Sunday, December 27, 2015

What the Wall Street Journal tells us about complications after surgery: Not much.

The Wall Street Journal published an article on Christmas day that told the story of an 83 year old woman who suffered a heart attack after a joint replacement at a rural hospital.  The story serves as an introduction to a piece about the higher cost and poorer care delivered at rural hospitals.  There are certainly some very interesting points I was not aware of with regards to financial incentives provided by the government to do procedures at rural 'critical access' hospitals, as well as higher 30 day mortality after joint replacement surgery at these rural hospitals.

The Wall Street Journal article does provide this nugget from a Harvard public health researcher: “Patients are getting bad outcomes, probably because they are getting procedures at hospitals without the experience to do it well.”  This certainly may be true, but no data exists in the article to back-up this assertion.  Are there more infectious complications of the surgery?  Are there more re-operations? Are the surgeons that operate at these centers less experienced?

The aim of the initial CMS initiative to expand access to care for rural patients seems to have worked. More patients are getting surgery closer to home as a result.  It is troubling that mortality rates are higher at these hospitals.  Perhaps the answer is to take away the incentives and move surgeries back to the larger hospitals.  I don't know, and the article isn't particularly helpful in answering those important questions. I would hope the folks in our profession who help shape public policy, like the Harvard physician quoted in the study, would be a little more careful in implying causation when all that has been discovered is a hypothesis generating correlation.  My hope is that he isn't advocating for changes to public health policy based on simple correlations.

I do take issue with the story used to make this point.  Unfortunately, a heart attack is a complication of any surgery.  It is not clear from the story what parts of care provided at this rural hospital were substandard.  Patients at teaching hospitals do have heart attacks post-operatively as well.  Differences in outcome may relate to delays in access to subspecialists you need in this situation.  Unfortunately, this article doesn't shed light on any of this.  It instead joins a laundry list of articles that leaves the distinct impression that something bad happened to a loved one at a hospital that was preventable. There are plenty of things I wish for.  I would love to have a light saber, I would love even more to travel at light speeds in the Millenium Falcon, and most of all I would love to live in a medical world free of any harm.  Elon Musk would lead me to believe we are a lot closer to flying in a Millenium Falcon than we are to working in a zero harm environment.  Surgery, especially, is not close to a zero risk endeavor.  While I have found estimates reported in the literature to be overstated at times, as many as 10 million patients (out of 200 million undergoing non-cardiac surgery) worldwide are estimated to suffer a major cardiac complication. There is a possibility that your 80 year old grandmother will have a complication of surgery even if it takes place at an ivory tower institution, and even if every single medical and surgical practice standard is met.

As we usher in 2016, I do have a solution that will definitely sate everyone's desire for zero risk.  In order to get to zero risk, I advocate we stop operating.  I feel safe in guaranteeing that there will be no complications of surgeries this coming year if there are no surgeries.

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