Your safer-surgery survival guide

Surgery is scary. It usually involves having your body cut open, and sometimes things go wrong. You react badly to anesthesia, or suffer breathing or heart problems. Or maybe the surgeon nicks a blood vessel, leaves an instrument inside, or even operates on the wrong body part.

Less dramatic but often as serious and far more common is when things go wrong after you leave the operating room. Up to 30 percent of patients suffer infections, heart attacks, strokes, or other complications after surgery and sometimes even die as a result. That’s what happened to Marvin Birnbaum, a retired New York City court reporter, after he developed an infection following hip replacement surgery, his daughter Jacqueline says.

Perhaps scariest of all, though many hospitals now gather data on those problems, patients for the most part remain in the dark about surgical safety. Industry insiders have access to some of that information because hospitals track how well patients do and report results to state and national officials.

Plus, some hospitals submit data to national registries so that they can see how they stack up against one another. But that safety information remains largely hidden from patients.

“Consumers have very little to go on when trying to select a hospital for surgery, not knowing which ones do a good job at keeping surgery patients safe and which ones don’t,” says Lisa McGiffert, director of Consumers Union’s Safe Patient Project. “They might as well just throw a scalpel at a dartboard.”

Our new surgery Ratings are part of an ongoing effort to shed light on hospital quality and to push the health care industry toward more transparency. “Because patients and their families shouldn’t have to make such important decisions with so little information,” McGiffert says.

What we measured

Our Ratings for the first time make public a measure that some hospitals now use to track quality—the percentage of Medicare patients undergoing surgery who die in the hospital or stay longer than expected.

We looked at results for 27 kinds of scheduled surgeries, which we combined into an overall surgery Rating, and also developed Ratings for five of those procedures: back surgery, replacements of the hip or knee, and procedures to remove blockages in arteries in the heart (angioplasty) or neck (carotid artery surgery).

To develop the Ratings, we worked with MPA, a health care consulting firm with expertise in analyzing medical claims and clinical records. This project uses billing claims that hospitals submitted to Medicare for patients 65 and older, from 2009 through 2011, and covers 2,463 hospitals in all 50 states plus Washington, D.C., and Puerto Rico.

“The beauty of this approach is that preventable complications correlate with post-operative length of stay,” says Arnold Millstein, M.D., M.P.H., director of the Clinical Excellence Research Center at Stanford University. He was not involved in our analysis but has studied how hospitals measure and improve quality. “This is about as good as complications measurement can be when using existing claims data,” he says.

Some experts say that may not be good enough. For one thing, factors other than complications can contribute to extended hospital stays. In addition, “we are concerned that the methods used to generate these performance ratings have not been validated against gold-standard measures,” says David M. Shahian, M.D., vice president of the Lawrence Center for Quality and Safety at Massachusetts General Hospital. “They are based on claims data rather than clinical data from patient records.”

Finally, our surgery Ratings are just one indication of a hospital’s performance. “There are a lot of dimensions to hospital quality, and no single measure captures everything,” says Peter Cram, M.D., director of general medicine at the University of Iowa Carver College of Medicine.

But we think our Ratings offer vital information to patients and hospitals. “We wish we had access to more comprehensive, standardized information, but this is the best that is available,” says John Santa, M.D., M.P.H., medical director of Consumer Reports Health. “Our surgery Ratings give patients more information so that they can make informed choices before surgery,” he adds. “And we hope that by highlighting performance differences, we can motivate hospitals to improve.”

Click on the map at right to find Ratings of hospitals nationwide. The Ratings include include information on our surgery Ratings, our hospital Safety Score, as well as some information on performance for more than 4,000 hospitals.

You can also download a PDF showing the overall surgery Ratings for 2,463 across the country.

Our analysis offers important and surprising insights for patients and hospitals:

• Some hospitals do a much better job than others. Our Ratings reflect wide variation, sometimes between hospitals only a few miles apart. For example, the Greater Baltimore Medical Center earned high marks in our overall surgery Rating, as well as for several individual procedures. But the Johns Hopkins Bayview Medical Center, also in Baltimore, got a low Rating. A representative for the hospital said, “We handle many complex cases and are always looking for ways to address any opportunities for improvement.”
• Teaching hospitals, thought to represent the nation’s best and the recipients of generous federal funding, often fell short in our surgery Ratings. Though some did rate high, on average teaching hospitals performed no better than other hospitals.
• Urban and rural hospitals can excel. We found several urban hospitals that did well despite often serving poorer, sicker patients, including Mount Sinai Hospital in New York and University Hospitals Case Medical Center in Cleveland. And rural hospitals actually did better, on average, than other hospitals.

• Big-name hospitals don’t always live up to their reputation when it comes to these surgery Ratings. For example, though several Mayo Clinic hospitals did well, others rated only average. And the Mayo Clinic Health System in Austin, Minn., got a low overall Rating.
• Hospital choice matters more for some procedures than for others. For example, we found wider variation for several surgeries, including hip and knee replacements and back surgery, than for others, such as colon surgery and hysterectomy.
• Specialty hospitals tended to do better. For example, six of the top performers for carotid artery surgery were heart hospitals. But that’s not always the case. For example, Hospital for Special Surgery in New York, which specializes in orthopedics, earned high marks in our other Ratings that focus on infections related to surgical incisions. But it got low marks in our hip and knee surgery Ratings, which look at how surgery patients fare over their entire hospital stay. A representative for the hospital said, “The results are not consistent with the data from our own research or with data from state and federal agencies.”

