Mortality Rises With Changes in Urologic Care from Inpatient to Outpatient
The incidence of preventable inpatient deaths associated with common urologic procedures increased significantly over a 12-year period coinciding with a shift of more procedures to the outpatient setting, investigators reported.
Overall mortality remained stable, but deaths attributable to “failure to rescue” (FTR) had an absolute increase of 18% during the study period.
Older, sicker patients had higher FTR rates, as did minorities, publicly insured patients, and patients who received care at urban hospitals. The findings point to opportunities for process improvement initiatives, reported Jesse D. Sammon, DO, of Henry Ford Health System in Detroit, and colleagues in BJU International.
“In the general surgical literature you see a trend toward decreased postoperative mortality,” Sammon told MedPage Today. “You also see a decrease in mortality following complications. We expected the same thing in the urologic literature. Instead, we found that the mortality rate overall was stable between 1998 and 2010, but the mortality rate after a complication increased by 1.5% per year over that time period.”
As a quality metric, FTR began to emerge following publication of the Institute of Medicine report, “To Err is Human,” which raised concerns about the safety of hospitalized patients. FTR refers to a provider’s ability to recognize complications and intervene before death.
Several recent studies of national trends in surgical outcomes have demonstrated decreased inpatient mortality, including one study that attributed the improvement to a decline in FTR, the authors said.
Numerous studies have examined mortality and FTR rates in high-risk urologic procedures, but no assessment of overall mortality and FTR has encompassed the “breadth of urological surgery,” including common nononcologic procedures, they continued.
Following trends toward favorable FTR rates in general surgery, Sammon and colleagues hypothesized that the volume of urologic procedures increased and that both overall mortality and FTR deaths decreased. To test their hypotheses, they analyzed data from theNational Inpatient Sample (NIS) for patients who underwent urologic surgery from 1998 through 2010.
The primary outcomes of the analysis were overall mortality, FTR mortality, and the proportion of mortality attributable to FTR, which the authors defined as a complication that “was potentially recognizable/preventable.” Complications of interest consisted of sepsis, pneumonia, deep vein thrombosis or pulmonary embolism, shock or cardiac arrest, and upper gastrointestinal bleeding during admission for surgery.
The authors used a published algorithm of preventable adverse events, derived from ICD-9 codes, diagnosis-related groups, and major diagnostic categories.
The query of the NIS database yielded 7,725,736 urologic procedures that required hospitalization during the study period. Investigators performed analyses for the entire cohort, the 10 most common procedures, and the 10 procedures that accounted for the highest proportion of surgical mortality.
Admissions for urologic surgery procedures decreased over the study period, from 605,629 in 1998 to 569,784 in 2010. Overall inpatient mortality was 0.71% (54,949 deaths). Adjustment for differences in patient and hospital characteristics resulted in a decline in overall inpatient mortality of 1% per year.
Mortality decreases occurred for several common urologic surgical procedures as well as common contributors to surgical mortality: transurethral resection of the prostate (TURP), radical prostatectomy, ureteric stenting, transurethral resection of bladder tumor (TURBT), percutaneous nephrostomy (PCN) placement, retrograde pyelogram, bladder biopsy, and percutaneous cystostomy.
A multivariable analysis identified the following independent (P<0.001) predictors of in-hospital mortality:
- Patient age: OR 1.041
- Black race: OR 1.504
- Comorbidity score of 2 versus 0: OR 1.187
- Comorbidity score of 3 versus 0: OR 3.271
- Public insurance: OR 2.468 (Medicaid) and OR 1.761 (Medicare)
- Urban hospital: OR 1.349
- Urgent admission: OR 3.478
- Teaching hospital: OR 1.357
The proportion of inpatient mortality attributable to FTR increased from 41.1% in 1998 to 59.5% in 2010. Among individual procedures evaluated, increases similar to the overall trend were observed for TURP, ureteric stenting, nephrectomy, TURBT, PCN placement, bladder biopsy, and cystectomy.
TURP had the largest decrease in inpatient admissions (119,915 to 49,829), which was associated with a reduced risk of mortality overall (OR 0.94). However, FTR mortality associated with TURP increased significantly (OR 1.06, P=0.004).
The observation that increasing FTR was associated with increasing patient risk did not come as a surprise, urologists told MedPage Today. Even so, the study provided some useful reminders to the urology community.
“We are always looking for ways to improve our outcomes, and this study showed that even though the inpatients are higher risk, we still have a chance for process improvement to increase patient safety,” said Thomas G. Smith III, MD, of Baylor College of Medicine in Houston.
Noting the authors’ reliance on an administrative database, Smith said variation in codes used to describe services also could have influenced the findings. As an example, he cited a patient who undergoes PCN for stone extraction. First, urologists do not perform the procedure very often, as it has transitioned into interventional radiology. Second, if a stone is associated with infection that leads to sepsis, the procedure still might be coded as a stone extraction.
The study is a reminder that process improvement requires “looking at the entire process,” said Christopher M. Gonzalez, MD, MBA, of Northwestern University in Chicago.
“We have to be hypervigilant with this older, sicker patient population,” said Gonzalez, a spokesperson for the American Urological Association (AUA). “We have to look at what happens to patients in the preoperative phase and what factors in the [operating room] are contributing to mortality. We have to ask what can be done, at the level of the individual hospital, for process improvement.”
If the FTR concept continues to gain traction, the findings potentially have future implications for policy and payment, said Christopher Tessier, MD, a urologist in private practice in Manchester, N.H.
“Identifying risk factors associated with FTR would allow us to lobby for risk adjustment based on the factors, particularly since we are entering the value-based payment system,” said Tessier, chair of the AUA committee on quality improvement and patient safety.
“If we can level the playing field by applying risk on the basis of these factors, we can isolate providers who are basically getting gamed by the system, because they have a higher-risk population, from those who are really not serving patients well.”
Identifying risks for FTR also will allow individual practices to take steps to optimize care for higher-risk patients, Tessier added.