Programs getting "dinged" and patients suffering M&M

[chocomorsel]

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Currently in a large program that does transplants and I am noticing that surgical/interventional doctors and programs are becoming risk averse in treating high acuity patients due to getting "dinged".

For example, surgeons avoiding valve replacement in patients who have infective endocarditis due to +BC and possibly of valve infection; refusing to catheterize patients with CRI due to fear of or worsening CRI and need for dialysis. Surgeons not doing transplants due to possibility of complications and death before the 1 year mark and getting dinged.

Are you guys in academics encountering this? What can be done about this? I and others feel like patients are not getting the proper care they need because of CMS "dings" and possibly lack of reimbursement from CMS/Insurance carriers. Patients are dying and worsening here. And yes, some are gonna die regardless but there are some that can be saved. Can we fix this?

 

[Psai]

I think we need to let more people die peacefully. The number of ridiculous surgeries we do on basically dead people is astonishing. Then people wonder why patients are getting postop mis and strokes.

 

[chocomorsel]

I think we need to let more people die peacefully. The number of ridiculous surgeries we do on basically dead people is astonishing. Then people wonder why patients are getting postop mis and strokes.

I think you have a valid point but there are some people who do need a chance. We all see more of is the prolonged, ridiculous ICU care with multiple pressors, transfusions, etc when they don't recover from said surgery. But I had a patient, otherwise healthy 30 year old who ended up dying due to AI and infected endocarditis who never got a chance. And it was from a tooth abscess not drugs. And she'd just given birth. Not a chance. Really?

 

[Man o War]

This is the future of US medicine, whether we like it or not. Rationing, death panels, whatever people call it.
We haven’t *seen* it at my place to a huge extent, but the hints are being dropped. It’s coming.

 

[chocomorsel]

I don't know if this equates to a death panel or rationing. But it's not right in many scenarios. There are some patients that we should pull back from when they aren't getting better, but there are those that aren't given a chance because of a possible bad outcome. Especially the young ones.

 

[narcotics999]

If the patient has a high probability to die in a year after transplant, should s/he be the candidate at all? After all, we don't have a ton of organs to squander.

 

[Orin]

What's an acceptable amount of risk for the patients or "dings" for a program?

No one is truly incentivized to do hard cases, even if they're worth doing.

 

[chocomorsel]

If the patient has a high probability to die in a year after transplant, should s/he be the candidate at all? After all, we don't have a ton of organs to squander.

That's a good point. And we shouldn't. But really that's not what I am focusing on. Guess I should talk more of patients who don't need organs? The dead new mom with IE is one of the ones that bug me. And ones like her.

 

[urge]

And yes, some are gonna die regardless but there are some that can be saved.

Some?

I would wager all.

 

[urge]

t I had a patient, otherwise healthy 30 year old who ended up dying due to AI and infected endocarditis who never got a chance. And it was from a tooth abscess not drugs. And she'd just given birth. Not a chance. Really?

Had she died after surgery, would you feel better despite the same outcome?

 

[chocomorsel]

Some?

I would wager all.

Well considering we are talking of 15-35% mortality versus 100% in IE, I would wager "some".
And yes, I would have felt better had they at least tried. As I am sure so would have her family, some of the nurses and docs who took care of her.

Listen, I am as cynical as they come when it comes to some of the flogging we do in the ICU to many of these patients. Probably worse than @FFP. Especially the old ones. But shouldn't we try a little bit more with some of our others? Especially when they have age on their side?

 

[chocomorsel]

What's an acceptable amount of risk for the patients or "dings" for a program?

No one is truly incentivized to do hard cases, even if they're worth doing.

What does it take to be "incentivized"?
Money? Status? Reputation? Ego? I don't know.

 

[trapperjohn4077]

What does it take to be "incentivized"?
Money? Status? Reputation? Ego? I don't know.

I get the impression that the problem is not so much about a lack of positive incentives, but the existence of *disincentives* to doing hard cases.

 

[vector2]

Well considering we are talking of 15-35% mortality versus 100% in IE, I would wager "some".
And yes, I would have felt better had they at least tried. As I am sure so would have her family, some of the nurses and docs who took care of her.

