Deaths rise with shift to outpatient urology
As hospitals have shifted common urological surgeries from inpatient procedures to outpatient, potentially preventable deaths have increased following complications. These were the primary findings of a study led by researchers at Henry Ford Hospital in Detroit.
The researchers initially expected that improved mortality rates recently documented for surgery overall also would apply to commonly performed urologic surgeries. The opposite turned out to be true. The research paper has been published online by BJUI, the official journal of the British Association of Urological Surgeons. The study included researchers at Harvard Medical School in Boston, the University of Montreal Health Center in Quebec, Canada, Yale University’s Department of Urology in New Haven, CT, and the Harvard School of Public Health in Boston.
The study also identified older, sicker, minority patients and those with public insurance as more likely to die after a potentially recognizable or preventable complication. "These high-risk patients are ideal targets for new healthcare initiatives aimed at improving process and results," said Jesse D. Sammon, DO, a researcher at Henry Ford’s Vattikuti Urology Institute and lead author of the study. "Urologic surgeons and support staff need a heightened awareness of the early signs of complications to prevent such deaths, particularly as our patient population becomes older and has more chronic medical conditions."
The study focused on a measure of hospital quality and safety called Failure to Rescue (FTR), derived from the Institute of Medicine’s landmark 1999 report To Err is Human, which highlighted significant concerns for patient safety in American hospitals. "Failure to rescue describes the inability of a provider or institution to recognize key complications and intervene before mortality," Sammon explained. "While comparison of overall complications and mortality rates penalizes hospitals treating sicker patients and more complex cases, FTR rates may be a more accurate way to assess safety and quality of care."
Using the Nationwide Inpatient Sample, the largest all-payer inpatient healthcare database in the United States, the researchers identified all patients discharged after urologic surgery between 1998 and 2010. This pool of more than 7.7 million surgeries was analyzed for overall and FTR mortality as well as changes in mortality rates. The researchers determined that while admissions for urologic surgery and overall mortality decreased slightly, deaths attributable to FTR increased 5% every year during the study period.
The researchers also identified each patient’s age, race, and insurance status, including private insurance, Medicare, Medicaid, and self-pay. In addition, the severity of each patient’s illness was determined based on co-morbidity. They found that the number of inpatient urologic surgeries dropped during the study period and surmised this was due to a major shift to outpatient procedures.
Sammon said that compared to other medical specialties, "these findings also raise the possibility that the care of urologic surgical patients is suffering from inadequate or poorly applied patient safety measures."
"It’s worrisome," he continues, "that the odds of FTR-related deaths have risen over time for the most common types of urologic surgeries including ureteral stenting, treatment of enlarged prostate, bladder biopsies, removal of a diseased kidney, and others."
