Are Arguably Unnecessary Medical Procedures Exposing Patients to Avoidable Risks?: Public Health Watch

There’s an old saying about minor medical procedures: they’re only minor if you’re not the person undergoing them.

A study published recently in JAMA Internal Medicine seems to prove this adage to be, at least in part, true. The investigators on the study analyzed hospital admission data from 225 public hospitals in New South Wales, Australia, over a 3-year period, focusing on cases involving 9330 patients who underwent 1 of 7 “low-value” procedures—namely, endoscopy for dyspepsia in people younger than 55 years of age (3689 cases); knee arthroscopy for osteoarthritis or meniscal tears (3963); colonoscopy for constipation in people younger than 50 years of age (665); endovascular repair of abdominal aortic aneurysm in high-risk patients who are asymptomatic (508); carotid endarterectomy in high-risk patients who are asymptomatic (273); renal artery angioplasty (176); and spinal fusion for uncomplicated low-back pain (56).

If you’re wondering, the answer is…yes, these are procedures that many medical professionals and health-system administrators would deem unnecessary, in that they provide little therapeutic value for the patients in the selected cases when weighed against the risks associated with them. Among those risks? What the investigators on the JAMA paper described as “hospital-acquired complications” (HACs).

Rates of HACs for the 7 selected procedures are enough to give anyone thinking about undergoing a “minor” surgical procedure pause. Although incidence of HACs was relatively low for endoscopy (0.1% for the procedure as used in this study population), knee arthroscopy (0.5%), and colonoscopy (0.3%), it was much higher for spinal fusion (7.1%), endovascular repair of abdominal aortic aneurysm (15.0%), carotid endarterectomy (7.7%), and renal artery angioplasty (8.5%), at least as used (or, some would say, misused) in this study.

Perhaps not surprisingly, the most common HAC was hospital-acquired infection, which accounted for 26.3% of all HACs observed in the study population. Renal artery angioplasty carried the highest risk for infection (8.4%) in the study. Notably, for all 7 low-value procedures, median length of stay for patients with a HAC was twice that of the median length of stay for patients without a complication.

The investigators wrote in their concluding remarks that “these findings suggest that use of these 7 procedures in patients who probably should not receive them is harming some of those patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate.”

A HAC that has received a fair bit of scrutiny in the US in recent years is sepsis, and a study published in another JAMA publication, JAMA Critical Care Medicine, yielded some similarly disturbing findings for this clinically challenging infection. In an effort to better understand the prevalence of sepsis-associated mortality in US acute care hospitals and how preventable these deaths may potentially be, the investigators of the study reviewed the medical records of 568 patients admitted to 6 hospitals who died in the hospital or were discharged to hospice and not readmitted. They then rated the preventability of each sepsis-associated death on a 6-point Likert scale.

Mean age of the patients included in the analysis was 70.5 years. Among the cases reviewed, sepsis was present in 300 hospitalizations (52.8%) and was the immediate cause of death in 198 cases (34.9%). What’s perhaps most shocking, though, is that the authors determined that “suboptimal care”—most often delays in the administration of antibiotics in patients with sepsis—occurred in 22.7% of all sepsis-related deaths reviewed for the study. Still, based on their criteria, the investigators concluded that 3.7% of the sepsis-related deaths were “definitely or moderately likely” to have been preventable, while 8.3% of these deaths were considered “possibly preventable.”

“In my own experience as a critical care physician, a lot of sepsis patients we treat are extremely sick and even when they receive timely and optimal medical care, many do not survive,” study co-author Chanu Rhee, MD, MPH, assistant professor of population medicine at Harvard Medical School, and intensivist/infectious disease physician at Brigham and Women’s Hospital, told Contagion®. “It is important to note that since we only reviewed medical records for patients who died, our study doesn’t highlight all the other patients with sepsis for whom timely recognition and care in the hospital actually did prevent death. One of the takeaways, however, is that we should also be thinking beyond the hospital and focusing on improving prevention and care of the underlying conditions that lead to sepsis-associated deaths.”

That arguably includes ensuring that the right procedures are being performed on the right patients.