See One, Do One, Harm One?

See One, Do One, Harm One?

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I recently cared for Ms. K, an elderly black woman who had been sitting in the intensive care unit for more than a month. She was, frail, weak and intermittently delirious, with a hopeful smile. She had a big problem: She had undergone an esophagectomy at an outside hospital and suffered a horrible complication, leading her to be transferred to The Johns Hopkins Hospital. Ms. K had a large hole in her posterior trachea, far too large to directly fix, extending from her vocal cords to where her trachea splits into right and left bronchus. She had a trachea tube so she can breathe, and her esophagus was tied off high in her throat so oral secretions containing bacteria did not fall through the hole and infect her heart and lungs. It is unclear if she will survive, and the costs of her medical care will be in the millions.

Ms K’s complication is tragic—and largely preventable. For the type of surgery she had, there is a strong volume-outcome relationship: Those hospitals that perform more than 12 cases a year have significantly lower mortality. This finding, based on significant research, is made transparent by the Leapfrog Group and several insurers, who use a performance measure that combines the number of cases performed with the mortality rate. Hopkins Hospital performs more than 100 of these procedures a year, and across town, the University of Maryland tallies about 60. The hospital where Ms. K had her surgery did one last year. One. While the exact relationship between volume and outcome is imprecise, it is no wonder she had a complication.

Ms. K is not alone. Of the 45 Maryland hospitals that perform this surgery, 56 percent had fewer than 12 cases last year and 38 percent had fewer than six.

One day, after the ICU team—nurses, medical students, residents, critical care fellows and the attending—made rounds on Ms. K, we stepped outside of her room. We talked about what we could do to help get her well and to a lower level of care. But we also discussed the evidence for the volume-outcome relationship, highlighting that the hospital that performed Ms. K’s operation performed one in the previous year. Upon hearing this, the medical students cringed, quizzically looking at each other as if observing a violent act. The residents and fellows, the more experienced clinicians, stood expressionless; they commonly see this type of tragedy.

The team asked why the hospital would perform an operation in which it has little experience. The medical students were especially concerned. As the conversation ensued, the team discussed issues of professionalism, health care disparities and accountability—issues that don’t typically come up in rounds but should more often. Don’t the hospital’s trustees and leaders have a responsibility to ensure that their physicians are competent to perform certain procedures? Doesn’t the surgeon have a moral obligation to tell the patient that the hospital did this procedure infrequently? Is it possible that Ms. K’s gender, race and socioeconomic status influenced the discussion about risks?

We don’t know all of the factors that led Ms. K to undergo the procedure where she did. However, the care team rounding on Ms. K agreed that surgeons should inform the patient about the volume-outcome relationship and that she would likely have a lower chance of dying if she had the operation at a higher volume hospital.

(Privately, later in the day, I asked Ms. K whether the hospital mentioned that her risks at this hospital may be higher. Unable to speak due to her tracheostomy, she shook her head no. I did not tell her that the surgeon and hospital put her at increased risk. I thought about it, reflected on what moral obligations I had to give her this information, and weighed what it would do to her, to the surgeon and hospital that performed the operation, to me and my hospital. Perhaps I protect the “tribe”—fellow physicians. In the end, I remained silent.)

At one point our team had been discussing Ms. K for 20 minutes. We had 10 more patients to round on, and two were due out of the operating room in an hour. We felt production pressure to continue rounds, discharge patients and make room for new admissions, yet no one wanted to stop the discussion. The ICU fellow said, “We spend too little time discussing safety, ethical and policy issues. We should continue and shorten rounds on less sick patients.”

As our conversation continued, we talked about what could be done to prevent these situations in the future. The ensuing discussion revealed deep political convictions regarding the role of regulation and free markets in addressing societal ills. Trying to unite the care team, I observed that our markets are the best wealth-generation machine humanity has ever known, as they have lifted more people out of poverty than any other intervention. Yet the markets work best when participants compete fairly, when all traders transparently know the risks and costs. Left to their own devices, markets often fail, competing on half-truths or sometimes outright lies.

