Don't jump to conclusions about that JAMA surgical readmissions paper

On February 3, JAMA published a paper online about readmission rates after surgery. The focus of most tweets was on the most common cause for readmission—surgical site infections (SSIs)—in 19.5% of readmitted patients.

At first glance, this suggests that infection rates after surgery were 19.5%, but that is not so. The paper said that 19.5% of the readmissions were caused by infections.

Of 498,875 total operations reviewed, only 30,270 (6.1%) were readmitted for any reason, and only 5576 (1%) of all patients were readmitted for SSIs.

According to the full text of the paper, the authors had two main points:

Charting Requirements Interfere with Patient Care

Yesterday’s column on the burden of nurse documentation in the New York Times by Theresa Brown, RN was spot on. She details many of the rather onerous charting requirements mandated by myriad regulatory agencies and insurance companies. She laments the fact that the documentation is so time consuming that it takes away from her mission to care for the patient. She says that nursing has always been guided by the dictum “If it isn’t charted, it isn’t done,” and points out that charting everything a nurse does during a shift is impossible in reality.

The problem has been compounded by the electronic medical record which makes it easy to insert pop-ups and drop-downs so that anything some bureaucrat fancies can be added to the chart. Of course, the nurse still has to login and get past a number of screens before she finally reaches the section she wants. Here’s the bad news. Other than the bureaucrats and operatives from the Quality Assurance Improvement department, NO ONE READS THIS USELESS INFORMATION. It simply clutters up an already very “busy” electronic chart.

Like nurses, we physicians have similar, sometimes comical, charting responsibilities. For instance, the Surgical Care Improvement Project [SCIP]* has a relatively new rule that Foley catheters must be removed within two days after surgery to prevent infection. If the catheter is not removed, a progress note must be written documenting the reason the catheter was left in place. Recently, I was cited by “Thought Police” [Quality Assurance Improvement] spies because I failed to document why a catheter was still in place on the third post-op day. Never mind that the patient was on mechanical ventilation in irreversible septic shock, on vasoactive drugs with marginal urine output and died the next day. [As a side note, on researching this topic just now, I found that perioperative death is an “exclusion” regarding this measure. In other words, I should not have received a ding. I have forwarded the link to KGB HQ.**]

For years, we were told that Medicare wouldn’t pay the hospital if the medical coders listed anemia as a discharge diagnosis unless we wrote somewhere in a progress note that the anemia was due to blood loss after surgery. This was required even if it was patently obvious that the patient had undergone an operation and had lost blood.

I could go on, but I will spare you. A future blog will elaborate on the pros and cons of the electronic medical record.

*I have commented on the questionable value of SCIP here and here.

**Update. SCIP defines "perioperative" as the time between the end of the operation and discharge from the recovery room. Therefore, the citation stands. Of course, by that definition of perioperative, anyone patient dies in the recovery room would almost invariably be withing the first two postop days. So why bother to even mention it? Who knows?

Bad News for Devotees of Process-Oriented Quality Assurance (Part 1)

The Surgical Care Improvement Project (SCIP) and its antecedent, the Surgical Infection Prevention project, have been around for several years. In short, these consist of several rules issued by various self-appointed agencies with important-sounding names and the Centers for Medicare and Medicaid Services (CMS), a federal agency. The main rules are (1) administer the correct prophylactic antibiotic before surgery, (2) give the antibiotic within one hour before the skin is incised and (3) discontinue the antibiotic within 24 hours of the end of the operation. The stated goal of these initiatives was to reduce the rate of surgical wound infections by 25% by the year 2010. It didn’t happen.

Surgeons and administrators have been obsessively following the rules and documenting their activities with squads of internal auditors (thought police). There are numerous papers showing a remarkable increase in the levels of compliance over the years to well over 90% in many hospitals. Compliance data have even been posted on line so that patients can compare institutions. CMS is thinking of linking hospital reimbursements to SCIP compliance rates. Unfortunately, a recent large study in the Journal of the American Medical Association (JAMA) has shown that SCIP has not only not decreased the rate of wound infections by 25%, it actually has had NO IMPACT at all on the infection rate.

So what happened? Why didn’t the rules work? They were based on some sound research. There are several theories. In order to comply with the “within one hour” rule, antibiotics are being given in the operating room and on many occasions, have not been completely infused as of the incision time. Thus, they will not have arrived at the wound in time to prevent the infection from occurring. Mary Hawn, MD, MPH, a surgeon and author of an editorial that accompanied the JAMA article, suggested that perhaps prophylactic antibiotics, which had been given for many years before the advent of SCIP, have already reduced the rate of infection as much as possible, and tweaking the timing may not make that much difference. She also pointed out that there are many other variables that influence the infection rate, such as the surgeon, the condition of the patient and type and duration of the procedure.

I asked Dr Hawn if SCIP should be changed or abandoned. She said, “SCIP is likely too narrow to have a meaningful effect on surgical outcomes. One response would be to add significantly more measures, but at that added burden one wonders if we really shouldn’t collect what we all care about – outcomes.” Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes. But would you as a patient rather choose a hospital that has a high rate of compliance with SCIP or a very low wound infection rate?

What we have here is the inevitable disconnect between process (the rules) and outcome (the infection rate). It’s not the first time, nor will it be the last. There will be more to come on the topic of process vs. outcome in future blogs.

*Metric: A metric is a measure for quantitatively assessing, controlling or selecting a person, process, event, or institution, along with the procedures to carry out measurements and the procedures for the interpretation of the assessment in the light of previous or comparable assessments. (Author’ note: Even the definition of a metric is convoluted. I promise I will not use the word “metric” again.)