Senate Committee Calls for Ban on Concurrent Surgeries

Marcia Frellick

December 08, 2016

The Senate Finance Committee released a report on Tuesday that calls for a ban on concurrent surgeries and more regulations on overlapping surgeries.

The committee, led by Senate Finance Committee Chairman Orrin Hatch (R-UT) and ranking member Ron Wyden (D-OR), defines concurrent surgeries as two surgeries led by the same surgeon, in which the critical procedures occur at the same time. They are rare, and Medicare won't reimburse for them.

The issue has been hotly debated since a Boston Globe investigation brought the practice of concurrent and overlapping surgeries and their ethical and practical ramifications to light in a 2015 series.

The reports led the American College of Surgeons (ACS) to update its guidance on the issue in April of this year, as reported by Medscape Medical News. The ACS said in its voluntary guidelines that concurrent surgeries were "inappropriate," but gave more leeway to overlapping surgeries.

Much concern has followed, in the wake of the Globe reports and ACS updates, about how strictly rules are followed and enforced and how much patients are told. The committee sent letters in February to 20 teaching hospitals asking for documents about their policies governing these procedures.

"While we are encouraged by the steps taken by the American College of Surgeons and a number of hospitals to address the concerns with concurrent surgeries, we remain concerned that the nearly 5,000 hospitals in America may lack thorough and complete policies covering these procedures and patient consent. By working with hospitals and surgeons in a collaborative manner, it is our hope we can continue to increase transparency and patient safety," Hatch and Wyden wrote in a joint statement.

Arguments for and Against

Defenders of overlapping surgeries say they improve efficiency, can reduce patient wait time, allow for trainees to work independently, and improve access to specialty surgeons. Arguments against them include claims that patients don't understand that this practice may happen during their surgery, that the double-booked surgeries are done with a motive of profit, that surgeons can't adequately focus on more than one patient at a time, and that patients may be at risk if the attending surgeon is away.

A story published by Medscape Medical News on Wednesday, however, reports that, according to Mayo Clinic researchers, overlapping surgeries are safe and have the same outcomes as nonoverlapping surgeries.

The Finance Committee report recommends changes to improve patient safety and transparency.

Among them are that hospitals ban concurrent surgeries and regulate overlapping surgeries in a way consistent with ACS guidance.

Hospitals should also formally identify the critical parts of procedures and decide which should not be part of overlapping surgeries.

Patient consent discussions should be structured so that patients are fully aware that their surgery will overlap with another patient's. Materials such as frequently asked questions should be developed and patients should get enough time to consider information about overlap so they have the option to find another surgeon if they wish.

The backup surgeon should be identified when overlapping surgeries are scheduled, the committee recommends.

The committee also stated that the hospitals should put systems in place to enforce concurrent and overlapping surgical policies and monitor outcomes.

Of the 20 hospitals contacted by the committee, 17 have changed their policies or created new ones related to the surgeries to conform with revised ACS guidance and three are in the midst of doing so, according to the report.

The American College of Surgeons told Medscape Medical News in an email that it has "had internal discussions this week about the new report and we did have an earlier meeting this year with the Senate Finance Committee about the issue.

"We believe that their recommendations are in line with our guidelines, and that many hospitals are already making changes to their own policies on concurrent operations."

Breaks New Ground

Jim Rickert, MD, an orthopedist in Bedford, Indiana, and president of The Society for Patient Centered Orthopedics, told Medscape Medical News that the Senate report breaks new ground. He said he was consulted for parts of the report.

The ACS guidelines were voluntary, he notes, and the Senate report "states that it's an institutional duty for the hospitals to have an informed consent plan in place which explicitly tells patients that their surgery is scheduled to be simultaneous."

That's more powerful than leaving that task up to individual surgeons, he said. "I'm not saying surgeons won't do it, but you will have spotty compliance."

He also applauded the recommendation that the conversations about consent be timely. Sometimes, patients are told about the overlap "as they are being wheeled into the [operating room (OR)]," he said. He also said too many euphemisms are used when surgeons explain the overlap to patients, including saying that the original doctor will "supervise" another doctor actually performing the surgery.

"That's much different from saying that Dr Jones is going to be doing the first part of your surgery while I'm operating on Mrs Smith in the other room. It's a very different conversation," he said.

Strengthening standards for patient consent was something he pushed for in talks with committee members, Dr Rickert said. But he had hoped the committee would also recommend a national standard for what is considered a critical element of the surgery.

The committee ruled against the ACS guidelines that surgeons can decide for themselves which parts are critical and said institutions should decide. But Dr Rickert says that leaves too much leeway, because an institution could say its policy is to let the surgeons decide.

He says there will be some pushback to the recommendations: "The practice that occurs now is lucrative," he said. "Hospitals get to squeeze more out of their ORs every day and it's lucrative for the surgeons. But I do suspect there will be more change going forward after this report."

Dr Rickert has disclosed no relevant financial relationships.

United States Senate Committee on Finance. Published December 6, 2016. Full text

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