The Leapfrog Group helps to level the playing field for consumers, by making public which hospitals meet its standards. However, only 20 percent of hospitals will voluntarily submit information to Leapfrog in its annual survey. Outside of the social pressure engendered by the group’s public reporting, there is no mechanism to make this information available and no regulatory requirement that doctors and hospitals with low volumes in a given procedure tell patients that they are at increased risk.

The ICU team discussed how policymakers have a spectrum of regulatory tools to use, ranging in restrictiveness. On the less restrictive end, legislation could require transparency by hospitals, ensuring that all patients in the market understand risks and benefits related to volumes. Policymakers could also create economic incentives for patients to use hospitals with better outcomes or higher volumes. On the more restrictive end, legislators could prohibit hospitals from performing certain procedures in which they have low volumes or poor outcomes.

One model that we can look to for solutions comes from the Centers for Medicare and Medicaid Services in how it ensures high quality care in transplant surgery. It is not perfect, yet it works reasonably well. Only CMS-approved centers of excellence perform transplants. These centers’ outcomes are closely monitored, and if a hospital’s outcomes fall below a threshold, CMS may eventually revoke its ability to do transplants. Our ICU team concluded that CMS should take the lead, replicate what it did in transplant surgery, and ensure safe care for other high-risk surgical procedures.

Ms. K may die needlessly, and the error will remain invisible. We need policies to protect her and to reduce the chance that what happened to Ms. K and thousands of others like her, never happens again.

Director of the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Peter Pronovost, MD, PhD is a practicing anesthesiologist and critical care physician who is dedicated to making hospitals and health care safer for patients. Pronovost has chronicled his work in his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. His posts will appear occasionally on THCB and on his own blog, Points from Pronovost.

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28 Comments on "See One, Do One, Harm One?"


Guest
Jul 13, 2012

A tremendous (and tremendously sad) story. There is no excuse for that hospital even to have countenanced doing that procedure. Absolutely reckless. Thanks for a darkly inspiring tale for all of us who have been trying (for decades) to improve medical care via data, informatics, and disclosure. Keep shouting this one from the rooftops.

Guest
Jul 13, 2012

Thank you for telling this story.

The CMS model for transplants is a good one.
I don’t think we l can leave it to hospitals and surgeons to disclose that lack of volume leads to higher risk. Moreover, an elderly or very sick patient may not fully understand the disclosure, or the degree of risk.

(Making safety data available is important, but I great many Americans cannot
sort through and assimilate that data.)

Finally, an aside : If “our markets are the best wealth-generation machine humanity has ever known, as they have lifted more people out of poverty than any other intervention” why is it that a we have a higher percentage of children live in poverty than in any other developed nation in the world? ” (Over 20% of U.S. children live below the poverty level: roughly $14,000 for a familiy of two, $22,000 for a family of 4.)

As the director of the National Poverty Center at the University of Michigan, has observed:. “Among rich countries, the U.S. is exceptional.. We are exceptional in our tolerance of poverty.”

“Basically, other countries do more,” he said. “They tend to have minimum wages that are higher than ours. The children would be covered universally by health insurance. Other countries provide more child care.”

As one 19th century economist pointed out: “Capitalism is designed to make
the smallest number of people possible very wealthy.” (I’m paraphrasing from memory.)

I dodn’t mean to take the thread off-topic, but as you note, Mrs K’s race and socioeconomic status probably had something to do with what happened to her. If she were upper-middle class (of any race) it’s much more likely that she would have wound up at a hospital where the procedure is done more
frequently.

Too often, the poor receive sub-par care in hospitals that are underfunded and understaffed. Some of those hospitals should be turned into community health clinics that could provide good preventive care and primary care, while patients who need surgery are shipped to a hospital in a wealtheir part of town. (Today, at least in Manhattan, some wealthy hospitals do not welcome the poor. And the poor know where they are welcome–and where they are not.)

