Wednesday, September 16, 2015

"Our patients are sicker."

There are several archetypal lies in America (and other countries!):

"The check is in the mail."

"I'll still respect you in the morning."

"I'm from the government, and I'm here to help you."

"I'm from academia, and I'm here to clarify things."

And many in the medical world have now added:

"Our patients are sicker."

The last Lake-Wobegon-inspired one occurs when you present a hospital leader or a doctor with risk-adjusted data showing that their record on quality and safety is below that of other places.  (An accompanying phrase is often, "I don't believe the data.")

A study from the Annals of Surgery a few years ago (Volume 250, Number 6, December 2009)  refutes this view of the world.  A friend summarizes:

Some people thought that hospitals with higher mortality rates had higher complication rates, but that seems not to be the driving factor behind increased mortality, at least according to this study. Using the Medicare database, this group found that the risk of complications such as pneumonia, MI, hemorrhage, etc. after high risk surgery was only slightly different (36.4% vs. 32.7%) between high and low mortality hospitals; however, the risk of dying from a complication once it occurred (i.e. failure to rescue) was much worse in the worst performing hospitals compared to the best (16.7% vs. 6.8%). This failure to rescue was in fact the major contributor to the 2.5 fold increase in risk-adjusted mortality at the worst performing hospitals compared to the best (8% vs. 3%).  

The authors concluded that high mortality hospitals are "not as good at recognition and management of complications once they occur." Although data on what makes a hospital good at patient rescue is limited, much of it may be related to trigger systems, teamwork, nursing culture and availability of certain services as they outlined in their interesting discussion.

In summary, the way work is organized in a hospital and a culture of communication and respect matter, even if "your patients are sicker."


Barry Carol said...

I wonder if part of the difference between high and low mortality hospitals includes whether or not family members are empowered to call for a rapid response team or at least an attending physician as opposed to a resident if they think it's warranted.

Matt Leo said...

So it's almost true. All you have to do is change one little word: Our patients get sicker.

Roger said...

Thanks for sharing these canards!

The response of medical staff and hospital leaders to adverse performance data is telling. Despite hearing "Risk-Adjusted", too many want to circle the wagons in the false belief that they are protecting the reputation of the medical profession or the hospital. True leaders will doff their protective attire and engage in solving the problem.

Mitch said...

Excellent post, and one of the reasons people demand services like Leapfrog. If such services are misleading or innacurate the hospital industry needs to fix it. At the most basic level, they need honesty and trasnparency. Most will fight the latter as I suspect there are a few really good ones and the majority are anti-Wobegons, actually below average.

Mike said...

This chimes well with Donabedian's quality model. I paraphrase slightly:

To get a quality outcome (reduced mortality) you need to take account not only of inputs (patient acuity amongst other factors) but also Process (response to deterioration). So those who claim sicker patients are ignoring the Process component in the model. Now is that ignorance or a deliberate act? Because I'm an optimist I'd opt for the former over the latter.