Surgery

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MRIs, Back Surgery and Primary Care

June 30, 2011 in Physician Compensation, Specialists, Supply of Medical Services | No comments

Do MRIs increase the liklihood a patient receives back surgery?

“Orthopedists and primary care physicians who begin billing for the performance of MRI procedures, rather than referring patients outside of their practice for MRI, appear to change their practice patterns such that they use more MRI for their patients with low back pain. These increases in MRI use appear to lead to increases in low back surgery receipt and health care spending among patients of orthopedic surgeons, but not of primary care physicians.”

What is it about patients who see primary care physicians that makes them less likely to get back surgery. I can think of a number of reasons:

  • Financial Incentives: Primary care physicians would not be the ones performing the surgery and thus have no financial incentive to favor surgery over rehabiliation.  Orthopedists who self-refer the surgery stand to gain thousands of dollars from this decision.
  • Provider Selection. Doctors who decide to become primary care physicians may favor less invasive treatment.
  • Patient Selection. Patients who visit primary care physicians may favor less invasive treatment. Or, patients who visit primary care physicians may be more likely to have lower income and less generous insurance coverage, and thus may be more likely not to opt for the back surgery.

Source

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Surgical Complications and Mortality Rates

December 16, 2009 in Hospitals, Medical Studies, Surgery | No comments

Mortality during surgery is dependent on two factors.  The first is the probability of having complications during surgery.  The second is the probability of dying conditional on having a complication.  One would expect that hospitals with low mortality rates would have both fewer complications and lower probability of death conditional on a complication.  

A paper by Gheferi, Birkmeyer, and Dimick (NEJM 2009) shows that this may not be the case.  After risk adjustment complication rates were not significantly higher in high mortality hospitals.  However, conditional on there being a complication, mortality rates were much higher in high mortality hospitals than low mortality hospitals.  

 

In Hospital Mortality (Gheferi et al. NEJM 2009)

How can doctors decrease mortality due to complications?  Gheferi, Birkmeyer, and Dimick recommend “timely administration of antibiotics in patients with sepsis, the rapid transfer of a patient to an intensive care unit (ICU), and the availability of interventional cardiologists during an acute myocardial infarction.”

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Economics 2.0: Are more experienced Heart Surgeons better?

April 23, 2009 in Quality, Specialists | No comments

According Economics 2.0′s review of Huckman and Pisano (2006):

WIth each additional operation the surgeon preforms in a clinic, the mortality factor of his or her patients there drops by 0.018 percentage points.  When that doctor performs an operation in another clinic during the same three-month period, patients’ death rates decline by only 0.001.  

Few heart surgeons are employed directly by hospitals.  Most cardiac surgeons work as independent contractors who operate on their patients in a variety of hospitals. It seems that when cardiac surgeons are more comfortable with their surroundings and have more established relationships with the nurses, anesthesiologists, and other support staff in the hospital, performance improves. The authors claim the following:

“The quality of a surgeon’s performance at a given hospital improves significantly with increases in his or her recent procedure volume at that hospital but does not significantly improve with increases in his or her volume at other hospitals. Our findings suggest that surgeon performance is not fully portable across hospitals (i.e., some portion of performance is firm specific). Further, we provide preliminary evidence suggesting that this result may be driven by the familiarity that a surgeon develops with the assets of a given organization.

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Medical Errors and Ninety-Day Cost and Outcomes

February 6, 2009 in Hospitals, Supply of Medical Services | 3 comments

A hospital is a place of healing.  It can also be a place of injury.  In the U.S., 2.9% of people who enter the hospital are actually harmed by the care they receive.  Yet what are the costs of these injuries?

A paper by Encinosa and Hellinger (HSR 2008) attempts to estimate the cost of hospitals failing to prevent advser medical outcomes.  The authors examine 14 patients safety indicators (PSIs) such as: anesthesia complication, accidental laceration, foreign body left in, iatrogenic pneumothorax, transfusion reaction,  infections due to medical care, sepsis, pulmonary embolism and deep vein thrombosis, acute respiratory failure, physiologic and metabolic derangements, hemorrhage/hematoma, wound dehiscence, postoperative hip fracture and decubitus ulcer. 

The authors found the following results:

“Excess 90-day expenditures likely attributable to PSIs ranged from $646 for technical problems (accidental laceration, pneumothorax, etc.) to $28,218 for acute respiratory failure, with up to 20 percent of these costs incurred postdischarge. With a third of all 90-day deaths occurring postdischarge, the excess death rate associated with PSIs ranged from 0 to 7 percent. The excess 90-day readmission rate associated with PSIs ranged from 0 to 8 percent. Overall, 11 percent of all deaths, 2 percent of readmissions, and 2 percent of expenditures were likely due to these 14 PSIs. ”

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Book Review: The Great American Heart Hoax

January 13, 2009 in Books | 2 comments

A new book by Dr. Michael Ozner takes on the cardiovascular surgery industry head-on.  The aptly titled Great American Heart Hoax claims that although insurers pay $60 billion per year  invasive cardiovascular surgery, 70%-90% of these procedures are unnecessary.   The book has three major themes: What is heart disease?  Why is heart surgery a hoax?  and What is the solution?