Guest
Pat S
Jul 13, 2012

This problem is far more widespread and severe than people know. Hospitals, some in smaller population centers but even hospitals in large urban areas where referral to more experienced centers is easy, are very slow to let patients know that they would be better off elsewhere. Hospitals, administrators, and hospital medical staff often pressure surgeons and other interventional specialists to push beyond the level of their competence because of reluctance to admit they cannot offer the level of expertise available elsewhere. Market considerations, pride and PR, and reimbursement issues frequently drive this to levels beyond good sense and ethical practice.

I often wonder how much of the poor performance of US health care for specific illnesses and trauma compared with systems in other developed countries is due to this type of overreach in attempting care that should be referred elsewhere, resulting in just this sort of adverse result.

Guest
Jul 13, 2012

As a head and neck surgeon, I have helped with esophagectomies and dealth with tracheal injuries. I have trained and worked for many years at a large tertiary academic center, and have spent time in smaller community facilities. I know what it is be busy in the OR and consistently doing tougher cancer cases and I know what it is when I get more involved in non-clinical work and spend less time operating. There is no question that otechnical skill – both hands and judgement – shift with volume.

Just two days ago, a nurse I work with said that she enjoyed having more flexibility with her work in the outpatient clinics and how happy she is to not be on the floors anymore. But she lamented that while she used to be an expert at getting tough IV access on patients, she could no longer get the simplest ones. Another colleague, a senior Urologist, commented that when he was doing 4 radical prostatectomies a year, he was taking 4hours, losing 2L of blood, and sweating the entire case. Once he was doing 30-40, he was done with each case in 2hours, with minimal blood loss and much less stress.

I think it’s fair to say that volume matters, both anecdotally and based on the broader data. There’s also no question about the disparity of care. And while transparency and data about outcomes is necessary (and is happening already), Maggie makes a great point that it is challenging for most people to know how to interpret the information enough to make the best decision. First of all, what quality measures matter? Is it 30dy in hospital complications – does getting urinary retention after knee surgery actually predict how well you will return to functionality? And, hospitals tend to be reductive in presenting the information in their marketing – what patient really understands the difference between getting ranked highly by Baldridge, HealthGrades, or USNews? Does it even matter? Is it really significant that ER wait times at a particular facility are 30min & does that actually correlate to the quality of care? When someone is sick, it’s a huge amount of confusing material to sort through for even the most savvy person.

For physicians, there used to be pride when you felt like you could do everything. A renowned Plastic surgeon I trained under lamented once that we’re all becoming specialists of the big toe. He had done hand work for 5yrs, then kids for 5, reconstruction for 5more, and had a huge breadth of skill. I met a General Surgeon recently in a small town who was used to taking care of everything from kids to elderly, and doing cases ranging from Neurosurgery to Ob. At Hopkins, he would be taking care of just the abdominal cases and fighting with his colleagues even for those, to determine who would be allowed to do what. In this small town, he was critical to care being delivered because the more narrow specialists simply did not exist.

As many more patients are added to the system, and wait times to see specialized providers grow, we are going to have to come to some decisions about how to stratify care. The VA already struggles with this and has significant volume issues in managing complex patients. We will need centers of excellence, much like in Europe and some of the larger health systems in the US, with physicians dedicated to the most complex cases.

But a question my former Chairman used to ask always haunts me. As we have work hour restrictions, with residents getting less experience and training in the same amount of years (though apparently more sleep), who will take care of us when we are older? It is important to do everything from assessing and communicating quality data, helping it to be usable, have specialized centers and so on. But we will also need to make sure that those at mid-level and less tertiary facilities still have the skills needed to handle not only moderate level of care, but continue to have the experience needed to develop those skills and to develop the judgement needed to care for the full range of patients that will come to them.

Guest
steve
Jul 13, 2012

I work at a tertiary care facility and at a couple of smaller hospitals and some surgicenters. This is a constant battle. The hospital and physicians are often motivated by money to do these procedures. Sometimes they run into a patient who does not, or cannot leave the area, which is a bit different. We also face a similar dilemma daily in our surgicenters. Surgeons want to do surgery on patients who are marginally, or not, acceptable at those facilities. If the facility or the anesthesia stuff say no, they risk losing that surgeon’s business. This makes for an ongoing conflict of interests.

