Is the 30-day mortality rate a good measure of surgical success?

Some medical experts say using a hospital's 30-day mortality rate as a measure of surgical success can hamper necessary follow-up care, especially for older patients, Paula Span writes in the New York Times' "New Old Age" blog.

A hospital's 30-day mortality number has long served as a "traditional yardstick for surgical quality," writes Span, and some states even require hospitals to publically report their 30-day mortality after certain procedures. In addition, Medicare has begun using risk-adjusted 30-day mortality rates, including deaths after pneumonia and heart attacks, to penalize hospitals that score poorly and reward those with good outcomes.

In a presentation to the American Academy of Hospice and Palliative Medicine last week, Boston-based geriatrician Perla Macip explained the case of her patient "Ms. S" in an effort to shed light on the problems of the 30-day mortality standard.

 She noted that Ms. S. sustained complications during cardiovascular surgery. But because her surgeons "were optimistic that she would recover" from such complications, discussions of palliative care options were put off until 30 days after her operation. By that time, her complications had worsened and she succumbed to sepsis and multiple-organ failure on Day 31.

What's undermining care improvements? Bad metrics, docs say.

Some experts argue stories like that should push the industry to rethink its reliance on 30-day mortality rates as a measure of surgical success. Gretchen Schwarze, a vascular surgeon at the University of Wisconsin-Madison and co-author of a JAMA editorial on such measurements, says, "Thirty days is a gameable number" that some say could lead physicians to discourage surgery or send patients to lengthy stays in ICUs and nursing homes.

At a presentation she gave last fall, she says that "surgeons in the audience stood up and said: 'I can't operate on some people because it's going to hurt our 30-day mortality statistics.'" Surgeons also might delay necessary conversations with patients about palliative care options or hospice or even ignore advance directives in order to keep ahead of their 30-day metrics, Span writes.

For instance, Douglas White, director of ethics and decision-making in critical illness at the University of Pittsburgh School of Medicine, cites a time a surgeon from a Pennsylvania hospital approached him for guidance on whether to accept a high-risk patient. The surgeon said, "We have been told that our publicly reported numbers are bad, and we have to take fewer high-risk patients" and other surgeons at the hospital had already refused to provide treatment. Eventually, the surgeon chose not to treat the patient and a helicopter transported the patient to a different hospital to receive care.

"The 30-day mortality statistic creates a conflict of interests," says Lisa Lehmann, an associate professor of medical ethics at Harvard Medical School, adding the metric "can lead to the violation of a physician's duty to put patients' interests first."

Cleveland Clinic CEO: 'Quality is more than just whether you live or die'

Leaders from the National Quality Forum—which evaluates quality measures for Medicare and other insurers—have endorsed a 30-day mortality measurement for coronary bypass surgery. Helen Burstin, the forum's chief scientific officer, says, "there is some concern [but] certainly no evidence" that the measurement has impacted patient care.

Still, others say different quality measures might be better. Such measures could include:

• 60-day or 90-day mortality rates;
• Alternate tracking of post-surgery palliative procedures to reduce symptoms; or
• Days spent in the ICU.

Schwarze concludes, "Medicine isn't just about keeping people alive. Some of it is about relieving suffering. Some of it is about helping people die" (Span, "New Old Age," New York Times, 3/2).

How the Advisory Board can help you improve other quality metrics

The Advisory Board's "Preventing Unnecessary Readmissions" study—which offers 17 best practices for avoiding return patient visits—has been used at hospitals across the country. Check out the popular study now, as well as the Nursing Executive Council's "Nurse-Led Strategies for Preventing Avoidable Readmissions" and the Cardiovascular Roundtable's "Reducing Preventable Readmissions."