CME: The Impact of Hospital Care Intensity on Surgery Outcomes

CME: The Impact of Hospital Care Intensity on Surgery Outcomes
Author Information (click to view)

Kyle H. Sheetz, MD, MS

Resident, General Surgery
Research Fellow
Center for Healthcare Outcomes and Policy
University of Michigan Health System

Kyle H. Sheetz, MD, MS, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

 

  1. Discuss the findings of a study that assessed at the relationship between a hospital’s care intensity and outcomes following seven common major surgeries among Medicare beneficiaries.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwNov3.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

FACULTY DISCLOSURES

Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Kyle H. Sheetz, MD, MS
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
 
AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Kyle H. Sheetz, MD, MS (click to view)

Kyle H. Sheetz, MD, MS

Resident, General Surgery
Research Fellow
Center for Healthcare Outcomes and Policy
University of Michigan Health System

Kyle H. Sheetz, MD, MS, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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High–care intensity hospitals appear to be slightly better at saving lives than lower–intensity care institutions, but they also have slightly higher rates of major complications. Hospitals may benefit by focusing more on the early detection, management, and even prevention of potentially life-threatening complications.
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Throughout the United States, use of aggressive treatment styles has been implicated in rising healthcare costs. Significant expenditures can accrue when caring for patients at the end of life as well as during inpatient surgical care. Most studies exploring the effects of aggressive treatment styles have focused on highlighting variations in the medical management of chronic disease, but few analyses have examined the relationship between hospital quality and care intensity for surgical patients.

Recent investigations have suggested that outcomes can improve modestly when patients are treated at high–care intensity centers after general, vascular, and orthopedic surgical procedures, but the extent to which care intensity modifies postoperative outcomes is unknown. “It’s important to examine variation in care intensity for surgical patients because it holds important policy and financial implications,” says Kyle H. Sheetz, MD, MS. It is unclear, however, if efforts to increase care intensity—especially when managing postoperative complications—results in measureable benefits with regard to patient outcomes.

Exploring Relationships

In a study published in JAMA Surgery, Dr. Sheetz and colleagues looked at the relationship between a hospital’s care intensity and outcomes following seven common major surgeries among Medicare beneficiaries. The study also sought to characterize the relationship between indicators of intensive treatment styles and a hospital’s access to resources to care for surgical patients. These data have the potential to enhance payment structures for surgical episodes of care.

After identifying more than 706,000 patients aged 65 and older who underwent major surgery at over 2,500 hospitals, Dr. Sheetz and colleagues calculated the study participants’ post-surgical outcomes. They then evaluated each hospital’s aggressiveness using measures taken from the Hospital Care Intensity (HCI) Index, which has been validated and is publicly available through the Dartmouth Atlas of Healthcare. The HCI index evaluates a hospital’s treatment of Medicare patients during their last 2 years of life.

Examining Results

“Our study showed that intensity of care provided by hospitals varied significantly across the U.S.,” says Dr. Sheetz. The most aggressive hospitals displayed 10 times the intensity of the least aggressive hospitals. “We didn’t observe any major differences in postoperative mortality across low–, average–, or high–care intensity hospitals,” Dr. Sheetz adds (Table 1). However, a small increase in major complication rates was observed among patients who underwent surgery at high– versus low–care intensity hospitals.

High–care intensity hospitals were 5% better at saving elderly patients with life-threatening complications after major surgery when compared to low–care intensity hospitals. However, high–care intensity hospitals also accrued higher Medicare costs, kept patients in the hospital for longer durations, had more inpatient deaths, and were less likely to refer patients to hospice during the last 2 years of life (Table 2).

“High–care intensity hospitals, presumably doing everything in their power to rescue surgical patients from major complications, were slightly better at saving lives, but the benefits of these efforts are questionable,” says Dr. Sheetz. “There was some benefit to being treated at a high–care intensity hospital, but the effect was marginal at best.”

Assessing Implications

The study findings have significant implications for surgeons as well as payers and policy makers. The data are important for surgeons because of the increasing age and preexisting disease burden of today’s surgical patients. Management of these patients and their complications imposes substantial demands on hospitals and groups that finance patient care.

It is becoming increasingly important for surgical care teams to better understand the benefits and drawbacks of efforts to treat patients who experience problems after their operations. It may behoove hospital administration to discuss how best to use its resources when caring for patients who have undergone major surgery. “We are likely better off improving efforts to detect and manage life-threatening complications rather than simply dedicating more resources toward those in crisis,” Dr. Sheetz says. “You can use all of the resources that are available, but it doesn’t necessarily mean that outcomes will improve. A culture of open communication and safety is necessary for surgical teams. This is the focus of our ongoing efforts to understand failure to rescue.”

Looking Ahead

Future research is needed to explore specific practice aspects that differ between high–and low–care intensity hospitals to see if some practices can lead to more effective management of major complications. Such efforts will require expertise and collaboration from surgeons, palliative care specialists, nurses, and ethicists. “Changing the hospital culture to focus more on safety is critical,” says Dr. Sheetz. “We should strive to examine the clinical evidence for and against specific care practices that underlie differences in treatment styles.”

Readings & Resources (click to view)

Sheetz KH, Dimick JB, Ghaferi AA. The association between hospital care intensity and surgical outcomes in Medicare patients. JAMA Surg. 2014;149:1254-1259. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1909804.

Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361:1368-1375.

Birkmeyer JD, Gust C, Dimick JB, Birkmeyer NJ, Skinner JS. Hospital quality and the cost of inpatient surgery in the United States. Ann Surg. 2012;255:1-5.

Silber JH, Kaestner R, Even-Shoshan O,Wang Y, Bressler LJ. Aggressive treatment style and surgical outcomes. Health Serv Res. 2010;45:1872-1892.

Kwok AC, Semel ME, Lipsitz SR, et al. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet. 2011;378(9800):1408-1413.

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