Risk reduction in elective surgeries
Incentivizing risk reduction for elective procedures.
Few would disagree that patient health should be optimized prior to elective surgery to decrease complication rates. In the United States there is a well intentioned movement to increase public reporting of complication and readmission rates around elective surgeries (by hospital, not by surgeon as of yet). In addition, hospitals may be financially penalized for readmissions and complications in the future.
Some risk factors for complications and readmissions such as diabetes control, weight loss, coronary artery disease optimization and smoking cessation can be very difficult to optimize.
Making hospitals responsible for complication rates from a financial and public reporting standpoint is conceptually an excellent idea. However the danger is that this may limit access to care for sicker patients, as hospitals become more concerned about complication risk. Risk adjusted outcome scoring can be used for challenging patients, but it is difficult to assign a cumulative risk for patients with multiple medical co-morbidities.
Some health systems have taken an alternative approach and have gone so far as to place hard stops for elective surgery. For instance as I understand it the National Health System in the United Kingdom currently limits elective hip and knee replacement to patients with a body mass index under 35 kg/m2.
What is the best way to incentivize the improvement in health of patients prior to elective surgery; 1. front end rules or guidelines limiting surgery to patients who meet certain criteria, or 2. back end financial and public relations incentives to drive a reduction in negative outcomes. Or we are certainly open to option 3…….
I am not in favor of front end rules. While this works to help decrease readmissions and complications, it is an imperfect science and there are still many patients that may fall outside of the established criteria that will do very well. To use the obesity example, although there are increased risks for hip and knee replacement patients with increased body mass, the success rates in those that are obese are still quite good, with more than 90% reporting good to excellent results. Some of these are going to be younger patients that are still working, and who may not be able to work if they don’t have the surgery, then they fall into the ranks of the unemployed and we end up paying for them in someone else’s budget. I don’t like the idea of denying or rationing care, it sets a bad precedent and where do you draw the lines?
I think there has to be a component of patient responsibility, either financial or otherwise, and even more of one if they have modifiable risk factors that they have not corrected. If you smoke or are obese, etc., it will cost the patient more out of pocket.
Working with front end rules can be performed, @Bergman this is what we do for a living. We only perform surgery on ASA 1 & 2 pt’s, which allows us to do it better planned and at lower costs. For more complicated Pt’s we work with general hospitals that get higher payments for these more compex surgeries.
Well that’s reasonable but one would call that “cherry picking”. May I ask what happens if you refer your ASA II-V patients to other clinics – do you receive a kick-back?
Joe, although I fully understand your points about patient selection, I do favor front end rules. I think they help identify patients where it is safe to proceed. As you said, though, there are many who really do need a procedure to continue to function. We are trying to develop a hybrid model for our total joint program. We will have rules; patients who meet the criteria can be scheduled by their surgeon. Patients who do not meet the criteria can request an exception. Exceptions would go to a panel of clinicians who review the case, the risk factors, and decide whether that patient is well enough to proceed with surgery. It takes the selection process for high risk patients away from the surgeon (which is often wanted by the surgeon) and on the system.
I spend my clinical time specializing in the care of patients that are high-risk. In fact, the vast majority of my patients have been turned down for conventional heart valve surgery and are referred for a less invasive option. They are high risk from a multitude of perspectives. Certainly they are of advanced age, frail, debilitated, and have multiple medical co-morbidities, in addition to the heart issue they present with. Our standard of care for these patients is to have them seen in a multidisciplinary clinic where myself(cardiologist), a cardiac surgeon, and a geriatric specialist see the patient and review the case in real-time together. The discussion of risk-benefit is significantly improved when physicians are working together to treat these high-risk individuals. And sometimes, the decision is we can’t help everyone.
One of the biggest improvements we made in surgical care was after getting NSQIP. Understanding we have areas to improve led to introspection, and specifically the pre-operative risk calculator. We actually validated the calculator for our population (oncology) and saw benefit in using it in the pre-op clinic. As a result of this process, anyone in the surgical process can call a high risk meeting where the surgery plans are peer reviewed. This has led to either going ahead with the surgery, delaying the surgery with “prehab” or not doing the surgery and looking towards other options for the patient.
Public reporting of outcomes can be a 2 edged sword. On the one hand, hospitals and physicians can be graded and held accountable for outcomes, and risk adjustment is often used in an attempt to “level the playing field” and not penalize physicians or programs that care for a larger percentage of higher risk patients. However, the system can be gamed and not accurately reflect the quality it supposedly delivers. While training in NY, which was one of the earliest to publicly report physician outcomes with CABG, I witnessed a dramatic increase in ancillary procedures being performed on higher risk patients because it would knock those patients out of a reportable category. This clearly circumvents the spirit if not the intent of outcomes reporting. Additionally, a significant number of patients were denied potentially life saving procedures out of concern that a physicians’ report card may be negatively effected and business lost as a result. Bottom line is that any system that acts as a disincentive to care for patients, even those with many co-morbidities, may not reflect well on the practice of medicine.