Risky Business

A report has just been published by the Royal College of Surgeons of England entitled “The Higher Risk General Surgical Patient: towards improved care for a forgotten group”. It is a very sobering examination of the outcome in non cardiac emergency surgery.

Higher risk non-cardiac general surgery is undertaken in every acute hospital. By way of comparison, the mortality for this group, which includes most major gastro-intestinal and vascular procedures, exceeds that for cardiac surgery by two to three fold and complication rates of 50% are not uncommon. There may be a lack of awareness of the level of risk. Among these patients, emergency surgery and unscheduled management of complications is common and this group of patients are one of the largest consumers of critical care resources. The health and financial costs are considerable. 

The most amazing statistic in this paper is the fact that “Complications occur in as many as 50% of patients undergoing some common procedures.”
My pet interest of variation in care and outcomes is addressed.

Review of 2008/9 hospital episode statistics (HES) data from Dr Foster reveal a greater than two-fold variation in relative risk of 30-day mortality (risk-adjusted) after non-elective lower GI procedures between trusts in the North West SHA (strategic health authority). It is known that the chance of a patient dying in a UK hospital is 10% higher if he or she is admitted at a weekend rather than during the week.

Anyone involved in ensuring good outcomes for surgical patients, or ensuring that hospital resources are used efficiently, (by reducing unnecessary complications) needs to read this.
 
 

Health care spend, any room to reduce it?

While not strictly looking at quality and cost at a hospital level, a paper just published by OECD examines the potential for savings in health expenditure. It suggest that countries can achieve savings up to 5% of GNP by all countries becoming as efficient as the best performing countries. Note that there does not appear to be much if any correlation between healthcare spend and outcomes across countries. The authors suggest that countries by reaching the level of the best performers would increase life expectancy at birth by two years; in contrast a 10% rise in health expenditure would increase life expectancy by three to four months.

Culture eats strategy for lunch

The title of this post refers to an oft quoted piece in business and change literature; to paraphrase, you can have a great plan but if it doesn't take into account the culture of the organization, you will fail. This I think is the crux around which healthcare reform and quality improvement specifically will succeed or fail. This is the great intangible that must be isolated and measured, so that we can truly begin to determine how healthcare providers differ from one another in terms of the quality of the service they deliver. As doctors we believe that the keys to a great service are world class doctors, state of the art facilities, the latest in IT; basically the best that money can buy.

However a study just published in the Annals of Internal Medicine, link here, (subscription required), suggests that this credo is incorrect. Curry et al interviewed 158 staff members from 11 hospitals, which were either in the top or bottom 5% nationally in the US for mortality post heart attack. The factor most highly correlated with outcomes was a cohesive organizational vision that focused on communication and support of all efforts to improve care. In other words, it was the culture, the communication ethos, mutual respect, leadership and desire to improve that should determine where you want to be treated, not all the high tech stuff and big names. This is consistent with my own observations nationally and internationally. All hospitals have problems, the high performers are the ones that seek out the problems and respectfully engage all their staff and leadership to solve them. It is my strongly held belief that one can distinguish between the high and low performers within an hour of visiting them.

Previous studies have suggested that the traditional factors that underpin success include being an academic medical centre, having more beds, and being located in a large city. Curry found that these factors accounted for only 20% of the difference. This is a very significant study, and provides ammunition for those of us who believe the system can be dramatically improved without massive expenditure; the down side is that changing culture can be extremely difficult.