HealthLawProf Blog

Editor: Katharine Van Tassel
Akron Univ. School of Law

A Member of the Law Professor Blogs Network

Thursday, October 22, 2009

Rescue for Post-Surgical Complications Better For Whites Than Blacks At Teaching Hospitals

Survival after surgery appears higher at teaching hospitals than at non-teaching hospitals, but this benefit is experienced by white patients and not black patients, according to a report published in February of 2009 called Silber et al., Hospital Teaching Intensity, Patient Race, and Surgical Outcomes, 144 Arch Surg. 113-20 (2009).

While the teaching versus non-teaching setting was not associated with different rates of complications for either white or black patients, whites are less likely to die following complications at teaching hospitals, a survival benefit not seen for black patients.

Putting this report together with the new study Ghaferi, A. et al., Variation in Hospital Mortality Associated with Inpatient Surgery 361 N.Eng. J. Med. 1368-75 (2009) discussed in my post, High Post-Surgical Mortality Rates Related to Failure to Rescue, and it appears that whites are being rescued from post-surgical complications while blacks are not. 

ScienceDaily reports on the study of teaching hospitals and explains that  

[l]ower death rates at teaching hospitals might result from preventing complications or preventing death after complications (preventing a failure-to-rescue). "While teaching hospitals are generally larger and have more advanced technology, greater volume and better nurse staffing (attributes that may aid in both preventing complications and successfully treating complications), it is by no means clear whether all patients benefit equally from these attributes," the authors write.

Jeffrey H. Silber, M.D., Ph.D., and colleagues from the Center for Outcomes Research at The Children's Hospital of  Philadelphia and the University of Pennsylvania, analyzed Medicare claims from 4,658,954 patients ages 65 to 90 who underwent general, orthopedic or vascular surgery at 3,270 acute care hospitals in the United States between 2000 and 2005. They compared rates of death within 30 days, in-hospital complications and the probability of death following complications between hospitals based on teaching intensity (defined as the number of resident physicians per hospital bed). Among all hospitals and all surgical procedures combined, the overall 30-day mortality rate was 4.23 percent, complication rate was 43.39 percent and rate of death occurring after complications was 9.75 percent.

"Combining all surgeries, compared with non-teaching hospitals, patients at very major teaching hospitals demonstrated a 15 percent lower odds of death, no difference in complications and a 15 percent lower odds of death after complications (failure to rescue)," the authors write. The associations were adjusted for patient illness on admission and did not change even when the researchers considered income, suggesting that the differences in death after complications is not due to unequal access to teaching hospitals between patients in different economic classes.

However, the survival benefits associated with teaching intensive hospitals were not experienced by black patients, who had similar odds of death, complication and failure-to-rescue at teaching and non-teaching hospitals. Furthermore, such differences were apparent even when analyses compared white and black patients inside the same hospital. There are several possible reasons for this disparity, the authors note.

One previous study reported black patients experienced longer delays before beginning defibrillation than white patients, suggesting potential differences in levels of monitoring. "Unintentional differences in communication might lead to less appropriate or less accurate monitoring of black patients or less involvement in their care by personnel who could make a difference in reducing failure to rescue," the authors write. There could also be varying levels of involvement by physicians-in-training in the care of patients in different racial groups, they note.

[KVT]

 

October 22, 2009 | Permalink | Comments (0) | TrackBack (0)

Ratio of Medical School Applicants to Available Slots Stays Flat

The WSJ Health Blog reports that the new figures on medical school applications from the Association of Medical Colleges came out on Tuesday. They show that the ratio of applications per available slot has stayed essentially the same for the past decade - two applicants for every slot:

The 2009 figures are out today from the Association of American Medical Colleges: 42,269 applicants for 18,390 first-year slots. That compares to 38,443 applicants for 16,221 slots in 1999.

Despite the long-term stability, there are some year-to-year variations. Between 2008 and 2009, the number of applicants didn’t change much. But there are about 350 more first-year students this year, largely because four new med schools seated their first entering classes (some existing schools also expanded their first-year classes).

