. This is what Benjamin Poulose and Michael Rosen had in mind when they came up with the idea of the AHSQC. As we are trying to switch from a quantity-based healthcare system to a quality-based one, it is important that surgeons are the ones who determine what is true quality. Hospitals, insurance companies, and entities are judging us on their quality metrics, and these groups are the least likely to know what true quality is or is not. The AHSQC enables surgeons to determine quality. In addition, another purpose of the AHSQC is to help those surgeons who may be having trouble and/or are on the lower end of the bell curve to improve their quality in a non-confrontational or punitive environment.
What does it entail on an individual surgeon/program level in terms of process and cost?
Dr. Voeller: Membership in the AHSQC is free. Any surgeon who wishes to join must be a member of the Americas Hernia Society (AHS), which costs $160 per year. There is no other associated cost with joining and actively being part of the Collaborative. Once a surgeon joins, the surgeon’s hospital will then enter into an agreement with the AHSQC regarding sharing and entering of patient data. This can turn out to be one of the more lengthy parts of the process and probably is the most significant hurdle for an institution that wants to participate in the quality collaborative. Lawyers are involved and, as always, this can take some time to work through the various systems. Once everything is approved, the individual surgeon will have to enter the hernia data on a case-by-case basis into the software of the collaborative. Normally when a surgeon finishes an operation, he or she has to speak with family, enter postoperative orders, and dictate an operative report. But it is best to enter this case data into the AHSQC database when the case is first completed. While this will add 3 to 10 minutes per case (typically 5 or less if you enter the data right after the case and closer to 10 if you are doing it at a later time when one must go back and find all the answers), and can be difficult for a busy surgeon to accomplish day in and day out, it is well worth the time in the long run.
It is important to note that maintaining the AHSQC as a free resource for surgeons really depends on participation; the more surgeons participate, the higher chance this will be able to remain free.
So to recap, in terms of cost, total cost is free if you are an AHS member, and cost of time is a couple minutes of time for data entry after each case.
Where are you now in terms of development?
Dr. Voeller: I know that Ben and Mike want to increase surgeon and institution numbers because that is the key to the success of the collaborative. Presently there are almost 200 surgeons with a total of almost 14,000 patients entered. There are about 400 new patients entered every month. This number will increase significantly when inguinal hernia becomes part of the collaborative this month.
What are the advantages for surgeons in joining the AHSQC, especially with Value Based Purchasing being enforced January 2017?
Dr. Rosen: There are many advantages to surgeons who join the AHSQC. First, you are actually able to track your own outcomes and compare yourself to a larger group in real time. This allows you to see what you are doing well, and what you might want to improve on in the future. This is often the first time many of our surgeons are able to actually see how they are doing amongst their peers, and it is very powerful.
Second, you are able to have real time data analytics to show your institution the exact value that you as an individual surgeon provide to their enterprise in the care of hernia patients. With the growing need to measure and report quality outcomes, it is critical for surgeons to control their own destiny by being involved in the data collection and outcome measures on which they are being judged. Waiting and hoping that your institution will do this for you in a fair and balanced means is often met with disappointment. Third, with value based payment adjustments starting this month, many surgeons are going to feel the 2% payment cut for Medicare patients if they are not deemed high quality surgeons. The AHSQC has been extremely proactive in this regard, and is now recognized by CMS as a qualified clinical data registry (QCDR), which basically means that your data in the AHSQC can be used to avoid these severe payment cuts. Fourth, we have a world class coaching system where collaborative-nominated surgical coaches are available to coach other surgeons via a cloud-based system to improve their outcomes and streamline their care processes.
Finally, it is an amazing experience to be part of a collaborative. For many surgeons out in practice, it can be very lonely and isolating. Being part of something that is much bigger than just one surgeon is a special experience, and every surgeon in our collaborative makes a difference.
What are the global benefits of the Collaborative?