Listen, I am as cynical as they come when it comes to some of the flogging we do in the ICU to many of these patients. Probably worse than @FFP. Especially the old ones. But shouldn't we try a little bit more with some of our others? Especially when they have age on their side?

There's gotta be more to the young mom AI Inf endocarditis story. I work with some pretty risk averse surgeons and even they wouldn't turn this down unless there were some pretty bad risks that would essentially preclude getting out of the OR alive. Was she full blown septic shock at the time? Multi system organ failure? Frank LV failure with pHTN? Echocardiographically, had the I.e. already abscessed out into the entirety of the aortic root, fibrosa between the mitral valve, or other chambers? The 15-35% risk applies to all comers- a specific pt may still have near a 100% 30 day mortality risk even if you take them to the OR.

 

[urge]

Well considering we are talking of 15-35% mortality versus 100% in IE, I would wager "some".
And yes, I would have felt better had they at least tried. As I am sure so would have her family, some of the nurses and docs who took care of her.

You are not looking long term.

I don't agree with doing Hail Mary surgery to make the family and other physicians happy with themselves. If the risk of an operation is too high then I don't see the point. The treatment of edocarditis is antibiotics. not necessarily surgery.

 

[anbuitachi]

feels to me many surgeons care about these metrics a lot. The ICUs keep transplanted patients that went badly alive in the ICU for however many days the metric cares about.

 

[Aether2000]

We need a Soylent Green type of option for people

 

[chocomorsel]

There's gotta be more to the young mom AI Inf endocarditis story. I work with some pretty risk averse surgeons and even they wouldn't turn this down unless there were some pretty bad risks that would essentially preclude getting out of the OR alive. Was she full blown septic shock at the time? Multi system organ failure? Frank LV failure with pHTN? Echocardiographically, had the I.e. already abscessed out into the entirety of the aortic root, fibrosa between the mitral valve, or other chambers? The 15-35% risk applies to all comers- a specific pt may still have near a 100% 30 day mortality risk even if you take them to the OR.

She was sedated but awake and intubated and writing notes on a pad the day they took her to take out her baby. And then the waiting began. And then a few days later she went to the OR in full blown HF. By then the spiral had began and it was too late. At that point yeah, she may have been close to 100%.
Her risk went up to >15% after she developed HF. Before that she was not yet in HF and her risk was a little less actually.

 

[chocomorsel]

You are not looking long term.

I don't agree with doing Hail Mary surgery to make the family and other physicians happy with themselves. If the risk of an operation is too high then I don't see the point. The treatment of edocarditis is antibiotics. not necessarily surgery.

It wasn’t a Hail Mary from the beginning. She had a good chance in the beginning. And she had severe AI due to vegetation so needed more than just Antibiotics.

 

[chocomorsel]

feels to me many surgeons care about these metrics a lot. The ICUs keep transplanted patients that went badly alive in the ICU for however many days the metric cares about.

Thirty days and one year.
So yeah, is it best for patients? I remember taking dead patients to the OR back in Houston while in residency. Had to die after 30 days I was told.
As outpatients they start dying off at one year. Sad.

 

[pgg]

If you really think there's a pattern of inappropriate care, not just a series of reasonable decisions you don't agree with, then you should probably speak with hospital risk management and/or the ethics committee.

This is why those entities and peer review exist. There will be a way to do so anonymously or confidentially.

 

[Ronin786]

My philosophy: I'm not a surgeon nor do I want to be. If my surgeon tells me the risk is too high for a procedure, I'm taking his word for it. Not going to try and convince someone to operate when they don't want to.

 

[Robotic Wis-Hipple]

I think you have a valid point but there are some people who do need a chance. We all see more of is the prolonged, ridiculous ICU care with multiple pressors, transfusions, etc when they don't recover from said surgery. But I had a patient, otherwise healthy 30 year old who ended up dying due to AI and infected endocarditis who never got a chance. And it was from a tooth abscess not drugs. And she'd just given birth. Not a chance. Really?

