David Reed Flum, MD, MPH, FACS

October 14, 2008 to the James IV Association of Surgeons

James IV Traveling Fellowship Report

Table of Contents

I. Introduction
II. England
III. Netherlands
IV. Sweden
V. Spain
VI. Singapore
VII. Malaysia
VIII. Conclusion

I. Introduction

I am grateful to the James IV Association of Surgeons for the honor and privilege of being a 2008 James IV traveler. My six weeks of travel were a precious opportunity to expand my professional network, gain a broader understanding of the professional issues I am most interested in, and spend concentrated time with my family learning about and exploring amazing places. I visited six countries (England, the Netherlands, Sweden, Spain, Singapore, and Malaysia) in six weeks and traveled with my wife and three children (ages 12, 10 and 5) for all but the last ten days.

My research and professional interest is in evaluating and improving the quality and safety of surgical care. Using a combination of observational research, public policy, and community- based participatory interventions, I have worked to advance these goals in the United States. In Washington State, I worked to create the Surgical Care and Outcomes Assessment Program (SCOAP), a 35-plus hospital coalition that tracks and provides feedback on performance data for general, bariatric, vascular, and pediatric surgical care with the aim of improving quality. Though I had heard that several countries have audit systems like SCOAP in place or in development, I had very little international exposure in these areas and little first-hand knowledge of the ways in which other healthcare systems were approaching these issues. I also knew few international surgeon leaders in these areas.

My focused interest during the travel fellowship was to better understand the ways in which different healthcare systems tackle critical issues in surgery: how new procedures and technology are introduced, how safety and quality in surgery are tracked, how costs are contained, and how variability in safety and quality is mitigated.

I began planning travel in January 2008 by reaching out to former James IV travelers and colleagues who then put me in touch with surgeons in ten countries by email and phone. Through several months of gauging interest and availability, I worked to coordinate schedules and plans with surgeons in eight countries, eventually limiting my travel to six countries for logistical reasons. I focused on surgeons and surgeon leaders who were interested in these topics in countries that represented a wide spectrum of healthcare delivery systems (from free markets to state-driven socialism) so that I could better understand the potential for system- level influence on surgical care. My main goal for this travel was to begin to understand the complex healthcare systems and to create a network of colleagues for future explorations in system comparison. My observations herein are not meant to be sweeping assessments or judgments but rather to reflect my experiences as they provide impetus for future evaluations.

II. England

My family and I began our travel in London on June 18. I first went to Oxford-affiliated Horton Hospital in Banbury to spend a "day in the life" of a community practice surgeon so as to best understand the way the healthcare delivery "system" impacts the experience of being a general surgeon. Throughout the day with Mr. Peter McCulloh, I participated in rounds on pre- and post-op patients, observed a laparoscopic cholecystectomy in the operating theater, and met with a group of registrars and training surgeons. I also met with health policy research fellows and reviewed their progress on an outcomes project concerning esophageal cancer surgery across National Health System (NHS) hospitals. We had the chance to talk about recent trends in NHS policy regarding surgeon attire, work hours and time-based performance metrics. There is a curious mix of frustration and pride that practitioners have for the NHS. Universally, the surgeons I met were happy to have the NHS, eager for it to change, and grateful that they did not live and work in other systems.

During a dinner with Jonathan Meakins at the Old Parsonage in Oxford, we discussed health policy and the complex interaction between academic centers and the NHS. There appears to be a frustrating disconnect between NHS management and consulting academic physicians, as well as an often antagonistic relationship between leaders of the system and clinicians and clinician leadership. Academic surgery is particularly frustrating when it comes to controlling clinical quality as the Department Chair has little control in hiring, firing, reassigning, or directing consultants. The Department does not train postgraduates, as that is the the purview of the NHS, and there is a plan to move to a 48-hour work week in 2009 that, though opposed by many academics, seems poised to take effect.

On June 20, I gave a Grand Rounds presentation at the John Radcliffe Hospital in Oxford entitled, "Outcomes of the Outcomes Research Movement -- Learning How Different Health Systems Impact the Health of the Surgical Field." Afterwards, I met with training surgeons, registrars, and researchers involved in health system evaluation. This built on my experience at a Balliol Colloquium in Oxford in April 2008, where I met surgeon health services researchers including David Taggert and leaders of the evidence-based medicine movement. My presentation was well received, with questions focused on how SCOAP and surveillance systems like it deal with innovation, how to do surveillance within the context of a "blame" culture, and how it is that we can do surveillance when the metrics may not be generalizable between patients of different clinical activity. My general observation of the way the NHS "runs" clinical care is that there is tremendous potential to have an evaluative component that would track and feedback performance data (process and outcome) to surgeons and surgical centers. This potential is not currently being recognized.

The NHS is also grappling with how to modernize and deliver the highest level of care through a centralized system. According to those I met, there has been less emphasis on quality control in the last few years. In the time I observed clinical care within the NHS, I noted the following within various clinical environments: there is no system to alerts doctors about quality of care metrics that are about to be missed (e.g., beta blocker use so postoperative withdrawal can be avoided), no mandatory referral system for complex care, no system to regulate quality, and inconsistent use of consultants or consultant supervision for much of the general surgical care provided in some environments. In the cases I observed, there was a completely paper- based record system for theater notes, no "time out," no meeting between surgeon and patient preoperatively, no antibiotics given preoperatively but rather as an afterthought at the 20- minute mark, no preoperative huddle to confirm patient and site with the surgeon (although the nurses did suggest they do this before the patient arrived), and no in-person hand offs between shifts. With only a few observations it is inappropriate to be critical about care delivery, but these observations suggest opportunities to develop a better system for regulating quality.