The new schools are affiliated with Florida International University, Texas Tech and the University of Central Florida; a fourth school, the Commonwealth Medical College, in Pennsylvania, is independent.

[KVT]

October 22, 2009 | Permalink | Comments (0) | TrackBack (0)

Tuesday, October 20, 2009

High Post-Surgical Mortality Rates Related to Failure to Rescue

The assumption is that high mortality hospitals have high complication rates. But a new report, Variation in Hospital Mortality Associated with Inpatient Surgery, 361 N.Eng. J. Med. 1368-75 (2009), shows complications are common after major surgery -- about one in six patients. What distinguishes good and bad hospitals is how proficient they are at rescuing patients from those complications. Patients at high mortality hospitals are twice as likely to die from a post-surgical complication. The story in ScienceDaily explains:


The report in Thursday's New England Journal of Medicine confirms that serious complications are common after major surgery – about 1 in 6 patients – but the study shows what drives hospital mortality is failure to rescue.

Low mortality hospitals have medical teams with the ability to rescue patients by recognizing and heading off potentially catastrophic complications such as deep wound infections, pneumonia, kidney failure, blood clots, and strokes.

In spite of similar patterns of complications, patients at high mortality hospitals are nearly twice as likely to die after developing a serious post-surgical complication, according to the study. It's a new view of what defines the safest hospitals for surgery.

"The general assumption has been that high mortality hospitals simply have higher complication rates. We were quite surprised to find that that's not true," says study author John D. Birkmeyer, M.D., professor of surgery and chair of surgical outcomes research at U-M. "Our finding was what distinguishes high quality hospitals and low quality hospitals is how proficient they are at rescuing people once a complication has happened," he says.

The study used data on 84,730 patients undergoing general and vascular surgery at 186 hospitals participating in the American College of Surgeons – National Surgical Quality Improvement Program.

[KVT]

October 20, 2009 | Permalink | Comments (0) | TrackBack (0)

Monday, October 19, 2009

Swine Flu Vaccine Shortfall, H1N1 Found in U.S. Swine and Mandatory Vaccination of Health Workers in NY Blocked

Nature.com’s blog The Great Beyond calls attention to three Swine Flu stories of interest.  

The first story relates to the vaccine shortfall and reports that "the US Centers for Disease Control and Prevention (CDC) now expects to have 28-30 million doses of swine flu vaccine by the end of October — down from the 45 million doses predicted in August and previous estimates of 120 million forecast earlier in the summer.”

The problem is caused by an inadequate supply of  antigen. The antigen is the part of the virus that is used in the vaccine to trigger the body to create the antibodies that are necessary to the body’s immune response. See also NY Times, AFP, Reuters, and Bloomberg.

The second story relates to the discovery of the first case of H1N1 in U.S. Swine. The U.S. Department of Agriculture has announced that they may have identified cases of Swine Flu in swine at the Minnesota state fair. If confirmed, these will be the first cases of the disease among American domestic livestock. Further tests are being performed. (USDA statement).

The third story reports that a judge has issued an order halting the mandatory vaccination of health workers in New York.  Three nurses who filed suit to block mandatory vaccination for both seasonal and H1N1 Flu were granted a temporary restraining order on Friday. As the New York Times reports:

The temporary restraining order by the judge, Thomas J. McNamara, an acting justice of the State Supreme Court in Albany, comes amid a growing debateabout the flu vaccine. On Friday afternoon, the State Department of Health vowed to fight the restraining order, saying that the authorities “have clear legal authority” to require vaccinations, and noted that state courts had upheld mandatory vaccinations of health care workers against rubella and tuberculosis. Justice McNamara scheduled a hearing for Oct. 30 on the three cases before him, involving the flu vaccine.

The state health commissioner, Dr. Richard F. Daines, through the State Hospital Review and Planning Council, issued a regulation on Aug. 13 ordering health care workers to be vaccinated by Nov. 30 or face fines.

