How Aggressive Is Your Hospital? - NYTimes.com

One morning during my training, I noticed that the belly of a patient in the I.C.U. had grown rounder and tighter overnight. The patient had gone through a difficult liver transplant a day earlier and was bleeding, it seemed, into his abdomen. I was the newest member of the transplant team, but even so, I knew what had to be done right away: We had to take this man back to the operating room.

But I hesitated for a moment. Not because I was unsure of whom to call or how to go about scheduling an emergency operation at the hospital. I paused because I wanted to brace myself for what I imagined would be the reaction of the surgeon in charge.

Wiry and impeccable in his person, the head surgeon of the transplant team was considered one of the finest, and most fearless, in his field. Patients whom others would have considered too far gone or who would have normally just lingered and died made Lazarean recoveries under this doctor's meticulous care. But my guess was that he wouldn't be happy to hear about a complication. Particularly one serious enough to require an urgent return to the operating room.

I was wrong. The doctor barely flinched when I told him the news. Instead of the blast of angry expletives I'd feared, I was greeted with a calm and simple request: "Book him for a take-back to the operating room."

When I later relayed the morning's events to a friend, another surgeon-in-training who was ahead of me in the same program by a year, he laughed. "It's not a lack of complications that makes a great surgeon," he said. "It's being aggressive about taking care of those complications."

Over the last few years, no other aspect of the health care system has lost its luster as much as aggressive care. Once considered a point of pride and a source of strength, aggressive care has now been transformed into the whipping boy for health care reformers of all stripes. Armed with data that shows geographic variations in spending and the outcomes of patients who have recently died, politicians from both sides of the aisle, administration officials and even insurers have transformed the nuanced caveats of the research into a broad "more-is-worse" rallying cry. In this heated environment, restricting payments to hospitals whose total expenditures, total I.C.U. days and total hospital days exceed the norm has become a foregone conclusion so appealing that even usually wary consumer watchdog groups have enthusiastically added their own licks.

The notion that aggressive care leads to worse outcomes has been easy to buy into because it seems to offer an easy remedy for spiraling costs while playing into our worst fears about overzealous health care providers.

But in journals and in newspapers there have been a few brave voices issuing cautions. And most recently one group of researchers has gone so far as to say that at least for one group of patients, hospitals that offer aggressive care are better than those that don't.

Analyzing the insurance claims data of more than four million Medicare patients admitted for vascular, orthopedic or general surgery operations, researchers from the University of Pennsylvania in Philadelphia and the University of Illinois in Chicago found no difference in the rate of complications for aggressive and nonaggressive hospitals. But when they looked at all the patients who had complications and examined their outcomes, the researchers found that regardless of the urgency of their operations, those patients who were cared for at more aggressive hospitals were significantly more likely to survive their complications than those who had their operations at less aggressive hospitals.

"There is something that is going right at those more aggressive hospitals," said Dr. Jeffrey H. Silber, lead author and a professor of pediatrics and health care management at the University of Pennsylvania and the Children's Hospital of Philadelphia. "Aggressive hospitals don't increase your chance of complications, but they decrease your chance of dying if you get a complication because you survive those complications better."

Referred to as "failure to rescue," the inability of a hospital to help its patients survive surgical complications may be a more accurate measure of quality than traditional indicators. Mortality rates, for example, are as dependent on the general health of a hospital's patient population as they are on the quality of care delivered. "The best hospitals are going to attract the sickest and most complicated patients, and that will inevitably taint mortality rates," Dr. Silber noted.

While Dr. Silber and his co-investigators found that a hospital's failure or success in treating surgical complications correlated consistently with factors that also characterized intensity of care — general expenditures, intensive care unit use and the total days of hospitalization — they found that benefits of this more aggressive care extended well beyond the time of the operation. "It's not like these patients were filled up with antibiotics only to die later," Dr. Silber said.

Clearly, lowering health care costs and increasing quality and efficiency will require approaches far more complex than broad penalties for hospitals that offer more aggressive care. "Most people have been saying that the health care system is too aggressive, implying that aggressiveness is bad because people are being operated on unnecessarily or too much stuff is being done on them and can harm them," Dr. Silber said. "But we have to do detailed research that compares the effectiveness of different treatment approaches, because aggressiveness is not necessarily bad and may in fact be sometimes associated with better outcomes."

He added, "We need to rein in expenditures, but we need to do it very carefully."

http://www.nytimes.com/2011/02/03/health/views/03chen.html

0 comments:

Post a Comment