Next, I spent a day at St. Mary's Hospital in London with Lord Ara Darzi, the highest ranking physician in the British government. We spoke at length about the challenges currently facing the NHS, his government's strategy in meeting those challenges, and his policy priorities, including the development of poly-clinics to bring what is non-critical but currently hospital- based care back to the general practitioner (GP), outpatient environments. Lord Darzi believes that over-utilization of hospitals for non-hospital care is one of the greatest impediments to the more efficient and cost-effective use of the healthcare system. The NHS has also placed a high priority on performance targets for hospitals. These have focused almost exclusively on access (e.g., time waiting in ER or for elective surgery) and trying to find ways to incentivize more production in a non-fee-for-service model. We spoke at length about the NHS challenges in addressing quality, which was to be a major issue for his upcoming white paper presentation to the House of Lords. He believes that quality has been a neglected area of British healthcare and one that is primed for focus. When I asked about variation between centers in performance and outcome, he noted that there was no consistent audit system and that this is a vulnerability of the system. He agreed that while the potential for this type of quality control has existed for years, several things contributed to what he described as a reactive and decidedly not proactive system: a lack of focus on quality because of a lack of clinician leadership, a lack of resources to create surveillance systems, and a "gotcha" mentality in the public and press that occupies the interests of leadership. He hopes to change some of that.

I then met with Lord Ara Darzi's staff and several health policy researchers. First I had the chance to meet with Professor Peter Dunbar who heads the health economic analysis unit. We discussed our mutual interest in finding ways to evaluate healthcare systems delivery by examining health state valuation and preferences by patients. He presented his work in measuring moment-to-moment decrements in valued life as a model for assessing everything from the impact of surgery on patients to explaining behaviors such as risk taking in health choices. I presented my group's work using utility measures to understand varying health states, specifically by using the EQ5D, an instrument his group from York both developed and critically revised. We talked about ways to modify health assessments in the future to help advance the science of patient assessment.

I then met Mr. Krishna Moorthy, a lecturer at the Imperial College London at St. Mary's Hospital. He and I have similar surgical interest in gastrointestinal disease and bariatric surgery and overlapping research interests. Mr. Moorthy is introducing the World Health Organization checklist into St. Mary's OR theater and working on OR team communication and quality of teamwork assessments, while I am introducing the OR safety checklist across Washington State and evaluating macro-level safety. We spoke about our mutual interests, the progression of academic surgeons within medical centers, and challenges he is facing in considering how to make the greatest impact on surgical practice. We also discussed the effective regionalization of gastrointestinal cancer surgery at approximately 30 hospitals and the potential for a voluntary audit related to process of care and outcomes. I gave him some information on SCOAP, and he is considering using it as a model for a prospective audit and feedback system.

After speaking with several health services researchers, my broadest impression was that the state of health services research in England is limited by the quality of clinical records and the amount of meaningful registry data available.

Following my visit with Lord Darzi, I visited the Royal College of Surgeons (RCS), where I toured the Hunterian Museum and met with RCS President Bernard Ribiero. We spent an hour discussing the state of the surgical field in England. He briefed me on attempts by the RCS to begin a process of re-certification that might someday include outcomes reporting. The initiatives that have been proposed focus on self-report rather than external audit, but despite that, he believes this will be an effective, albeit limited, tool to accomplish what is now elusive -- an ability to know how a surgeon or center is performing. We spent most of our time discussing the chasm between NHS leadership and the RCS. He has spent most of his 3-year tenure pushing back against governmental regulations on work hours (expected to be limited to 48 unless an exception is made for surgical trainees), wait list metrics related to elective surgery, draconian outcome reporting related to flawed administrative data (HES data- abstracted by less than qualified abstractors and widely held among clinicians to be inaccurate), and workforce training issues that have failed to effect meaningful change in the "pre-training" problem. He does not feel there is professional readiness for individual accountability for outcomes or interest in voluntary reporting, or that there is much likelihood that in the near term variability on a system-level would be meaningfully assessed or mitigated.

To continue my exploration of the British healthcare system, I spent a morning at the Department of Health (DoH), where I met with Dr. Helen Woodward, Clinical Advisor to Sir Liam Donaldson, Chief Medical Officer of the Department of Health. The DoH is responsible for NHS policy and execution, and Sir Donaldson has been a key leader in both the WHO safety checklist and in the planned reinvention of the NHS related to quality metrics. We spoke about the ways in which "arms-length" organizations (around 30) regulate different aspects of quality, technology integration, safety assessment and audit. It was a great primer on how the system works and how surgeons and surgical care do and do not influence healthcare delivery. The general sense I got is that there is not the kind of political readiness for systematic tracking of variability or interventions based on quality, and that NHS politics restrict the impact of the system on care delivery. The GP-focused delivery of resources has led to fragmentation in the system so that "surgical care" is not an entity that can be addressed centrally but rather is a local issue.

This conversation was continued with Mr. Ian Dodge, Director of the Policy Support Unit in the Department of Health, who explained the policy implications of changing governments on quality aspects in the NHS. We spoke at length about incentives that have been and will be introduced into the NHS that may help in the delivery of more effective care. These include a "money flows with patient" concept, tariffs on treatment received rather than per-capitation, and changing of present, time-based metrics (e.g., patients must be seen in the ER within four hours) to quality of care metrics.

I met with John Scarpello, Deputy Medical Director, and Joan Russell, Head of Anesthesia, in the NHS National Patient Safety Agency (NPSA). This free-ranging conversation helped me better understand the way audit is and is not being used, the way MRSA and C. dificile are being tracked across hospitals, and the likelihood that elements of surgical and perioperative safety (e.g., beta blocker discontinuation) will be tracked (unlikely unless there is more political pressure on the system). They both spoke about a very responsive, reactive system that precluded proactive addressing of variation issues.

