Wednesday, August 12, 2015

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.


Anonymous said...

I am not tired of hearing about it. If we don't examine all facets of reporting, we won't know whether or not it is good enough or we need to improve on it. I don't want to use half baked research to chose a doctor. This also teaches people to think critically about what they read and whether or not they should trust it.

Skeptical Scalpel said...

Anonymous, thank you for your comment. I'm glad you aren't tired of hearing about it. Maybe I was projecting my own feelings on those of my readers. Unfortunately, the torrent of criticism has not stopped most people from heaping praise on the Surgeon Scorecard.

Marshall Allen - ProPublica said...

I don't usually respond to anonymous critics, but will go ahead and mention that the dozens of experts/doctors we consulted, including surgeons who did the procedures included in Surgeon Scorecard, felt it was fair to call death during an admission for a low-risk elective surgery a complication. Was this study specifically looking at deaths during admissions for low-risk elective operations, or all deaths in a hospital? There's a big difference, as you know.

You can go here to see what experts in quality improvement and quality measurement say about Surgeon Scorecard go here:

Skeptical Scalpel said...

I respect Mr. Allen and think he means well. The scorecard was a good try.

Here's what I said to him when he made the same comments to me on Twitter: "Peter Pronovost was critical of the scorecard. [Dr.] Mick consulted on the project. What would you expect him to say?"

frankbill said...

What is low-risk elective surgery? I had a sister that almost died after having her gallbladder taking out. Unknown to the surgeon she had pancreatitis.

artiger said...

Frankbill, I'd have to ask to clarify...did she have stones? Didn't someone check a lipase and amylase prior to surgery? Pancreatitis is usually pretty painful, and if it's secondary to stones, you usually see some abnormal liver function tests to boot. I can't speak for everyone, but I was taught to not take the gallbladder out until the pancreatitis has waned, if not resolved.

I probably shouldn't be Monday morning QBing her surgeon, so forgive me if that came off as harsh. I'm just not clear on how pancreatitis slipped by someone. If it's too private to discuss I understand.

frankbill said...

As this was in 1997 would be hard to know what blood work was done. As she had stones they though that was the cause of the pain also had growth around the gallbladder. Think she was told that the gallbladder was trying to isolate it self from the rest of the body.

Since this was laparoscopic surgery the pancreas wasn't examined. The surgeon said at the time he didn't like not being able to look around as he would have done in open surgery. He did get to do this later on.

frankbill said...

Since I am in the VA health care system I have very little choice of providers. It is the luck of the draw. If I don't like the provider I can request a different one but have no say in who that new provider will be.

frankbill said...

Medical scope makers cited for safety lapses.

Federal regulators have found safety violations in the manufacturing practices of all three companies producing a specialized medical scope that has been linked to deadly superbug outbreaks at U.S. hospitals — a precursor to possible legal action against the firms.

The warning letters are the most sweeping action taken by the FDA since USA TODAY first reported in January that duodenoscopes had been linked to superbug outbreaks that have sickened scores of patients and killed more than a dozen. The scopes, which doctors run down patients’ throats to treat gallstones, tumors and other blockages of the bile and pancreatic ducts, are used about 650,000 times a year nationwide.

How big a deal is this? If the scope wasn't used what would be the outcome?

Skeptical Scalpel said...

To the more than a dozen who died and their families, it's a pretty big deal. There must be a way to design a scope that can be cleaned properly. That would be a better solution than stopping all endoscopies. Meanwhile, maybe too many people are getting scoped.

frankbill said...

I under stand it being a big deal to the dozen or so died out of the 650000+.

When I look at five people I know that had heart surgery since 2008 . Out of the five of them two died. Much higher risk in heart and other kinds of surgery then in using the scope.

frankbill said...

I need to correct the above statement. Out of the five I know three died from having heart surgery. Of the three that died they most likely would have died without surgery or would have had a very poor quality of life.

frankbill said...

This is a bit of history on one of the the three I know that died from heart surgery. I am putting it here so you Drs can learn from it and because what happened where was most likely preventable. Was told much was learned that may help others that find they need heart lung support for an extended time. There should be a case study of this at Carl J. and Ruth Shapiro Cardiovascular Center of Brigham and Womens Hospital. Not sure how to get access to it but someone must know.

Sometime about 2008 this vietnam Vet had his arotic valve replaced at the West Roxbury, MA VA Medical Center.

Altho this Vet was able to resume a somewhat normal life he still thought sowething was wrong. The VA was telling him they couldn't find any thing wrong.

About Feb 20 2013 he went to the ED at the Dartmouth Medical Center. After there running tests they found the replacment valve was two small. After a check of the record they found that the surgeon had some problems that made him put the smaller Valve in.

After reviewing the case it was decided to replace the smaller valve with a larger one. This was to again to be done at West Roxbury, MA VA Medical Center. This was done May 12 2013. While in the recovery room they became aware of a problem and opened back him up in the recovery room. They thought it was air in the blood. Not sure what is stated as the cause. But it is beleved that it was due to how the stiching was done. This was belived reduce blood flow through the heart and caused the right ventrical to stop working.

They now have him on the heart lung machine. His chest is left open a few days so they can work on him.

Notes my sister made
May 15
He is still improving but his right ventrical still isn't working like it should. The doctor talked to me this morning telling me different options for things that might help. One of the things he talked about was nitris oxide to help the right side of the heart. But that is only available at Brigham and Womens Hospital.

They have something here that will work the same way so they are going to try that to see if it will work

May 16
The procedure they tried to get the right ventrical working did not work out. They plan to move Steve to Brigham and Womens Hospital.

May 17
Now at Carl J. and Ruth Shapiro Cardiovascular Center" of Brigham and Womens Hospital. He was taken there yesterday afternoon.

Every few days they had to clean out his chest. They tried other things but in the end it failed.

He passed away around three thirty on Saturday Oct 5th. 2013 he was 63.

Skeptical Scalpel said...

Sorry to hear this story. Thanks for letting us know.

frankbill said...

This was my sister's boyfriend. She met about two years before this happened. My hope is this can help someone else.

Hard to know sometimes to accept things as they are or take the risk that surgery will fix you.

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