Today in the NY Times there is an article questioning the utility of the 30 day mortality as a valid quality metric in cardiac surgery. In some states, hospitals are required by law to publicly report 30 day mortality rates after cardiac procedures like valve replacement and coronary bypass grafting. The article presents a case study wherein a 94 year old patient underwent aortic valve replacement and, unsurprisingly, suffers multiple post operative setbacks and complications. Ultimately, discussions of palliative care and withdrawal of aggressive support were delayed until she reached the magical 30 day milestone. On day 31, she was made DNR and expired shortly thereafter.
The article makes valid critical points about the arbitrary nature of "30 day mortality rates". Specifically, that surgeons may be reluctant to pursue aggressive care in certain patients for fear of hurting their "stats". In addition, there is a real concern that palliative/hospice care may be delayed even when it becomes obvious that the situation is futile, thereby subjecting the patient to weeks of unnecessary suffering hooked up to ventilators in an ICU.
These are good points. But the lede has been buried.
The real question ought to be: "Why the hell would you perform aortic valve replacement on a 94 year old patient?" Simply choose to not put such a patient on the operating table and you don't have to worry about keeping her alive for 30 days. And if surgeons feel increasingly dissuaded from performing high risk surgery on poor surgical candidates, then so be it. Maybe that wouldn't be such a bad thing. I like the idea of total transparency in surgery. I like published mortality rates. I like the idea of comparing hospitals using hard cold data. And I think Americans ought to have a right to access information that may impact decision making in terms of where an operation is performed. This ought not to be all that controversial....
The article makes valid critical points about the arbitrary nature of "30 day mortality rates". Specifically, that surgeons may be reluctant to pursue aggressive care in certain patients for fear of hurting their "stats". In addition, there is a real concern that palliative/hospice care may be delayed even when it becomes obvious that the situation is futile, thereby subjecting the patient to weeks of unnecessary suffering hooked up to ventilators in an ICU.
These are good points. But the lede has been buried.
The real question ought to be: "Why the hell would you perform aortic valve replacement on a 94 year old patient?" Simply choose to not put such a patient on the operating table and you don't have to worry about keeping her alive for 30 days. And if surgeons feel increasingly dissuaded from performing high risk surgery on poor surgical candidates, then so be it. Maybe that wouldn't be such a bad thing. I like the idea of total transparency in surgery. I like published mortality rates. I like the idea of comparing hospitals using hard cold data. And I think Americans ought to have a right to access information that may impact decision making in terms of where an operation is performed. This ought not to be all that controversial....
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