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You are here: Home / Patients can improve their own surgical outcomes

Patients can improve their own surgical outcomes

All medical interventions carry risks. Too many of us learned this truth all too painfully during the coronavirus pandemic.

But in the crush to return to full normalcy, with huge numbers of folks racing to undergo postponed tests and procedures, will too many trusting patients experience disappointment — or worse — by failing to exercise one of their fundamental rights: informed consent? This means they are told clearly and fully all the vital facts they need to make an intelligent decision about what treatments to have, where to get them, and from whom.

As millions decide to undergo various new and delayed surgeries, common sense, curiosity, and savvy self-interest should lead them to ask their doctors lots of questions about their prospective procedures. Good surgeons welcome these questions, neither dismissing nor exaggerating the real risks of their work. In addition, rigorous and growing research not only can better inform patients but also can optimize their experiences and medical outcomes in at least these five ways:
 

1. Older patients have huge reasons to learn all they can about surgeries

Older patients absolutely must inform themselves about surgeries and their risks because they are so likely to have them.

Patients 65 and older undergo nearly 40% of all surgeries in this country, and, until recently, medical scientists knew too little about the procedures’ outcomes, the independent, nonpartisan Kaiser Health News service (KHN) reported, noting:

“Nearly 1 in 7 older adults die within a year of undergoing major surgery, according to an important new study that sheds much-needed light on the risks seniors face when having invasive procedures. Especially vulnerable are older patients with probable dementia (33% die within a year) and frailty (28%), as well as those having emergency surgeries (22%)… Patients who were 90 or older were six times as likely to die than those ages 65 to 69.”

KHN reported that experts have zeroed in on data regarding major surgeries, including procedures to “replace broken hips, improve blood flow in the heart, excise cancer from the colon, remove gallbladders, fix leaky heart valves, and repair hernias, among many more.” The experts — who included Dr. Thomas Gill and colleagues at Yale, and whose recent work was published in a medical journal — cautioned that:

“Older adults tend to experience more problems after surgery if they have chronic conditions such as heart or kidney disease; if they are already weak or have difficulty moving around; if their ability to care for themselves is compromised; and if they have cognitive problems …Two years ago, Gill’s team conducted research that showed 1 in 3 older adults had not returned to their baseline level of functioning six months after major surgery. Most likely to recover were seniors who had elective surgeries for which they could prepare in advance. In another study, published last year in the Annals of Surgery, his team found that about 1 million major surgeries occur in individuals 65 and older each year, including a significant number near the end of life.” 

2. Crucial information about your surgeon

Even the most timid patients can do themselves a huge favor, research shows, by asking two vital questions of their surgeons: How many times have you performed this procedure, and when was the last time?

Consumer Reports summed up why these queries are so important: 

“Research has found that the more often a surgeon has performed a particular surgery, the lower the risk of complications — and even death. However, the right number varies from surgery to surgery. When it comes to hip or knee replacements, for example, you ideally want a surgeon who has done at least 50 such procedures in the previous year and has a complication rate of 3% or less. For laparoscopic hysterectomies, surgeons may have a learning curve for the first 100 procedures, according to recent research.”

The Clarify Health Institute, which describes itself as bringing expertise with big data to health care, has scrutinized outcomes from some of the now most commonly performed surgeries, especially for older adults: knee and hip replacements. These researchers reported of their examination of information on 180,000 operations:

“Providers with higher surgical volume are expected to have fewer medical errors and defects, better acute outcomes overall, and other post-acute benefits following the surgical procedure. However, existing studies have only been able to leverage relatively small samples of data for specific surgical procedures. There is little to no publicly available information about surgical volume readily accessible for patients, their families, and payers. [But we have examined] a large, observational sample of national health insurance claims for patients undergoing hip and knee replacement surgeries performed in 2021 …

“Our findings imply clinical benefits for patients who undergo hip and knee replacement surgeries with high-volume surgeons, even after adjusting for patient and other characteristics. Thousands of negative clinical events (i.e., readmissions, emergency department visits, and revision surgeries) could be avoided each year by steering patients to high-volume providers.”

3. Silence isn’t golden. Ask questions!

It’s natural to be tongue-tied when a doctor first mentions you should consider surgery. That’s okay — this is only the beginning of a journey of questioning and understanding. The next step is to write down questions and concerns. This is especially so for any procedures that may be costly, invasive, painful, and debilitating.

