Dont jump to conclusions about that JAMA surgical readmissions paper

On February 3, JAMA published a paper online about readmission rates after surgery. The focus of most tweets was on the most common cause for readmission—surgical site infections (SSIs)—in 19.5% of readmitted patients.

At first glance, this suggests that infection rates after surgery were 19.5%, but that is not so. The paper said that 19.5% of the readmissions were caused by infections.

Of 498,875 total operations reviewed, only 30,270 (6.1%) were readmitted for any reason, and only 5576 (1%) of all patients were readmitted for SSIs.

According to the full text of the paper, the authors had two main points:

One, "because most readmissions were attributable to well-described postoperative complications, readmissions after surgery are mostly a proxy measure for postdischarge complications and in effect penalize hospitals twice [my emphasis] for postoperative complications (ie, other pay-for-performance programs include postoperative complications such as SSI)."

Two, "the majority of hospital readmissions were related to SSI and ileus [non-mechanical failure of bowel peristalsis]. Identifying clinical interventions to reduce the occurrence of these complications to below current levels has been challenging."

An article about the paper in US News quoted an editorial by Lucian Leape who said "system-wide changes need to be made." One such system change, the Surgical Care Improvement Project (SCIP), has been ongoing for more than 10 years.

The paper confirms what I wrote in 2010 about SCIP and other process measures and points out that "Most hospitals in the United States have high adherence rates for the SCIP SSI-prevention process measures; however, compliance with these process measures has not been shown to be strongly associated with reduced SSI rates."

And I am unaware of a conclusive study showing that the incidence of postoperative ileus can be lowered by any intervention.

I agree with the comments of the papers authors who say, "It is important to note that many readmissions may be unavoidable and are actually the correct course of action for surgical patients. [My emphasis] Many complications should be treated in the inpatient setting, and surgeons should not be deterred from readmitting patients because of concerns about quality measure performance and resulting penalties."

Every effort should be made to lower the infection rates of all procedures. But this papers results should be viewed not with alarm, but rather as reassurance that the problem is not out of control.

Read More..

German airliner crash A system error with a system solution

From the Associated Press: Airlines around the world on Thursday began requiring two crew members to always be present in the cockpit, after details emerged that the co-pilot of Germanwings Flight 9525 had apparently locked himself in the cockpit and deliberately crashed the plane into the mountains below.

This represents an organizations typical response to a problem. The crash, which by all accounts was caused by a single deranged individual, has been perceived as the result of a “system error” and will be dealt with as such.

The idea that a flight attendant going into the cockpit whenever one of the pilots has to pee will prevent anything seems a bit absurd to me. How is a 5’2” 120 pound female flight attendant supposed to stop a 6’3” 210 pound pilot who is hell-bent on committing suicide by airplane?

When I tweeted a similar thought yesterday, someone suggested that she could simply sound an alarm and unlock the cockpit door. I suppose that’s true as long as the crazed pilot does not punch her in the face and knock her out or shoot her first.

After 9/11, a federal law was passed allowing pilots who were properly screened and trained to carry guns. If an armed pilot decides to commit suicide, an unarmed flight attendant will not be able to stop him or her.

According to a CNN story, Andreas Lubitz, the pilot who drove the plane into the mountain, had passed all medical tests before being hired. He recently had been given a medical leave note by a doctor. However, Lubitz ripped it up and threw it in a wastebasket in his apartment. He did not disclose the fact that he had been undergoing medical treatment to the airline. So much for self-reporting which is standard for pilots.

Why didnt the doctor tell the airline? I dont know. Do they have HIPAA in Germany?

The two people in the cockpit rule is smoke and mirrors. The airlines can now say that they have taken steps to prevent something like the Germanwings crash from happening again so dont worry, its still safe to fly. But as I have pointed out, a determined maniac will be able to easily overcome this system solution.

I am reminded of the proposals like arm the janitors, arm the teachers, or give them shields or scissors that always come forward after school shootings.

Footnotes:

1. "Two people in the cockpit” is not an FAA regulation but is said to be a standard policy for US airlines. Its purpose is not to prevent a suicide but to have someone available to let the other pilot back into the cockpit in case the pilot who did not leave passes out or is otherwise disabled.

2. The Germanwings incident represents an unintended consequence of reinforcing and locking cockpit doors after 9/11.

Read More..