Dr. Daines later explained the reasoning behind the vaccine, saying in a statement on Sept. 24:

Questions about safety and claims of personal preference are understandable. Given the outstanding efficacy and safety record of approved influenza vaccines, our overriding concern then, as health care workers, should be the interests of our patients, not our own sensibilities about mandates. On this, the facts are very clear: the welfare of patients is, without any doubt, best served by the very high rates of staff immunity that can only be achieved with mandatory influenza vaccination – not the 40-50 percent rates of staff immunization historically achieved with even the most vigorous of voluntary programs. Under voluntary standards, institutional outbreaks occur every flu season. Medical literature convincingly demonstrates that high levels of staff immunity confer protection on those patients who cannot be or have not been effectively vaccinated themselves, while also allowing the institution to remain more fully staffed.

Terence L. Kindlon, a lawyer for three nurses who sued the state, asserting that the order violated their civil rights, said the judge’s ruling was a victory. New York was the only state in the country to mandate vaccinations for health care workers, he said.

[KVT]

October 19, 2009 | Permalink | Comments (0) | TrackBack (0)

Sunday, October 18, 2009

52 Percent Lower Chance of Dying At Top-Rated Hospitals According to New Study

According to the HealthGrades Report on patient outcomes at 5000 hospitals, the quality gap continues. Patients who have access to high quality hospitals have a 52% lower chance of dying.

As reported in ScienceDaily, the study also found the following:

  • Overall, inhospital, risk-adjusted mortality at the nation's hospitals improved, on average, 10.99% from 2006 through 2008.
  • Across all 17 procedures and diagnoses in which mortality was studied, there was an approximate 71.64% lower chance of dying in a five-star rated hospital compared to a one-star rated hospital.
  • Across all 17 procedures and diagnoses studied, there was an approximate 51.53% lower chance of dying in a five-star rated hospital compared to the national average.
  • If all hospitals performed at the level of a five-star rated hospital across the 17 procedures and diagnoses studied, 224,537 Medicare lives could potentially have been saved from 2006 through 2008.
  • Approximately 57% (127,488) of the potentially preventable deaths were associated with just four diagnoses: sepsis (44,622); pneumonia (29,251); heart failure (26,374) and respiratory failure (27,241).
  • Over the last three studies, Ohio and Florida consistently have had the greatest percentage of hospitals in the top 15% for risk-adjusted mortality. 
  • Across all procedures in which complications were studied, there was a 79.69% lower chance of experiencing one or more inhospital complications in a five-star rated hospital compared to a one-star rated hospital.
  • Across all procedures studied, there was a 61.22% lower chance of experiencing one or more inhospital complications in a five-star rated hospital compared to the U.S. hospital average.
  • If all hospitals performed at the level of a five-star rated hospital, 110,687 orthopedic inhospital complications may have been avoided among Medicare patients over the three years studied. 
  • Joint Commission stroke-certified hospitals were almost twice as likely to attain five-star status in stroke (30.1% of certified hospitals were five-star versus 15.7% of non-certified), and fewer of the stroke-certified hospitals fell into the one-star category (12.3% versus 19.6%).
  • Joint Commission stroke-certified hospitals have an 8.06% lower risk-adjusted mortality rate compared to hospitals that were not stroke-certified.

The HeathGrades Report is based on the following process:

HealthGrades rates each of the nation's 5,000 nonfederal hospitals in nearly 30 procedures and diagnoses, allowing individuals to compare their local hospitals online at http://www.healthgrades.com. The ratings are objective, created from data provided by the Centers for Medicare and Medicaid Services and 17 states that publish outcomes data. HealthGrades' hospital ratings are independently created; no hospital can opt-in or opt-out of being rated. No hospital pays to be rated. Each hospital receives a one-, three- or five-star rating for each procedure or diagnosis, reflecting the mortality or complication rates at that hospital. Mortality and complication rates are risk-adjusted, which takes into account differing levels of severity of patient illness at different hospitals and allows for hospitals to be compared on equal footing.

[KVT]


October 18, 2009 | Permalink | Comments (0) | TrackBack (0)