On June 25, I travelled to Coventry and the University of Warwick, where I met with a gastroenterologist and public health specialist, Professor Bernard Crump, Chief Executive Officer of the NHS Institute of Innovation and Improvement. This "arms length" group has 4 roles: 1) developing leadership in the NHS; 2) identifying and adopting best practices for the NHS (University of the NHS concept); 3) shepherding innovative ideas from industry concept to distribution in NHS; and 4) running programs that allow benchmarking across NHS systems (to which SCOAP is most akin). We spoke at length about the promise of NHS in being able to evaluate variation and theoretically reduce variation, and also of the chasm between what NHS leadership is involved with and what local communities are working on. This disconnect is one of the areas in which his group works. The function of working to develop innovative pre- market technology was very interesting in that the system is so labyrinthine that they felt they were putting companies at a strategic disadvantage and were at risk of losing the tax base and number two ranking they currently have in medical technology development.

I spent a day at the National Institute of Clinical Excellence (NICE) in London, where I met with Peter Littlejohns, Clinical and Public Health Director, Dr. Gillian Leng, Deputy Chief and Director of Implementation, Sally Gallaugher, an analyst within the interventional procedures group, and Dr. Hannah Patrick and Mirella Marlow who run the intervention group. We spoke about the ways in which new procedures, devices, and implants are considered for coverage by the NHS. Their threshold for approval of new procedures is based on safety first and then a low bar for proof of efficacy, which is distinct from the ways in which drugs and more mature procedures are appraised, which are efficacy based but with a much higher RCT-driven bar. The latter is considered in appraisals that result in "guidances" that must be carried out by all service centers within 3 months. These usually involve drugs, but spinal fusion, cardiac stents, and bariatric surgery have also had an appraisal process. The appraisals must consider the NICE criteria of safety, efficacy, and cost analysis, and they result in either approval, approval with conditions, or rejection. There are also guideline development and public health programs. The procedure program is distinct in that it tries to make early assessments of emerging technology and only requires limited evidence of efficacy (case series adequate) and safety. The decisions usually are "approval with special conditions", meaning with a planned audit or after a special conversation with hospital leaders or patients through a special consent process. This often means that new procedures and technology are "approved" but not implemented because of a local lack of resources or priorities at the GP level. We spoke for a long time about the current status of implementation of guidances and surveillance programs so they know if the guidance of NICE is being followed. This is a weakness of NICE -- it does not tie NHS payments to their guidances. NICE leaders are optimistic that this will be built into an expanding NHS.

June 30 was the highlight of my London visit. Lord Darzi invited me to be his guest as he addressed the House of Lords on the occasion of the 60th Anniversary of the NHS and his delivery of the "Next Stage Report of the NHS." In this 90-minute presentation and debate, Lord Darzi laid out his agenda for the next few years. The report was a year in preparation, including 2000+ clinicians from all regions and sectors giving their input. The central focus was recognizing that the last 10 years of government investment in the NHS had accomplished the goals of better access to care and through-put but had not really taken on the mantle of quality. His report outlined an ambitious agenda to expand NICE to include quality measures and a dashboard for performance targets, to increase the speed of NICE approval of drugs, to include clinicians in the management of local healthcare trusts, to expand access to new technology, and to improve the training system. There was the general feeling throughout the speech and the following discussion that their system suffered from a "lack of doing" rather than the common US presumption that we are "doing too much." In this debate, I could not tell if the US is just 15 years ahead (paying a lot for new things but not getting much for it), or if England is chasing the US notion that more is better. Lord Darzi's report called for greater investment and a wider scope of quality assessment, including patient-centered outcome measurements such as like CMS survey work and more emphasis on money following the patient to assure higher accountability.

My visit to the House of Lords was impressive in many ways. The physical space can only be described as regal. The Parliament building has elements that have been in place since 1300, and every element of the architecture and physical space is ornate. The political theater of the event was also revealing. The same speech that Ara Darzi gave was being repeated simultaneously in the House of Commons by Secretary of State Alan Johnston and became an immediate political football, as it was representing the work of a relatively unpopular Gordon Brown Labour government. It demonstrated to me the importance of the Federal Health Board recommendation on which several US legislators are gathering consensus. The idea of de- politicizing a process that requires a long-term perspective, a carefully considered objective hand on the tiller made imminent sense as Conservatives and Liberals all attacked the piece of the puzzle that they liked least. The US is not immune to this squabbling, but because the NHS is overseen by Parliament, it may be more susceptible to problems of partisan game playing. Lastly, an observation based on all the trainees I met. They are disgruntled by a pre-training process that can last three to four years, which is followed by an additional seven to ten years in a surgical training program. A program recently promoted by Liam Donaldson that would streamline training applications was criticized for attempting to redirect pre-trainees into available training program spots, forcing many qualified doctors out of the system. Ultimately, this program is not as merit-based as trainees would like. In addition, the reduction in training hours has been particularly problematic, because British trainees already feel they have fewer training opportunities and more required years of training than their colleagues in Germany and the United States.

At the end of ten days in London, I felt I had learned a lot, from the highest level surgical leaders in the Royal College, Department of Health, and government and from community surgeons and trainees in the wards and in the operating theatre. The NHS has tremendous potential to more effectively tackle the issues of technology integration and variability but also is challenged to accomplish this potential through infrastructural and cultural barriers.

