Researchers: White Patients Benefit More Than Blacks in Surviving Surgical Complications at Teaching Hospitals

Elderly patients who undergo surgery at teaching-intensive hospitals have better survival rates than at nonteaching hospitals, but these better survival rates apparently occur in white patients, not black patients.

"We found an advantage in surgical outcomes for patients in teaching-intensive hospitals compared to nonteaching hospitals, as we had expected from other studies," says study leader Dr. Jeffrey Silber, M.D., director of the Center for Outcomes Research at The Children's Hospital of Philadelphia, and a professor at the University of Pennsylvania. "What we didn't expect was that better outcomes in teaching hospitals occurred for white patients but not for black patients."

Furthermore, he adds, the survival advantage from teaching hospitals came from lower death rates after complications (lower rates of a measurement called "failure-to-rescue"), not from lower complication rates.

The study appears in the February issue of the Archives of Surgery.

The study group analyzed Medicare claims from 4.6 million patients aged 65 to 90 admitted for general, orthopedic and vascular surgery at 3,270 acute care hospitals in the United States from 2000 to 2005. Hospitals were classified as nonteaching hospitals if they had no residents, and teaching hospitals were scaled by their ratio of residents to hospital beds.

The researchers measured mortality 30 days after surgery, in-hospital complications and failure-to-rescue, defined as the probability of death following complications. They found that compared to nonteaching hospitals, hospitals with the highest ratio of residents to beds had 15 percent lower mortality after surgery, no difference in complications, and 15 percent lower odds of death after complications (failure-to-rescue). However, these benefits were observed in white patients, not black patients. These associations were adjusted for patient illness on admission, and adjusting for income level did not change these results. Unlike whites, for black patients, the odds of death, complication and failure to rescue were similar at both teaching and nonteaching hospitals.

Silber's group did not find lower rates of complications in teaching-intensive hospitals. "Overall, the improved survival rates were not because patients were less likely to have complications, but because they were less likely to die from those complications in teaching hospitals," said Silber, who first developed failure-to-rescue as a quality of care measure more than a decade ago. The National Quality Forum subsequently adopted it as a hospital quality indicator.

Black patients displayed higher complication rates than white patients at both teaching and nonteaching hospitals, though there was no difference in complication rates between teaching and nonteaching hospitals for both black or white patients. While white patients at teaching hospitals experienced better survival rates after complications than black patients when compared to nonteaching hospitals, black patients experienced the same survival after complications at both types of hospitals. The researchers found this racial disparity existed not only across different hospitals, but also for white and black patients within the same hospitals.

"We don't yet know why these racial disparities exist in surgical outcomes, but we have some working hypotheses," says Silber. His group offers possible explanations, such as unintentional differences in communication between patients and providers. Also, in previous work, Silber and colleagues found that surgical procedures take longer for black patients than white patients in some hospitals. "That finding raised the question of whether less experienced physicians might be more often operating on black patients," he adds.

However, Silber notes, the current study relied on Medicare claims data, not on detailed medical records, so it did not provide specific information on patient care that might shed light on the reasons for the observed racial disparities. "Our findings provide a starting point for further studies of detailed patient care that might shed light on why these disparities exist and how they could be reduced."

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Phone Support After Traffic Accidents Reduces Problems, Improves Quality of Life

People who were injured in road accidents had fewer problems and a much higher quality of life if they received a simple follow-up call from a nurse three weeks after being discharged from hospital, according to research in the January issue of the Journal of Clinical Nursing.

During the two-year study, researchers from Umea University in Sweden followed up 568 car occupants, cyclists and pedestrians who had attended the same emergency department after an accident.

They found that patients in the telephone support group were 35 percent less likely to complain of pain and discomfort than patients in the control group and that this rose to 40 percent when it came to car occupants. Patients who received support also reported fewer problems with anxiety, depression, everyday tasks and mobility.

The patients, who were between 18 and 70, were randomly assigned to the intervention group (288 people) or the control group (280). People with mental health problems or dementia were specifically excluded. 510 people completed the six-month study –- 147 were car drivers, 178 were cyclists and 185 were pedestrians.

All the patients were asked to fill in the same quality of life questionnaire two weeks and six months after their accident.

Patients in the intervention group also received a follow-up call after three weeks. These ranged from an average of 12 minutes in the 38 percent of patients who didn't need advice and 24 minutes in the 62 percent of patients who did ask for advice.

The study finds that women were more than twice as likely to seek advice as men (69 percent versus 31 percent).

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Medical Errors Cost $8.8B, Result in 238,337 Potentially Preventable Deaths: Study

Patient safety incidents cost the federal Medicare program $8.8 billion and resulted in 238,337 potentially preventable deaths during 2004 through 2006, according to HealthGrades' fifth annual Patient Safety in American Hospitals Study. HealthGrades' analysis of 41 million Medicare patient records found that patients treated at top-performing hospitals had, on average, a 43 percent lower chance of experiencing one or more medical errors compared to the poorest-performing hospitals.

The overall incident rate was approximately three percent of all Medicare admissions evaluated, accounting for 1.1 million patient safety incidents during the three years studied. With the Centers for Medicare and Medicaid Services scheduled to stop reimbursing hospitals for the treatment of eight major preventable errors, including objects left in the body after surgery and certain post-surgical infections, starting October 1, the financial implications for hospitals are substantial.

