Surgical Care in Lake Wobegon

December 2015

Radio personality Garrison Keillor often describes his fictional hometown of Lake Wobegon as a place where “all the women are strong, all the men are good-looking, and all the children are above average.”  Too many surgeons and hospitals view their own performance the same way.

As we have pointed out in this note and in other publications, there is a wide range of quality and cost both between hospitals and within them.  So what explains the gap between perception and reality?  Part of it is that hospitals and surgeons are drawing conclusions without knowing what the results of their care actually are.

How could they?  In the current environment of healthcare, patients are discharged quickly following inpatient care, and increasing numbers of operations are being performed in the outpatient setting with the patient sent home for recovery. Many never return to see their surgeon, and those that have problems may seek care from an emergency department other than at the hospital where care was delivered. It is currently estimated that 20-40% of readmissions following major surgical care are at a different hospital from the site of the operation.[1] The reality is that surgeons and hospitals do not know how their results of care compared to others.

Surgeons and hospitals need to know the results of the care that they provide; including post-discharge events. Hospitals are assessed penalties by Medicare for excessive readmission rates. Commercial entities are publishing the outcomes for hospitals and surgeons that may or may not accurately reflect the true results. Without objective measurement and knowledge of results, it is not possible for providers to fairly benchmark their outcomes of care to others and defend themselves against external claims. Providers cannot engage in true quality improvement if objective measurement is not available.

Surgical Care in Lake Wobegon. Risk-adjusted total hospital cost. Risk-adjusted inpatient adverse outcomes.

At MPA Healthcare Solutions, we use sophisticated risk-adjustment strategies to define observed outcomes for hospitals and surgeons that are compared to nationally-derived prediction models. By specific procedures we can provide risk-adjusted inpatient and 90-day post-discharge mortality rates; measures of severe inpatient complications; and 90-day post-discharge readmission rates. We will soon have Emergency Department visitations without readmissions among the major surgical categories.

By using the national Medicare Database, we can identify readmissions and emergency department visits to all hospitals and not just those returning to the index hospital. Metrics for outpatient adverse outcomes are presently being developed. We can provide you with a benchmark of your risk-adjusted outcomes compared to other facilities performing these operations. Care improvement strategies in potentially problematic areas can then be pursued with objective measurement tools that will permit a fair assessment of improvement. Don’t assume that you live in the surgical Lake Wobegon and that all is above average. We would love to talk with you about our objective metrics for the evaluation of surgical outcomes of care.


[1] Kim Y, Gani F, Lucas DJ, et al: Early versus late readmission after surgery among patients with employer-provided health insurance. Ann Surg 2015; 262:502-511.

Donald Fry

Donald E. Fry, M.D. is Executive Vice President for Clinical Outcomes Management at MPA Healthcare Solutions, Adjunct Professor of Surgery at Northwestern University, and Professor Emeritus of Surgery at the University of New Mexico School of Medicine. At MPA Healthcare Solutions, Dr. Fry provides clinical leadership in analyzing and evaluating clinical performance, guiding quality improvement, and creating incentives for coordinated, cost-effective care.

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