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Poor Surgical Outcomes for Safety-Net Hospitals


NEW YORK - Hospital resources, and not necessarily patient characteristics, may be causing safety-net hospitals to deliver inferior surgical outcomes at increased cost in elective surgical procedures, according to a new study.

"Analysis of Medicare Hospital Compare data revealed that safety-net hospitals perform worse on Surgical Care Improvement Project (SCIP) measures and have less efficient emergency departments throughput," first author Dr. Richard S. Hoehn from the University of Cincinnati, Ohio, said by email. "This last category indicates that these hospitals have insufficient staffing and/or resources to handle their patient burden."

"Safety-net hospitals care for a vulnerable population and maintain an open door to all patients, regardless of their ability to pay. Our study of nine major surgical procedures at academic medical centers in the United States found that hospitals with the highest safety net burden have the most patients of low socioeconomic status, extreme severity of illness, and in need of urgent surgery," Dr. Hoehn said.

"These hospitals also had the worst mortality and readmission rates and highest costs for most procedures. After controlling for patient age, race, severity of illness, and socioeconomic status, safety-net hospitals still had worse outcomes. Their inferior mortality and readmission rates were somewhat reduced, but the increased costs observed at these centers persisted, implying that other characteristics intrinsic to safety-net hospitals are associated with increased costs," he added.

Dr. Hoehn and colleagues analyzed outcomes for nine surgical procedures at 231 hospitals in the University HealthSystem Consortium over a four-year period ending in 2012, accounting for more than 12.6 million patient encounters. They sorted the hospitals into high safety-net burden (HBH) versus hospitals with low (LBH) or medium (MBH) safety-net burden.

They found the HBHs overall to have the most patients likely to be young, black, have the lowest socioeconomic status, and have the highest severity of illness and the highest cost for surgical care (p<0.01 for all). They also had the highest proportion of patient-emergent cases and the longest lengths of stay (p<0.01 for all).

After the researchers adjusted for patient characteristics and hospital volume, the HBHs still had higher odds ratios of mortality for three procedures (OR, 1.81 to 2.08, p<0.05), readmission for two procedures (OR, 1.19 to 1.30, p<0.05), and the highest cost of care for seven procedures (risk ratios, 1.23 to 1.35, p<0.05).

Postoperative mortality was worse for colectomy, esophagectomy, pancreaticoduodenectomy, and ventral hernia repair. Readmission odds were higher for coronary artery bypass, colectomy, kidney transplant, and ventral hernia repair.

"[W]hen assessing markers of emergency department throughput, HBHs were inferior to LBHs in all measures, including time from arrival to evaluation, admission decision time, times from arrival to departure for discharged and admitted patients, time for pain medicine administration to patients with long-bone fractures, and patients who left without being seen (p <= 0.002 for all)," the researchers write in JAMA Surgery, online October 14.

In an accompanying editorial, Dr. Larry R. Kaiser of Temple University School of Medicine, Philadelphia, and colleagues note, "At best, emergency department throughput as a surrogate for staffing adequacy and systems efficiency is an indirect estimate of these important hospital factors. Deficiencies in documentation and coding may or may not be influenced by overall hospital performance but could have a significant influence on expected rates of death and complications."

Dr. Kaiser said by email, "Physicians and surgeons should be very careful in drawing substantive conclusions from the study because of factors we don't know about these patients. Let the message be greater resources should be provided to those hospitals bearing the burden of caring for this underserved population of patients who, if anything, are more complex than commercially insured patients with similar problems."

"It's important to acknowledge that this study is not trying to criticize safety-net hospitals," Dr. Hoehn emphasized. "We are trying to highlight the unique situation these providers face, and also show that current policy changes that financially penalize these hospitals may adversely impact surgical care and further exacerbate the disparities in health care that already exist in our country. Safety-net hospitals in America have always been important institutions that train doctors and care for indigent patients, and our goal is to find a way to preserve this model in the face of changing healthcare policy."

Dr. Hoehn continued, "There are two options to improve the care at these centers: either close these hospitals and send their patients elsewhere or invest in initiatives that will allow these hospitals to improve not only their outcomes but also their efficiency. To do this, we must better understand their needs."

Dr. Kaiser said, "Continued scrutiny of outcomes with transparency and sharing of data with all those involved in the care of patients will result in continued quality improvement. Participation in [universal health care] that allows institutions to benchmark their data with similar institutions will tend to push those who need improvement to continue to improve."

"There must be a concerted effort among all involved in caring for patients at an institution to continue to improve quality. The designation of a chief quality officer working in concert with the chief medical officer also is critically important in working toward improved quality. But all of this depends on accurate recording and reporting of quality metrics," he concluded.

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