III. Netherlands

We took the night ferry and then several trains to Amsterdam. During the Dutch portion of our travels, I spent a day at the Amsterdam Medical Center (AMC) and at St. Erasmus Hospital in Rotterdam. Along with gaining a better understanding of surgical healthcare delivery in the Netherlands, another interest was in understanding how this small country has been responsible for so much high quality surgical research. I spoke with Dan Poldermans in Rotterdam, the lead investigator in several high profile beta blocker surgery trials and seven surgeons and investigators from the high powered team at AMC led by Dr. Marja Boermeester. Dr. Boermeester and I spent the afternoon with her research team, all PhD graduates who are in various phases of surgical training, and spoke of the emergence of a multi-hospital trials culture, how the cross-fertilization of PhD and clinical training has enhanced the scope of translational research, how there is an expectation that to enter surgical training you should have received a PhD, and that patients and clinicians both expect research to be a component of care. We also discussed how the system finances clinical research through targeted grants to evolving researchers only if they are committed to PhD level training. Dr. Boermeester has been responsible for the high profile ReLap trial (RCT in JAMA of on demand versus standard relaparotomy among critically ill pts with intra-abdominal infections), the recent Lancet published ProBiotics RCT demonstrating a higher than expected mortality rate when these popular "all-natural" agents are used in critically ill surgical patients, and has just finished a two-year prospective cohort study evaluating diagnostic imaging in the ER at 6 centers showing that AXR is virtually worthless. The accomplishments of this group are amazing and reflect both the individual talents of the lead and a culture that supports this important and high quality research.

The Netherlands has a unique model of healthcare delivery quite distinct from England and in some ways similar to the US. Everyone has to have insurance that is provided by one of 15-20 insurance companies. The costs for the insurance are born by the individual, their employer, or the government if they are unemployed and do not have the means. The different insurance policies have different levels of care (e.g., one plan may not included dental while another may not include rehab care), but all provide a baseline level of care and cover hospital-based and trauma system care. The costs and quality of care are controlled not so much by the insurance companies but through a very small system of hospitals that regulate themselves and are regulated by an Inspector General (IG) who reviews each hospital twice yearly. Most small hospitals have been linked to larger ones and have limited the scope of practice to not provide high risk surgical care. The IG has limited high risk surgery such as esophagectomy to centers where more than ten per year are performed, and this effectively has regionalized high risk surgery. While this is an effective mechanism, it is low-hanging fruit, and the harder work is to follow. For example, when it comes to quality of care, the Dutch system is at the same point the NHS is -- i.e., they essentially have a lot of interest in assessing and doing something about perceived variability but have no system-level way of assessing quality or variability, rely on self report using flawed data systems and are only now evolving data requirements and tackling guideline development. Marja is very involved with the surgical safety aspect of quality variation and has been instrumental in pilot testing what she is calling a checklist but is really a clinical pathway with stop points. This is being rolled out now at six hospitals and tracks every element of generic surgical care from preop to discharge. The program has the flow stopping when there is missing equipment, when the anesthesiologist does not see the patient preop, etc. This is being rolled out as a research project, but she works within the national guidelines group and believes it will be national policy via the IG within 5 years. There is no national data system for clinical care beyond the administrative, and only self reported data are produced at year end. The IG does require a description of how complications are reported and the manner with which they are dealt. All major complications and deaths are supposed to be audited, but there is a general sense that this is underutilized. Theoretically, the IG does do a root cause analysis with hospitals when they inspect, but this seems like a system with few actual teeth in it. The IG does have the capacity to control practice or close a hospital, but it has not done this according to these surgeons. A day in the life of an operating surgeon at AMC may not be typical of surgeons at community hospitals in the Netherlands, but it is telling of their ability to insert clinical research into clinical care. For example, a patient coming into the ER would have every element of their care tracked online for prospective research about their pain, the disease evaluation, the clinician's certainty of disease, and the tests performed. In the OR, an extended time out to accommodate the clinical pathway implementation would have the case not starting if the equipment was not correct, having the nurses and floor nurses doing a standardized transfer of care during hand offs and have each element of postoperative care tracked and monitored. Interestingly, if a surgeon wanted to know how they or their patients "did" on any of these elements there is no system to allow that to happen. Their research orientation may provide important insights into how we should deliver care, and will probably be good for the patients at the 6 hospitals where this has been implemented, but it remains to be seen if this is a good public health approach to surgical quality and variation. This team of surgeons is very much focused on implementation as well as new evidence generation, and I suspect that in 5 years non-research surgical healthcare in Holland will look very much like this research-environment.

In a small system, the surgeon leaders felt that they had enough control over the practice of surgery in the Netherlands that the community of surgeons could and would mitigate variability if it was sizeable. Interestingly, when I asked other surgeons whether there were surgeons they knew who performed procedures that they would not want to send a family member to they said yes, and that the system had little influence on the quality of care delivered. The other conclusion is that they feel they have "just about enough surgery and surgeons for the population," and that there is little perceived over-use or under-use because of community controls and insurer oversight-they take these conclusions on faith and it is unclear if the reason for this faith is that they have not looked for the data on variation that the US is currently dealing with or not feeling pressure to look at it because the percentage of GDP associated with healthcare is much less than the US. Again, in some ways the US is 15 years ahead in recognizing these problems about variation and introduction of new technology, but England and the Netherlands may be 15 years ahead in having a mechanism (i.e., state- owned financing or tight relationships between government regulators and insurers) for dealing with this variability -- an interesting dichotomy that we can learn from in the US. The English and Dutch in turn may be able to learn from us as they become more critical of their own country's healthcare delivery.

