What Is a Complication, Anyway?

Dr Fry is executive vice-president of Clinical Outcomes Management for MPA Healthcare Solutions of Chicago, and adjunct professor of surgery at the Northwestern University Feinberg School of Medicine. He is a career academic surgeon and former Chair of Surgery at the University of New Mexico School of Medicine. He has a career interest in surgical infections and is editor-in-chief of the journal Surgical Infections. Current research interests are measurement of outcomes of care and healthcare payment redesign.
When asked “what is your surgical site infection rate?” one will get an answer that is almost certainly removed from reality.
As a career academic surgeon, it has always been interesting to me how surgeons evaluate complication rates in their own clinical practice.
 
When asked “what is your surgical site infection rate?” one will get an answer that is almost certainly removed from reality. Is there an intent to deceive? Are they simply making a gross estimate? Do they have selective forgetfulness? Do they even know, since many of their post-operative patients are seen in emergency departments or at hospitals other than where the surgical care was delivered? Objective measurements are lacking for surgical site and other complications of care.
 
The charade of “What is your surgical site infection rate?” continues when research results are published. Several years ago, I published a study of elective colon surgery from the National Inpatient Sample from the Healthcare Cost and Utilization Project. The surgical site infection rate coded in the discharge abstracts was 3.9% in our study, which I did not believe and stated as such in the manuscript.
 
For roughly the same time period, the National Healthcare Surveillance Network reported surgical site infection rates in colon surgery between 4-9 % depending upon the risk profile of their study population. The National Surgical Quality Improvement Project reported an overall rate of about 9-11 % in the same procedure. And a prospective, clinical trial performed in elective colon surgery for an FDA approval of the study drug has reported surgical site infections that were greater than 20%.
 
Clearly different definitions and difference surveillance methods were used. What is the real number and how could any assessment of complication rates be made when there were such different reported rates? What is a complication, anyway?
 
The Complication of Complication Rates
The cruel reality of 2016 is that we do not know the complication rates of surgical care. For major operations such as colon resections or open-heart surgery, our studies have identified that 40% to 70% of patients will have one or more coded complications in the discharge abstract. Obviously, some are more serious than others and some are inconsequential for patient recovery.
 
Individual hospitals code very different rates of complications for the same operation and coded complications have no severity indicator. Should a positive urine culture following inpatient urinary tract catheterization that is quickly managed with prompt antibiotic management be given the same equivalency as fulminate postoperative urinary tract sepsis? One will never know from the discharge codes because all are commonly given the same coded designation.
 
Furthermore, coding selected complications (not urinary tract infection) have the perverse incentive with Medicare Part A hospital payments of increasing revenue for an episode. Despite poor definition of actual complication rates, there is a rush by many patient advocacy groups to publish complication rates by hospital and by clinician in the hopes that this represents discriminating information for the identification of best and worst performance.
 


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