A 30-day surgical standard is under scrutiny

What she wanted, the patient told the geriatricians evaluating her, was to be able to return to her condominium in Boston. She had long lived there on her own, lifting weights to keep fit and doing her own grocery shopping, until a heart condition worsened and she could barely manage the stairs. So at 94, she consented to valve replacement surgery at a Boston medical centre. “She never wanted to go to a nursing home,” said Dr Perla Macip, one of the patient’s geriatricians.

Perla presented the case to a meeting of the American Academy of Hospice and Palliative Medicine. The presentation’s dispiriting title: The 30-Day Mortality Rule in Surgery: Does This Number Prolong Unnecessary Suffering in Vulnerable Elderly Patients? Like Perla, a growing number of physicians and researchers have grown critical of 30-day mortality as a measure of surgical success. That seemingly innocuous metric, they argue, may actually undermine appropriate care, especially for older adults.The experience of Perla’s patient – whom she calls Ms. S. – shows why.Ms. S. suffered cardiopulmonary arrest during the operation and needed resuscitation. A series of complications followed: irregular heartbeat, fluid in her lungs, kidney damage, pneumonia. She had a stroke and moved in and out of the intensive care unit, off and on a ventilator. After two weeks, “she was depressed and stopped eating,” Perla said.

The geriatricians recommended a “goals of care” discussion to clarify whether Ms. S., who remained mentally clear, wanted to continue such aggressive treatment. But “the surgeons were optimistic that she would recover” and declined, Perla said. So a discussion of palliative care options was deferred until Day 30 after her operation, by which time Ms. S. had developed sepsis and multiple-organ failure. She died on Day 31, after life support was discontinued. The key number here, surgeons and other medical professionals will recognise, is 30. Thirty-day mortality serves as a traditional
yardstick for surgical quality.

Questioning the rules

Medicare has also begun to use certain risk-adjusted 30-day mortality measures, like deaths after pneumonia and heart attacks, to penalise hospitals with poor performance and reward those with better outcomes. However laudable the intent, reliance on 30-day mortality as a surgical report card has also generated growing controversy. “Thirty days is a game-able number,” said Dr Gretchen Schwarze, a vascular surgeon at the University of
Wisconsin-Madison and co-author of an editorial on the metric in JAMA Surgery.

Last fall, she led a session about the ethics of 30-day mortality reporting at an American College of Surgeons conference.“Surgeons in the audience stood up and said, ‘I can’t operate on some people because it’s going to hurt our 30-day mortality statistics,’” she recalled. The debate is particularly urgent for older adults, who are more likely to undergo surgery and to have complications. Those questioning the 30-day metric point to
potential dilemmas at both ends of the surgical spectrum. Surgeons may decline to operate on high-risk patients, even those who understand and accept the trade-offs, because of fears (conscious or not) that deaths could hurt their 30-day results.
At a hospital in Pennsylvania, for instance, a cardiothoracic surgeon declined to operate on a man who urgently needed a mitral valve replacement. He wasn’t elderly, at 53, but he was an alcoholic whose liver damage increased his risk of dying. Dr Douglas White, the director of ethics and decision-making in critical illness at the University of Pittsburgh School of Medicine, was asked to consult. According to Douglas, the surgeon explained that “We have been told that our publicly reported numbers are bad, and we have to take fewer high-risk patients.”

Other surgeons at the hospital, under similar pressure, also refused. A helicopter flew the patient to another hospital for surgery. An outlier case? A study compared three states that require public reporting of coronary stenting results to seven nearby states that didn’t report.

Older-adult patients having acute heart attacks had substantially lower rates of the stenting in the reporting states. Doctors’ concerns about disclosure of poor outcomes might have led them to perform fewer procedures, the authors speculated; they might also have weeded out poorer candidates for surgery. Perhaps as important for older people, when things go wrong, surgical teams concerned about their 30-day metrics may delay important conversations about palliative care or hospice, or even override advance
directives.

That may have been what happened to Ms. S. Or perhaps her aggressive treatment resulted from a surgical ethos that has little to do with mortality reports. “We want to cure patients and help them live, and we consider it a failure if they don’t,” said Dr Anne Mosenthal, who heads the American College of Surgeons committee on surgical palliative care. With surgeons already prone to optimism and disinclined to withdraw life support, the effect of reporting failures, if there is one, is subtle.  

Surgeons tell themselves, “Maybe if we wait a little longer, he’ll improve; there’s always a chance,” Anne said. But many older patients, and their families, have different ideas about what makes life worth sustaining and might welcome a frank discussion before a month passes. “The 30-day mortality statistic creates a conflict of interests,” said Dr Lisa Lehmann, an associate professor of medical ethics at Harvard Medical School. “It can lead to the violation of a physician’s duty to put patients’ interests first.”