The Kaiser Health News folks suggest  a list of solid queries worth asking to start a positive conversation with your doctor:

What’s the goal of this surgery and how will it make things better for me?

Does it deal with an imminent threat or fix or remedy something in a notable way?

Will it improve my life — and how?

Will it extend my life, and how so?

If the surgery goes well, what should I expect?

What’s the best-case scenario?

What kind of complications might occur, how serious might these be, and what is the worst-case scenario for this procedure?

What’s the most likely outcome of this surgery, especially given my age, health, and current level of function?

How strongly (or not) do you recommend this procedure for me?

What are my alternatives and how do they compare, from start to finish, versus the proposed surgery?

KHN, Consumer Reports, and the seniors’ group AARP all urge patients, especially older individuals, to consider letting your doctor know in advance and bringing along a loved one or trusted partner to any appointments in which you learn about planned, complicated medical procedures, especially surgeries.

Your companion can take notes, see issues that you might not, and help ask questions that you might not want to.

They might, for example, ask your doctor to discuss the costs of a procedure — all the costs, including for preparation, recovery, other specialists who may be involved (e.g., anesthesiologists and pathologists).

Patients also should determine if pre-approval for operations must be secured from insurers, and if new medications may be required. Companions should not speak formally for you unless you have worked with your attorney to permit this.  It is a great idea to ensure, especially before undertaking a major operation, that you have worked with your loved ones, doctors, and legal and financial professionals to keep up to date key documents, including advance medical directives, powers of attorney, and estate planning materials.

Photo credit: National Cancer Institute

4. Follow the doctor’s advice

Patients can play a crucial role in improving the outcomes of their surgery by listening carefully to and following medical directives before procedures and during recovery.

As the Kaiser Health News service reported, quoting Dr. Sandhya Lagoo-Deenadayalan, a leader in Duke University Medical Center’s Perioperative Optimization of Senior Health or POSH program:

“Preparing for surgery is really vital for older adults: If patients do a few things that doctors recommend — stop smoking, lose weight, walk more, eat better — they can decrease the likelihood of complications and the number of days spent in the hospital.”

The news article also said this about the Duke program, also quoting Emily Finlayson, director of the UCSF Center for Surgery in Older Adults in San Francisco:

“When older patients are recommended to POSH, they receive a comprehensive evaluation of their medications, nutritional status, mobility, preexisting conditions, ability to perform daily activities, and support at home. They leave with a ‘to-do’ list of recommended actions, usually starting several weeks before surgery. If your hospital doesn’t have a program of this kind, ask your physician, ‘How can I get my body and mind ready’ before having surgery, Finlayson said. Also ask: ‘How can I prepare my home in advance to anticipate what I’ll need during recovery?’”

The American College of Surgeons, recognizing the importance of excellent communications with patients, offers on its website robust resources for what is described as getting strong before procedures and how to recover well from them. The site details the importance of patients improving their diet, controlling their blood sugar, losing weight, and giving up detrimental habits (and substances), notably cigarette smoking.

To be clear, surgeons are not trying to be puritanical. But in especially challenging procedures, notably in organ transplants, doctors need to know about patients’ substance use — alcohol, marijuana, and drugs. They want to ensure patients’ successful outcomes, especially with organs so difficult to come by. They may tell patients they need to forgo substances for a period before and even for some time after an operation — again, not as a lifestyle judgment but to optimize patients’ health.

With the recovery process, KHN reported this:

“There are three levels to consider: What will recovery in the hospital entail? Will you be transferred to a facility for rehabilitation? And what will recovery be like at home? Ask how long you’re likely to stay in the hospital. Will you have pain, or aftereffects from the anesthesia? Preserving cognition is a concern, and you might want to ask your anesthesiologist what you can do to maintain cognitive functioning following surgery.

“If you go to a rehab center, you’ll want to know what kind of therapy you’ll need and whether you can expect to return to your baseline level of functioning. During the Covid-19 pandemic, ‘a lot of older adults have opted to go home instead of to rehab, and it’s really important to make sure they have appropriate support,’ said Dr. Rachelle Bernacki, director of care transformation and postoperative services at the Center for Geriatric Surgery at Brigham and Women’s Hospital in Boston.

“For some older adults, a loss of independence after surgery may be permanent. Be sure to inquire what your options are should that occur.”

5. Data and research can visualize risks

When it comes to evaluating difficult situations, rigorous research and the hard data it produces can be illuminating and persuasive — especially if it is clearly and visually displayed.

