Archive for category Variations in Care
Emergency general surgery (EGS) is common in the United States. 11% of surgical admissions require emergency surgery. The statistics on EGS seem to create more questions than they answer:
- The 11% of surgerys classified as EGS are associated with 50% of all surgical deaths.
- Poor people who have EGS have a greater risk of death than average
- Rich people who have EGS have a lower risk of death than average
- Seven surgeries (removing part of the colon, removing part of the small-bowel, removing the gallbladder, operations related to peptic ulcer disease, removing abdominal adhesions, appendectomy and other operations to open the abdomen) accounted for 80% of the deaths and hospital costs related to EGS.
- The cost of ECS in the U.S. is about 7 billion dollars per year.
- EGS patients admitted by a surgeon have lower hospital costs than those admitted by a hospitalist.
- Specific quality guidelines for ECS do not exist.
One might be tempted to say the diagnosis is so complicated nothing could improve the situation for patients. However, this would be like the situation for pilots and passengers 30 years ago when major airliner accidents happened at least once a year. The quality movement swept over the airline industry which is now is rated as one of the safest of complex human endeavors. Those same measures need to be applied to EGS.
When an airplane has an emergency the crew pulls together and acts as a team. They follow a procedure practiced many times. They have simulators and tests. If an engine fails, if there is a fire, if a landing gear fails there’s a procedure to follow. Each pilot does not invent a procedure just because they are the pilot that day. Likewise, every surgeon should not invent a procedure just because they are the surgeon that day.
It would be easy to blame surgeons or the patients themselves for such dismal outcomes. But, as people in the quality improvement department say:
IT’S NOT THE PEOPLE, IT’S THE PROCESS.
The first step is to acknowledge EGS is a process. When a patient arrives in the emergency room with abdominal pain, low blood pressure, free air in the abdomen and a high white blood count there should be no barriers to evaluation an treatment.
- The goal is to have the patient in the operating room within 90 minutes from crossing the ER threshold (T).
- Blood tests and CT scan of the abdomen are done by T+ 20 minutes.
- Surgeon is in the ER to evaluate the patient by T + 30 minutes
- A decision for operation is made by T + 45 minutes.
- Pre-op antibiotics, fluids, and pressors are started as needed.
- Anesthesiologist begins care of the patient in the ER by T + 60 minutes.
- Central line is inserted, operating room is notified, ICU is notified, critical care team is notified by T+75 minutes.
- Patient is transported to the operating room. The opening incision is made by T + 90 minutes.
Such a process is obviously difficult. First, the ambulance crew can not transport a patient with an abdominal emergency to a facility unable to deal with the problem, like a small rural hospital or an urban community ER. This will require training of the ambulance crews and communication with a high level ER.
General surgeons and back-up general surgeons must be available within 30 minutes. It’s a difficult life to be immediately available — the hospital is responsible to either pay surgeons to be on-call or to hire surgeons to stay in the facility. Hospitalists are not an appropriate substitute to deal with an acute abdomen or even severe abdominal pain of uncertain cause. A helicopter ride to a higher level facility is the best solution for patients with severe abdominal pain entering a facility not capable of following the above protocol. The crazy practice of having a night-time hospitalist admit a critical surgical patient for a surgeon to see “in the morning” must come to an end.
Since the mortality rate of EGS patients is quite high the intensive care unit is the place they should go after surgery even if they seem stable in the operating room. Complications are very common so early recognition and treatment is essential. Returning to the operating room later may be needed and should not delayed. Critical care consultation should be strongly considered. Multidisciplinary rounding with critical care specialists, nurses, pharmacists, dietitians, and social workers is strongly advised. Rushing to get the patient out of the hospital to a secondary level of care is a mistake since re-admission is fairly common. The patient needs to be as stable as possible before discharge. Hospitalization for 1 – 2 weeks is not uncommon.
The difference in outcome of EGS between rich and poor is not uncommon for many things in medicine and surgery. Several factors are at play but probably the biggest is fear of big medical bills — if you can’t pay one would wait till the last moment. Second, medical literacy — always a bigger problem for lower socioeconomic groups — if you think Tums or Rolaids will fix anything you might wait too long to go for help. Finally, a negative bias toward Medicaid or “cash” patients — sometimes the finances determine whether a hospital will keep or transfer patients. At midnight many cases seem to be too “hard” and must be sent to a referral hospital which wastes valuable time.
Since prospective research is difficult and time consuming (taking years or decades) a local and national registry should be utilized. The diagnosis, the surgical approach and the outcome must be tracked to find the best combinations for the best outcome. As best practices are identified surgeons and hospitals must quickly change protocols and surgical techniques. U.S. healthcare can not stand the usual 15 years needed to implement new practices.
