Journal Watch

“Hospitals with low and high perioperative death rates have surprisingly similar rates of perioperative complications, which suggests that “failure to rescue” is the primary determinant of in-hospital mortality.”

…”Rates for all complications and for major complications did not vary significantly among hospitals; however, death rates among patients with major complications were almost twice as high in hospitals with the highest overall mortality than in hospitals with the lowest overall mortality (21.4% vs. 12.5%).” (Emphasis added)

…”Researchers evaluated data from the American College of Surgeons National Surgical Quality Improvement Program on 84,730 patients who had undergone general or vascular surgical procedures at more than 150 hospitals.”

This study was published in the October 1 issue of the New England Journal of Medicine.

Neil H. Winawer, M.D., F.H.M, founding  editor and editor-in-chief of  Journal Watch Hospital Medicine, comments on what the study shows.

“As the authors note, ability to rescue a patient from a postoperative complication relies on timely recognition and effective management of that complication. Although quality nursing care, high nurse-to-patient ratios, and the presence of intensivists* are factors that can contribute to better outcomes at very low–mortality hospitals, an unmeasured but valuable contributor also could be hospitalist comanagement of surgical patients. As an active presence at the bedside, hospitalists* are uniquely positioned to recognize complications and intervene promptly. Although avoiding postoperative complications is crucial in lowering perioperative mortality, this study shows that the care patients receive when complications occur is just as important.” (Emphasis added)

(* Ed. Note: Intensivists are doctors who work only in intensive care units, which can be general or specialty ICUs. Hospitalists are specialists who act as the patient’s own doctor while the patient is in the hospital. What is the difference? ICU doctors care only for patients in critical condition or in a critical period of recovery. The hospitalists are generalists, in that they care for all hospital patients on the unit or areas for which they are responsible. It is the newest, fastest growing medical specialty.)

— Neil H. Winawer, MD, FHM

The Patient Report

There has been a crusade in surgery in the last decade to prevent complications before they can happen.

Working up a patient carefully to identify risk factors for complications is key.

When the patient’s condition permits, giving patients time to reduce those risk factors is beneficial, and often achieves results.

Providing pre-operative care, known to reduce the risk of complications, has been a near obsession in many hospitals, as it should be. An example would be giving a patient a specific medication 24 hours beforehand.

When prevention doesn’t prevent those complications, then what can be done?

Team care, focused on quickly identifying signs of  complications and responding to them, is the best way to save patients who can be saved, as the expert comment above notes.

How can you choose a hospital which does respond quickly to post-surgical complications? After all, these subtleties have escaped competent surgeons for, it appears, a long time.

A problem unidentified is a problem which no one can solve. That appears to be the situation here.

While surgeons and hospitals read this study and review their own care systems…

What Can You Do?

Hospital Compare

Medicare has developed a helpful website tool, Hospital Compare.

It enables you to see how one or more hospitals your surgeon recommends compares with all other hospitals nationally with specific measures.

One measure to watch here is the one which tells you what percentage of the time the hospital’s care pre-and post-operatively in the first 24 hours met the standard set. This is a “right-care-right-time” measurement.

This statistic or measure combines prevention of and response to complications. This data point does not getting straight at the point of the survey—after-surgery complications management—-but it is useful.

The other measure you want to see: Comparisons of mortality rates 30 days after discharge. How does the mortality data of the hospitals recommended to you compare to the national standard? You can also see how one hospital’s mortality data compares to another in the area where you live.

When Hospital Compare was launched, I had misgivings.  I was not alone.  There was significant protest from medical societies and hospitals, who objected to the way the data was collected. There was self-interest, of course, but the objections were based on more than that. Nothing like this is as good as it will be later. It’s data. The more you have and the longer you collect it, the more valuable it is.

Initially, the number of reporting hospitals and the data sets seemed too thin. At the start, I compared hospitals I know a lot about in the Washington, D.C., region. I was not comfortable with what I saw. There were some hospitals which appeared to me to be ranking higher than I knew they should although I saw none rated lower than they should be. The problem, though, was a great hospital and a so-so hospital could look equivalent back then.

When running  the same kind of check today on Washington, D.C. area hospitals, the stats show pretty much what I expected to see.

These data also confirm what can only be called the grapevine—what doctors say about hospitals and what patients or family members say about the hospital care. (Hospital Compare offers a patient experience measure, too. Grapevine check.)

Hospitals of any size have many hundreds or many thousands of patients and family members in and out of them every day in one year. No single person’s view, including mine, may be right but if you keep your ears open, trends start to emerge. To be clear, I also know a couple of hospitals whose patients think they are great and they are, objectively, not. That is why checking more than one way is smart. Reputation in the community is an important standard but so is the data.

When the trends in the comments about hospitals I hear about match the Hospital Care data, then that is confirmation two ways.

Naturally, most of you do not go around asking people about their hospital experiences, but as you go about your days, you hear things. Just listen. Those informal reports may be useful some time when you least expect it.

No data system like this is going to be perfect. Hospitals will, rightly, have some objections to the process from time to time. Still, Hospital Compare now looks sturdy enough to this reviewer to recommend your giving it a try.

I am only one person, like you, checking about hospitals where I live.

That is its point.

That is the true test of its usefulness. Does it work for you? I would be willing to choose a Washington, D.C., area hospital based on the data even if I were a stranger now.

Hospital Compare is  one tool— among many—you should use when you have time to choose a hospital.

Physicians’ opinions still are extremely important. Most doctors are candid about what hospital is better and why.

So is the community’s opinion. Once when I had a minimally-invasive surgical procedure, my husband went into the copy shop to take care of some work while I woke up. He and the man in the copy shop fell into conversation. My husband explained why he was far away from his workplace. “Oh, him! Boy, when Dr. ___ tells people they will be well, they get well.”

At the very least, Hospital Compare certainly is more useful than having no data at all. You must remember these charts are based on Medicare patients only, the idea being that they are among the sickest patients. If a hospital does well with the elderly, it is reasonable to infer it will do as well for others.

However, Hospital Compare has come a long way and can help you make a life-saving decision.

Source: Journal Watch, September 30, 2009

Citation: Engl J Med 2009 Oct 1; 361:1368.