Hospital Quality: Tough Issue!

by Wayne Myers

In April of last year, scholars at the Harvard School of Public Health published a study in the Journal of the American Medical Association (JAMA) on death rates in Critical Access Hospitals (CAHs) compared to other, larger hospitals.  They found that in in 2002 the death rates in the two sets of hospitals of patients admitted with heart attack, pneumonia or heart failure were the same.   Over the next eight years, death in the larger hospitals had decreased while death rates in the small rural hospitals hadn't improved.  By 2010, patients in the larger hospitals with one of these diagnoses were 1.8 percent less likely to die than patients in CAHs.

Authors attributed the widening gap to the fact that larger hospitals were required to report their deaths to Medicare while CAHs were not.  The problem, according to the authors, was the lack of accountability.  The JAMA article was picked up by lots of outlets including USA Today and Public Broadcasting, typically with such headlines as, "Why Rural Hospitals May Pose a Greater Risk of Death."

I believe this is a flawed article.  I've written elsewhere about the authors' failure to acknowledge the complexity of patients' decisions to get their care for life-threatening illness in small local hospitals, specifically patients with heart attacks opting for care in a hospital without coronary catheterization capability.

The 21st century has seen a remarkable improvement in the quality of medical care, particularly in hospitals.  I think this movement was triggered by the Institute of Medicine* report, Crossing the Quality Chasm, published in 2001.  Many, many people—from administrators and medical and nursing directors to aides and housekeeping staff—have worked terribly hard on a huge range of issues.  It's a real and continuing success story.

At this point, though, I'm more concerned with a more difficult issue wrapped up in hospital "quality," its measurement and rewards. I'm afraid there may be a dark side to hospital quality—a situation in which hospital incentives may not always serve the patient's wishes.  By that I mean that hospitals have incentives to keep people alive to discharge regardless of the patient's wishes, or the consequences of the patient's wishes.

Hospital intensive care units, ICUs, have been around for a little over 50 years.  Most referral hospitals have intensive care units.  Very few CAHs have them.

It's been known for as long as there have been ICUs that they made people temporarily crazy.  The phenomenon is called "ICU psychosis."  Only now, though, are we learning that about a third of survivors of intensive care suffer from post-traumatic stress disorder (PTSD).  Perhaps a fifth of ICU patients develop some degree of long-term dementia.

ICUs embody much of what's good about modern hospital care.  They can do wonders.  On the other hand, the ICU is never quiet, dark, private, predictable or understandable to the patient.  If the patient has something communicable, everyone caring for him disappears behind caps, masks, gloves and gowns, with only eyes showing.  The staff has trouble remembering that the person in the bed, even if paralyzed by drugs, is probably hearing and remembering every word.

I don't think the severe consequences of intensive care are new developments.  They're just newly recognized.  People who do focused, inpatient care may not pay much attention to anything beyond survival.  Indeed, they probably never see the patient once s/he leaves the ICU.

I suppose, to the extent the mental damage following intensive care was noticed, it was blamed on the condition causing the need for intensive care rather than the care itself.  Only when hundreds of ICU graduates were systematically followed up by people at Vanderbilt was it realized that the damaging factor was the ICU care itself.

Have some older people seen something among their friends coming home from stays in large hospitals and thought, "This doesn't look good to me"?

Pneumonia used to be regarded as "the old man's friend" because it was a common, painless way to die.  No more. With antibiotics pushed as hard as necessary, and ventilator support of breathing becoming more routine, most patients can be brought through.  The antibiotic treatment puts the patient at risk for a particularly bad kind of diarrhea.  Care on a breathing machine, a ventilator, requires that the patient receive intravenous anesthesia, then an intravenous paralyzing agent, then a tube into the windpipe.  In most hospitals no special permission is required, though the risks are greater than for many kinds of surgery.

With a ventilator the clinical team can push excess fluid out of the lungs, rest the tired or broken chest, control the gases being breathed.  The doctor doing the intubation earns a large fee.  The hospital earns an astronomic rate.  If it can get the patient to discharge, and avoid a readmission for 30 days, even with the patient in a nursing home, it avoids a reportable death on Hospital Compare, the Medicare quality reporting website.  It also protects its "quality purchasing" arrangement with Medicare.

But what if the patient objects to the prospect of being knocked out and put on the vent?  S/he may have no say.  S/he may be regarded as upset, oxygen starved, delirious, "a sundowner" in hospital parlance.  The bottom line is that the business deal and the quality measurement arrangement are between the hospital and Medicare or another insurance company.  The patient is not party to the deal.

Can you imagine a pragmatic hospital CEO figuring, "If they don't want their lives saved, and saved the way we save them, they shouldn't come here.  Nobody dies on my watch.  If they leave a little more dingy than they came in that's the price they pay for living longer.  I'd rather be criticized for overtreatment than neglect."

But there are those who don't see things that way.  I am aware of doctors having "NO CODE" tattooed on their chests.  They realize that the odds of restarting a stopped heart without brain damage are quite low, and don't want people trying to bring them back to life.   Will we be seeing "NO VENT," meaning "no ventilator," when older docs unbutton their collars?  Will anyone honor that wish?

People need to think through and talk through the possibilities before they get sick, certainly before they go in the hospital.  If they don't want heroics they should have their wishes in the hospital record, but also in indelible marker on tape on the head of their bed or their forehead.

The quality improvement movement has certainly improved care in all hospitals.  Medicare's translation of quality goals into business incentives may bypass patients' wishes when it comes to intensive care.  I don't think I'd trade high probability of long-term PTSD and/or dementia for a modest increase in odds of survival, but everyone should have the chance to decide for themselves and not for the hospital's business interests.

*In March 2016, the Institute of Medicine changed its name to be the Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and Medicine.

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

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