- Washington Post
- JAMA Surgery
- J Trauma Acute Care Surg.
- The Joint Commission
- J Trauma Acute Care Surgery
- J Trauma Acute Care Surgery
- J Am Coll Surgery
If any nurse out there has a standard order-set for EGS please share it.
Hospitals are responsible to rescue patients from inappropriate treatment — especially when the need to intervene is obvious. The hospital has a board of directors responsible for the care delivered in a hospital. They hire the CEO who hires a quality manager. When bad quality management hurts or kills patients it is the hospital’s fault.
An article by Dr. Behnood Bikdeli and colleagues (JCHF. 2015;3(2):127-133) describes a huge study at 346 hospitals about treatment of patients with congestive heart failure (CHF). Here is the essence:
- CHF is life-threatening condition where the body collects too much fluid, usually due to a weak heart. The fluid gets into the lungs and causes shortness of breath.
- The treatment for CHF is to remove fluid from the body and give medications to improve heart and kidney function.
- The absolutely wrong thing to do is to give extra fluid by the veins.
- The study found about 12% of patients with CHF were treated with 1 to 2 liters of fluid in the veins during the first 2 days of hospitalization. AND, most alarming, compared to similar patients not treated this way, they were more likely to end up in intensive care or die.
- The most telling statistic is how often various hospitals let this dangerous use of intravenous fluid happen: 0% to 71%. This means some hospitals did not let it happen (0%). Some hospitals let it happen a lot (71%) — just hope your grandmother did not go to that hospital!
It is not rocket science to say fluid overload is not treated with extra fluid. This is easy to detect when the admitting diagnosis is CHF and the doctor orders say “NS IV at TKO” (translation: give salt water in the veins at a rate to make sure the veins stay open). NO NO NO the patient does not need extra fluid. This should not happen and there are lots of ways to prevent it or even rescue patients when Dr Welby writes such an order (or tries to use leaches).
- Mandate doctors use standard orders for treatment of CHF — there is plenty of latitude to customize such orders. But, IV fluid is not one of the choices without stating why.
- Educate staff that IV fluid is not required to admit a patient (an old fashioned insurance rule).
- Educate staff that IV fluid is not a cure-all. Fluid would help a dehydrated patient but not others.
- Nurses do a double check before admitting a patient from the ER with the question: does this patient have CHF and an order for IV fluids — if so, call the physician to clarify the situation or to change the order — no clarity=no admit.
- All CHF patients should be weighed daily — if the weight is going up it means more fluid is being retained — the patient needs to be rescued. Fix the problem or find someone who can, NOW.
Attention patient and family. This is easy to spot. The admitting doctor says the diagnosis is congestive heart failure but you see IV fluids being pumped into yourself or your family member. SPEAK UP! “Why is fluid treatment needed?” do not accept the answer of “everybody gets an IV”.
Attention hospital board members: do you know what your hospital is doing to prevent this obvious problem? Quality is your responsibility, you must do something besides listen to financial statements. Is your hospital the one with 0% or 71% record of treating CHF with IV fluids?
Ambulatory Surgery Centers (ASC) are adept at hiding problems. Just try to find death rates, numbers of transfers to hospitals, organ punctures, and surgical procedures required to correct errors. Nope — you won’t find those crucial bits of data for public view. Here is a link to statistics collected for “internal” review: Quality Reporting Program.
As with most health care entities the public expression of “quality” is “certification” — which means an outside reviewer thinks the organization has the right programs and procedures so nothing stands in the way of quality care. Likewise, nothing usually stands in the way of a student getting an A+ on a test — but A+ is not always the grade. As Confucius says: “there are always greater and lesser”.
So, as a patient, what should you look for; what questions should you ask?
- Is the ASC certified? If not, find another ASC.
- How many patients does the surgeon treat at the ASC — expect at least 10 per week.
- How often does the surgeon do the procedure you need at the ASC — expect at least 10 per month.
- Will you be sedated? — if so, make sure an anesthesiologist or nurse anesthetist will be monitoring you while sedated — if not — find a different ASC.
- How close is a hospital if you have one of those serious complications listed in the consent-for-surgery form? If an ambulance would take more than 10 minutes to get you to the hospital consider another ASC.
- If you have severe heart or lung problems (like a history of congestive heart failure or COPD) consider having your procedure at a hospital rather than at an ASC.
- Ask if a pre-op check list, like the one the World Health Organization recommends, is used for all surgeries — if not, quality is a questionable. If the surgeons says they don’t need a check list find a different surgeon. Keep this in perspective — every airplane pilot must follow a pre-flight checklist, is your surgery any less important?