You might hope that medical providers will do the right thing on their own, and most of the time they will. However, a not insignificant part of the time, the loudest, most domineering or financially important figure will win the argument not based upon merit. Too many times I have seen young docs, and some older ones for that matter, knuckle under to do things they should not have done.

Steve

Guest
bev M.D.
Jul 13, 2012

Some excellent comments. At the risk of seeming paternalistic (or maternalistic in my case) , I agree with those who say that we cannot expect patients to be able to make these decisions, especially in the face of market-type behavior like misleading advertising, pumping up service lines in the name of the almighty dollar, etc. If we want to save future Mrs. K’s we are going to have to regulate. Do we check a U.S. airline’s safety record before we fly? No, we rely on the FAA to keep us safe from the potential for ‘market behavior’ (e.g. corner cutting) in all airline operations. Why do we pussy-foot around with the health industry when our very lives are equally at stake?
Dr. Pronovost – having just read your excellent book, with respect I would submit that you should definitely NOT let this “error remain invisible”. Without demonizing a single hospital since we know it is widespread, I think you should use your hard-won influence and respect to push this issue to the max at the national level. You would be performing another great service to patients – which include all of us.

Guest
Barry Carol
Jul 13, 2012

I’ve been told that when it comes to hospital inpatient care, hospitals make the bulk of their money from surgical procedures and cancer treatment. There must be a clear bias to keep these cases in house, especially if the patient’s insurance is likely to pay well above the hospital’s costs. There needs to be some mechanism to counterbalance this bias besides just counting on the hospital and its surgeons to “do the right thing” and transfer the patient to a higher volume hospital if necessary.

Guest
Jul 14, 2012

As Barry suggests, it would save money and perhaps also save lives if the government established and funded tertiary care centers.

I am certain that if Medicare simply gave Johns Hopkins a lump sum for difficult cases, this could save billions of dollars as compared to paying for one ICU day and one surgery after the other.

Basically it is cheaper to own medical care than to rent it.

But as Barry suggests, a rational capitated funding approach would deny some local hospitals their biggest paydays. It is not accidental that the Canadian government (which relies on global budgets) has out and out closed quite a few provincial hospitals.

The American government, Democratic or Republican, is understandably terrified about doing anything that costs jobs, and hospitals have been propping up the American labor market for years. So reform is a ways off.

Guest
Barry Carol
Jul 14, 2012

Bob –

While I would like to see ACO’s emerge that can be paid on a capitated basis instead of fee for service to care for a large population of patients, the problem is that it’s no simple matter for a hospital system that would lead such an organization to estimate its costs a year in advance so can figure out an appropriate capitated rate to charge. Moreover, it would need to also control the entire continuum of care, especially the doctors, who would probably need to be hospital employees and paid a salary plus bonus. For services performed outside the ACO network because the ACO can’t handle them, there would either have to be contracted rate agreements and, for services delivered out-of-network under emergency conditions or outside the ACO’s home region, reimbursement would likely have to be at something like Medicare rates by law. There would probably also need to be risk adjustment payments both into and out of the ACO depending on whether its patient population is above or below average risk.

I get a little tired frankly of hearing about the healthcare system as a job creator. The most recent data I’ve seen suggests that 14.3 million people are now employed in our healthcare system including 4.8 million who work in hospitals. The same people who extol job growth in healthcare are the ones who complain about the middle class getting killed financially by minimal inflation adjusted wage growth over the last 20-30 years. If healthcare costs (and higher education costs) grew only in line with general inflation over that time, there would have been a lot more money to provide wage increases and college education would have been much more affordable to boot. College and universities, by the way, have also been the source of considerable job growth over the years but it’s not necessarily a good thing there either.

