Are surgeons the cause of high postoperative readmission rates?

No, according to a recent paper published online in JAMA Surgery.

The authors concluded, "The majority of the variation in readmission was attributable to patient-related factors (82.8%) while surgical subspecialty accounted for 14.5% of the variability, and individual surgeon-level factors accounted for 2.8%."

The investigators looked at data for over 22,000 surgical patients treated at Johns Hopkins and found the overall rate of readmission within 30 days was 13.2%. After the exclusion of those who performed fewer than 21 operations per year, 56 surgeons made up the study cohort.

Multivariable analysis showed significant non-modifiable patient-related factors associated with readmission were African-American race/ethnicity, more comorbidities, occurrence of postoperative complications, and an extended length of stay.

Variation in readmission by subspecialty ranged from 2.1% after breast, melanoma, or endocrine surgery to 37% following cardiac surgery.

The authors pointed out that this study "echoes growing concerns regarding the use of readmission as a quality metric based on its current methods."

Let's compare it to the controversial ProPublica Surgeon Scorecard.

Both the Surgeon Scorecard and the JAMA Surgery paper used data from the years 2009 through 2013. The scorecard involved only eight high-volume low-risk in-patient procedures while the paper looked at in-patient surgery of all types.

From an article written by the authors of the Surgeon Scorecard: "If a patient was readmitted to any hospital (not just the hospital where the surgery was performed) within 30 days of a surgery for one of the conditions we identified, we counted the case as a complication for the surgeon who performed the initial procedure."

What we learned from the JAMA Surgery paper raises some questions about the the Surgeon Scorecard. On Twitter, I asked for comment from Marshall Allen, the lead author of a white paper [not peer-reviewed] describing the methodology of the Surgeon Scorecard.

Between attacks on my credibility because I choose to use a pseudonym, he said that they did not count most readmissions as complications. It is unclear from the article, the white paper, or its appendices exactly which complications were included. For clarification, we could ask the "surgeon experts" who advised ProPublica, but their names have not been disclosed. They are anonymous, just like me.

According to the white paper, surgeons were blamed for 64,367 (46%) of all complications incorporated into the Surgeon Scorecard. Table 3 of the white paper lists the 20 most frequent complications. The top three, comprising 26,795 complications, were postoperative infection, iatrogenic pulmonary embolism, and infection/inflammatory reaction due to internal joint prosthesis.

Other studies have shown that not all occurrences of those three complications are attributable to a surgeon's misdeed. Among the rest of the top 20 causes of readmission were postoperative pain, fever, and dysphagia (difficulty swallowing)—again possibly not the fault of a surgeon.

So the JAMA Surgery paper says surgeons are responsible for 2.8% of readmissions within 30 days, but ProPublica's self-published white paper says 46% of all readmissions are due to something a surgeon did or did not do.

Who to believe?

Note added at 7:27 a.m. on 9/2/15: See my next post for a clarification about causation and variation. 

The full text of the peer-reviewed JAMA Surgery paper is available here.

In 22% of kids with appendicitis, antibiotics do not prevent perforation

Those clambering aboard the "antibiotics for appendicitis" bandwagon should read this interesting paper about appendicitis in children.

A group of emergency physicians from Maimonides Medical Center in Brooklyn, New York found that "Increasing in-hospital time delay from ED presentation to OR appendectomy is associated with increased risk for developing appendicitis perforation in children who present with CT-documented uncomplicated appendicitis."

Children with simple appendicitis who were taken to the operating room longer than 9 hours from the time of ED presentation were much more likely to develop a perforation than those who had surgery in less than 9 hours.

During the four years of the study, 404 consecutive children ≤ 18 years of age had a CT scan diagnosis of acute appendicitis; 156 (38.6%) had evidence of perforation at the time of presentation and were not included in the final analysis.

A medical student in Cuba is looking for advice

Someone writes: I am trying to help a friend's brother who is not a US citizen and currently a medical student in Cuba, and I came across your very informative web site. The brother most likely is going to be able to come to the United States in the fall.

