Sunday, August 30, 2015

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 On Twitter, I asked for comment from Marshall Allen, the lead author of a white paper [not peer-reviewed] describing the methodology of the Surgeon Scorecard.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.


Marshall Allen - ProPublica said...

Hi - I'm afraid you are misunderstanding our analysis. Appendix B, which is found by following the link you provided, actually lists the readmissions that we counted as complications. So that is not a mystery or undefined, as you seem to be saying in this blog post. Also, you seem to be saying that we are blaming the surgeons for each complication. But we have said in our whitepaper and in our stories that we cannot say whether surgeons are to blame for the complications. We have never said the surgeons are to blame, because we don't know that to be true. We are saying that surgeons are responsible for the entire episode of care, including any complications related to the surgery. This is a position we came to after consulting with surgeons, the position of the American College of Surgery, and many other experts. We are publishing the risk-adjusted complication rates of each surgeon so that they can see what happened in the various cases and identify ways that they or their surgical teams can improve. Also, I'm not attacking your credibility by asking why you hide your identity. But I'm pointing out that it would improve your credibility if you identified yourself because then people would know your expertise and your biases.

Skeptical Scalpel said...

Thank you for commenting. I appreciate your willingness to discuss your work.

And thank you for clarifying which complications were counted as the responsibility of the surgeon. In looking at complications after laparoscopic cholecystectomy, a number of them are either so vague (Other postoperative infection, Surgical complications—digestive system, Other digestive system complications) or of debatable relevance (abdominal pain, unspecified site and abdominal pain right upper quadrant) that they may not even be complications.

For example, abdominal pain after an abdominal operation is not exactly unheard of. Some patients tolerate pain better than others. We have all had patients return with abdominal pain after laparoscopic cholecystectomy only to find no specific cause. Other digestive system complications could be anything including nausea secondary to pain medication.

As I suspected in the post, deep venous thrombosis was counted as a complication, but others have shown that even when VTE prophylaxis is administered perfectly, VTEs can result. I discussed this recently (

I won't belabor the point any further.

As for my anonymity, I've been blogging for five years and have written over 700 posts. I think by now most people have figured out what my expertise and biases are.

Emily said...

This is anecdotal, but I wonder if you could comment on this:

I had an open appendectomy and was in the hospital for 6 days. After just a few hours home, my incision site started to leak. It looked like blood to me, but it was given another name (?). That evening I went to the ER of my hospital, where they opened me up, treated me, and inserted a kind of vacuum device, then spent another 3 days in the hospital. I had this device in for 5 weeks whereby home health care nurses came twice a week to clean out the instrument. During that time I saw the surgeon twice. Anyway, later I received the ER report and noticed that instead of the correct number of days after surgery when I was readmitted (6), it read 36 days. This error didn't affect me, so I never brought it up to anybody. But now I'm wondering if that could have been an intentional typo on the part of the hospital so they would get paid for treating the infection. I know it's a cynical conclusion, but it does seem an easy fudging on their part to avoid a financial loss. Just wondering.

Marshall Allen - ProPublica said...

Thank you for posting my comment. You are correctly pointing out one of the limitations of billing data - it's vague in its descriptions. That's why it's important to attribute individual complications to the surgeons who performed the procedures. They can look at the clinical info and see what actually happened and what caused the complication.

Also, remember that it wasn't just that the patient experienced something like "abdominal pain." They had to be readmitted for that pain, as the "principal" diagnosis (not one of the secondary diagnoses). So that means it was severe enough pain to be readmitted to the hospital, which is no small thing for the patient and the providers -- and the taxpayers funding the care, in the case of Medicare.

You may be right that VTEs can occur even when things are done correctly. But VTE prophylaxis can also vary from surgeon to surgeon or surgical team to surgical team. So all the more reason to attribute complications like VTEs to individual surgeons so that they can see what the cause was for the complications. That way future patients can be protected from similar suffering, if possible.

As for your anonymity. Clearly you're comfortable with it. That's great for you. But I don't know who you are and don't think it's reasonable for you to think people should have to read 700 posts to understand your biases and expertise on any individual blog post. The standard practice is for people to put their name behind their work, particularly if they are going to be critics. Lots of surgeons and doctors offer critical opinions and aren't afraid to identify themselves. So why do you need to hide behind a nickname? As I've said, the nickname is clever. You could still use it. But you should also put your name on your work so people immediately know your expertise and biases. Why hide?

Anonymous said...

The problem is in the way things are coded. I've seen too often that things are coded so the other doctor didn't make a "mistake". Or they undercode or don't diagnose something. So maybe somewhere between your stats and Propublica's would be an issue. The problem comes in the definition of complication. Is that complication a problem of the surgeon or of the surgery no matter what or the fact the patient didn't take medications or did exercise they weren't supposed to? If someone got pneumonia due to the surgeon carrying a bug and passed it on to his patient, that would not be the same as pneumonia from an old person who simply had it and it wasn't checked before the surgery.

