The best magazine
Potentially preventable deaths after complications related to inpatient urological procedures increased from 1998 to 2010, according to a study published online August 19 in the British Journal of Urology International.
"Overall in-hospital death following urologic surgery stayed stable over the study period, but deaths attributable to failure to rescue [FTR] increased 1.5% per year on average," first author Jesse D. Sammon, DO, a researcher at the Vattikuti Urology Institute in the Henry Ford Health System, Detroit, Michigan, told Medscape Medical News. "Older, sicker, and minority patients, as well as those with public insurance, were more likely to [have] a potentially preventable death."
"FTR describes the inability of a provider or institution to recognize key complications and intervene before mortality," Dr. Sammon explained. The concept of FTR comes from a landmark 1991 Institute of Medicine report called "To Err is Human," focused on improving quality of care.
The last 2 decades have seen major improvements in healthcare safety and quality for many types of surgical procedures, resulting in lower overall mortality attributed to FTR. This trend, however, appears to be the opposite for the urological procedures included in this study, according to Dr. Sammon.
Using the Nationwide Inpatient Sample, the largest healthcare administrative database in the United States, Dr. Sammon and colleagues identified all patients who had urologic procedures between 1998 and 2010. They also looked at patient age, race, type of insurance (Medicare, Medicaid, private, or self-pay), and presence of cooccurring health conditions.
Although more than 7.7 million in-hospital urological surgeries took place in the United States during the study period, admissions for urological surgery decreased 0.63% per year (P = .008). In particular, admissions for transurethral resection of the prostate (TURP; performed for benign prostatic hyperplasia) greatly decreased, going from 119,915 in 1998 to 49,829 in 2010. This finding probably relates to shifting TURP to the office setting and improved medical management of benign prostatic hyperplasia, the authors note.
Although the likelihood of mortality from all causes fell about 1% per year (odds ratio, 0.99; 95% confidence interval, 0.99 - 0.99), the likelihood of death from FTR increased 5.0% per year (odds ratio, 1.050; 95% confidence interval, 1.038 - 1.062). Patients who were older, had more comorbidities, had public insurance, and received care in urban hospitals had a higher likelihood of dying from FTR (P < .001).
More low-risk procedures are now taking place in the outpatient setting, Dr. Sammon explained, and patients eligible for ambulatory surgery tend to be healthier. In fact, during the study period, the percentage of patients undergoing inpatient urologic surgery without other health conditions fell from 73.7% to 65.3%.
"This suggests that the inpatient population is, on average, presenting with a higher burden of comorbid conditions," Dr. Sammon emphasized. "Urological surgeons and ancillary staff need to recognize that urology inpatients are [now] generally at higher risk of complications and FTR mortality. A heightened awareness [of] early signs of complications may mitigate unfavorable outcomes."
The trend found by this study is "concerning, but not wholly unexpected," according to G. Joel DeCastro, MD, MPH, assistant professor in the Department of Urology at New York Presbyterian Hospital, Columbia University Medical Center, New York City. Dr. De Castro is also codirector of Urology at Allen Hospital in Northern Manhattan, New York City, which sees a high proportion of patients who are members of minority groups and/or receiving public insurance.
Medicaid and Medicare reimbursements are partially based on existing preventative measures for common surgical complications, Dr. De Castro pointed out, as part of the federal government's effort to improve quality of care.
Studies looking at complications and mortality from FTR, however, are commonly limited by their inability to look at how effectively such measures are implemented in daily hospital care, Dr. DeCastro explained.
"Older patients tend to have more comorbidities, and this places them at higher risk of mortality from FTR," he added. "Similarly, there is likely an interplay between minority status, type of insurance, and socioeconomic status."
Past studies have suggested that lower socioeconomic groups have higher risk for FTR, explained largely by receiving care at hospitals that have higher FTR rates in general (JAMA Surg. 2014;149:475-481). Other studies have found that sheer volume plays an important role: Hospitals that care for larger numbers of patients seem to have better track records at identifying and treating surgical complications (Med Care. 2011;49:1076-1081).
"The message from this study is clear: Better efforts must be made to implement already well-established preventative measures, especially in vulnerable groups," Dr. DeCastro emphasized. "However, established preventative guidelines may not be sufficient for higher risk groups like older and more comorbid patients. Studies into more aggressive measures should be undertaken."
The current study had several limitations including those inherent to administrative databases. Coding errors or changes in coding practice, as well as to the inability to link multiple hospital admissions for the same patient, could have affected results. In addition, the Nationwide Inpatient Sample does not include important variables that can affect surgical complications, such as smoking and body mass index.
One coauthor reports serving on the advisory boards for sanofi-aventis, Dendreon, and Myriad. The other authors and Dr. DeCastro have disclosed no relevant financial relationships.
BJUI Int. Published online August 19, 2014.
Source: ...