Quality in health care means doing the right things right. Traditional efforts to improve the quality of surgical care have concentrated on improving surgical performance: doing things right. Performance quality in surgery is usually measured in terms of mortality or complication rates, and problems are indicated by variations in outcome rates. Efforts to improve quality usually focus on improving processes of care, from how skillfully the operation is performed to how well patients are cared for after surgery.
Although performance quality is important, so too is the quality of clinical decision-making: doing the right thing. To measure this aspect of quality, it is necessary to ask whether the initial decision to proceed with surgery was correct. “Preference-sensitive care” comprises treatments that involve significant tradeoffs affecting the patient’s quality and/or length of life. Decisions about these interventions – whether to have them or not, which ones to have – ought to reflect patients’ personal values and preferences, and ought to be made only after patients have enough information to make an informed choice. Measuring decision quality is much more difficult than tracking mortality or complication rates. However, as with performance quality, variation is an important indicator of problems in the quality of decision-making.
Our rates of inpatient surgery are based on the Medicare Provider Analysis and Review (MedPAR) file. The procedure codes (numerators) used in the MedPAR file are based on the International Classification of Disease (ICD-9-CM). Selection of procedure codes was based on review of the literature and/or consultation with clinical experts. Enrollee counts were obtained from the Medicare Denominator file. The Medicare enrollee population includes those alive and age 65 to age 99 on June 30 of the measurement year. Measures based on a count of fewer than 11 patients are not displayed for reasons of patient confidentiality. Rates with fewer than 26 expected events are also suppressed because of a lack of statistical precision. These cells are marked "na." The rates are adjusted for the age, sex and race of the underlying Medicare population using the indirect method.