- The person that comes with you needs to write down what the surgeons says after the procedure. Patients who have been sedated, even if they seem fully awake, will have impaired memory for many hours. Have the person with you write down what was found at surgery — what is the diagnosis and what are the specific instructions.
- Absolutely avoid late afternoon surgery — because you will be shipped to the hospital for minor complications — the ASC will close and they don’t have staff to provide care after closing.
Highly educated and experienced cardiologists just can’t get it right: the correct dose of aspirin after a heart attack is 81 mg (called low-dose), NOT 325 mg (called high-dose). The current prescribing error rate is 60.9% as published by the American Heart Association in 2014.
Personal communication with several cardiologists elicits the comment: the higher dose is needed because of the risk of another heart attack — and “in my experience” it just works better. It’s hard to believe this clinical error in this age of quality assurance. The problem is BLEEDING not heart attacks! The stomach BLEEDS due to aspirin and the higher the dose the higher the risk of BLEEDING.
Just imagine the risk and strain for a recent heart attack victim who vomits blood, needs a transfusion and must undergo a stomach scope — some patients die. From a cardiology standpoint: “they died from something unrelated to the heart attack” — great thinking.
Cardiologists completely and totally get it wrong when they simultaneously prescribe high dose aspirin and the anticoagulant warfarin — the ghastly mistake happens 40% of the time.
The chemical reaction of “acetylation” is caused by aspirin within small blood cells called platelets. Acetylation of platelets is responsible for the favorable heart effects of aspirin. It has been known for at least 30 years that 81 mg of aspirin completely acetylates every platelet a person has — more aspirin does no more. According to the 2012 TRITON-TIMI trial:
“We observed no difference between patients taking a high dose versus a low of aspirin as it relates to cardiovascular death, heart attack, stroke or stent thrombosis,” according to Payal Kohli, MD involved in the study and quoted in Science Daily.
Hospital quality improvement programs need the “guts” to just say NO. 325 mg is not correct. Cardiologists are the sweetheart doctors making millions of dollars for hospitals — it should not matter, JUST SAY NO.
It’s almost impossible for even the most proactive patient to question the great doctor that just saved their life. So, hospital quality assurance has an even greater responsibility than usual. The prescribing error needs to be corrected — hospital pharmacists and quality improvement departments need to be strongly involved — this error has gone on far too long.
Deaths from surgery increase from a low on Monday to a high on the weekend according to a BMJ study just released May 28, 2013. The researchers evaluated about 750,000 scheduled surgeries and suggest the likely explanation is poor quality care on Friday and weekends.
Friday surgery has a 44% increase in the odds of death within 30 days compared to Monday. Weekend surgery is worse with an 82% increase in risk.
The 3-in-1 hospital. All hospitals are divided into three hospitals because of nurse shift assignments, weekends, holidays and vacations. And, the tendency for senior staff to gravitate to the weekday shifts. The hospitals are:
- The day hospital
- Then night hospital
- The weekend and holiday hospital
The day hospital has a full staff with the most senior doctors and nurses available and the operating room working at optimal capacity.
The night hospital has a limited staff of doctors and nurses and limited operating room staff.
The weekend and holiday hospital — this problematic hospital is when the staff levels are low, the operating room is on a standby, the least senior nurses are working and the weekday doctors are replaced by on-call doctors usually doing double duty (often overworked, not familiar with the patients and sleepy from long night hours). Furthermore, on-call surgeons may try to delay treatment of surgical complications until weekday surgeons are available.
The real surprise in this study is that the death rate rises as the week progresses. The cause is not clear but some possibilities include fatigue, surgeons being less available to resolve hospital problems when at an outpatient clinic, afternoon golf, and possibly scheduling patients just discovered to have surgical problems that week in the ER (delay in care).
Another negative factor is the global surgical payment (surgeons receive one payment for a surgery including all pre- and post- surgical care). So, unless there is a very equitable system within a group the surgeons who round on weekends are not paid and have little incentive to do more than “howdy” rounds.
How to correct the problem:
- Hospital actions: spread the surgical service activity over more shifts and weekends. At least one third of nursing staff on any shift should have more than 5 years experience. Pay surgical hospitalists to attend to surgical patients when the primary surgeon is not in the hospital and to service the emergency room at any time.
- Surgeon actions: Provide the hospital with a surgical hospitalist who is at the hospital 24/7. Allow the surgical hospitalist to do surgery on patients admitted from the ER. Reduce the Friday and weekend workload with more physician staff on those days. Provide monetary compensation for covering doctors (not just payment in kind).