Where the F are you at? Meanwhile I’ve done a 3x redo for 3rd time IE.

 

[chocomorsel]

Where the F are you at? Meanwhile I’ve done a 3x redo for 3rd time IE.

LOL

 

[deleted87051]

Where the F are you at? Meanwhile I’ve done a 3x redo for 3rd time IE.

In 2016 I took care of a young couple 6 weeks apart. They each got TVR for IE.

 

[anbuitachi]

Thirty days and one year.
So yeah, is it best for patients? I remember taking dead patients to the OR back in Houston while in residency. Had to die after 30 days I was told.
As outpatients they start dying off at one year. Sad.

yea its making me doubt studies that compare differences in mortality. how many of alive patients are only kept alive for metrics?

 

[deleted171991]

True story from the beginning of my fellowship (breaks my heart every time I remember it - thankfully it's all becoming a blur):

Very nice patient in her 50s/60s, from good family and background, with no pertinent history of IVDU etc. admitted with infectious endocarditis of unclear origin (big vegetation on one of the valves, can't remember which). S/he decompensates fast, on high dose multiple pressors by the end of the second day. We see early tamponade on TEE, convince the interventional cardiologists to place a pericardial catheter. In less than 24 hours s/he is almost off pressors and awake, still intubated though. The next day or so, the genius cardiac fellow removes the catheter. By the next day, we are back to square one, barely keeping the patient alive. I BEG them to put the catheter back in, they refuse, arguing that they can't see enough fluid on their stupid TTE. I point out the obvious relation to the changes in clinical status, nobody with a brain at home. The patient continues deteriorating because of bacteremia, gets AKI and all the good stuff: after a couple of days, the family makes the patient comfort measures only, based on known patient wishes.

Typical example of doctor with knee-jerk thinking, who wouldn't do the right thing for the patient; the hospitals are full of people like this, so I totally understand where @chocomorsel is coming from. (In this case, the cardiac surgeon was also reticent about considering the patient for surgery.)

I will repeat myself: why is it so hard for healthcare workers to treat their patients as if they were their family members? Just do the right thing for the patient.

(Another thing that I "loved" in this patient's care was the ID genius who was treating a triple-pressor patient with just cefazolin IV, based on the blood cultures. Some people really can't see the forest, and don't belong in medicine, but that's another story.)

 

[wholeheartedly]

Came across this today, seemed somewhat relevant to this discussion

Implementation of the Hospital Readmissions Reduction Program Associated With Increase in Patient-Level Mortality
Implementation of the Hospital Readmissions Reduction Program Associated With Increase in Patient-Level Mortality

 

[chocomorsel]

We hardly do cultures on our patients with fevers, WBCs or septic pictures if they have CVCs or Foleys in our ICUs Just throw broad spectrums at them and start peeling off stuff or adding more stuff if they do or do not improve. It’s lovely.

 

[cards67]

Certainly a big issue. Public reporting, misleading statistics, skewed data, gaming the system, up/down coding, etc. Admin, CMS, insurance know-nothings thinking they can control healthcare and fit patients into neat little boxes. A talented coder and/or savvy admin and protocols can make a hospital/doc look really good. USnews is big time marketing, but I've heard crazy stories of the things some of these big name hospitals would do to preserve their rankings. Mt sinai raised eyebrows awhile ago for their monster cath numbers. Some hospitals report using "mechanical support" before lvads were fda approved, just goes to show everyone coding differently. THI/St Lukes got bad press this past year for poor outcomes, a hospital known for aggressive care. Reporters using statistics, patient stories to weave a dramatic, sensationalized, and eventually contradictory story. Then the CMS know-nothings who've never worked in a hospital withdrew funding, certainly they bought into the hype. Though it seems the hospital keeps going about their business, seeing patients and doing transplants. While I agree that sometimes we overdo care, it's easy to say that as the doctor but not as easy for the patient. Having been on the other side as a patient somewhat recently, I get it. Recently we had to deny care to a willing young patient who had a low probability, but our outcomes was near the forefront of the decision and it was a difficult.