A growing number of physicians and researchers have grown critical of 30-day mortality as a measure of surgical success. That seemingly innocuous metric, they argue, may actually undermine appropriate care, especially for older adults, reports The New York Times.
Dr Perla Macip, presented a case to a meeting of the American Academy of Hospice and Palliative Medicine. Ms S sustained cardio-pulmonary arrest during an operation and needed resuscitation. A series of complications followed: irregular heartbeat, fluid in her lungs, kidney damage, pneumonia. She had a stroke and moved in and out of the intensive care unit, off and on a ventilator. After two weeks, "she was depressed and stopped eating," Macip said. The geriatricians recommended a "goals of care" discussion to clarify whether Ms S, who remained mentally clear, wanted to continue such aggressive treatment. But "the surgeons were optimistic that she would recover" and declined, Dr Macip said.
So a discussion of palliative care options was deferred until Day 30 after her operation, by which time Ms S had developed sepsis and multiple-organ failure. She died on Day 31, after life support was discontinued.
The report says the key number here, surgeons and other medical professionals will recognise, is 30 – 30-day mortality serves as a traditional yardstick for surgical quality. However laudable the intent, reliance on 30-day mortality as a surgical report card has also generated growing controversy with some experts believing pressures for superior 30-day statistics can cause unacknowledged harm, discouraging surgery for patients who could benefit and sentencing others to long stays in ICUs and nursing homes.
"Thirty days is a game-able number," said Dr Gretchen Schwarze, a vascular surgeon at the University of Wisconsin-Madison. Last fall, she led a sessionabout the ethics of 30-day mortality reporting at an American College of Surgeons conference. "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,'" she recalled. The debate is particularly urgent for older adults, who are more likely to undergo surgery and to have complications.
Those questioning the 30-day metric point to potential dilemmas at both ends of the surgical spectrum. Surgeons may decline to operate on high-risk patients, even those who understand and accept the trade-offs, because of fears (conscious or not) that deaths could hurt their 30-day results. "We want to cure patients and help them live, and we consider it a failure if they don't," said Dr Anne Mosenthal, who heads the American College of Surgeons committee on surgical palliative care.
With surgeons already prone to optimism and disinclined to withdraw life support, the effect of reporting failures, if there is one, is subtle. Surgeons tell themselves, "Maybe if we wait a little longer, he’ll improve; there’s always a chance," Mosenthal said. But many older patients, and their families, have different ideas about what makes life worth sustaining and might welcome a frank discussion before a month passes.
"The 30-day mortality statistic creates a conflict of interests," said Dr Lisa Lehmann, an associate professor of medical ethics at Harvard Medical School. "It can lead to the violation of a physician's duty to put patients' interests first."
But leaders at the non-profit National Quality Forum, which just endorsed 30-day mortality as a measure for coronary bypass surgery, find such fears overblown. The forum evaluates quality measures for Medicare and other insurers, and went ahead with its endorsement despite some physicians' objections. "There is some concern," said Dr Helen Burstin, the chief scientific officer of the forum, but "certainly no evidence" that the metric is unduly influencing patient care. "Is it better not to measure and compare, just because we can't get it perfect?" added Dr Lee Fleisher, a co-chair of the forum's surgery standing committee.
But critics think other quality measures might serve better. Perhaps the benchmark should be 60- or 90-day mortality. Perhaps patients having palliative surgery to relieve symptoms should be tracked separately, because comfort is their goal, not survival. Maybe quality should include days spent in an ICU or on a ventilator, Schwarze said. "Medicine isn't just about keeping people alive," she said. "Some of it is about relieving suffering. Some of it is about helping people die."
[link url="http://www.nytimes.com/2015/03/03/health/a-30-day-surgical-standard-is-under-scrutiny.html?_r=0"]Full report in The New York Times[/link]
[link url="http://archsurg.jamanetwork.com/article.aspx?articleid=1876618&resultClick=3"]JAMA Surgery editorial extract[/link]