IV. Sweden

We flew from Amsterdam to Stockholm and met our host and guide Per-Olof Nystrom, a colorectal surgeon at the Karolinska Institute. He generously offered the use of his flat in downtown Stockholm, and we spent a day getting oriented. We took a train the next day to his country house in south central Sweden for a day of talks about healthcare and his life as a surgeon. We met Chairman of Surgery at the Karolinska Juan Permert on Sunday at a retreat in Southern Sweden overlooking a beautiful lake. With graphs and figures, we spent the afternoon and evening discussing Swedish socialized medicine, the culture that leads to consensus driven change, and QI, specifically how the Stockholm region with its 8+ hospitals caring for over 2.5 million people is being reorganized (under Juan's leadership) to direct all specialized surgical care through a telemedicine, multidisciplinary consultation service. This implementation of more organized surgical healthcare policy is a growing trend across the 7 counties (state equivalents) and is the most matured version of organized care systems I have seen. This is one way Swedish medicine effectively regionalizes, how it controls over/under use, and how it hopes to mitigate variability in quality. I spent a day at the Karolinska Institute Huddinger campus hospital. I observed morning rounds with GI surgeons, walk rounds with the senior consultants and junior surgeons, and went to the operating theater to observe a complex abdominal procedure. The Karolinska has had considerable organization around the QI process and reflects an extreme example of how a system can be created to deliver optimal care. Patients are referred to the system by any number of regional hospitals and clinicians. The referral call is handled by senior surgeons whose jobs for several weeks at a time are to sit in a room with a head set and navigate the system for the patient. An example is a patient with severe dysphagia and a mass on a UGI. The senior coordinating surgeon will decide which additional tests are needed such as an endoscopy with biopsy, CT and/or MRI, where those will be obtained and who will do them and when. There is a two-week data-gathering process, and the patient is seen after these data are presented to a multidisciplinary group that makes management decisions. These decisions are carried out locally if they do not involve surgery (RT or chemo) or at the Karolinska if surgery is needed. The surgery will be performed by a surgeon who meets the patient the night before and may very well not have been involved in the decision making process. The surgeons have agreed to similar approaches to patient care and demonstrate a willingness to accept the group decision over their own preference when the conflict. The procedure is performed by a senior surgeon often with a more junior but already completely trained surgeon. A training surgeon will be a second assist (this assisting surgeon will be at the Karolinska learning upper GI surgery for 10-12 years and will leave at the Associate Professor level ready to take over a local unit doing GI surgery). After the OR the anaesthesia team cares for the patient for 24 hours, then the recovery is guided by another senior surgeon whose job it is to run postop care. This surgeon will likely not have operated on the patient but "owns" the recovery. The patient goes to a rehab unit outside of the hospital run by another surgeon and then to local hospitals or home as needed. The operating surgeon may or may not see the patient postop beyond the conversation of what happened in the OR. The system has been fragmented so that every component of it is done in a consistent and regimented fashion, but not by the same person. This lends itself to a system approach, allows the system to be tweaked more easily to include EBM and decreases the number of variables in the delivery of care. Doctors understand their roles (e.g., a junior faculty member would know to call a senior faculty member to discuss case management before the OR), but not all doctors will do all roles. This competence-based system means that the hardest operations are not done by all and that the quality of these procedures is therefore optimized.

Swedish surgical care represents the most solid manifestation of a real healthcare "system" and is very effective. The system is completely "state owned," meaning that politicians have responsibility for the hospitals, while the state has responsibility for the medical schools and academics. There is a key difference between Unlike in the NHS where private GPs dominate the release of funds and each hospital is paid for the projected number of procedures they will do in the following year. If they do more they either lose money or shift the last ones into the next fiscal year, and if they do less, they are asked for money back, and the budget process gets refined. This removes financial incentive for over-use. Since there is no financial incentive for over-use, there is less pressure for controlling who performs which procedures. For example, they are experimenting with nurse endoscopists and project that most screening endoscopies and colonoscopies will be performed at this level. There are also many fewer hospitals (about 45 for a country of 9 million that is geographically quite large -- compare that to the 60 hospitals in Washington State for 6 million people and a much smaller geographical area). In addition, they are close to having all patients with cancers referred to cancer centers for management, effectively closing off a big avenue of introduced variability. They have addressed variability in performance and outcome by putting many procedures and disease management on rigorous registries (approximately 31 registries including cancer surgery of the colon and rectum, gall bladder and hernia surgery) with benchmarking against colleagues and feedback of performance data to hospitals and surgeons.

Interestingly, this healthcare system is not top down at all. There is no Secretary of Health per se dictating policy beyond broad rules such as "all should have equal care." The "system" leaves it to groups of professionals to self-regulate and hospitals to affect the broader policy goals. The pieces of the system work as a social unit for cultural as much as employment purposes. Each has its role, and part of that role is assuring that the system works well. An important way that Swedish healthcare self-regulates for quality is seen in the example of rectal cancer management. Rectal cancer is a good model disease to evaluate because it is more common than other high-impact procedures, has less of a volume outcome relationship, requires the integration of advanced diagnostics and evolving periprocedural multidisciplinary care, and for which there has been a high periop mortality/morbidity rate and variable long term survival.

For rectal cancer, it is widely accepted that not all general surgeons will do these procedures. It is not part of standard training, and a non-trained rectal cancer surgeon would never think to do this operation, nor would a hospital allow him or her to do so, as it would reflect poor judgement on the part of all involved. There are approximately 30 centers at which rectal cancer surgery is performed with about 100 surgeons doing this work. Each case goes on registry, and the data about outlier status for outcome are reflected back to surgeons and centers. Although nobody is "watching" these data from a federal level, the surgeons at these centers have worked over the last few years to gather consensus about who should and should not do these procedures, have restricted the number of sites performing the work, and have found a non-punitive way to self modulate risk based referrals. Undoubtedly, this is based on the lack of financial incentives to perform procedures. A hospital is then paid by the local government to perform X procedures based on need. In reviewing the Swedish performance data on rectal cancer, it becomes remarkable that there is essentially no volume outcome relationship-all hospitals simply "do it well enough." Below is a sample of these data from the high and low volume hospital groups. What is remarkable is that there is no higher risk outlier in the high volume group and only 1 outlier with a higher risk of adjusted 5 year mortality in the low volume group (which I think may be a statistical artifact based on power, a Type 1 error).

High Volume Hospitals risk adjusted mortality for rectal cancer

Low volume hospital's risk adjusted rectal cancer mortality rates-notice only one hospital with higher than expected mortality

When this is compared to what we have observed in SCOAP, this is a remarkable finding. While there will always be hospitals that look like they are doing better because of process or structure, it is remarkable that there is no significant outlier status with a completely self- regulating system. This is a real tribute to the social system of care delivery and a real answer to my question about how a system might work to control variability.

