Deaths rise with outpatient urologic surgeries

As a number of common urologic surgeries have shifted from the inpatient to outpatient setting, potentially preventable deaths have increased following complications, the authors of a recently published study reported.

However, the finding may suggest that urologists change not where procedures are done but how they are done, says one expert in the field.

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The study was led by researchers at Henry Ford Hospital in Detroit, who initially expected that improved mortality rates recently documented for surgery overall would also translate to commonly performed urologic surgeries. The opposite turned out to be true.

The findings were published online in the BJU International (Aug. 19, 2014).

Dr. SammonThe study, which included researchers from Harvard Medical School and Harvard School of Public Health, the University of Montreal Health Center, and Yale University, also identified older, sicker, minority patients and those with public insurance as more likely to die after a potentially recognizable or preventable complication.

“These high-risk patients are ideal targets for new health care initiatives aimed at improving process and results,” said lead author Jesse D. Sammon, DO, of Henry Ford’s Vattikuti Urology Institute in a news release.

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“Urologic surgeons and support staff need a heightened awareness of the early signs of complications to prevent such deaths, particularly as our patient population becomes older and has more chronic medical conditions.”

The study focused on failure to rescue (FTR), a metric that measures the ability of providers and institutions to recognize complications and intervene before mortality.

“While comparison of overall complications and mortality rates penalizes hospitals treating sicker patients and more complex cases, FTR rates may be a more accurate way to assess safety and quality of care,” Dr. Sammon said.

Using the Nationwide Inpatient Sample, Dr. Sammon and colleagues identified all patients discharged after urologic surgery between 1998 and 2010.

This pool of more than 7.7 million surgeries-including ureteral stenting, BPH treatment, bladder biopsy, and nephrectomy, among others-was analyzed for overall and FTR mortality as well as changes in mortality rates. The researchers determined that while both admissions for urologic surgery and overall mortality decreased slightly, deaths attributable to FTR increased 5% every year during the study period.

The researchers also found that the number of inpatient urologic surgeries dropped during the study period and surmised this was due to a “major shift” to outpatient procedures. In addition, older, sicker, and minority patients, as well as those with public insurance, were more likely to die after a potentially recognizable or preventable complication of their urologic surgery.

Besides the study’s primary conclusions, Dr. Sammon says the research also suggested that compared to other medical specialties, “these findings also raise the possibility that the care of urologic surgical patients is suffering from inadequate or poorly applied patient safety measures.”

Steven Kaplan, MD, of Weill Cornell Medical College in New York, says it is true that the practice of medicine has changed over the past decade, with one of the chief drivers being the need to curb costs.

Dr. Kaplan“One example is the shifting of surgeries from an inpatient to outpatient setting. In theory, one would expect greater cost savings and efficiency given the economic incentives of participating surgeons and associates,” said Dr. Kaplan, a member of the Urology Times Editorial Council, who was not involved in the study.

Do the findings indicate that outpatient surgery is less favorable than inpatient surgery and that urologic patients are suffering?

“It is more plausible to look at this data and see it as a calling for us to not change where we do things, but how we do them,” Dr. Kaplan said. “Moreover, given the improvement in heath and digital informatics, we should utilize these tools to better inform, monitor, and care for surgical patients in all environments. Let us look at this data not as a repudiation but rather as a call to best utilize all the instruments available and in our grasp, both surgical and technological, to offer the best, safest, and most efficient therapy to our urologic patients.”

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