Wednesday, November 6, 2013

Do more hospital resources equal better care?

For surgical patients, the answer is "Yes."

A recent study from England found that mortality rates for patients admitted with high-risk general surgery diagnoses were significantly lower in National Health Service Trust hospitals that used more CT scans and ultrasounds and had more ICU beds.

During the first decade of this century, nearly 368,000 patients were admitted as emergencies to English hospitals with surgical diagnoses carrying mortality rates in excess of 5%.

The diseases were bowel obstruction, liver/biliary conditions, hernias with obstruction or gangrene, peritonitis, gastrointestinal ulcers, perforated diverticulitis, bowel ischemia and miscellaneous diagnoses.

The 30-day risk-adjusted in-hospital mortality rate for the eight illnesses was 15.5% with a range of 9.2% in low-mortality hospital trusts (LMHTs) to 18.2% in high mortality hospital trusts (HMHTs). An operation was performed in 37.4% of patients, and 14.9% were readmitted within 28 days.

Three factors significantly differentiated LMHTs from HMHTs:

LMHTs had 20 ICU beds per 1000 beds vs. 14 for HMHTs, p = 0.017.
LMHTs performed 24.6 CT scans per bed per year vs. 17.2 for HMHTs, p < 0.001.
LMHTs performed 42.5 ultrasounds per bed per year vs. 30 for HMHTs, p < 0.001.

Some limitations of the study included the fact that it was based on administrative data. There was no way to determine if the increased use of imaging or availability of ICU beds had a direct effect on patients admitted with emergency surgical diagnoses. Also, variables such as delays in surgery or competence of surgeons could not be investigated.

Despite its limitations, this study is provocative.

No doubt the HMHT hospitals, which have fewer ICU beds and perform fewer imaging studies, are not as expensive.

But the study suggests that if you have the misfortune to arrive at an HMHT hospital with one of the surgical diagnoses listed above, you may have twice the chance of dying than if you had gone to an LMHT hospital that utilizes more resources.

This study is supported by a Viewpoint article in October's JAMA Surgery which looked at two studies of postoperative care in the UK and Europe. In both papers, many seriously ill postoperative patients did not receive appropriate levels of critical care. "Among patients who died during hospitalization after major surgical procedures in the United Kingdom in 2001, approximately 8.5% were admitted to an ICU at some point in their hospital stay. During the same period in the United States, this figure was 7 times greater, 61%."

In the European study, only 5% of surgery patients had planned admissions to intensive care, and 75% of those who died postop did not spend any time in an ICU.

The authors added, "in efforts to achieve good surgical outcomes, there really may be no free lunch: tradeoffs between cost and quality are inherent to the contemporary delivery of intraoperative and postoperative care."

What do you think?


Anonymous said...

If my patient were to crash, I would hope he/she would be in the ICU. There is less chance of a "failure to rescue," if already in intensive care. Time is of the essence if things are going south. If in doubt, a high-risk patient should be in the ICU -- that is what you would want for your own loved one.

No, doctors can't diagnose everything with their bare hands. Sometimes they need the US or the CT to make the diagnosis.

These studies are in accord with common sense.

Anonymous said...

P.S. Is the Oscar Wilde quote a sly dig at us, the anonymous ones?

Skeptical Scalpel said...

First anon, thanks for commenting. I agree with you. Common sense, but everyone doesn't agree with the concept.

Second anon, no it's about me. I'm anonymous too.

Anonymous said...

Did the study look at differences between patients arriving in each type of trust and the staff who cared for them? Maybe the HMHT's treated sicker patients (ie, from poorer regions) and/or failed to attract good doctors.

Skeptical Scalpel said...

The results were corrected for patient acuity. I don't think that the quality of the doctors was addressed. That is a difficult thing to assess.

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