That’s why patients may wish, with their doctors, to consult the surgical risk calculator posted online by the American College of Surgeons National Surgical Quality Improvement Program.

The college, a nonprofit professional group with more than 78,000 members, says it strives through its NSQI program to provide practitioners and patients evidence-based “estimates [of] the chance of an unfavorable outcome (such as a complication or death) after surgery. The risk is estimated based upon information the patient gives to the health care provider about prior health history.”

As the website further explains:

“The goal of the … risk calculator is to provide accurate, patient-specific risk information to guide both surgical decision-making and informed consent. The risk calculator uses 20 patient predictors (e.g., age, ASA class [category of healthfulness], BMI [height and weight], HTN [blood pressure measures]) and the planned procedure … to predict the chance that patients will have any of 18 different outcomes within 30-days following surgery.”

The outcomes include serious and unplanned complications, infections, the need for a return to the operating room, or discharge to a rehabilitation facility or nursing home, as well as readmission, and death, the website says.

The college reports that its calculator — built on “data collected from over 5 million operations from 874 hospitals” — was updated in late 2021.

To use the calculator, doctors and patients not only provide health information but also the procedure planned and its CPT (Current Procedural Terminology) code, as used in medical records and for medical billing.

The college stresses that the site’s color-coded visual array of displayed risks are only estimates. They can be valuable in prompting laudable doctor-patient conversations about surgeries but are “not intended to replace the advice of a doctor or health care provider about the diagnosis, treatment, or potential outcomes,” the college says, adding: “ACS is not responsible for medical decisions that may be made based on the risk calculator estimates, since these estimates are provided for informational purposes. Patients should always consult their doctor or other health care provider before deciding on a treatment plan.

More oversight needed on gear and techniques

Though even well-intentioned practitioners try to provide patients with careful, thoughtful, and thorough information about prospective procedures they will undergo, at least two major aspects of surgery remain challenging, at best, for regular folks to wrap their minds around — how doctors actually perform operations and the gear they rely on when they do them.

It is all too human for surgical techniques and medical apparatus to remain, even in the 21st century, part of doctors’ “secret sauce.” These two elements, history has shown, can make and break practitioners’ reputations — and help determine their compensation.

Critics say that state and federal regulators, as well as medical scientists, need to step up and debunk much of the hype — and even patient peril — associated with these components of operations. But surgeons insist they should be less questioned than applauded for how they improve patient outcomes and allow for medical advances.

Women, alas, have borne the undue burden of surgeons’ “innovations” in techniques and with gear. It was just a relative blink ago, for example, that surgeons were gung-ho to sell patients — mostly women — on seeing dramatic weight loss through “lap-band” procedures. The laparoscopic operations were widely promoted by some surgeons for their ease, convenience, and reversibility. But they quietly have fallen out of favor only after hard experience showed they were far less effective than other weight-loss operations — and they too often led to serious complications, including multiple, repeat follow-up surgeries.

Even as doctors quietly shelved lap-band procedures, other surgeons were forced all too slowly by negative outcomes to abandon what they viewed as promising, minimally invasive procedures to attack cervical cancer. Surgeons advanced the technique, with small slits in the abdomen instead of a large incision, in the belief that it was safe and would help patients recover faster. But research over time showed instead that the minimally invasive approach led to greater cancer recurrence and death.

Surgeons largely shut down their use of another minimally invasive approach, along with a much-touted medical device, in procedures involving women’s reproductive organs. Instead of opening patients’ abdomens and cutting out tissues, surgeons relied on “keyhole” procedures and a device called a morcellator to grind up and vacuum them out. As the Wall Street Journal reported, this surgical “innovation” later was suspected of not only leaving microscopic, diseased tissue behind but also dispersing it widely and causing cancer to  spread.

The New York Times reported this about the absence of oversight on novel surgical techniques:

“Surgery is not regulated the way drugs are. Although the Food and Drug Administration must approve new surgical devices, it does not control the way they are used. A tool approved for one purpose can be used for another. Surgeons can try new approaches, and innovations can catch on and spread, as long as hospitals allow it. Some innovations have backfired. “

While the FDA is supposed to oversee medical devices, critics say the agency has bungled its responsibilities. It has allowed a “Wild West” atmosphere to flourish, putting patients at great risk and allowing manufacturers and doctors to profiteer.

At least 32 million Americans (1 in 10 of us) have at least one medical device implanted in us, items including artificial joints, cardiac stents, surgical mesh, pacemakers, defibrillators, nerve stimulators, replacement lenses in eyes, heart valves and birth control devices, according to one expert estimate.