The HealthGrades study, which also identifies those hospitals with patient-safety incidence levels in the lowest five percent in the nation, also found:

• Medicare patients who experienced a patient-safety incident had a one-in-five chance of dying as a result of the incident during 2004 to 2006.
• Overall death rate among Medicare beneficiaries that developed one or more patient safety incidents decreased almost five percent from 2004 through 2006.
• However, four indicators, post-operative respiratory failure, post-operative pulmonary embolism or deep vein thrombosis, post-operative sepsis, and post-operative abdominal wound separation/splitting, increased when compared to 2004.
• Medical errors with the highest incidence rates were bed sores, failure to rescue, and post-operative respiratory failure and accounted for 63.4 percent of incidents. Failure to rescue improved 11.1 percent during the study period, while both bed sores and post-operative respiratory failure worsened during the study period.
• Of the 270,491 deaths that occurred among patients who developed one or more patient safety incidents, 238,337 were potentially preventable.

If all hospitals performed at the level of Distinguished Hospitals for Patient Safety, approximately 220,106 patient safety incidents and 37,214 Medicare deaths could have been avoided while saving the U.S. approximately $2.0 billion during 2004 to 2006.

“While many U.S. hospitals have taken extensive action to prevent medical errors, the prevalence of likely preventable patient safety incidents is taking a costly toll on our health care systems – in both lives and dollars,” says Dr. Samantha Collier, HealthGrades' chief medical officer and the primary author of the study. “HealthGrades has documented in numerous studies the significant and largely unchanging gap between top- performing and poor-performing hospitals. It is imperative that hospitals recognize the benchmarks set by the Distinguished Hospitals for Patient Safety are achievable and associated with higher safety and markedly lower cost. ”

The fifth annual HealthGrades Patient Safety in American Hospitals Study applies methodology developed by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality to identify the incident rates of 16 patient safety indicators among Medicare patients at virtually all of the nation's nearly 5,000 nonfederal hospitals. Additionally, HealthGrades applied its methodology using 13 patient safety indicators to identify the best-performing hospitals, or Distinguished Hospitals for Patient Safety, which represent the top five percent of all U.S. hospitals.

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Video: What's Up Robodoc?

Robots have not yet replaced doctors. But one physician has found way to use a videoconferencing robot to check on his patients when he is miles away.

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Breakthrough Video Game for Teens Helps Save Lives

A new video game called “Re-mission” is designed to give young cancer patients a sense of power and control over their disease. Rated T for teen, the 3D game is a 20 level journey through the bodies of fictional patients with different types of cancer. Players control a nanobot named Roxxi. The task? Blast cancer cells, battle bacterial infections, and manage realistic, life-threatening side effects.

But the game is more than a fun challenge. Studies show that young cancer patients who play the game are more likely to take their medicine, undergo needed therapy and understand their illness. That's because the game is geared to help teenagers better adhere to their cancer treatment and embrace vital behaviors to improve their health.

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Overcrowded Hospitals May Risk Adverse Events on Busiest Days

Hospitals that operate at or over their capacity may be at increased risk of adverse events that injure patients, according to a study led by investigators from Massachusetts General Hospital (MGH) and Brigham and Woman's Hospital (BWH). The report in the May issue of the journal Medical Care suggests that efforts to meet two primary challenges facing hospitals today – reducing costs and improving patient safety – may work against each other.

"While financial and political pressures to make health care more efficient are leading to increased hospital occupancy and greater patient turnover, patients and policymakers are quite rightly demanding that health delivery systems be made safer," says Joel Weissman, of the MGH Institute of Health Policy, the report's lead author. "Our study suggests that pushing efficiency efforts to their limits could be a double-edged sword that may jeopardize patient safety."

In order to examine their hypothesis that increased workload could raise the likelihood of adverse events, the investigators examined data from four hospitals in two states – two large urban teaching hospitals and two suburban teaching hospitals – over the 12 months from October 2000 through September 2001. To compile patient care information they reviewed patient charts and billing records on almost 25,000 patients, selecting 6,841 for comprehensive review, and analyzed that data against information on hospital workloads and staffing patterns, with a focus on variations within each hospital.

From the nearly 7,000 records receiving detailed review, 1,530 adverse events – defined as preventable injuries not resulting from patients' underlying medical condition – were identified. The most common such events were wound infections and adverse drug events. At three of the four hospitals, the rate of adverse events did not appear to increase at times of peak workload. But at the fourth – a major urban teaching hospital with consistently high occupancy rates, exceeding 100 percent for more than three months – workload increases and higher patient-to-nurse ratios were associated with more adverse events.

"While we looked at only four hospitals, which limits the ability to generalize these findings, the hospital where we found a relationship between working conditions and adverse events was disproportionately crowded for much of the study period," says study co-author Eran Bendavid, MD. "That suggests hospitals operating at the high end of their capacity may need to examine safety systems with an eye towards coping with periods of high stress."

Formerly with the MGH Institute of Health Policy, Bendavid is now at the Center for Health Policy at Stanford University.

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