Beyond 30-day mortality: aligning surgical quality with outcomes that patients value.

Abstract

Because of their strong sense of responsibility for the lives of patients, surgeons frequently struggle to withdraw postoperative life supporting treatments when patients or their families request it.1 Although surgeons experience this as therapeutic optimism or the emotional pull of error and responsibility, these forces are accentuated by the increasing emphasis on 30-day mortality reporting. Recent expansion of outcomes profiling imposes an unconscious bias in these critical decisions: surgeons who report concern about physician profiling are more likely to decline to operate on a patient who prefers to limit life support, or refuse to withdraw life support postoperatively, than surgeons who perceive less pressure from outcomes reporting.2,3 Public reporting of 30-day mortality may motivate surgeons and hospitals to improve outcomes and theoretically empowers patients to make informed choices.4 However, use of this single metric unintentionally fails to accommodate patients who might benefit from palliative surgery, or patients who would prefer death to prolonged postoperative treatment in the intensive care unit or long-term chronic care after a major complication. Surgeons should be able to offer informed patients a risky but potentially beneficial surgical option and then allow patients to refuse aggressive treatments if they have become overly burdensome or when patients’ goals for surgery are no longer possible. Reconciling the effects of an approach designed to ensure high quality surgical care with the needs of vulnerable patients is challenging, particularly for high-risk operations where hard outcomes like mortality are easily observed and other important outcomes are more difficult to assess. Strategies to mitigate the impact of 30-day mortality reporting through consideration of alternative quality metrics are required to protect the needs of surgical patients and the practices of surgeons who could make a valuable contribution to their patients’ quality of life.