Health and Medical News and Resources

General interest items edited by Janice Flahiff

[News article] Hospital readmissions after surgery associated with new post-discharge complications

From  the  February 3, 2015  Science Life article (University of Chicago)  by John Easton in At the BedsideSidebar

surgery

A study including data from 346 hospitals found that readmissions during the first 30 days after surgery were associated with new complications—post-discharge problems related to the surgical procedure—and not, as previously suspected, to the worsening of medical conditions the patient already had or acquired while hospitalized for surgery.

In this study, published in the February 3 issue of JAMA, Ryan P. Merkow, MD, MS, a clinical scholar in residence at the American College of Surgeons, now chief surgery resident at the University of Chicago, and colleagues examined the reasons, timing, and factors associated with unplanned postoperative hospital readmissions within 30 days after surgery.

Financial penalties for readmissions have made them an important quality and cost-containment issue for hospitals and clinicians. Hospitals try to reduce readmissions, but until now little has been known about the reasons for readmission after surgery. Identifying these reasons could advance quality-improvement efforts and reduce surgical readmissions.

“The Hospital Readmission Reduction Program is federal law and is here to stay,” Merkow said. “Hospital administrators and quality departments must determine how to approach readmissions, and in particular readmissions after surgery.”

“Until recently, efforts were primary focused on medical conditions,” he said, “namely heart failure, myocardial infarction and pneumonia. However, a growing emphasis by policy makers now specifically targets readmissions after surgery. Yet, surprisingly, little is known about why surgical patients are being readmitted. It is completely unclear if oversight initiatives such as public reporting and pay-for-performance should be similarly applied to both medical and surgical patients.”

“Unlike patients being admitted for a medical condition, surgical patients experience a discrete, invasive event (i.e., surgery) with known risks of complications,” Merkow said. “We believe this study definitively separates medical and surgical readmissions as distinct entities that require unique reduction strategies.”

In this study, the unplanned 30-day readmission rate following 498,875 operations was 5.7 percent. Rates ranged from 3.8 percent after hysterectomy to 14.9 percent after lower-extremity vascular bypass. Only 2.3 percent of patients were readmitted for a complication they had experienced during their index hospitalization.

The researchers found that the most common reason for unplanned readmissions was surgical-site infections, followed by intestinal ileus or obstruction, bleeding or anemia, blood clots, and surgical-device issues. Surgical-site infections (SSI) ranged from 11.4 percent after bariatric surgery to 36.4 percent after lower extremity vascular bypass.

The findings have at least two significant policy implications, the authors insist. First, because most readmissions result from post-operative complications, “readmissions after surgery penalize hospitals twice.” And second, because it has been difficult to reduce the most common post-operative complications, such as surgical site infections, penalizing hospitals for problems they do not know how to prevent could be counterproductive, leading to untested solutions that may be ineffective or even counterproductive.

“Understanding the underlying reasons for readmission, the timing, and the associated factors should help hospitals undertake targeted quality-improvement initiatives to reduce readmissions,” the authors wrote. “However, surgical readmissions mostly reflect post-discharge complications, and readmission rates may be difficult to reduce until effective strategies are put forth to reduce common complications such as SSI.”

Efforts should focus on reducing complication rates overall rather than just those that occur after discharge, the authors insist. “This will subsequently reduce readmission rates as well. Readmissions after surgery may not be an appropriate measure for pay-for-performance programs but rather better suited as a measure for hospitals to track internally.”

February 4, 2015 Posted by | health care | , , , , , , , , , | Leave a comment

[Reblog from KevinMD.com] Insurers should stop paying for robotic hysterectomies

Those of you who follow me know I do not usually post items on specific procedures.
However, I frequently repost items which point out contributions to rising health care costs.
Thus this entry.

From the 21 October 2013 post by Jennifer Gunter MD at KevinMD.com

A new study confirms what previous studies tell us. That a robotic hysterectomy is not a safer or a more efficient way to remove a uterus for non-cancerous (benign) surgery than a traditional laparoscopic approach. This study indicates that there is little difference between the two types of surgery with one glaring exception, a robotic hysterectomy was $2,489 more expensive than a laparoscopic hysterectomy.

