TECHNOLOGY AND SURGERY: Dilemma of the Gimmick, True Advances, and Cost Effectiveness

Technology has allowed surgeons to incorporate minimally invasive techniques into everyday clinical practice. Unfortunately, this progressive technology has occurred during an era of economic retraction. As a result, we, as surgeons, have become more cost conscious. Today we are interested in quality first and the value of our health care product second. This latter sentence is most important to understand. Careful definitions of quality and value are required. As surgeons, our most common health care product is a procedure. The value of that procedure can be defined as a quality product provided at a reasonable cost. We can deliver quality when the procedure is appropriately utilized and the short- and long-term results are well within an established range. The components of quality, therefore, are appropriate utilization and adequate short- and long-term results. After all of these quality issues are considered, the cost of the procedure must be reasonable to achieve the desired result—that is, provide value. The following equations define the value of a surgical procedure: The value equation can apply only to a procedure that is appropriately utilized. In order to determine if a procedure is a "gimmick" or a true advance, the health care team evaluates the "outcome" of a procedure to determine quality. We know this process as quality assessment. Synonymous with quality assessment is outcome assessment. Surgeons have always assessed the quality of procedures in our literature with short- and sometimes long-term result studies. These quality assessment methods are not foreign to us. Examples are retrospective or prospective clinical trials. Outcome assessment must be done by physicians who best understand the health care product. These types of assessment should not be left to business administrators or economists. When money is factored into quality or outcome assessments, then value can be determined. Value assessment has become most important during these times of economic retraction. The denominator of value is cost. Value assessment, even today, does not include costs because the business of health care has traditionally relied upon charges and reimbursements. In North America, business administrators have discovered that costs are more important than charges. The emphasis on costs in North American businesses has been realized only within the last decade and, in regard to health care, only within the last several years. During the 1980s, North American auto makers discovered that the success of Japanese industry lay in the principles of continuous quality improvement. These principles were first given to the Japanese by an American physicist, W. Edwards Deming. 1 His ideas could apply to surgical procedures as well as automobile manufacturing if we realize that doctors deal with human beings and not machines. Basically his ideas were that the results of any process must be quantitated into an acceptable range (the gold standard). This included asking the opinions of the consumer. If the results are not within the acceptable range, the worker providing that result is not at fault. Rather, the fault lies in the process we have created. In regard to medicine, it follows that once established, any range of acceptable results can be achieved only if the process has been correctly utilized. Therefore, surgeons have begun to focus on our results first by quality evaluation and then by improvement with new technologies to narrow the range of an established norm. A good example is discussed in detail—improving the open inguinal hernia repair utilizing lessons learned from laparoscopic inguinal hernia repairs.