• Kaestner, Silber and Fisher, Skinner

    Before someone tells me there is more debate in the literature on the Kaestner/Silber-type results I summarized earlier, here it is. I haven’t read it yet.

    Aggressive treatment style and surgical outcomes, by Silber JH, Kaestner R, Even-Shoshan O, Wang Y, Bressler LJ.

    OBJECTIVE: Aggressive treatment style, as defined by the Dartmouth Atlas of Health Care, has been implicated as an important factor contributing to excessively high medical expenditures. We aimed to determine the association between aggressive treatment style and surgical outcomes.

    DATA SOURCES/STUDY SETTING: Medicare admissions to 3,065 hospitals for general, orthopedic, and vascular surgery between 2000 and 2005 (N = 4,558,215 unique patients).

    STUDY DESIGN: A retrospective cohort analysis.

    RESULTS: For elderly surgical patients, aggressive treatment style was not associated with significantly increased complications, but it was associated with significantly reduced odds of mortality and failure-to-rescue. The odds ratio for complications in hospitals at the 75th percentile of aggressive treatment style compared with those at the 25th percentile (a U.S.$10,000 difference) was 1.01 (1.00-1.02), p<.066; whereas the odds of mortality was 0.94 (0.93-0.95), p<.0001; and for failure-to-rescue it was 0.93 (0.92-0.94), p<.0001. Analyses that used alternative measures of aggressiveness–hospital days and ICU days–yielded similar results, as did analyses using only low-variation procedures.

    CONCLUSIONS: Attempting to reduce aggressive care that is not cost effective is a laudable goal, but policy makers should be aware that there may be improved outcomes associated with patients undergoing surgery in hospitals with a more aggressive treatment style.

    Comment on Silber et al.: Aggressive Treatment Styles and Surgical Outcomes, by Elliott Fisher and Jonathan Skinner

    Response to Commentaries on Silber et al.: Aggressive Treatment Styles and Surgical Outcomes, by Jeffrey H. Silber and Robert Kaestner

    • You know, I hate it when you publish evidence which contradicts stuff I believe. If you had asked me, I would have predicted an insignificant difference. That said, there is a missing part here. As is often the case, mortality is a relatively crude measure. In the anesthesia world we have been looking at cognitive dysfunction in these elderly patients after surgery. We might save some lives, but send patients to extended care facilities (or home depending on circumstances), but they may not return to their prior mental status for a very long time. I think that would make Skinner and Fisher’s comments more pertinent.