Patient Characteristics and the Occurrence of Never Events

Michael Pine and Associates, 5020 S. Lake Shore Drive, Chicago, IL 60615, USA.
Archives of surgery (Chicago, Ill.: 1960) (Impact Factor: 4.93). 02/2010; 145(2):148-51. DOI: 10.1001/archsurg.2009.277
Source: PubMed


To determine whether the occurrence of "never events" after major surgical procedures is affected by patient and disease characteristics and by the type of operation performed.
Epidemiological analysis.
Derivation and assessment of predictive equations for postoperative infectious events and decubitus ulcers using Healthcare Cost and Utilization Project Nationwide Inpatient Sample administrative claims data for patients hospitalized between 2002 and 2005.
C statistics for each predictive equation with and without hospital dummy variables.
Predictive equations for 6 of 8 complications had C statistics greater than 0.65 without hospital variables, while 2 had C statistics of less than 0.55. All equations had C statistics greater than 0.75 when hospital dummy variables were included.
Patient characteristics and type of operative procedure are important predictors of complications of surgical care evaluated in this study, undermining the rationale for their current classification as "never events." Variations in risk-adjusted complication rates among hospitals support the influence of quality of care on their occurrence. Development and use of warranties to cover costs associated with caring for the unavoidable components of potentially avoidable complications is proposed as a means of rewarding high-quality providers without creating unrealistic expectations or perverse financial incentives.

