The Panel on Anesthesia Audit at the World Congress of Anaesthesiologists at the Hague provided the audience with interesting differences in attitude. In the United States, audit is called quality assurance, or in its latest transmogrification, continuous quality improvement.
During his introduction, Dr. Alaistair Spence, president of the (newly) Royal College of Anaesthetists in London, said that insistence by the government had led to the development of audit mechanisms in the United Kingdom.
The first two speakers were in striking contrast. Dr. Terry Vitez, Vice President for Medical Affairs at Premier Anesthesia, explained his method, well known in the USA, of judging clinical competence. The method accepts the idea that humans are inherently fallible, and that decisions about performance must be made by knowledgeable peers. He said these decisions must include measures of both the process and outcome of anesthesia. He has developed a zero to 10 scale of outcome scores which convert written descriptions of the outcome of an anesthesiologists care of the patient into a number. It is of interest that last year and in another context, the ASA House was concerned enough about the validity of placing a number on an anesthesiologist’s competence that it referred the matter back to the Peer Review Committee for further study.
Dr. Spence followed by stating that although he remains optimistic about the usefulness of audit, he cautioned the audience that he is disillusioned about its possibilities. He warned us to limit what we audit only to key information; such things as drug usage, use of manpower and appropriate training, frequency of preoperative visits and problems of intubation. He said we should be wary of auditing complications because ‘acceptable’ rates of occurrence are unknown and vary with practice settings and the status of the patient. He had the same concerns about the study of critical incidents. He also emphasized that whatever system one used to audit patient care the validity of the findings must be tested and retested.
Dr. Fred Cheney, Director of the ASA Closed Claims Project, reviewed the information gleaned from malpractice case files and described the study of large numbers of adverse outcomes; the results can give perspective when performing audit. He stressed that the project results give no estimate of the overall incidence of adverse outcomes, that they are not balanced geographically in the USA and that there is selection bias in the claims that are reviewed. His most important statement about the applicability of the project’s results to audit appeared when he described reasonable interrater reliability between the judgments of reviewers but marked bias against practitioners who had more severe outcomes even when the clinical scenarios were identical. This suggests a weakness in the Vitez method of enumerating a practitioner’s competence and supports Dr. Spence’s caution about validity.
Dr. Cheney described other findings from the project which have led to changes in practice. For example, the findings of the frequency and devastating consequences of difficulties with intubation have given an added incentive to the development of the difficult airway algorithm by the ASA.
Dr. John Lunn of the University of Wales stated that the Confidential Enquiry into Perioperative Deaths (CEPOD) is a form of audit. This enquiry is a rare example of cooperation between anaesthetists and surgeons! The enquiry extends to deaths occurring up to 30 days after surgery. Dr. Lunn said that this is not research because there is no prior hypothesis about perioperative death. It is ran independently of the government yet the authorities fund it. It is also independent of the Royal Colleges (the premier academic bodies in the U. K.) yet they act as watchdogs. In its study of perioperative death the enquiry seeks to avoid judgment of peers. But the enquiry does ask whether the care was appropriate or inappropriate. Dr. Lunn said therefore it is a form of quality assurance but he also warned that his case reviewers could be divided into hawks and doves.
The CEPOD, being national in scope, allows the collection of valid numerators and denominators. Each year there is a different focus; for example in 1989, the enquiry looked at perioperative death in children and this year, death rates associated with specific operations.
Dr. Burton Epstein, Chairman of the ASA Committee on Standards of Care, discussed the pros and cons of setting such standards. He quoted Dr. John Eichhorn’s statement that anesthesia is the specialty most amenable to setting standards for itself. He added that the pressures for establishing standards largely came from government, insurers, third party payers and the public. He described how the ASA has updated monitoring standards as technology, experience and opinion have changed. He explained that the standards for obstetric anesthesia care have been liberalized to guidelines to respond to acceptable variations in practice. He felt that it was unlikely that any more new standards would be developed for anesthesiologists but that practice parameters (how to do it?) would take over.
Dr. Dupuy, a physician and an ethicist, followed and told us that in the past there had been reluctance to introduce audit in Continental countries; yet recently there had been an upsurge in interest. It sounded cynical, but she said that ethics, which is concerned with the quality of care, and economics, are linked. She explained this on the basis that money spent on one patient cannot be spent on another and medical audit tends to increase the number of medical interventions. The first part of this statement is not likely true of the USA except perhaps in Oregon. She described the activities of the Dutch Governmental Committee on Choices in Health Care. This committee strongly recommends the use of treatment protocols, the use of audit and gives advice on the how to deal with the ‘difficult patient who shops from doctor to doctor in the medical mail.
It was clear to this audience that there is little unanimity about what is an acceptable and valid technique of auditing our care of patients but there was little doubt that we must do it.
Dr. Zeitlin is a member of the Department of Anesthesia, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA and is also an Associate Editor of the APSF Newsletter.