You are probably familiar with the CMS “never events” initiative. CMS has decided it will not reimburse hospitals for treatment related to complications that it says should never occur. Here is the current list.
Foreign object retained after surgery
Stage III and IV pressure ulcers
Falls and trauma
Manifestations of poor glycemic control
Catheter-associated urinary tract infection
Vascular catheter-associated infection
Surgical site infection after coronary artery bypass graft, bariatric surgery for obesity and certain orthopedic procedures
Deep vein thrombosis/pulmonary embolism after certain orthopedic procedures
According to American Medical News, two more complications have been proposed as additions. One is acquired conditions stemming from cardiac implantable electronic device surgeries and the other is iatrogenic pneumothorax associated with venous catheterization.
I have no problem with some of the items on the list. Foreign bodies like sponges or instruments should not be left in patients after surgery. Air embolism and blood incompatibility should be 100% preventable.
But I do not see how catheter-associated UTIs or vascular catheter associated infections can be completely prevented. Some sick patients with depressed immune systems are going to get infections.
I believe it is impossible to completely prevent wound infections in all clean cases. As has been shown in studies of SCIP compliance, some patients get wound infections after colon surgery despite the timely use of the right antibiotic.
DVT/PE cannot be prevented in every orthopedic procedure. I am unaware of any DVT study in which no patients in the experimental arm developed DVTs or PEs. Patients will develop DVT or PE even with the best evidence-based care.
With very few exceptions, every large published paper on central line insertions, even those using ultrasound guidance, reports some instances of post-procedure pneumothorax. There is no way it can be completely avoided. For example, this study of 937 ultrasound-guided central line insertions reported 2 (0.2%) post-procedure pneumothoraces. That’s a published study by radiologists. The real world incidence of pneumothorax is much higher, often quoted at 2-5%.
To me, these rulings are simply a way for CMS (and other payers who are sure to follow suit) to avoid paying. Where is the input from “organized medicine”? Was any evidence-based research looked at by those who decided all this?
Why are we allowing this to go unchallenged?
Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For 2 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 230,000 page views, and he has over 3,200 followers on Twitter.