M & M Conferences Need Upgrade

SAN FRANCISCO -- Morbidity and mortality conferences at Massachusetts General Hospital missed 3 out of every 4 complications and 1 of every 2 deaths in surgical patients over the course of a year, Dr. Matthew M. Hutter said 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) to cases discussed at weekly morbidity and mortality (M\&M) conferences.

Among 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 6.4% 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 6 due to patient disease and 7 that occurred after patients were transferred to a medical service or when they were being treated as outpatients within 30 days of surgery. One death unaccounted for 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, 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.

The hospital 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 of dollars, 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 of the University of Washington, Seattle , who was a discussant of the paper.

Dr. Flum noted that while 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, Dr. Flum added, noting some Massachusetts General deaths were due to carcinomatosis or total gut necrosis discovered during surgery.

Nonetheless, an accurate and consistent real-time surveillance system will provide invaluable information and will undoubtedly 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." 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 for decades

"Without a system to measure outcomes and to make change, it is difficult for any hospital to become a center of excellence. The key is getting physicians and surgeons involved in selecting the specific data system and agreeing to meet regularly to review results and begin changes in practice to improve outcomes," said Dr. John (Jeb) W. Hallett, Roper St. Francis Heart and Vascular Services, Charleston, S.C., when asked to comment.

"It is very helpful to use a national data collection system so your hospital can benchmark with other centers of excellence. By nature, surgeons are competitive and want to improve their outcomes," Dr. Hallett added.