How the system controls the introduction of new technology is equally impressive. Doctors and hospitals decide on new technology, and any significant expansion requires that the hospitals convince politicians about its benefit. I spent an afternoon speaking with a nurse endoscopist who runs a GI clinic that is responsible for screening a large cohort of patients in Stockholm for colorectal cancer. CT colonography was considered and rejected based on local GI and surgeon experts who observed its added cost, decreased sensitivity, and variable interpretation based on radiology skillsets. Because the technology just "didn't make sense," it was not introduced. No one was making money off its introduction, and there was little pressure to introduce it. A focused system of screening was proposed that would call all 60 year old Stockholm residents in 2 year groups for fecal occult blood testing (FOBT). Any patients with FOBT now go to full colonoscopy which is increasingly performed by nurse endoscopists. Again, this is an example of a system recognizing a screening need, getting the correct care to the correct patient done by the correct level clinician at the correct cost and at the correct time in the patient's life. The cost of drugs is arguably the more important driver of healthcare costs. The Swedish government has a limited formulary; all drugs are available only after a price negotiation with the company that brings them in on bottom dollar costs. Drug companies just know that the Swedish system will not take them on unless they are acceptably priced, and so there is very limited price gouging. There is also more limited availability of the most investigative drugs but this does not appear to have limited cancer-free survival on any metric.

The Swedish system spends about 8% of its GDP on healthcare (compared to 14-16% in US) and achieves some of the best scores on nearly every measure of healthcare. This is largely driven by a culture that accepts an individual's smaller role in a system that is being increasingly designed to work well, efficiently and cost-effectively. The systems biggest threats include the restraints that come with higher taxation on GDP growth (usually 1-3% compared to 3-4% among non-socialized systems), but in light of the ups and downs of the free-market economy, consistent 1-3% growth may not be so bad. Taxation of most people is about 60% of total income (with a VAT of 25% for purchases). The top rate in the US is 37%, but a comparison to the US is challenging, because the Swedish tax pays for college and graduate school for all as well as healthcare and childcare. There are also no copayments or premiums for healthcare, no real out of pocket healthcare expenses, no bankruptcy due to healthcare costs, no inflated state taxes to deal with the uninsured and ER expenses of folks receiving sub-optimal care. It is true that this taxation and reduced salaries leaves little for discretionary income, has resulted in a differential from top 10% to bottom 10% of only double compared to greater than 10-fold in the US, and means that over time there is less growth and higher interest rates. There is also growing pressure from immigration and the culture changes that occur with less homogenization and less of a common socialized indoctrination from an early age (all Swedes have free pedagogical child care where socialization occurs at the start). This indoctrination reinforces the social norm that all people will work if they can, that if they are injured or sick they will be cared for, that if you can't work you'll be cared for, and when you retire everyone will have enough to live a good quality of life. It does require that all who can work do so and that no one takes more than they need. The system is built around a belief that all should have enough, not some having all and some having none. The biggest threat to the overall Swedish system (including its healthcare system) is that it works best when no more than 10% are on the social support system. It is currently at 20%, and that diminishes growth and threatens sustainability.

V. Spain

In Madrid, I met Jose Tellado, a hepatobiliary surgeon affiliated with the largest of the hospitals linked to the University of Madrid. He and I spent a morning talking about all aspects of the Spanish healthcare system, including how the system is organized, the effect of this organization on measuring quality and mitigating variability, and the way new technology is introduced into the system. He spoke of his thoughts on the future of the system and its challenges and opportunities. Spain emerged from the highly centralized Franco administration with a constitution that expanded the role of regional governments and shrunk the ability of central control to exert influence. The results in healthcare have been almost total regional autonomy for healthcare delivery and oversight with very few national guidelines or metrics beyond the responsibility of all regions to provide a common level of universal healthcare to all Spanish citizens. The system is socialized as well with taxation that occurs on a national level (with an exception in the Catalonia and Basque regions where there is regional taxation), and the money is allocated to regions based on population density. The tax level for the highest earners is 42%. As in Sweden, college and healthcare are free to citizens. On a regional level, healthcare dollars are allocated by the government to hospitals based on yearly budgets leaving cost control within a year at the discretion of the hospital leaders. This limits the salaries of physicians, prevents the expansion of services, and limits the use of new and expensive treatments. Hospital leaders have the greatest potential to exert influence on quality but in fact do little to monitor quality for most programs. Instead, they deal with the more politically attractive endpoints of having high profile programs (e.g., liver transplants) that bring in more money and meet wait list demand. These are politician-based priorities and result in a very short timeline to elective operation (<3 weeks) that must be maintained even if it means sending the patient to another hospital. Expensive program expansions must be justified by clinical committees that demonstrate to hospital leaders and then politicians that there is an important population of interest, that the costs are reasonable and that there is no need to change infrastructure significantly. The general sense is that they are doing "enough" when it comes to new technology but don't have extensive redundancy in the system with equipment or technology (e.g., there are only 1-2 MRIs and 1-2 pieces of expensive in-OR equipment across a region).