- Patient actions: Ask about whether there is an experienced surgical hospitalist available in the hospital at all times (not just a resident or medical hospitalist). If not, refuse elective surgery on Friday or on weekends.
How do the Brits do it? They made a healthcare system with twice the quality at half the price compared to the US (according to the Commonwealth Fund cost per person per year US $7960 UK $3487, developed country quality rank UK #2 US #7). Simply, they do it by having original ideas and a willingness to adopt good ideas from other countries.
The National Health Service (NHS) of the UK was born in the aftermath of WWII. Taxes pay for the system, which is free to citizens at the point of care. Internally, the system is based on capitation — doctors and hospitals are paid by the size of the population they serve. The system grew to be one of the highest quality and least expensive systems in the world. In the 90’s it was bogged down by waiting lines and old facilities until a modernization push got it back on track around 2000.
The DRG example: In 1983 Medicare adopted a way to pay hospitals with a single payment for each case based on the diagnosis of the patient. This revolutionary idea was called the diagnosis related group or DRG. NHS experts embraced the Medicare cost saving idea and renamed it the HRG (health resource group) and started using it in about 2003. Consequently, by adopting what works, the UK has strikingly transformed the financial workings of the NHS.
The NHS noticed cost variations between providers and solved the problem with “Best Practice Tariffs”. That means if the provider follows a well established guideline they get a full payment, if not, the payment is lower. In the US we call that concept “value based purchasing” (VBP) but the US only has a few pilot projects and only dreams about making VBP happen on a large scale.
The UK decided they wanted better results. The reform was called Payment by Results (PbR) and implemented in 2013. The results they expected were high quality, adequate volume of services, and cost efficiency. The NHS basically tweaked the capitation formula with incentives for the desired results.
The US Affordable Care Act (Obama Care) encourages the aggregation of doctors and hospitals in an economic model called an Accountable Care Organization (ACO). The US thinks it invented the idea behind the “Accountable Care Organization”. Actually, the concept is just a spin-off from the Primary Care Trusts and Hospital Trusts in the UK which have been functioning for over 60 years. Think: “Trust”=”ACO”.
The recent “Perspective” in the New England Journal of Medicine (NEJM 668;16 April 18, 2013, page 1465-1468) describes the recent IOM report requested by Congress. The authors lament the “Geographic Variation in Medicare Services“. The NHS is well known for controlling health care costs. Looking across the pond to the UK, here are some references that might be helpful to them:
- A simple guide to Payment by Results
- A person based formula for allocating commissioning funds to general practices in England: development of a statistical model
- Payment by Results: time for a rethink?
- Regional variation in the productivity of the English National Health Service.
Some understanding about how the NHS works would also be helpful. The following diagram is an overview of how the NHS controls cost associated with hospitals and doctors. They also have a good system for dealing with drugs and devices — a good topic for a future blog.
(figure revised 7/11/13)
Other charts of organization can be found at Nuffield Trust – New Structure of the NHS slideshow, NHS website – new structure, and History of the NHS.
In the UK 90% of health care is controlled by the government and 10% by the private sector. The UK Parliament sets a budget for health care which is administered by the Department of Health. Based on the funds allocated in the budget the Department of Health makes a national price list for services (unlike the US where there is no cap on expenditure) .
The “SUS” approves payments to providers based on the national price list (national tariff) and adds the features of PbR (payment by results). The commissioners are the paymasters and transfer funds to the providers. The providers keep track of actual costs and must provide cost data to the Department of Health (unlike the US where real costs are proprietary information and hospitals use the infamous “chargemaster“).
The US could learn a lot from other countries. The NHS in the UK seems very willing to share what they have learned over the years — and it is in English. The old saying “America and England are two countries separated by a common language” is especially true for health care.
The above graph is from the Dartmouth Atlas of Health Care and shows the Medicare expenditure per patient for medical equipment in each state. As with most Dartmouth graphs, the point is to highlight tremendous variability across the country. The rules of payment are the same across the country yet the system fails to follow the rules. Consistency means reliability, but the opposite is also true, inconsistency means unreliablilty. Medical equipment includes such things as nebulizers, wheelchairs and walkers to name a few.
Sadly, the medical equipment business is a hotbed of fraud and incompetence. There are just as many elderly people per capita in Iowa as Florida, but Florida has no grip on costs. Arizona monitors Medicare equipment spending quite well, but Texas is out to lunch.
There are so many problems it is hard to know where to start, here are a few examples:
- The rules for equipment are incomprehensible (just look at the CMS web site for proof) so States have difficulty following the rules and crooks can easily submit fraudulent claims.
