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Validation of the 30-Day Postoperative Mortality Standard and Its Relevance

Validation of the 30-Day Postoperative Mortality Standard and Its Relevance In March 2015, The New York Times reported on a patient in her 90s who underwent valve replacement surgery complicated by progressive deterioration.1 The surgeons were optimistic that she would recover, recommended aggressive care, and deferred palliative care options until postoperative day 30, by which time the patient had developed sepsis with multiorgan failure. She died on postoperative day 31. Did the surgeons purposefully delay death beyond 30 days? Concerns have been raised that public disclosure of 30-day postoperative mortality as a metric of surgical quality might result in either reluctance of surgeons to operate on high-risk patients or delaying death until after 30 days. In this issue of JAMA Surgery, Smith and colleagues2 look at 3 years of surgery within the Veterans Health Administration (VHA) and present data on 30-, 90-, 180-, and 365-day overall survival. The authors calculated survival by deciles of risk for mortality. In all surgical specialties, survival at 30 days was associated with patient risks and correlated well with subsequent survival up to 1 year. Mortality between postoperative days 25 and 35 by risk decile showed no evidence of delayed death. The authors concluded that there was no compromise in patient care to meet the 30-day mortality metric. Thus, the 30-day mortality metric was validated as a standard surgical metric. The authors2 acknowledge that their study could not discern any unethical behavior that might delay care or treatment to meet the 30-day mortality metric. In addition, this study did not measure whether surgeons refused to operate on high-risk patients to avoid a death at 30 days. The VHA has taken the lead in measuring quality of surgical care through the National Surgical Quality Program, which was later adopted by the American College of Surgeons. The programs did well over time and, within the VHA system, improved mortality from 3.2% in 1994 to 1.0% in 2014.3 The VHA has also taken the lead in implementing patient-centered care, but available metrics do not account for patient-informed decisions that can adversely affect those metrics. As advocated by Schwarze et al,4 it is time to align quality metrics with outcomes that patients value. Quality metrics, such as 30-day mortality, are now used in public-reporting social media and pay-for-performance programs, resulting in care that is now metrics driven rather than patient centered. We can and should realign patient care with metrics that matter through well-established and developed processes of care.5 Quality metrics initially developed to improve systems and processes of care should continue to be refined to take into consideration the care that matters to patients and is of value to both patients and the health care system. Back to top Article Information Corresponding Author: Kamal M. F. Itani, MD, Department of Surgery, Veterans Affairs Boston Healthcare System, 1400 VFW Pkwy (112A), West Roxbury, MA 02120 (kitani@va.gov). Published Online: January 6, 2016. doi:10.1001/jamasurg.2015.4889. Conflict of Interest Disclosures: None reported. References 1. Span P. A surgery standard under fire.New York Times website. http://www.nytimes.com/2015/03/03/health/a-30-day-surgical-standard-is-under-scrutiny.html?_r=0. Published March 2, 2015. Accessed October 18, 2015. 2. Smith T, Li X, Nylander W, Gunnar W. Thirty-day postoperative mortality risk estimates and 1-year survival in Veterans Health Administration surgery patients [published online January 6, 2016]. JAMA Surg. doi:10.1001/jamasurg.2015.4882.Google Scholar 3. VA National Surgical Office. Unadjusted 30-day morbidity and mortality rates for VASQIP risk assessed procedures. http://vaww.dushom.va.gov/surgery/index.asap. Accessed October 25, 2015. 4. Schwarze ML, Brasel KJ, Mosenthal AC. Beyond 30-day mortality: aligning surgical quality with outcomes that patients value. JAMA Surg. 2014;149(7):631-632.PubMedGoogle ScholarCrossref 5. Bilimoria KY. Facilitating quality improvement: pushing the pendulum back toward process measures. JAMA. 2015;314(13):1333-1334.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Validation of the 30-Day Postoperative Mortality Standard and Its Relevance