 

Several months ago the American Congress of Obstetricians and Gynecologists (ACOG) issued these statements:

Robotic surgery is not the only or the best minimally invasive approach for hysterectomy. Nor is it the most cost-efficient. It is important to separate the marketing hype from the reality when considering the best surgical approach for hysterectomies.

And,

there is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.

Robotic hysterectomies for benign disease provide nothing additional from a medical perspective although they are a welcome marketing ploy for doctors and hospitals (Hey, we have a robot! Come see us! That’s so cool!). Some hospitals and GYN practices have literally built their marketing around the robot. And obviously the more robotic hysterectomies performed the greater the profits for the makers of the da Vinci robot.

There is enough data for insurance companies to say, “We won’t pay the price difference.” If insurance companies capped hysterectomy fees at the cost of a laparoscopic procedure then if hospitals and doctors wanted to eat the price difference or pass that price difference along to their patients, so be it.

Wasting money on a procedure that offers nothing over a less expensive alternative is an outrage. As an aside, this is the biggest issue I have with Obamacare. We should all be insured, but doctors, hospitals, and medical device companies should not be allowed to take advantage of that. The need to curtail egregious expenses is urgent. A robotic hysterectomy does offer advantageous for cancer surgery, so I’m all over that, but isn’t it better to channel the money to where it can actually improve outcomes?

And so my plea is to insurance companies. Whether procedures and drugs are covered or not depends in a large part on the body of medical literature and recommendations by professional organizations (like ACOG). There is not one study that shows the benefit of robotic hysterectomy over a traditional laparoscopic approach. Since the doctors and hospitals that push robotic hysterectomies don’t have the ethics to police themselves, insurance companies must step in and stop the madness. Insurance companies can either flat-out deny robotic hysterectomies or simply cap what they will pay at the cost of a traditional laparoscopic procedure. If there were a $2,489 co-payment for a robotic hysterectomy versus a $200 co-payment for a laparoscopic hysterectomy, given they have similar outcomes, which do you think would be more popular?

It is wrong to pass the additional cost of a more expensive and non medically advantageous procedure along to other purchasers of the same insurance. I don’t want my premiums to go for medically unindicated expenses and I certainly don’t want my premiums paying for corporate perks at Intuitive Surgical (makers of the da Vinci, and who are, by the way, laughing all the way to the bank).

Given that we are all curators of the health care system it is unethical to recommend robotic hysterectomies for benign disease. If doctors and hospitals refuse to read the literature (never mind reducing the waste in the system) then they should not be surprised at all when a third party steps in to do it for them.

Someone has to help stop the madness.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

 

Excerpts

“The study, published in the Journal for Healthcare Quality earlier this year, focused on incidents involving Intuitive Surgical’s da Vinci Robotic Surgical System over nearly 12 years, scrubbing through several data bases to find troubled outcomes. Researchers found 245 incidents reported to the FDA, including 71 deaths and 174 nonfatal injuries. But they also found eight cases in which reporting fell short, including five cases in which no FDA report was filed at all.”

“James F. Blumstein, director of the Vanderbilt Health Policy Center and Professor of Constitutional Law and Health Law & Policy, said with robotic surgery, for patients it’s not necessarily about knowing which procedure would be best but being fully informed of their options. He said that if there are known injuries and routine problems, health care providers need to disclose that information to patients.

“If you as a patient are going to a doctor, and they’re using a robot, it’s a question of who’s in charge,” Blumstein said. “If it’s a mechanical malfunction, would the professional standard of care apply to a robot?”

If problems occur during robotic surgery and subsequent litigation, a question might arise about whether the doctor, the hospital or the manufacturer was responsible, introducing the potential issue of product liability. But there may be protection for doctors performing robotic surgery in disclosing the risks, Blumstein said.

“If a doctor discloses to a patient there’s a comparative risk (between regular surgery and robotic surgery) and that disclosed risk materializes, I would have a hard time thinking the doctor would be considered negligent,” he said.”

November 7, 2013 Posted by | health care | , , , , , , | Leave a comment

   

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