The only procedures that are systematically tracked for quality are transplant (based on an EU tracking system) and a research-based volunteer program for colorectal cancer tracking has been developed. There is a re-accreditation system for transplant that in part uses data such as these in considerations of certification but in truth the system is not data driven and has never "shut down" a program. There is a sense that the Madrid region is working toward more effective healthcare but for now the system appears fragmented (e.g., there are 4 major medical centers providing all levels of services for all patients), poorly coordinated (i.e., to meet the demand of a 3 week wait period they pay employees overtime but the OR work hours for "regular cases" stop at 3PM), and simply not tracked. The system does provide universal healthcare to all citizens, and there are only 2 classes of patient, citizen and resident. Only undocumented aliens are a third group that may not be covered, but even then the ER system would likely treat them. The system is being helped by relative under-employment and immigration is providing an important tax base for the support of the social welfare system. There is a growing interest in private insurance for the upper class (estimated at less than 15% market penetration) mainly oriented to getting more personalized care (e.g., private rooms, better choices of physician, etc.), and a branch of MD Anderson recently opened to work in this space. This does not appear to be a dominant theme however. There is optimism that the system can move from "care delivery to all" to "high quality care delivery to all." There appears to be several challenges to this. Spanish healthcare is really comprised of several large sub-systems, and mitigating variability requires either a small community of clinicians or a centralized system strong enough to exert control. Neither scenario exists. Regional control requires that systems "give up" high profile but expensive and risky program, and this may be untenable given the political interest in delivering high profile care. My family and I spent the next few days touring around Southern Spain and then returned to Seattle. I operated for a week, saw patients in follow-up, and then left for Asia for the last part of my travels.

VI. Singapore

I traveled to Singapore as a speaker for a conference organized by JAMA in coordination with the National University of Singapore. The conference was exploring the emergence of diabetes in Asia and discussing novel treatment approaches for this growing global health crisis. I spoke about the role and mechanism of gastrointestinal surgery (gastric bypass, foregut bypass and central small bowel resection) in diabetes. The mechanistic issues are critical in the development of pharmacologic interventions that may hold promise in shifting the treatment paradigm of diabetes. I met with surgeons from the NUS (Dr. Jimmy So Bok Yan) and private sector (Dr. Anton Cheng Kui Sing) who are involved in bariatric surgery, and they helped me understand the status of surgery in Singapore and the issues, challenges, and unique aspects of their system that impact surgical care delivery. I had the opportunity to meet with the Minister of Health (Khaw Boon Wan) who is not a physician but an engineer, with a very technology friendly view of the next 5 years of their healthcare system. I also met with the director of the Health Technology Assessment program (Dr. Mabel Yap), a group modeled on NICE in England, and a specialist in surgical technology assessment (Dr. Derrick Heng). The conference lasted 2.5 days and was a great exchange of ideas and insights. Over a series of workshops, lunches and dinners these are the impressions with which I was left. Singapore is one of the few developed nations in Asia whose healthcare system is both universal and full service. They are a young country (celebrating its 42nd national day in September) and have considerable financial resources because of the country's dominant role in shipping and international trade. These financial resources have allowed the creation of technologically advanced healthcare system with both private and public hospitals that are fully staffed with generalists and specialists, have a full range of diagnostic and therapeutic technology, complete EMRs in most hospitals and a 5 year working plan for a country-wide EMR that will move seamlessly with the patient from outpatient to inpatient environments. The system is completely market based-everyone in the country has a personal health account that they finance with their own money. The system has 3 levels of care, A, B and C, which have differential co-payments and features. Level C hospital provisions have 4 beds in a hospital room, the hospital and doctor cannot be chosen and there is little to no co-payment. Level B offers more choice, hospital but not doctor choice, and 2 beds instead of 4. Level A costs the most, but allows the selection of hospital and doctor. All care is provided at all levels of service, but elective care includes hefty co-payments and in that way is discouraged. Technology is only introduced at the public hospitals after approval by the HTA, and then it must be offered to everyone. Those with resources can get non-approved technology and drugs but must finance all of the costs. Perhaps the most effective way that healthcare costs are contained is through the use of family healthcare accounts. Funds in the accounts are transferable within families, so decisions about the use of expensive care become a family decision. For example, an older parent may chose to decline expensive, non-life prolonging treatments so that resources are conserved for other family members. Family members pool resources for the greatest benefit of the family. There is little sense of entitlement and a real sense of community. When it comes to monitoring quality and mitigating variability, the Singapore healthcare system is really no better than most: there is no national audit, no surveillance of morbidity, and no restriction on practice. They expect market forces to even out variability but have little proof that it works this way.

Anecdotally, when I spoke with conference organizers and hotel workers, each knew where they would go if I wanted the best surgical care, which surgeon did what procedures and what they would be trading if they wanted to save some money on co-payments. Everyone I spoke with was optimistic about their planned countrywide EMR as a way to track and improve surgical care, but this is all in the future and is not a reflection of the present. There is some concern that since private care is incentivized the system will drain those with more talent and skill away from the public system, but surgeon salary differentials are modest and more care delivery is not as incentivized as one might think. The net effect is that for now the country spends only 4% of its GDP in health and almost all metrics of health system performance indicate that they perform better than many countries spending in excess of 12% of GDP. The Singapore experiment is relatively new -- it is a small country (3 hours across by car and just one million people) with lots of financial resources, minimal unemployment or extreme poverty, a cultural expectation of community-minded care, and little entitlement. These features make Singapore novel in some ways but there is a take home message for more developed countries grappling with over-use and appropriate use of care. Having patients pay for their healthcare instead of a third party payer forces tough but real choices about what care is needed, necessary or wasteful. This market-based system also demands accountability on the part of surgeons and hospitals that should help restrain the out of control growth and over-use of healthcare in other systems.

