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.
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.
“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.”
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.”
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.