At a recent Infection Control meeting, a case was brought up for discussion. It involved a revision (“redo”) orthopedic procedure that was very complicated and prolonged. Every risk factor for surgical site infection was present, and not surprisingly there was a superficial infection afterwards. This was easily treated and the patient made a good recovery. However, it had to be reported to Medicare as a complication. The discussion centered on whether the hospital could afford to perform this type of surgery since the hospital would get penalized by Medicare for “poor” quality when compared to hospitals not doing the procedure. Not only would the hospital not get paid for any additional care needed to treat the patient but the hospital might have to pay large penalties to Medicare because of poor performance. The fact that a patient who had been previously disabled was now able to walk was not up for discussion. It was all about the bottom line and staying in business.
Value Based Health Care and Risk Assessment
Cost-based decision making was not the intent of the Affordable Care Act but unfortunately, it has become an unexpected consequence of its rules. In the future, as healthcare delivery shifts to value based care, there is a real possibility that only low risk patients will undergo invasive procedures. A person who is high risk will not be touched and maybe even those who are moderate risk will also be avoided once risk aversion sets in. This won’t be done overtly, but hurdles can be introduced that will wear down even the most intrepid. Some clinicians will resist, but since most physicians are employees of hospital systems there may be few options for someone who wants to keep their job.
Examples of patients who may be affected by risk aversion include:
- Any older adult, regardless of physiologic status
- A patient with any history of cancer
- A patient requiring high-risk surgery like a Whipple procedure (pancreaticoduodenectomy)
There needs to be an alternative way to manage risk other than opting for dysfunctional risk aversion. The alternative should be simple and reliable and enable clinicians to rapidly identify patients who can undergo procedures without serious complications. One way to achieve this is by using automated medical algorithms to identify:
- Significant comorbid conditions
- Specific risk factors for a procedure
- Modifiable risk factors that can be addressed prior to surgery
- Risk factors for postoperative complications
- Possible compliance issues
- Risk factors for readmission
Surgical Risk Calculator Bundle
Once the patient has been risk profiled then a strategy can be developed to reduce existing risks and promote personal strengths. Below are just some of the algorithms from our knowledge base which will aid a clinician in surgical risk assessment.
- Risk Equation for Predicting Adverse Cardiac Outcome in Patients Undergoing Noncardiac Operations
- Criteria for Operability in Patients Undergoing Lung Resective Surgery
- Risk Score for Pulmonary Complications After Thoracic or Abdominal Surgery
- Identifying Patients at High Risk for Surgical Site Infection (SENIC Risk Index)
- Risk Factors for a Surgical Site Infection in an Older Adult
- Risk Score for Surgical Site Infection Following “Clean” Surgery
- Preparations for Reducing Perioperative Complications in a Patient with Morbid Obesity
- Categories Used to Determine If a Patient Is Unfit for General Anesthesia and/or Major Surgery
- Preoperative Smoking and Drinking Cessation
- Mortality Risk in Patients with Coexisting Conditions Undergoing Elective Surgery
- Model for Predicting Postoperative Complications from ASA Classification and Perioperative Variables
- Prognostic Index for Predicting Operative Mortality in Geriatric Patients
- Risk of Serious Perioperative Complications Based on Patient and Surgical Characteristics Including Self-Reported Exercise Tolerance
- Identification of Patients Undergoing Head and Neck Cancer Surgery at High Risk for Medical Complications
- Estimation of Physiologic Ability and Surgical Stress (E-PASS), with Preoperative Risk Score (PRS), Surgical Stress Score (SSS) and Comprehensive Risk Score (CRS)
- Criteria to Identify High Risk Surgical Patients
- Risk Factors for Postoperative Complications in an Elderly Patient
- Determining the Medical Necessity of an Intervention
Incorporating surgical risk assessment tools into the clinical decision making process will result in better outcomes for patients, clinicians, and hospitals.