My friend is wondering if he should complete the last year of medical school there in Cuba or come here and continue on. It seems like there is no benefit from completing med school in Cuba, given the difficulty to be licensed in the U.S. And the difficulty in getting a residency position.

Does any of the course work from his studies in Cuba transfer over to U.S? Is it likely that he'd have to get a bachelor's degree here before ever going to a U.S. Med school? My friend says that he has an outstanding record in the Cuban medical school, speaks excellent English, does well on tests, etc. Any advice you could give?

As far as I know, no medical students from Cuba have transferred to a med school in the United States recently or possibly ever. Regarding your questions, I can only give you my best guesses.

I doubt very much that a course from the Cuban medical school would be accepted here in the US. US med schools that accept a few transfers from Caribbean schools like Ross or St. George's usually take those students at the beginning of the third year of medical school.

A few schools are doing combined BS/MD degrees in five or six years, but I don't know of a single US school that would take a student directly out of high school into a 4-year program.

Male docs are more often involved in medicolegal actions than female docs

"Male doctors are more likely to have experienced medico-legal actions compared to female doctors. This finding is robust internationally, across outcomes of varying severity, and over time," concluded a recent meta-analysis.

The study, published online in BMC Medicine, said men were 2.45 (95 % CI, 2.05–2.93) times more likely to have been the subject of legal proceedings.

Legal action was defined as disciplinary action by a medical regulatory body, malpractice experience, complaints received by a medical regulatory or healthcare complaints body, a criminal case, or when a paper on the topic did not specify one of the above.

Data from 32 published papers were pooled and analyzed. At first glance, the methods seem reasonable, and the conclusion may even be correct.

But to their credit, the authors mention that the paper has some limitations which, in my opinion, probably invalidate the results.

A “shallow water blackout” is a silent killer

In Jacksonville, Florida, a 50-year-old woman was found at the bottom of her backyard swimming pool. She was an experienced scuba diver who “often stayed at the bottom of the 9-foot deep end without oxygen to increase [her] lung capacity for future dives.”

Despite receiving CPR from her son, she could not be revived.

The Associated Press story about this tragic incident did not explain why a swimmer with her background drowned.

It appears to be a classic case of “shallow water blackout.” This phenomenon occurs when people hyperventilate before diving.

An increasing level of carbon dioxide (CO2) is what triggers the urge to breathe. Hyperventilating causes hypocapnia, a reduced amount of CO2 in the blood. If a swimmer uses up enough oxygen to pass out before the CO2 trigger point for breathing is reached, drowning will occur without notice. Victims are usually found at the bottom of the pool.

Here’s what it looks like in a diagram from Wikipedia:

A physician who lost her son to this little-known phenomenon started a website to heighten awareness of the problem. The site contains more information and stories about other drownings caused by shallow water blackouts.

Here is a video of a woman swimming laps of a pool underwater. Advance to the 0:50 point and watch what happens as she begins to slow down. [Addendum 8/13/15 12:50 pm: Warning. The video is graphic. It shows the unconscious swimmer being pulled from the water.]
 

A shallow water blackout may have been responsible for the death of Natalia Molchanova, the world’s foremost freediver, who went missing a few days ago.

Hyperventilating prior to diving is not recommended. Tell your friends.

Why in-hospital deaths are not a good quality measure

You may be tired of hearing about the Surgeon Scorecard—the surgeon rating system that was recently released by an organization called ProPublica. Like many others, I have pointed out some flaws in it. You can read my previous posts here and here.

I had decided to stop commenting about it because enough is enough, but a recent paper in the BMJ raises a question about one of the criteria ProPublica used to formulate its ratings.

ProPublica defined complications 1) as any patient readmission within 30 days and 2) "any patient deaths during the initial surgical stay."

The authors of the BMJ paper randomly selected 100 records of patients who died at each of 34 hospitals in the United Kingdom. The 3400 records were reviewed by experts to determine whether a death could have been avoided if the quality of care had been better.