I think you bring out an interesting point on Propublica. One of the problems is getting the medical community to admit to the high range of problems. So getting a current surgeon to do it or someone retired to do it, goes against the code of medicine. That's how blacklisting and gaslighting work: current and former physicians engage in those behaviors to hide issues. Look at Christopher Duntsch again: how many years did he operate when those around him, and finally the state medical board (composed of physicians who are *supposed* to look out for patients) did nothing but hide their heads in the sand.

Skeptical Scalpel said...

Emily, you may be right that it was an attempt to not have a readmission within 30 days. However, the dates reported by the hospital to the insurance company or Medicare would have to be correct. Dates are easily checked, and other entities such as consultants and the visiting nurse service would have been using the correct dates.

Anon, You are right that it is simplistic to just list all complications as the responsibility of the surgeon regardless of what the American College of Surgeons or anonymous experts say. Each complication should be reviewed to see if it was the surgeon's fault or someone else's fault. For example, if a patient doesn't take her meds and gets sick or picks at her wound until it gets infected, how can that be the surgeon's fault?

Regarding Duntsch, if I recall correctly, the surgeon who operated with him the first time he did a case reported him to the medical board immediately. It took the board a long time to do something about it. That was tragic since many more patients were harmed. Hospitals also shared the responsibility (blame) for allowing him to get privileges elsewhere.

Oldfoolrn said...

Hi Dr. Skeptical
The fact that someone is asking you to break with your long standing anonymity speaks very highly of your credibility. Not a soul has ever asked for my name. : - )

Skeptical Scalpel said...

Ha. Thanks.

frankbill said...

" We are saying that surgeons are responsible for the entire episode of care, including any complications related to the surgery."

How can surgeon be responsible to know what they find before doing surgery. Case in point my cousin had all testing required even had the drawing as to how the bypasses would be put in place. Believe they planed on four. Once they opened him up they found he needed seven. They did do the seven but was to much shock for his system to handle.

The Doctor Isn't In said...

it is SO easy to suggest that we surgeons are always to fault. Our side of healthcare but its own nature is a "get in and get it done and return the Pt to the PCP" Today the problem is the PCP is never around any more. We have hospitalists PAs NPs etc who barely know the case and we come in and do our "thing" only to find that there were 5 comorbidities that we are ill equipped to deal with so we look to the rest of the team to step up. I can easily order embolism stockings for every patient regardless of need and even order automated air boots but then I have to listen to the billing department complaining why I did so as they were not covered or now need a 2 page write up to justify them.
I am damned if I do and damned it I don't but the provider who sees them the other 322 days a year who could help determine which ones needs the auto boots and which ones can get away with simply elastics is never to be found but we get the blame for the post operative re-admit.
I used to order 100% of the patients to have 30 days of at home follow up care so that we limited the re-admits. The home health people would heads up me on post op pain or swelling or other things SURGICALLY related and would call the PCP if comorbidities were in fact exacerbated by the procedure but had nothing to do with the surgery. EXCEPT that was deemed excessive care and too expensive. So what do you want me to do let the grandkids take of grandma and hope they do it well or let home on her own in hopes she doesn't need an ED visit or do the right thing and have a professional look in on her to limit the hospital's need to eat a re-admit?
The one thing I can ASSURE you is I am not doing house calls! :)
Dr D (and yes I am all over the Internet and my signature is purely Dr D as our leader here has chosen to limit his exposure my credibility is not in question. Kudos to standing behind your position!

Anonymous said...


Why don't your ask Marshall Allen about some of his responses to harmed patients on the FB page? They have been (at least from what I understand still are) monitoring every post there. It also seems that some of the people who complained (harmed patients) were not allowed to post items and many were questioning why. Propublica responded that they didn't have the time for them. There have been a number of questions on the people that were allowed to post: it appears many of them are using the harmed patients for their own "research" without any HIPAA laws against them. Now this can include lawyers or the like, to get info to protect their clients. Or it can be for the NSPF, which has no record of doing anything to allow harmed patients a big voice at the table, or any record of all of what they've done for harmed patients in fact.

I suggest you go ahead and make sure this is noted because I know a number who can back up what I say. I've heard the stories. What is Propublica's true interest? Why not allow all patients to speak? They have a convenient excuse but my understanding is that people wanted to post medical resources and Marshall wouldn't allow that. Wonder why?

PS There are also questions on retaliation for some of the people who have seriously been harmed but booted off for questioning Propublica. From what I've seen those patients have a point.

Skeptical Scalpel said...

Thank all of you for commenting.

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