What is heart disease?  

The book has a nice summary of some of the risk factors from heart disease as well as the types of cardiovascular surgeries.  Dr. Ozner also describes the different the side effects from bypass surgery and pharmaceuticals used to treat atherosclerosis.  This portion of the book is educational and clearly explained.

Why is heart surgery a hoax?

Dr. Ozner cites numerous studies demonstrating that bypass surgery does not generally help heart patients.  Two studies–the Coronary Artery Surgery Study (CASS) and the European CASS–both found that “a majority of patients who underwent bypass surgery did not live significantly longer or have fewer heart attacks than those who did not undergo surgery.”  However, bypass surgery can be beneficial for patients with “critical left main coronary artery disease and a weak heart muscle, and patients with severe disabling chest pain despite maximal medical therapy.”  Most patients who undergo bypass surgery, however, do not fall into these groups.

Dr. Ozner also criticizes the use of other surgical procedures.  The Atorvastatin Versus Revascularization Treatments (AVERT) Trial found that “the lives of patients treated with angioplasty were not significantly prolonged compared to similar patients who received medical therapy alone, nor did they suffer fewer heart attacks.”  Stents were also shown to be problematic in the Occluded Artery Trial.  

Even CAT scans are dangerous because they expose patients to excessive radiation.  CAT scans can be useful when heart disease symptoms appear, but Dr. Ozner finds that CAT scans are counterproductive for healthy patients.  When the doctor conducts a CAT scan, it may substitute for time spend taking the patient’s medical history–which is much more useful. 

The problems with these types of surgeries are certainly the heart of the book.  Financial incentives, however, continue to give doctors the motivation to continue performing these surgeries.  Showing that these high cost surgeries may not be in the patient’s best interest is the most important contribution of the book.

What is the solution?

This portion of the book is fairly disappointing.  Dr. Ozner’s solution is to eat healthier and exercise more.  This is nothing new.  In the “eating healthier” portion, Dr. Ozner pushes the “Mediterranean Diet” he advocated in an earlier book.  Getting people to eat healthier and exercise is easier said then done.  Deep dish pizza tastes better than broccoli; eating healthier means forgoing some of these tasty treats.  Further, some people enjoy exercise while others dread it.  Working out 30 minutes per day involves a significant time and energy commitment.  Thus, while Dr. Ozner’s solution is sensible, it is not easily implemented.  

Conclusion

Overall the book is important in that it clearly explains the dangers of excessive heart surgery.  However, the solutions of eating healthy and exercising are already well-known and the Dr. Ozner’s support of the Mediterranean Diet dominates the last half of the book.

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A Study in Quality: Ambulatory Surgery Centers vs. Hospital Outpatient Departments

January 7, 2008 in Hospitals | Permalink

There has been a recent trend for more and more surgeries to take place in ambulatory surgery centers (ASCs). In fact according to the Medicare Payment Advisory Commission, in 2004 up to 70% of surgeries took place in these ASCs. Do ASCs offer better quality surgical procedures than Hospital Outpatient Departments (HOPD)?

ASCs may be an improvement over HOPDs because these centers preform a high volume of a few specific procedures which may increase quality. Further, ASCs often have newer equipments than hospitals. On the other hand HOPDs generally have more resources than ASC to deal with complications and economies of scope may help hospitals to provide more effective care.

How do we find out which facility offers better quality? This question seems easy to answer: find a quality metric and measure whether ASCs or HOPDs score higher. The problem is that physicians may choose to conduct surgery on healthier patients at the ASC and perform the surgery on sicker patients in the HOPD. This way, if there are complications from surgery on a relatively sicker individual, the hospital will have more capabilities to deal with the situation. This selection problem, however, can bias studies which simply compare the quality levels of ASCs and HOPDs without taking into account difference in patient characteristics in each facility type.

A study by Chukmaitov et al. (HSR 2007) attempts to measure these quality differences using patient-level surgery data in Florida between 1997 and 2004. The authors attempt to eliminate the selection bias using physician diagnoses (i.e.: DRG/HCC methodology) to quantify the ex-ante and ex-post health status of the patient. The key to this methodology is that the authors also have information on any of the patients’ secondary diagnoses.

With this data, the author do in fact find that HOPDs do have a sicker patient base. Thus, it is important for researchers to correct for this selection problem. Secondly, Chukmaitov and co-authors found that “…neither organizational type (ASCs or HOPDs) performed better overall, there appear to be important differences in quality outcomes for certain procedures. These differences may be related to variations in organizational structures, processes, and strategies between ASCs and HOPDs.”

On problem with the study is that the authors use mortality as their quality metric. A more sensitive metric could better capture quality differences. Also, one may worry about the accuracy of the doctor diagnoses. HOPDs may be more sensitive to DRG creep than ASCs–or vice versa–and this may leaded to an incorrect selection correction methodology.

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