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Seven Days After Discharge: Studies Show Unintended Costs and Complications of Routine Surgery in the United States

Apr 28, 2014, 3:00 PM

New research shows that where you receive surgical care does matter, and the quality measures driving patient care may not be telling the whole story.

Supported by the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, 12 studies were selected for inclusion in the May issue of Surgery. These studies provide important insights into the risks and benefits of different procedures, fresh insights into surgical outcomes, and reasons hospitals may adopt treatment therapies despite a lack of evidence about their effectiveness.

Unintended consequences of routine surgery are greater than current measures report.

Researchers studied nearly 4 million patients treated at 1,295 ambulatory surgery centers in California, Florida, and Nebraska. While 95 percent of these patients were discharged and sent home, researchers discovered that nearly 32 out of every 1,000 patients needed hospital care within a week after leaving the ambulatory center. “Hospital transfer immediately after ambulatory surgery care is a rare event, but one week later is a far different story,” said lead author Justin P. Fox, MD, who conducted the research as an RWJF Clinical Scholar at Yale University. “The rate of ambulatory patients who need acute care after they have gone home is nearly 30 times higher and varies across centers, so it may be a more meaningful measure of assessing quality.”

Some “low-risk” procedures lead to costly outcomes.

Surgically removing kidney stones may not be as low-risk as previously thought. A review of 93,000 patients who had kidney stones surgically removed showed a surprising number of ER visits and hospitalizations up to 30 days after the procedure. And the cost of that follow-up care ranges from $23,000 to more than $47,000. “Where a patient has this procedure does matter in terms of unintended consequences and cost,” said Charles (Chuck) Scales, MD, a surgeon at Duke University Medical Center and an RWJF Clinical Scholars program alumnus. Scales found that patients who had their surgery at high-volume centers—whether hospital or ambulatory—were much less likely to need unplanned follow-up acute care. “If we want to reduce health care costs, we need to reduce unplanned follow-up care,” said Scales.

For-profit hospitals more likely to adopt higher-cost, less-proven therapies.

Women in need of breast cancer therapy may find for-profit hospitals more likely to utilize more expensive brachytherapy—a form of radiation therapy given to some patients following surgery—and more likely to provide this treatment to older women who are least likely to benefit. “Provider incentives or reimbursements were more likely to drive the use of a particular breast cancer treatment rather than its effectiveness,” said Cary Gross, MD, co-director and alumnus of the RWJF Clinical Scholars program at Yale University. The study showed that for-profit hospitals were more likely to adopt the more expensive breast cancer therapies, even though they may not be proven effective. “If a treatment costs more than the widely used standard of care, it should be more effective,” said Gross. 

Good communication helps maintain patient trust when something goes wrong

In surgery, there is always the chance that something can go wrong. How do these complications affect the surgeon-patient relationship, and what can surgeons do to maintain trust? RWJF Clinical Scholar alumna Arden M. Morris, MD, MPH, found that a surgeon’s quality of communication with the patient was a better predictor of whether a patient maintained trust in the surgeon, even when complications occurred. The survey of patients after colorectal cancer surgery found that 25 percent had suffered complications, but that those who reported good communication maintained a high level of trust in their surgeon. Furthermore, the level of communication explained trust above race, education, socioeconomic status, and overall patient health.

Additional studies with Clinical Scholars-affiliated authors in the special Surgery issue include:

  • “A Qualitative Analysis of Acute Care Surgery in the U.S.: It’s More Than Just a Competent Surgeon with a Sharp Knife and a Willing Attitude,” Heena P. Santry, MD, MS
  • “Accountability for End-Stage Organ Care: Implications of Geographic Variation in Access to Kidney Transplantation,” David A. Axelrod, MD, MBA
  •  “Identification of Modifiable Factors for Reducing Readmission After Colectomy,” Elise H. Lawson, MD, MSHS
  • “Implementation of a “Real World” Learning Healthcare System: Washington State’s Comparative Effectiveness Research Translation Network (CERTAIN),” David R. Flum, MD
  • “Patient Expectations and Patient-Reported Outcomes in Surgery,” Jennifer Waljee, MD, MS
  • “Quality of Surgical Care in Safety-Net Hospitals,” Arden M. Morris, MD, MPH
  •  “Referring Physicians’ Decision Making for Pediatric Anti-Reflux Procedures,” Stephen M. Downs, MD, MS
  •  “User-Centered Design of Quality of Life Reports for Clinical Prostate Cancer Care,” John L. Gore, MD, MS.

Read more about the new studies here.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.