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Available from: Donald E Fry, Apr 20, 2015
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    • "A medical complication is an unfavorable event during medical care of a patient, whereas the term never event was coined by Ken Kizer [6], the former CEO of the National Quality Forum, to describe a medical outcome that should never occur. While some of the never events, such as wrong site surgery, accidentally leaving foreign bodies during surgery, and post-operative falls and hip fractures, may be attributed to deficiencies in process of care, there are other designated never events (such as post-operative pneumonia, Clostridium difficile infection, infection with microorganisms resistant to penicillin, post-operative infections, and decubitus ulcers) which could occur due to the immuno-compromised nature of the patient or any other patient level attribute rather than an obvious deficiency in the care process at the hospital [7]. To our knowledge there is no published research on occurrence of the above mentioned infection-related never events in patients undergoing spinal fusion using a nationwide dataset. "
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    ABSTRACT: To examine the prevalence and predictors of infection related never events (NE) associated with spinal fusion procedures (SFP) in children (age < = 18 years) in the United States. We performed a retrospective analysis of the Nationwide Inpatient Sample for the years 2004 to 2008. All pediatric hospitalizations that underwent SFP were selected for analysis. The main outcomes measures include occurrence of certain NE's. The association between the occurrence of a NE and factors (patient & hospital related) were examined using multivariable logistic regression analysis. Of 56,465 hospitalizations, 61.7% occurred among females. The average age was 13.7 y and two-thirds were whites. The major insurance payer was private insurance (67.4%). About 82% of all hospitalizations occurred on an elective basis. Teaching hospitals accounted for a majority of hospitalizations (87.9%). Two-thirds were posterior fusion techniques, 52.3% had underlying musculoskeletal deformities, and the most frequently present co-morbid conditions (CMC) included paralysis (10.9%), chronic pulmonary disease (9.7%), and fluid/electrolyte disorders (7.6%). Overall rate of occurrence of a NE was 4.8%. Post-operative pneumonia was the most frequently occurring NE (2.9%). Female gender (OR = 0.78) and elective admissions (OR = 0.66) were associated with lower risk of NE occurrence. Medicaid coverage (OR = 1.46), primary diagnosis of other acquired deformities (OR = 1.82), spinal cord injury (OR = 6.94), other nervous system disorders (OR = 2.84) were associated with higher risk of NE occurrence. Among CMC, those with chronic blood loss anemia (OR = 2.57), coagulopathy (OR = 1.97), depression (OR = 2), drug abuse (OR = 3.71), fluid/electrolyte disorders (OR = 2.62), neurological disorders (OR = 1.72), paralysis (OR = 1.75), renal failure (OR = 5.45), and weight loss (OR = 4.61) were risk factors for higher odds of a NE occurrence. Hospital teaching status, region, hospital size, and patient race did not influence the occurrence of NE. The never events examined in the current study occurred in 4.8% of children hospitalized with SFP. Certain predictors of NE are identified in this study.
    Full-text · Article · Nov 2013 · PLoS ONE
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    • "A logical extension could determine how HACS differently impacts various at-risk populations. While it seems logical to propose process variables such as VTE prophylaxis administration for measuring quality of care, it is also clear that VTE is a problematic outcome because it can occur even with proper prophylaxis [54], [55], [56], [57]. Enforcing policies to prevent VTE can decrease access to care and pose a theoretical risk of increasing overall complication rates. "
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    ABSTRACT: The Hospital Acquired Condition Strategy (HACS) denies payment for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The intention is to reduce complications and associated costs, while improving the quality of care by mandating VTE prophylaxis. We applied a system dynamics model to estimate the impact of HACS on VTE rates, and potential unintended consequences such as increased rates of bleeding and infection and decreased access for patients who might benefit from TKA. The system dynamics model uses a series of patient stocks including the number needing TKA, deemed ineligible, receiving TKA, and harmed due to surgical complication. The flow of patients between stocks is determined by a series of causal elements such as rates of exclusion, surgery and complications. The number of patients harmed due to VTE, bleeding or exclusion were modeled by year by comparing patient stocks that results in scenarios with and without HACS. The percentage of TKA patients experiencing VTE decreased approximately 3-fold with HACS. This decrease in VTE was offset by an increased rate of bleeding and infection. Moreover, results from the model suggest HACS could exclude 1.5% or half a million patients who might benefit from knee replacement through 2020. System dynamics modeling indicates HACS will have the intended consequence of reducing VTE rates. However, an unintended consequence of the policy might be increased potential harm resulting from over administration of prophylaxis, as well as exclusion of a large population of patients who might benefit from TKA.
    Full-text · Article · Apr 2012 · PLoS ONE
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    • "The benefits of any surgical procedure are heavily influenced by the accompanying morbidity and mortality. The development of complications after surgery not only worsen the outcomes, but also prolong the hospital stay and are associated with a significantly increased cost in hospital care [1] [2] [3]. It has been estimated that nearly one fourth of deaths occurring within 6 days of all surgeries are related to postoperative pulmonary complications [4]. "
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    ABSTRACT: Postoperative pneumonia (PP) and respiratory failure (PRF) are known to be the most common nonwound complications after bariatric surgery. Our objective was to identify their current prevalence after bariatric surgery and to study the preoperative factors associated with them using data from the American College of Surgeons' National Surgical Quality Improvement Program. Patients undergoing bariatric surgery were identified from the National Surgical Quality Improvement Program (2006-2008), a multicenter, prospective database. Univariate analysis and multivariate logistic regression analysis were performed. Of 32,889 patients, PP was diagnosed in 187 patients (.6%) and PRF in 204 patients (.6%). The overall 30-day morbidity rate was 6.4%, with PP and PRF accounting for 18.7%. The 30-day mortality rate was greater for the patients with PP and PRF than those without (4.3% versus .16% and 13.7% versus .10%, P < .0001). The hospital length of stay was also longer in patients with PP/PRF (P < .0001). On multivariate analysis, congestive heart failure (odds ratio 5.3, 95% confidence interval 1.20-23.26) and stroke (odds ratio 4.1, 95% confidence interval 1.42-11.49) were the greatest preoperative risk factors for PP. Previous percutaneous coronary intervention (odds ratio 2.8, 95% confidence interval 1.64-4.74) and dyspnea at rest (odds ratio 2.64, 95% confidence interval 1.13-6.13) were the factors most strongly associated with PRF. Bleeding disorder, age, chronic obstructive pulmonary disease, and type of surgery were risk factors for both (P < .05). Smoking also predisposed to PP, and diabetes mellitus, anesthesia time, and increasing weight also predisposed to PRF (P < .05 for all). Although PP and PRF are infrequent, they account for one fifth of the postoperative morbidity and are associated with significantly increased 30-day mortality. They can be predicted by various risk factors, emphasizing the importance of patient optimization and careful selection before bariatric surgery.
    Full-text · Article · May 2011 · Surgery for Obesity and Related Diseases
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