JAMA Surgery , Volume 151 (5) – May 1, 2016

Validation of the 30-Day Postoperative Mortality Standard and Its Relevance

Abstract

In March 2015, The New York Times reported on a patient in her 90s who underwent valve replacement surgery complicated by progressive deterioration.1 The surgeons were optimistic that she would recover, recommended aggressive care, and deferred palliative care options until postoperative day 30, by which time the patient had developed sepsis with multiorgan failure. She died on postoperative day 31. Did the surgeons purposefully delay death beyond 30 days? Concerns have been raised that...
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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2015.4889
Publisher site
See Article on Publisher Site

Abstract

In March 2015, The New York Times reported on a patient in her 90s who underwent valve replacement surgery complicated by progressive deterioration.1 The surgeons were optimistic that she would recover, recommended aggressive care, and deferred palliative care options until postoperative day 30, by which time the patient had developed sepsis with multiorgan failure. She died on postoperative day 31. Did the surgeons purposefully delay death beyond 30 days? Concerns have been raised that public disclosure of 30-day postoperative mortality as a metric of surgical quality might result in either reluctance of surgeons to operate on high-risk patients or delaying death until after 30 days. In this issue of JAMA Surgery, Smith and colleagues2 look at 3 years of surgery within the Veterans Health Administration (VHA) and present data on 30-, 90-, 180-, and 365-day overall survival. The authors calculated survival by deciles of risk for mortality. In all surgical specialties, survival at 30 days was associated with patient risks and correlated well with subsequent survival up to 1 year. Mortality between postoperative days 25 and 35 by risk decile showed no evidence of delayed death. The authors concluded that there was no compromise in patient care to meet the 30-day mortality metric. Thus, the 30-day mortality metric was validated as a standard surgical metric. The authors2 acknowledge that their study could not discern any unethical behavior that might delay care or treatment to meet the 30-day mortality metric. In addition, this study did not measure whether surgeons refused to operate on high-risk patients to avoid a death at 30 days. The VHA has taken the lead in measuring quality of surgical care through the National Surgical Quality Program, which was later adopted by the American College of Surgeons. The programs did well over time and, within the VHA system, improved mortality from 3.2% in 1994 to 1.0% in 2014.3 The VHA has also taken the lead in implementing patient-centered care, but available metrics do not account for patient-informed decisions that can adversely affect those metrics. As advocated by Schwarze et al,4 it is time to align quality metrics with outcomes that patients value. Quality metrics, such as 30-day mortality, are now used in public-reporting social media and pay-for-performance programs, resulting in care that is now metrics driven rather than patient centered. We can and should realign patient care with metrics that matter through well-established and developed processes of care.5 Quality metrics initially developed to improve systems and processes of care should continue to be refined to take into consideration the care that matters to patients and is of value to both patients and the health care system. Back to top Article Information Corresponding Author: Kamal M. F. Itani, MD, Department of Surgery, Veterans Affairs Boston Healthcare System, 1400 VFW Pkwy (112A), West Roxbury, MA 02120 (kitani@va.gov). Published Online: January 6, 2016. doi:10.1001/jamasurg.2015.4889. Conflict of Interest Disclosures: None reported. References 1. Span P. A surgery standard under fire.New York Times website. http://www.nytimes.com/2015/03/03/health/a-30-day-surgical-standard-is-under-scrutiny.html?_r=0. Published March 2, 2015. Accessed October 18, 2015. 2. Smith T, Li X, Nylander W, Gunnar W. Thirty-day postoperative mortality risk estimates and 1-year survival in Veterans Health Administration surgery patients [published online January 6, 2016]. JAMA Surg. doi:10.1001/jamasurg.2015.4882.Google Scholar 3. VA National Surgical Office. Unadjusted 30-day morbidity and mortality rates for VASQIP risk assessed procedures. http://vaww.dushom.va.gov/surgery/index.asap. Accessed October 25, 2015. 4. Schwarze ML, Brasel KJ, Mosenthal AC. Beyond 30-day mortality: aligning surgical quality with outcomes that patients value. JAMA Surg. 2014;149(7):631-632.PubMedGoogle ScholarCrossref 5. Bilimoria KY. Facilitating quality improvement: pushing the pendulum back toward process measures. JAMA. 2015;314(13):1333-1334.PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: May 1, 2016

Keywords: survival analysis,postoperative care,postoperative period,quality indicators,united states department of veterans affairs

References