Jun 29, 2015

Dr. Kiefer: If you have complications after surgery, being readmitted to the same hospital can make all the difference. We'll talk about that next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Dr. Kiefer: I'm talking with Dr. Benjamin Brooke, Assistant Professor of Surgery at the University of Utah. Dr. Brooke, your research turned up some pretty striking findings that I found surprising. What did you find?

Dr. Brooke: Well, we were interested in looking at whether patients who underwent major surgery, if they had a complication after their surgery, if they had better outcomes if the went back to the same hospital where their operation occurred versus the comparison being another hospital. We looked at a very large composite of patients for this survey. In fact, we used Medicare claims over a 10-year period that included 12 major surgeries. And that included surgeries along the spectrum from knee replacements, hip replacements, up to coronary bypass surgery and aortic aneurysm repair. So really a large spectrum of different patients.

What we found is that across the board, all these patients received a benefit from going back to the same what we called "index hospital" where their operation occurred. It wasn't just that one or two or three of these procedures had this finding, it was all 12. And the benefit ranged from between 20 to almost 40% mortality reduction from going back to that same hospital. And that was found within the 90 days after their readmission.

Dr. Kiefer: So they were less likely to die if they returned to the same hospital.

Dr. Brooke: Correct.

Dr. Kiefer: That's a pretty striking finding.

Dr. Brooke: Correct.

Dr. Kiefer: So, in other words, if they had just stayed in their local hospital the entire time, they would have done better even if that was a smaller hospital.

Dr. Brooke: Yes, that was what our data showed, which was interesting because we always feel like a lot of times when patients have their operation at a small hospital and they have a complication, I think a lot of physician's biases is that they're going to receive better care at the bigger, high-volume hospital with perhaps better services. But our data actually came to a different conclusion that the continuity of care between going back to the same doctors or surgeons who treated them at the initial hospital, whether it be a small hospital or a big academic hospital, was really the more important metric of quality.

Dr. Kiefer: And can you talk about that? I mean, you're a practicing surgeon. I mean, this wasn't exactly part of your study, but, anecdotally, why do you think it might be important for the patient to be seen by the same doctors?

Dr. Brooke: I think a bias of myself and a lot of other surgeons is that if you do a big operation on a patient, a lot of these operations are very complex, they require a lot of planning before the operation. During the operation, the anatomy is always very unique in that when you operate on a patient, what you find when you make the incision is very individualized. You as a surgeon, having the familiarity with that patient's anatomy, and perhaps all their pre-hospital indications for surgery as well as their post-operative course is, I think, very powerful in giving you some insight into what could have caused the complication and what perhaps is the best treatment.

Dr. Kiefer: And is this something that happens a lot, that people kind of hop from hospital to hospital for their initial treatment and then follow-up?

Dr. Brooke: Roughly 25% of patients are going to be going to a different hospital if they become readmitted. So 25%, if you look at all patients across the country undergoing big operations, it's still a pretty big number. So what our research is trying to show is that if we can perhaps make people realize that this is a metric of quality that we think should be enforced, perhaps we can change practice patterns.

And when I talk about that, that might relate to ambulances, when they pick up a patient who's had a problem and they need to go back to a hospital after surgery, do they think twice about going to that hospital that might be closer, that might be just down the road but is not the hospital that the patient had their operation in. Perhaps they'll think twice about doing that and take the patient back to the index hospital.

Or, the other thing that we think could be changed is that a lot of times patients are brought back to another hospital, but it's the emergency room personnel and physicians who could recognize that getting that patient transferred back to the index hospital is a potential metric of quality and something that could improve their outcome.

Dr. Kiefer: One thing that I find a little bit hard to wrap my mind around is that you're measuring a pretty dire outcome, which is risk for death, but you looked at surgeries ranging from coronary bypass surgery, which I can imagine is pretty risky, but down to knee surgery, which most people wouldn't think is associated with death. So can you explain how something like a knee surgery can result in death?

Dr. Brooke: That's an excellent question. So if you look at all patients who have knee operations, you're absolutely correct. The risk of dying after a simple knee surgery is very low. However, when somebody experiences a complication and needs a readmission, the risk of death resulting from a complication goes up dramatically. So that could be a medical complication such as a heart attack or pneumonia, or it could be surgical complications, such as a surgical site infection or something that mandates the patient undergo a re-operation to fix something. I think right off the bat, you're looking at complications that are associated with a dramatic increase in the risk of mortality. So having that continuity of care, I think, is very important.

Dr. Kiefer: Well, it seems like it also has implications for kind of this trend of traveling to regional hospitals, large centers of excellence, to have certain procedures done.

Dr. Brooke: The data shows that going to a high-volume hospital is that it is very experienced in a certain type of surgery, the patients get great outcomes and the best quality of care, but what our data is trying to show is that while that may be the case, if there is a complication after one of these operations, that if the patient has traveled a long distance to have their index operation at one of these "centers of excellence" as a lot of people refer to them, that if they don't get readmitted to that same hospital, there might be a consequence.

So a lot of hospitals have patients after an operation stay within the surrounding community. And so, for example, if you go to the Mayo Clinic to have a major operation, I know sometimes they'll say, "Why don't you stay in Rochester for the next week after you get discharged just in case there is a problem?" You can come back and they can have at least one follow-up visit. And in a lot of other cases, patients are just expected to follow up in their own community hospital and not have to go back to these big centers. And so this is a potential problem.

Announcer: Interesting, informative, and all in the name of better health. This is the Scope Health Sciences Radio.

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