Dr. Voeller: The global benefits to the Collaborative have the potential to be tremendous. First, and most importantly, it will allow us to find out what techniques, meshes, methods of mesh fixation and other issues in hernia repair work or don»t work. Also, part of the Collaborative is a mentoring and teaching function that will help educate surgeons on improving their techniques for hernia repair. Surgeons can look at their data and have access to other data on the Collaborative to help not only in education, but improvement in outcomes. In addition, research can be and has been done using the data on the Collaborative. It is well known that randomized prospective trials can leave many more questions unanswered than answered due to the difficulty in controlling variables. The Collaborative allows ready access to a tremendous amount of data to analyze what»s going on in the real world. The research potential is huge. Lastly, the companies are very interested because the FDA has said if data gathered on the Collaborative shows a product can be used safely in an instance where it may not have approval, the FDA may approve the new indication solely based on the data from the Collaborative. That is a totally new paradigm that helps patients, hospitals, and new product developers.
Speaking of data, what happens to members’ individual data and how is the data being used on a national level to help surgeons?
Dr. Rosen: The real power of our quality collaborative is that an individual surgeon can make a tremendous difference and their outcomes and experience counts. By pooling data from all practice patterns, and all levels of experience, we are able to see what is actually happening in the real world. As Guy mentions, all too often the peer review publications come from centers with high volumes and specialized practices, and this often doesn’t represent data that is relevant to most surgeons that are fixing hernias. In participating in this endeavor, surgeons are able to level the playing field and let their experience count.
In practice, each surgeon has access to their own data through our export function and can see their own results compared to the collaborative real time. Their data is also used as an aggregate analysis on the collaborative level. We have a publications committee that reviews protocols from any surgeon that wishes to analyze and perform research on our data and is a member of the AHSQC. This allows all of our collaborative surgeons to also have access to the larger data set to answer key questions in hernia surgery. In a few short years, we have been able to answer critical questions about the effectiveness of epidural analgesia after ventral hernia repairs, utilization of chlorhexadine scrubs prior to ventral hernia repairs, and outcomes of patients receiving bowel preparation before ventral hernia repairs, and have developed a validated readmission reduction tool for institutions to implement to reduce costly readmissions.
We are excited to report that participation in this collaborative is now recognized by the American Board of Surgery as acceptable for fulfilling the Maintenance of Certification Part IV requirement. As mentioned, we have also been recognized by CMS as a QCDR, which is critical in the quality payment program of CMS that started this month.
What are some of the major barriers to joining the AHSQC?
Dr. Rosen: There are a few barriers to joining the AHSQC, some of which are perceived and some are real and due to the fact that the system in which we practice medicine is not really ready for us to work together on a large scale to improve the care of our patients. It’s worth going into detail about some of these issues to provide surgeons a better understanding of what it takes to become a part of a collaborative.
Perhaps the most important barrier to discuss is the surgeons themselves. We simply were not taught to collaborate with our fellow surgeons. In fact, we were taught to compete against the fellow surgeon at all costs. This bitter competition has led to distrust in collaboration. It is so unfortunate, because while we do not work together as a group, many others are coming together and they are organized, and often don’t have the surgeon’s or patient’s best interest in mind. No one has a closer bond with their patients than a surgeon, and we need to be at the table when important decisions are being made. Surgeons must move past this discomfort with collaboration in order to be successful in today’s healthcare climate.
The second barrier to joining a collaborative is the HIPPA laws that currently make sharing of data extremely difficult amongst different surgeons in different institutions. Depending on what your practice type is, a contract lawyer from your institution must sign off on the agreement to allow us to share data. Despite over 200 institutions across the country already signing that contract, we have found that many hospitals also resist joining this endeavor simply because they are not equipped to share data for the greater good of their patients, and instead fear public reporting, or misuse of their data. It is unfortunate, because so many groups with much less accurate administrative data are already publically reporting on all of us, for which we have no say, validation, or basic risk adjustment to control the accuracy of what is being released.
Hopefully as the quality collaborative movement grows, the inappropriate resistance that many institutions put forth will be eliminated. It is also important that surgeon champions be ready to fight for their right to know their own risk adjusted outcomes, which is a very powerful position to be in when negotiating with your institution.
The final barrier is the perceived amount of time that is required to participate in this effort. It is important to point out that half of our membership is composed of private practice surgeons. You do not need a fleet of data abstractors to complete the data entry. This is surgeon-entered data and takes roughly 3-10 minutes per case. This is well worth the effort as we can now answer key questions that have plagued hernia surgeons for years, and have a seat at many tables to begin to shape some of the policy decisions involved in the practice of surgery.