Guest
Jul 14, 2012

Actually, what I had in mind was a global budget that, in effect, tells a hospital what its revenues will be in the coming year, and the hospital has to adjust. Short of an epidemic or a Katrina in their neighborhood, this is not impossible. Fire and police departments do it every year. I think we have been too indulgent in letting health systems (and colleges) force us to bear their costs.

Thanks for your thoughtful input as always.

Guest
Jul 14, 2012

Very Sad Story. I respect your article. It will be valuable to anybody who utilizes it, as well as myself. Keep doing what you are doing.

Guest
Jul 14, 2012

This jumped off the screen at me–
surgeons should inform the patient about the volume-outcome relationship and that she would likely have a lower chance of dying if she had the operation at a higher volume hospital.

As a non-medical caregiver in my post-retirement life I can relate to the practice-makes-perfect observations. I never saw an ostomy before last year but with a bit of OJT coaching and a couple of You Tube videos I was off and running. After fifty or sixty applications I have become really good at emptying and replacing those bags and wafers. You’re never too old to learn new skills.

Routine care can result in danger to the patient (or resident). One moment of carelessness or common tripping hazards can contribute to a fall in the bathroom or anywhere. But surgery is far more risky. It seems to me some kind of risk scoring system is needed. I wouldn’t be surprised if the insurance people already have such a metric but it may be closely-guarded proprietary information.

(I’m leaving a comment mostly to be notified as more comments are added. With this many from most of the right people in less than 24 hours something tells me this will be a very informative thread.)

Guest
Pat S
Jul 14, 2012

In response to some of the comments suggesting this is mostly financially driven, let me suggest that it is at least as strongly driven by issues of prestige and public relations. Although the two issues are closely related, many centers are more concerned that they will be labeled second rate than that they will lose a handful of procedures each year.

While this obviously has some impact on financial performance, pride may be more important.

There are also a couple of financial issues that affect this issue. First, when Medicare patients are transferred from one institution to another, the associated DRG is unbundled in a way that works to the disadvantage of the referring hospital. Work done to stabilize and diagnose the patient is under reimbursed compared to payments if the patient is treated definitively at the original center. Second, patients who are either not insured or who are insured by Medicaid are often very hard to refer out. Although the original center is often forced to accept patients as emergency admissions because of legal requirements, there is no legal obligation to accept the patient in transfer for definitive surgery. I have seen this be a problem for patients with no insurance, with Medicaid coverage, and sometimes with private plans with large co-pays and deductibles or low caps. Inviting another center to accept losses in the tens or hundreds of thousands of dollars can be a very hard sell. Some patients can be left at a less capable center not because the center wants to keep them, but because no one else will take them.

Guest
Barry Carol
Jul 14, 2012

Pat S. –

Thanks for the very informative comment as usual. You raise three separate issues here.

First, with respect to the uninsured and those insured by Medicaid, this is an issue that policymakers need to address. We need to find a way to get the uninsured covered and Medicaid reimbursement rates probably need to be raised closer to the Medicare level. That will be tough to accomplish in the near term due to fiscal realities at both the federal and state level.

Second, for patients with Medicare coverage, either CMS should be able to fix this by tinkering with how they handle DRG unbundling or the sending and receiving hospitals might be able to work something out between them so the referring hospital can at least recoup its costs assuming it’s efficiently run.

As for the issue of institutional pride, I suggest that the leaders who have these thoughts should ask themselves: what if the patient were my family member? Would they really want to subject their family member to the possibility or even likelihood of a less favorable outcome because they’re afraid they might lose institutional standing? If the answer is yes, shame on them.

Guest
steve
Jul 15, 2012

It is my understanding that Medicare reimbursements are also tied to the acuity of patients being treated. Smaller hospitals are under pressure to do bigger procedures to increase revenues.

Steve

Guest
southern doc
Jul 14, 2012

The problem is caused by CMS and private insurers paying way too much for procedures and their fellow-traveler radiology studies, lab tests, pathology,etc. Hospitals wouldn’t be competing to do them if they weren’t so lucrative.

Pay for procedures the way they pay for office visits (in the case of Medicare, overhead minus 10%), and a large part of the problem will be solved.