Unavoidable Factors at Play in ‘Never Events’

Abstract

Older patients and those having specific surgical procedures are more likely to experience “never events” even if health care providers adhere unerringly to best practices, a study in the Archives of Surgery found. In October 2008, the Centers for Medicare and Medicaid Services began denying payment for costs associated with treating certain complications of hospital care that it considers to be completely avoidable. That policy is counterproductive because some patients will suffer from acquired complications no matter how hard providers try to avoid them, according to Donald E. Fry, MD, of Northwestern University, Chicago, and his associates. “Use of the term ‘never event’ and denial of payment for all such events imply that these complications result entirely from avoidable clinical errors,” they wrote. “This clearly is true for rare complications such as wrong-site surgery or retained surgical sponges. However, CMS's list of current and proposed never events includes medical and surgical complications that may occur even when the highest current standards of care are met.” The investigators analyzed the federal Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample, selecting data on adults who underwent one of five surgeries: colon resection, coronary artery bypass grafting (CABG), total hip replacement, abdominal hysterectomy, or aortofemoral bypass. All patients were treated at hospitals that performed more than 100 of those procedures over a 4-year period from 2002 to 2005 (Arch. Surg. 2010;145:148–51). Factors such as the complexity and severity of a patient's medical conditions and the nature of the required interventions are beyond a provider's control but still will affect outcomes, according to Dr. Fry and his colleagues. For example, patients undergoing aortofemoral bypass surgery, CABG, and colon resection, along with older patients, were significantly more likely to have postoperative pneumonia, they found. Malnourished/underweight patients or those with chronic renal failure or lung disease also were more likely to contract postoperative pneumonia, as were those with a history of alcohol abuse, congestive heart failure, or those who had been admitted to the hospital on an emergency basis, their analysis found. Instead of denying payment for these events, CMS should consider developing a system that adjusts payments to reflect the predicted incidence and cost of complications based on patient and disease characteristics and on planned interventions, Dr. Fry and his colleagues proposed, adding that such a system could reward providers who have fewer complications than expected. In a commentary accompanying the study, Jana B.A. MacLeod, MD, associate professor of surgery at Emory University, Atlanta, noted that institutions will be discouraged from caring for high-risk patients if they are penalized financially for treating patients who suffer from never-event complications. “In our attempt to eliminate the avoidable, we cannot allow the public and private health care funding groups to punish us for the inescapable,” she wrote. Jane Anderson is a freelance writer based in Urbana, Va.