Physicians

See One, Do One, Harm One?

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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GHD Rarechristian louboutin modelBenoit BlondeauDeterminedMDMichael Millenson Recent comment authors
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GHD Rare
Guest

So, it could be concluded that hair straightener is safe as long as it is use correctly keeping the precautions in mind.
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christian louboutin model
Guest

Hva Gapastione ikke hadde forventet var kontakt fra Alexi Giannoulias. Senatet kandidat christian louboutin brown thomas kalt Al Joe kort tid etter segment på FOX News gikk på lufta. Gapastione, og bemerker at han ikke hadde christian louboutin sales sendt et brev til Giannoulias sa, Han bare så stykket på TV og ringte meg. Giannoulias sendte noen representanter red bottoms christian louboutin fra hans kontor for å forklare dagens programmer som hjelper små Illinois bedrifter beholde lavere renter.
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Benoit Blondeau
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Benoit Blondeau

Currently, physicians and hospitals perform what they want on whom they want, except as mentioned above transplant and may be other specialized care, shocking isn’t it? Fortunately, there are guidelines and common sense, to assist in patient care. Unless you are a VA patient, where each facility is assigned a level of care (not all VA provide open heart surgery or organ transplant or even colectomies). When a patient presents with a condition that cannot be addressed locally, she is referred to the VA institution with the appropriate level of care. The above-mentioned story is sad. Sad and partial. We… Read more »

DeterminedMD
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DeterminedMD

I would just like to say this seeing my comment was retained to now: I am surprised but appreciative it was kept. Per the Baltimore Sun Newspaper printing this shows guts in making sure all the facts are related to the public. Maybe a PR ploy to support Hopkins, or some other agenda I cannot surmise after some contemplation, but, it does show the agenda of the legal system in attacking doctors until proven otherwise. People write above that Hopkins should report poor clinical care when seen, and I wholeheartedly agree. But, why is it paraprofessionals, and that is how… Read more »

Michael Millenson
Guest

Peter1: I think your point about reporting to the medical board is a persuasive one; I’d like to see a response from those who believe otherwise.

As for DeterminedMD:
i’m not sure who wants to marginalize physicians. I would say the opposite: demanding that doctors practice medicine as flawlessly as thoughtful system design and human nature allow is an implicit recognition of physician importance: with great power comes great responsibility.

DeterminedMD
Guest
DeterminedMD

Although I have essentially been censored from this site, I believe after reading this post and the accompanying thread that readers should know all the facts to what goes on these days with the push for non physician care and then who gets the liability assault when consequences do play out. The following link has nothing to do with the case above, but, involves Hopkins, and I think it nothing less than outrageous that the case was litigated without the involvement of the midwife who has since lost her license. The situation?: http://www.baltimoresun.com/health/maryland-health/bs-hs-hopkins-malpractice-midwife-20120713,0,5002415,full.story I hope the link works because I… Read more »

Michael Millenson
Guest

This is an important story — but highlights the crucial difference between an “insider” blogger and outside accountability of the type that is provided by journalists, regulators and others. I think Dr. Pronovost was correct not to mention his concerns about the initial hospital’s qualifications to the patient. And he does a tremendous public service in telling this story publicly because of who he is AND how cogently and clearly he frames the issues. This is unusual. And yet: that same hospital could do the same thing tomorrow. If Dr. Pronovost were to name it in his blog, he might… Read more »

Peter1
Guest
Peter1

“I think Dr. Pronovost was correct not to mention his concerns about the initial hospital’s qualifications to the patient.”

“And yet: that same hospital could do the same thing tomorrow.”

“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.”

Michael, under what circumstances would you expect action by a medical facility toward another to result in the word “preventable”? Why is an examination by the state board not appropriate where BOTH sides could be examined?

Maggie Mahar
Guest

I agree with Peter 1 that Hopkins should have reported this case to the state board. Ideally, a physician would also report it, but in too many cases, an individual physician would be exposing himself to a lawsuit he couldn’t afford. (In this regard, laws have to be changed.) Hopkins, however, would be in a position to do it– unless, as Peter 1 suggests, it is worried about the politics of the sitution. Obviously a woman’s life is more important that inter-hospital politics. And Pat is right that this is about prestige and public relations as well as money (though… Read more »

J. Stefan Walker, M.D.
Guest
J. Stefan Walker, M.D.

This underscores your call in other posts for standardization of healthcare delivery, and resonates with Atul Gawande et al. Future generations will be appalled at the blatant lapses in quality of care we are still allowing. But being upset or appalled is not doing anything about the problem. Besides implementing meaningful use of EHRs in our clinics, how can PCPs like myself adopt evidence-based standardized approaches to primary care delivery, to create cockpits in private practice, akin to the work in the ICU which you champion? There are great lapses in primary care which will only be addressed by an… Read more »

Peter1
Guest
Peter1

“Ms. K, an elderly black woman” Poor, with little education and virtually no PCP care? “The team asked why the hospital would perform an operation in which it has little experience.” Practice? If she’s poor without an advocate then what’s the risk and they can transfer if complications as Pat S points out. “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… Read more »

John Ballard
Guest

Ouch!

southern doc
Guest
southern doc

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.

Barry Carol
Guest
Barry Carol

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… Read more »

steve
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steve

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

Pat S
Guest
Pat S

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… Read more »

John Ballard
Guest

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… Read more »

dana dcosta
Guest

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.