Standardizing optimization in surgery

Given the complexity of surgery, standardization is challenging and practice variation within surgical systems is inevitable, particularly when viewed at a global level. This makes the evaluation of new surgical advances challenging, although international guidelines have facilitated successful approaches that are rigorous and evidence-based.1 Clinicians should all strive to provide care that is individualized and patient-centred, incorporating shared decision making that aligns with the patient's values and preferences.2 Local knowledge and experience within surgical systems may certainly guide effective care within a patient's sociocultural milieu. However, when clinical decision-making is left entirely to an individual clinician and patient level (with no systemic influence), two patients with the same pathology may experience significantly different treatment pathways. Unwarranted clinical variation can arise from processes of clinical decision-making, which are affected by personal and organizational capacity, agency, motivation, and evidence amongst other factors.3 This phenomenon is merely augmented by the intraoperative variance which may be seen surgeon to surgeon. However, while practice variation within surgical systems is inevitable, patient outcomes are only affected when the degree of variation in practice is significant. Given the success of the Surgical Safety Checklist in reducing surgical morbidity and mortality worldwide as a result of standardizing practice in the immediate perioperative setting,4 the development of Standard Operating Protocols has been a major focus of the World Health Organization's High 5 s Project that incorporates numerous international collaborators.5 To improve patient outcomes at a far greater scale than that possible from most individual clinical decisions,6 surgical systems should aim to optimize patient care via an evidence-based approach, and then standardize these optimized approaches as broadly as possible. This ‘optimization’ of surgical care ensures the minimization of unwanted clinical variation, and can reduce discrepancy in patient and system outcomes. The latter still remains an issue at the global level.7 This article aims to explore the issues that may arise from the multiple forms of surgical practice variation, and discuss the need for broad pursuit of evidence-based approaches to ensure safe and reliable methods of standardization (and minimization of unwanted clinical variation), such as research and clinical audits. Clinical practice variation has multiple definitions. In some instances, practice variation may be used to refer to instances in which the currently available evidence presents a clear ‘Best practice’, but that real-world practice does not adhere to this evidence base.8 This type of practice variation presents an immediate issue of concern, as it suggests that some patients may not be receiving the optimal evidence-based care. Surgical practice variation of this nature is particularly evident with respect to geographic variations in practice of centres being within similar socioeconomic settings, regardless of consideration being at a relatively small scale9 or trans-globally.10 Multiple strategies have been investigated to ameliorate this issue, and within surgical practice the use of evidence-based guidelines and decision aids have demonstrated usefulness across a range of clinical circumstances.11 However, despite these strategies, significant variations in practice may still exist,12 and further innovation and research is required to address the issue. An alternative, or additional, definition of practice variation encompasses instances of ‘professional uncertainty’.13 This phenomenon describes instances in which a profession is uncertain as to the most effective course, and, accordingly, approaches may differ. This type of practice variation immediately highlights the need for further research. In some instances, the nature of the condition being managed may explain why there is a lack of evidence, such as extremely rare conditions. However, in other cases, this uncertainty may identify gaps in the existing literature that may be amenable to highly clinically relevant studies. Similarly, there may be variation in the implementation and post-implementation monitoring of clinical guidelines in surgery. It could be argued that there is practice variation with respect to the methods of combatting practice variation. The generation of high-quality evidence regarding best practice also requires high-quality evidence to ensure that it is implemented in clinical practice. Avenues that have been highlighted as potentially suitable for future interventions include policy, regulatory, and financial strategies.14 One of the potential critiques of the aim towards standardization of care is that it may lead to ‘cookbook medicine’.15 This term is used to describe the concern that clinical guidelines may lead to unthinking adherence and limitation of clinicians making decisions that they feel are best for their patients. Beyond the described concern for limitation of freedom of thought, it has been suggested that clinical guidelines may have legal and funding implications for the types of treatments available to patients.16 Rather than detracting from the importance of clinical guidelines, these concerns may be considered to highlight the importance of systematically evaluating the effect of clinical guidelines. Clinical audits evaluating adherence to current guidelines are integral to the process of reducing unwanted practice variation and improving evidence-based quality in surgery.17 Of note, nationwide mortality audits, such as the Australian and New Zealand Audit of Surgical Mortality (ANZASM), are useful in improving outcomes and optimizing cohesion across surgical services.18 For audits conducted at such a large scale, determining the optimal balance between cost, safety, and reliable data that is measurable can be challenging, however if governed effectively can produce surgical advancements that result in cost savings and patient benefit.19 Previous studies evaluating surgeons' perceptions of audits, such as surgical mortality audits, have demonstrated that such audits are perceived to be effective strategy in Australian centres.20 The publicly-available Royal Australasian College of Surgeons (RACS) guidelines on surgical audits provide a foundation for interested parties to learn about the audit process and facilitate self-directed audits.21 An increased role, recognition, and funding of audit activities in hospitals may help to create an environment that enables greater standardization of evidence-based care delivery, and hence better outcomes. Practice variation in surgery is an ongoing issue. The need for standardization has been long-standing, and various initiatives are ongoing worldwide to address this need while seeking to characterize and overcome barriers that may prevent widespread application. Evidence-based efforts must continue be made within the surgical community to optimize the delivery of care and standardize these optimized approaches broadly. However, in addition to the production of reliable evidence to guide best-practice, research is required regarding how to best communicate and implement this information to improve real-world clinical practice. Systematic evaluation of the application of clinical guidelines to ensure that they do not have significant unintended consequences, and do result in improvements in patient care is vital. Clinical audits have an ongoing important role in the evaluation surgical practice variation over time and ensure that adherence to optimal practices is enduring. Open access publishing facilitated by The University of Adelaide, as part of the Wiley - The University of Adelaide agreement via the Council of Australian University Librarians. Joshua G. Kovoor: Conceptualization; investigation; writing – original draft; writing – review and editing. Stephen Bacchi: Conceptualization; investigation; writing – original draft; writing – review and editing. Aashray K. Gupta: Conceptualization; investigation; writing – review and editing. Patrick G. O'Callaghan: Conceptualization; investigation; supervision; writing – review and editing. Markus I. Trochsler: Conceptualization; investigation; supervision; writing – review and editing. Guy J. Maddern: Conceptualization; investigation; supervision; writing – review and editing.