With billions of dollars at stake in such gear, scandals have erupted over surgeons’ use of everything from nuts, bolts, and screws to faulty cardiac pumps to million-dollar robotic assistants.

We all pay added health care costs, of course, because surgeons insist on their individual techniques and choices for materials used in procedures. As part of informed consent, patients should insist that their doctors be as clear and persuasive as possible about these vital components of operations. This might include asking if rigorous clinical trials have been conducted to demonstrate the benefits of an approach or device. (Hint: These aren’t often run, and if material is available it may be provided by a device maker, hospital, or other party with financial interests and potential conflicts.)

Patients’ diligence a must with booming surgery centers
 

With hospital costs ever soaring, millions of patients increasingly may find that their surgeries won’t be performed in the big, shiny buildings that cost hundreds of millions to construct on sprawling, distant campuses. Instead, they may find themselves going around the corner to free-standing, specialized facilities for their operations.

Caveat emptor, experts say, about so-called ambulatory surgical centers.

The USA Today network and the Kaiser Health News service investigated these facilities recently, digging into patients’ nightmares with surgical centers, not only those performing “routine” procedures but also those handling increasingly longer, more complex, and difficult operations. The surgeries, once the province only of big and well-staffed hospitals, put patients at risk, the news organizations reported:

“[Our] investigation found that surgery centers operate under such an uneven mix of rules across U.S. states that fatalities or serious injuries can result in no warning to government officials, much less to potential patients. The gaps in oversight enable centers hit with federal regulators’ toughest sanctions to keep operating, according to interviews, a review of hundreds of pages of court filings and government records obtained under open records laws. No rule stops a doctor exiled by a hospital for misconduct from opening a surgery center down the street.”

USA Today and Kaiser collected information on deaths and patient harms that have occurred in some of the 5,600 free-standing, specialized surgical centers nationwide.

Such centers have burgeoned because they can be nimbler than the hospitals and academic medical centers they now outnumber. The centers can be set up without hospitals’ high overhead costs, including for staff and equipment that may be unnecessary for a specialty practice. The facilities also can be set up closer to patients, theoretically offering them greater access and convenience, with easy navigation and parking.

But regulators have been slow to adapt, leaving critical oversight to organizations that are retained by doctors and the centers themselves to certify crucial safety and quality measures.

The federal Agency for Healthcare Research and Quality has sought to partner voluntarily with centers across the country to improve patient safety and the quality of care, with an effort to get staff to use evidence-driven procedure checklists and with a program to boost training and standards.

The Leapfrog Group — which describes itself as a “national health care nonprofit driven by employers and other purchasers of health care” and which issues hospital ratings — expanded its institutional scrutiny, starting four years ago, to surgical centers. Patients can examine the group’s criteria and ratings for centers that voluntarily report key data to the group (hospitals have criticized the Leapfrog letter grades and its methodology for assessing them).

While it is true that many of the surgical centers specialize in one-day procedures with supposedly fewer risks — endoscopy, colonoscopy, and plastic surgery — no operation is risk-free. Patients should know about the credentials and experience of not only their surgeon but also the anesthesiologist and surgical staff (nurses and other surgical assistants). They also should know what contingencies facilities have if complications arise and more expertise and emergency resources are required — for example, how often are patients transferred to a major hospital and is one nearby. Patients also must drill down with their surgeons about the recovery and follow-up processes for them after undergoing an operation in a surgical center.

Patients, alas, have become accustomed to, even adept at, researching where they get their health care as increasing attention has focused on hospitals’ safety and quality. The federal government — along with groups like Leapfrog and U.S. News and World Report provides star ratings of hospitals based on more extensive and detailed criteria.

More Helpful Resources for Your Consideration

Our law firm has posted online a collection of videos to inform the public about important legal topics, including:

What people need to know about informed consent and medical care

Evaluating the validity and worth of a medical malpractice case

How to advocate for yourself after receiving sub-standard medical care

How medical bills get paid in personal injury lawsuits

Our beliefs about secret settlements in personal injury case

Curious how a legal case proceeds from start to after a trial? The firm’s website, with videos and text, explains the common steps for those unfamiliar with lawyers and courts.

HERE’S TO A HEALTHY 2023!

Sincerely,

Patrick Malone
Patrick Malone & Associates

Copyright © 2023 Patrick Malone & Associates P.C., All rights reserved.

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