Attribution 2.0: whose complication is it?

BACKGROUND: Payment models aimed at improving quality and curbing costs are being deployed, and hospitals are evaluating complications more closely. To decrease complications, hospitals must first "attribute" them to a responsible party. Our study uses a rigorous approach to attribution in the trauma population. METHODS: Twelve months of complications were reviewed by a multidisciplinary panel. Physicians, patients, nursing, and the hospital were all incorporated into the model. A point system was developed for each complication. Fractional points were given when multiple parties were involved. RESULTS: One hundred twenty-five complications were analyzed. Complications were attributed as follows: 30% neurosurgery, 22% trauma surgery (100% using the traditional method), 17% orthopedic surgery, 14% nursing, 9.6% plastics, 3.8% hospital, 1.6% patient, 1.4% urology, and .6% vascular. CONCLUSIONS: Up to 78% of complications were incorrectly ascribed using the traditional method. Almost 20% of complications resulted from factors outside the physician's control. Before complications can be reduced, their most proximate cause must be identified. Surgeons should own these data and lead the effort to improve quality and decrease complications.

Acute care surgery: trauma, critical care, emergency general surgery and preventative health?

BACKGROUND: Acute care surgeons (ACS) often care for patients with limited access to health care. They may not participate in preventative screenings and interventions (PSIs) such as mammography, colonoscopy, or pneumococcal vaccinations (VAs). We sought to identify barriers to compliance and determine if ACS have an opportunity to facilitate PSI participation. METHODS: All patients evaluated by an ACS were considered for inclusion in the study. Patients meeting national PSI inclusion criteria were enrolled. Surveys were administered to assess compliance and identify barriers to participation. RESULTS: The overall compliance rate with PSIs was 57%. Patients without a primary care physician had a compliance rate of 23%. The most common barrier to participation was lack of knowledge of PSI recommendations (42%). Males were less compliant than females (47% vs 62%). CONCLUSIONS: ACS evaluate a large number of general surgery and trauma patients. The acute care surgeon-patient encounter represents a valuable opportunity for education and improved PSI compliance. Additional research should focus on developing interventional strategies and evaluating their impact on patient outcomes.

Attribution: whose complication is it?

BACKGROUND: To improve quality, programs such as accountable care organizations need to determine the part of the health care system most "responsible" for a complication. This is referred to as attribution. This provides a framework to compare physicians for patients and third-party payers. Traditionally, the attribution of complications has been to the admitting physician. This may misidentify the physician "responsible" for the complication. This is especially difficult in trauma patients who have multiple providers. We hypothesized that the current mechanism for attributing complications in trauma patients is inadequate and will need to be modernized. METHODS: All trauma admissions during a 12-month period were reviewed. Patients with single-system trauma were excluded. We reviewed our trauma database for mechanism of injury, complications, and readmissions. The trauma director and the medical director of our accountable care organizations reviewed all complications and attributed them to the appropriate health care provider. These were compared with the hospital decisions using the traditional definition. RESULTS: The trauma service had 1,526 admissions. After exclusions, 1,019 patients were reviewed. One hundred twenty-five complications occurred in 73 patients. Using the traditional definition, the acute care surgery service was assigned all 125 complications. Using the trauma director and medical director method, the neurosurgical attending accounted for 36% (45 of 125) of complications. The acute care surgery attending was responsible for 34% (43 of 125) of complications, and orthopedic surgery was identified as the causative factor in 22% (27 of 125). The remaining 8% (10 of 125) were attributed to various other services. Seven patients had unexpected readmissions. Most (6 of 7) of these were related to orthopedics. CONCLUSION: Hospital complications are now being assigned to individual surgeons. Which physician is responsible for each complication will be a controversial matter. Without a critical review process with physician input, up to two thirds of complications could be attributed incorrectly. The attribution process needs to be refined. LEVEL OF EVIDENCE: Epidemiologic study, level IV.