- Wheelchairs are essential for quality of life for many people. But, for many elderly people who have other people push them around the much less expensive “transport chair” is sufficient.
- Compressor/nebulizer equipment for asthma and COPD is 99% boondoggle and 1% needed. Patients who have a prescription for an inhaler do not need a nebulizer — but medical suppliers pass them out anyway. Medicare should not pay for nebulized medications in the first place since the usual medications are generic. There is near-universal agreement (except for suppliers) that a meter dose inhaler (MDI) is more effective than a nebulizer. So if Medicare is bent on providing inhaled medication at least provide the cost effective MDI. Canadian doctors rarely find a need for nebulizers because the government provides MDIs.
- Walkers are a good hedge against falling. A broken hip is a lot more expensive than a walker. But, why does Medicare pay $65 for walkers that probably cost $20 to manufacture?
- The idea of letting the supplier get the prescription directly is inviting fraudulent behavior. The local supplier does not have the staff to investigate the truck-loads of rules so what do you think happens? Forms are filled out like the ones that passed the system before, the equipment is delivered (mostly) and Medicare pays.
- Set a national Medicare budget for equipment with some sort of priority if the budget is tight.
- Medicare should nationally purchase large volumes of commonly used equipment then send it to people by UPS or FedEx (like Amazon)
- Physicians should prescribe equipment by computer directly to Medicare (or a national clearing house). Medicare and insurance companies could then monitor the indications electronically before providing the equipment. Also, this would allow contract bidding for the equipment. The equipment vendor makes no decisions except how to deliver the goods.
An Interim Report from the Institute of Medicine (IOM) about geographic variations in care was just released. This is a very scholarly report with massive statistical analysis. The basic idea was to review what Medicare paid for various types of medical care, devices and drugs across the US to see if some pattern could be identified. The hope was to find some way to alter the payment scheme to improve the value of health care. Alas, they could not find a pattern, only wild variation. An individual doctor might be cost-effective for one disease and a money-waster in another, doctors within a group would range from judicious to wildly profit-motivated and the variations between hospital referral areas show the same scatter.
The holes in the target above are an example of wide variation. The archers did not hit the bulls-eye very often — there is a lot of variation. A particularly interesting graph from the report is redrawn above on the right. This is about how often gastroenterologists in an unnamed state perform a stomach scope (EGD) with the billing diagnosis of heartburn (i.e. gastroesophageal re-flux) .
The vertical axis is the number of EGD procedures per 100 diagnoses of heartburn (the procedure rate). The horizontal axis is the ordered list of 403 gastroenterologists in the state. The list is in order of the lowest to highest rate of performing EGD. The ovals placed on the s-shaped curve represent 17 different doctors all in the same group. The remainder of the 403 gastroenterologists are plotted as dots on the curve. If all the gastroenterologists approached heartburn in a consistent and reliable manner the graph would just be a horizontal line somewhere in the lower part of the graph. Instead we see some gastroenterologists performing a scope on 100% of people they see who have heartburn — to be clear, this is the picture of unnecessary procedures or “padding” the bill.
What does it mean?
Gastroenterologists are poor marksmen. No, no, no. It means they are shooting at different targets. Some aim to maximize revenue, some aim to follow evidence based (lower cost) guidelines and some aim in-between. Keep in mind that a gastroenterologist is paid about $200/hour for clinic visits and about $1000/hour when doing procedures. The doctors on the right side of the graph clearly have targeted the high paying procedures “scope first and ask questions later!”
The IOM claims no insight into the mysterious variation. It is not necessary to study this more! Look at other countries, they don’t have this problem because other countries don’t pay doctors by the number of procedures performed. Simply pay the gastorenterologist the same hourly wage for seeing patients in the clinic as doing a procedure. In the big picture, the variation can be markedly reduced by having doctors employed by an accountable care organization (ACO). The ACO sets the salary, pays the malpractice insurance and provides the office to practice — a doctor in an ACO just has to focus on doing what is right for the patient, not what is most profitable for the gastroenterologist.
What should be done?
Although the graph puts gastroenterologists in the spot light the data show the same scatter across the spectrum of doctors. US health care is sliding more and more into the swamp of poor quality and high cost. The US needs doctors to aim for the right target and to aim for reliability, which means to consistently hit the bulls-eye. Hopefully the IOM will have the strength to recommend strong action to change the whole system of payment for US doctors, hospitals, drug companies and equipment manufacturers. Instead of trying to make a perfect system we need a good system that can be adjusted as needed to achieve both high quality AND low cost care.