VII. Malaysia

I next flew to Kuala Lumpur, Malaysia, and was hosted by Dr. Cheng Har Yip, Professor of Surgery at the University Hospital Malaysia. I spent the next 3 days getting a great overview of the Malaysian surgical community, its infrastructure and issues and challenges it faces. I had dinner the night I arrived with Dr. Yip, representing the academic, public health system, Dr. Noor Hisham Abdullah, representing the Ministry of Health (MoH) hospitals, and Dr. Lum Siew Kheong, President of the Malaysian Surgical Society and a member of the private practice/private hospital community. These 3 sectors cover this much larger (than Singapore) country of 25 million with the bulk of care taking place in MoH hospitals. The MoH hospitals include a spectrum of high-tech/modern/semi-private and much older, ward style, crowded centers that have over a thousand beds and surgeons barely hanging on to deliver care. I had the chance to visit both types of MoH hospitals. The crown jewel of the MoH system is Putrajaya. It services the government workers and demands significant co-payments for top level services, such as double and single rooms. This is the hospital that a highest level government worker might go to and has short wait-lists and specialist surgeons. The opposite extreme is the famous Klang hospital. With wards containing over 70 patients, separated into 8-16 bed clusters, no privacy, and minimal nurse support, they service thousands of poor patients (mostly Indian Malaysians) with 7 general surgeons and few specialists. Klang delivers almost universally free care. No copayments are required because almost all are low income patients, and the MoH hospitals are free. Interestingly, while the modern, clean hospital has an EMR, they do not use it for surveillance of quality while at the older more chaotic Klang hospital a strong surgeon leader demands excellent audit and feedback to these surgeons on details such as frequency of mortality and serious complications. The MoH does not have a rigorous system for surveillance yet but is working towards one. Thirty minutes up the road in a very rural section of Malaysia where palm oil plantations mark the road, I visited a district hospital in Bangting. Here there are about 10 large open wards with few doctors, nurses and medical interns deliver care for needs ranging from treatment for Dengue fever to post trauma rehab, and they screen and send patients with higher care needs to Klang. This is a tiered approach to care -- unable to staff anesthesia and surgical services, they make sure everyone has access to a care system and then the system redirects patients to the care level they need.

I spent the morning at University of Malaysia hospital meeting with surgical trainees and junior faculty, touring the hospital, and attending their mortality review conference. Here patients pay co-payments based on their ability. Families are expected to come up with resources or their families come together to pay for care. The hospital will do means testing before it pays for care but ultimately does pay for care and then tries to get payments post-discharge. Since families are large, and it is culturally unacceptable to not pay for care, families ultimately finance care. Decisions about care are driven by resources; however, some treatment options (e.g., biologics) are simply not an option for families that do not have resources. Since 2001, surgeons have been able to run private practices after hours, so from 5PM on every night the OR is working, clinics are open and patients are paying for private type care. This private care option means shorter wait-list time, picking their surgeons, and having more privacy when hospitalized. The 7 public health academic hospitals train all the surgeons in the country and are being threatened by a flight of surgeons to the private care system (hundreds of hospitals where the reimbursement for clinicians is considerably better).

The mortality conference was the principal forum for tracking on surgical quality issues. As a classic M&M, there was some link to the risk management system in that it alerted them when a potentially exposing case was generated. There is no system level way for performance monitoring in this system either. In spending a day with Dr. Yip, I found that this senior level surgeon was a single guardian of the healthcare quality of her entire breast cancer service. With dedicated surgeons like Dr. Yip, the system needs not worry about the care it is delivering, but should rather focus on how to clone her and build a system to protect these patients when she goes on vacation or retires.

The last sector for healthcare delivery is the private hospital system, which is a large group of hospitals that are mostly unmonitored in terms of audit. All patients pay for their care and transfer out to the public hospitals when they can longer afford care. Surgeons in this sector have a complete market-based approach, in that a laparoscopic cholecystectomy will cost the patient and their family $2,000, or less for an open procedure. Chemotherapy A might cost $10,000, while chemotherapy B costs $7,000, with the cost determining which chemotherapy the patient chooses. In other words, decisions about what patients want are driven by their means. A surgeon who can deliver better care may choose to raise his or her fees, and a set of bad outcomes and a perception that care delivery is problematic will result in a surgeon not being renewed at a hospital. Practitioners in this market system believe it works without much information about whether it does or not.

These three systems within Malaysia are trying their best to deliver care in a very challenging environment. Unlike Singapore, Malaysia is a developing country with considerable poverty, very low reimbursement for surgeons, limited state financed resources for healthcare and a set of cultural norms that may not be as community oriented. For example, the three main ethnic groups, Malay (approximately 60% of the population), Chinese (approximately 30%) and Indian (approximately 10%) do not divide labor, jobs, or healthcare resources equally but rather fall along ethnic/cultural lines. This makes healthcare decisions and choices a multi-ethnic, multi-cultural challenge. There is energized leadership working to help Malaysian healthcare overcome its challenges, and it will be an exciting system to watch.

VIII. Conclusion

I view this James IV fellowship as an amazing gift. First, I was given the opportunity for extended time with my children and wife in beautiful and remarkable places. We will always remember this time together and cherish the memories of our travel. I am deeply indebted to the colleagues who showed their generosity and helped plan and complete my travels, specifically Carlos Pellegrini, Patch Dellinger, Ara Darzi, Marja Boermeester, PO Nystrom, Juan Permert, and Cheng Har Yip. From a professional perspective, this was the start of an international network of colleagues who share my interests and who are grappling with the same issues in surgical care improvement but working in very different systems. In making the observations on this report I have tried not to over-simplify these complex systems with their nuanced and subtle features, and I acknowledge that the perspectives I encountered were unique and are not necessarily representative of the whole. Nevertheless, I got a glimpse into these systems, and it has inspired me, challenged my notions, and given me many questions that I will spend the next years trying to address.

The US healthcare system is going through a major evolution, and bringing international experiences for consideration will be an important way to invent the future of our system at home. I am encouraged by the hard work, creativity, dedication, and generosity of my international colleagues and extend an invitation to our home as they travel in the US. I am most grateful to the James IV Association of Surgeons who saw fit to extend to me this precious opportunity. I tried to do my best to honor the spirit of the award by exchanging through both social and professional avenues with colleagues across the world. I am sure this experience will have a lasting impact on my career as a surgeon and am proud to have carried the title of James IV traveler.