The number of patient records in which a death was at least 50% likely to have been avoidable was 123 or 3.6%.

There was a very weak association between the number of preventable deaths and the overall number of deaths occurring at each hospital. By two measures of overall hospital deaths, the hospital standardized mortality ratio and the summary hospital level mortality indicator, the correlation coefficient between avoidable deaths and all deaths was 0.3, not statistically significant.

From the paper: "The absence of even a moderately strong association is a reflection of the small proportion of deaths (3.6%) judged likely to be avoidable and of the relatively small variation in avoidable death proportions between trusts [hospitals]. This confirms what others have demonstrated theoretically—that is, no matter how large the study the signal (avoidable deaths) to noise (all deaths) ratio means that detection of significant differences between trusts is unlikely."

The Surgeon Scorecard was derived from administrative data. No individual analysis of patient deaths was undertaken. According to a ProPublica article discussing some key questions about their methodology, "As for deaths, we took a conservative approach and only included those that occurred in the hospital within the initial stay."

Maybe that wasn't such a conservative approach after all.

And maybe we need to rethink that 2013 paper claiming that medical error caused up to 440,000 deaths per year.

Some venous thromboembolic events can’t be prevented even with optimal care

I have written several posts about how I get things right before others see the light, but none better than one from three years ago pointing out that some of the Centers for Medicare and Medicaid Services (CMS) "never events" can't really be completely prevented and therefore should not be considered "never events."

One specific "never event" I questioned was hospital acquired venous thromboembolic (VTE) disease which encompasses deep venous thrombosis (DVT) and/or pulmonary embolism (PE). I wrote "I am unaware of any DVT study in which no patients in the experimental arm developed DVTs or PEs. Patients will develop DVT or PE even with the best evidence-based care."

Along comes a brief research letter published last month in JAMA Surgery by a group from Johns Hopkins led by surgeon Elliott R. Haut.

Of 92 patients in their institution who had VTEs in a single year, 43 (47%) had received defect-free care. That is, each of those patients received all doses of risk-appropriate pharmacological prophylaxis ordered for the entire hospitalization.

To put it another way, VTEs for those 43 patients were not preventable. There would be no way to do a quality improvement project for a group of patients who received the right prophylaxis throughout their hospital stays and still got VTEs.

The Joint Commission/CMS criterion states that a hospital is in compliance with VTE prophylaxis if a patient receives one dose of an appropriate drug within 24 hours of admission. The Hopkins study showed that of the 49 patients (53%) whose care was suboptimal, 36 (73%) missed at least one dose of prophylaxis that was correctly ordered. Other studies have shown that missing even one dose of prophylaxis at any time during a hospitalization increases the risk of VTE.

So about half of VTEs are not preventable even with perfect adherence to the prophylaxis protocol, and the standard for compliance established by the JC/CMS is inadequate to judge the quality of an institution's performance for VTE prevention.

The study shows that 1) a lot of good information can be delivered in a two-page paper, 2) JC/CMS criteria for compliance with VTE prophylaxis need to be revisited, and 3) VTE should be removed from the list of "never events.”

A high school student has questions about a medical career and pathology vs. surgery

A female high school student asks about pathology, surgery, and medicine in general. [Email edited for length.] See if you agree with my answers.

The field I am most interested in is pathology. I have a very logical mind and would enjoy being able to solve the complex puzzle of disease. I would also like the somewhat flexible hours compared to other more intensive specialties. However, I do have some qualms.

I'm also interested in general surgery. I would love to learn how to perform all the different types of surgeries that surgeons perform. If I were to be a pathologist, would it be "knife-free"? Pathology really intrigues me, but participating in the occasional surgery sounds like it would be extremely interesting and full of learning opportunities.

There is some knife wielding in pathology. Specimens must be properly cut, and there is the occasional autopsy. However, it's definitely not surgery.

What does a pathologist really do? I've looked at various descriptions online, and none of them seem to be very specific. What would a typical day look like for a pathology resident? I was also wondering what types of skills pathologists are taught?