SAN FRANCISCO — Morbidity and mortality conferences at Massachusetts General Hospital missed three out of every four complications and one of every two deaths in surgical patients over the course of a year, Dr. Matthew M. Hutter reported at the annual clinical congress of the American College of Surgeons.
Dr. Hutter and associates compared statistics compiled by a nurse reviewer in conjunction with the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) with cases discussed at weekly morbidity and mortality (M&M) conferences.
In 1,439 sampled cases representing 24% of operations, the NSQIP reviewer found a 29% morbidity rate and 28 deaths. Weekly M&M conferences during the same year addressed morbidity in just 6% of cases and made note of just 14 of the deaths.
An analysis of the cases determined that the ACS-NSQIP program identified significantly more complications of every subtype, including wound infections, cardiac complications, urinary tract and renal issues, and others.
Deaths not mentioned in any M&M conference included six due to patient disease and seven that occurred after patients had been transferred to a medical service or when they were being treated as outpatients within 30 days of surgery. One death unaccounted for in M&M conferences had incomplete data.
“At Massachusetts General, we pride ourselves … in a supposedly rigorous academic environment. We decided things had to change,” said Dr. Hutter, director of the hospital's Center for Clinical Effectiveness in Surgery and a member of the surgery department faculty at Harvard Medical School, Boston.
As a result of the study, the hospital has significantly bolstered the content and revised the structure of its M&M conferences, by including, for example, an ongoing review of its own NSQIP results and comparative data from other hospitals. It also has introduced a Web-based reporting tool that standardizes definitions for complications and allows residents and others to quickly input information about any case.
Although the confidential system can be accessed only for peer review, it contains data about everything from a postsurgical infection to an unanticipated return to the operating room or intensive care unit.
The Web-based system serves as an objective, watchful eye on individual patients and the care they receive. It also captures trends that can be identified and used to improve systems, feedback, and approaches to care.
The changes cost $100,000, but if they reduce complications at the same rate seen in the landmark Veteran's Administration NSQIP study, it will end up saving millions, Dr. Hutter asserted.
The NSQIP system was implemented in 1991. By 2001, the NSQIP system in Veterans Affairs hospitals had documented a 27% decrease in complications and a 45% improvement in morbidity, including a 50% drop in major complications, resulting in $11,000 in savings for each case in which a complication did not occur.
“With this report, we are starting to hear the death knell of the traditional M&M conference,” said Dr. David R. Flum, a surgery department faculty member at the University of Washington in Seattle who served as a formal discussant of Dr. Hutter's paper.
Dr. Flum noted that although M&M conferences were “never really intended to be a surveillance system” and served a historic function of revisiting errors, they have often been grounded in opinion, marred by recall bias, and sometimes even driven by “personal and political vendettas.”
Not every complication or death offers a lesson to be learned, he added, noting some of the Massachusetts General deaths resulted from carcinomatosis or total gut necrosis discovered during surgery. But an accurate and consistent real-time surveillance system will provide invaluable information and lead to improved care, he said.
“They took the best elements in this system—standardized definitions, standardized reporting criteria—and they empowered their residents to become the surveillance system,” he noted.
M&M conferences were established in the early 1900s by Dr. Ernest Amory Codman, the “father of surgical outcomes,” who called the review of cases an “end results system.”
Weekly M&M conferences have been required by the American College of Graduate Medical Education for surgical residency programs since 1983 and have been an integral tradition of surgical departments in academic and community hospitals for decades.