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 Researchers examined data on more than 700,000 mostly male patients
who had surgery at 143 VA hospitals nationwide from 1999 through
2014.
The proportion of patients who had major complications dropped from
10 percent to 7 percent during the study period. Among patients who
did have major complications, the proportion that died as a result
declined from 24 percent to 15 percent.
“Our data in many ways mirror trends that we find in the private
sector as well,” said lead study author Dr. Nader Massarweh, a
researcher at Baylor College of Medicine and the Michael E. DeBakey
VA Medical Center in Houston.
“Some of what we are seeing is probably the end result of underlying
trends that have been occurring over time across all of healthcare
relating to our ability to simply provide better care,” Massarweh
added by email.
At the VA in particular, surgical care may have also improved as a
result of a quality initiative started in the 1990s to track
surgical outcomes, identify problems and evaluate fixes, Massarweh
said.
One focus of this effort was to minimize the potential for patients
to die after complications develop following surgery, a situation
known in the healthcare industry as “failure to rescue.”
This might happen, for example, when a patient undergoes a colon
operation, develops pneumonia after surgery, ends up in the
intensive care unit on a ventilator and then dies, Massarweh said.
“Our goal is to minimize the number of patients who experience
complications and in those who do to treat them as quickly and
definitively as possible,” Massarweh said. “This is one of the
reasons failure to rescue has gained traction as measure of quality
– it acknowledges that complications do occur, but that timely
recognition and treatment are really the things we can control to
minimize their impact on patients.”
To assess how quality improvement efforts have influenced surgical
outcomes at the VA, researchers analyzed data on patients having
inpatient surgery or operations for vascular, spinal, orthopedic,
neurological, thoracic, genital or urinary issues. They excluded
cardiac surgeries from the analysis.
Overall, patients were about 64 years old on average and 96 percent
were men.
During the entire study period, almost 98,000 patients (14 percent)
had complications after surgery, and failure to rescue occurred for
about 13,000 of them.
Roughly 67,000 patients (9.5 percent) had major complications during
the study, and failure to rescue happened in about 12,000 cases.
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The odds of postoperative death or failure to rescue were about 40
to 50 percent lower by the end of the study than at the start,
researchers report in JAMA Surgery.
Researchers received funding for the study from the VA.
Limitations of the study include the lack of a comparison group of
hospitals that didn’t implement the VA’s quality control initiative
because it was done systemwide, the authors note. The findings also
don’t prove what caused any improvements in outcomes.
Researchers also lacked data on surgical volume, which can influence
the outcome of quality improvement efforts because surgeons are
thought to be better at procedures they do more frequently, the
authors note.
The study doesn’t examine access to care issues including long waits
for appointments that have been raised at the VA in recent years.
“I think we have to separate out access and quality of care as the
current paper does not specifically address surgical access,” said
Dr. Jason Johanning, cao-author of an accompanying editorial and
researcher at the Nebraska Western Iowa VA Health System in Omaha.
“The paper does confirm once again that VA surgical outcomes are
comparable to private sector data and that the VA’s quality
reporting which has been adopted and replicated in the private
sector can provide a robust look at the quality of surgical programs
in the nation’s largest integrated healthcare system,” Johanning
said by email.
SOURCE: http://bit.ly/2d7gYfL and http://bit.ly/2cULBBy JAMA
Surgery, online September 21, 2016.
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