We wanted to see which hospitals did well across a broad range of surgeries. So we looked first at hospitals that got our highest overall surgery Rating, then narrowed it down to those that regularly did at least 10 kinds of surgeries and got a high Rating in at least 30 percent of those, without earning a low Rating for any surgery. You might be surprised by the 10 U.S. hospitals, listed alphabetically, that meet that test.

• Anne Arundel Medical Center,  Annapolis, Md.

• Christ Hospital, Cincinnati

• Enloe Medical Center, Chico, Calif.

• Greater Baltimore Medical Center, Baltimore

• Memorial Health System, Colorado Springs, Colo.

• Oklahoma Heart Hospital, Oklahoma City

• Penrose-St. Francis Health Services, Colorado Springs, Colo.

• Scripps Green Hospital, La Jolla, Calif.

• Trinity Rock Island, Rock Island, Ill.

• Yavapai Regional Medical Center, Prescott, Ariz.

Problems during or after surgery often start small, then escalate, sometimes with devastating effect. Case in point: Marvin Birnbaum.

The only thing holding him back from enjoying retirement was a painful left hip, his daughter says. So he decided to get it replaced at St. Luke’s-Roosevelt Hospital Center in New York. The surgery itself went well. But what followed was horrific, she says, as her 85-year-old father and his team of doctors battled infection.

After running an eight-week gantlet of treatments, including open-heart surgery to treat an infected heart valve, her father’s body finally shut down. “He spent two more weeks in a persistent vegetative state before the family made the agonizing decision to remove life support,” says Birnbaum, a music therapist at New York University.

St. Luke’s-Roosevelt earned a low overall surgery Rating but scored well on communications with patients and pain management in our previous hospital Ratings. A representative says its mortality rates for joint replacement surgeries are within the averages for New York hospitals. “Even under these high standards, patients, unfortunately, still can develop complications,” he says. “It is a challenge that every hospital faces.”

Her father’s downward spiral started, Birnbaum says, with one of the most common and serious types of complications—an infection he contracted in the hospital after the procedure. Surgical incisions, catheters, and intravenous lines give bacteria direct access to a patient’s bloodstream.

Surgery patients are also prone to blood clots, in part because reduced mobility prevents blood from circulating. Clots that break off and travel to the heart or lungs can be deadly. And the combination of lying flat and shallow breathing hampers the body’s ability to clear the lungs, leaving patients susceptible to pneumonia.

Those are the most common serious complications. But of course, anyone recuperating in a hospital after surgery is vulnerable to a host of other mishaps, such as drug allergies or interactions, and falls.

Fortunately, experts have developed ways to reduce many complications. For example, some hospitals have actually eliminated infections introduced through intravenous catheters by following a checklist. The best hospitals pay attention to detail, says Ateev Mehrotra, M.D., a lecturer at Harvard Medical School and a policy analyst at the nonprofit RAND Corporation. “It’s often the accumulation of a lot of little things instead of one big thing that leads to a worse outcome,” he says.

1. Go prepared

Start healthy. Be as active as possible in the weeks leading up to surgery. Make sure blood pressure and blood sugar are well controlled. If you smoke, quit—even if only temporarily—because smoking slows recovery and increases your risk of infection.

Schedule carefully. Having surgery early in the week is best. Research shows that the death rate for patients having scheduled surgeries is higher later in the week and on weekends. Staffing may be lighter on weekends, nights, and holidays, and it can take longer to get lab results. Time of day may matter, too: Earlier surgeries may benefit from a fresher surgical team.

Appoint an advocate.  Ask a friend or family member to help monitor your care, by asserting your needs and preferences, asking questions, retaining copies of important medical documents, and advocating for you if problems arise. Ideally, your companion should help you during check-in and discharge, and visit daily.

2. Avoid infections

Rid your body of harmful bacteria. Carefully follow your surgeon’s instructions for cleaning your body before you go to the hospital.

Get your nose swabbed. That can check for methicillin-resistant Staphylococcus aureus (MRSA), a hard-to-treat bacteria you might bring into the hospital with you.

Ask about antibiotics. For most in-patient procedures, antibiotics should be started within an hour of your surgery and, in most cases, stopped 24 hours later.

Say no to razors. Razor nicks provide an opening for infection. If hair must be removed, electric clippers are safer.

Stay warm. The drop in body temperature that occurs during surgery can impede blood flow and impair immune function. Ask whether a surgical blanket or another technique will be used to keep you warm.

Insist on clean hands. Ask your nurses, doctors, and anyone who touches you to wash their hands before examining you if you didn’t see them do so.

Ask every day whether tubes can be removed. The longer urinary catheters, central lines, or breathing tubes stay in your body, the greater your risk of developing a potentially deadly infection.

3. Prevent blood clots

Assess your clot risk. Make sure your doctor asks about factors such as smoking or use of oral contraceptives that can increase the risk of developing a clot, which can cause leg pain or, more dangerously, travel to your lungs.

Ask about prevention. You may need to take blood-thinning medications or to use inflatable cuffs on your legs after surgery to prevent blood clots.

Get moving.   When you’re able, make sure a hospital staff member helps you get out of bed to sit in a chair or walk down the hall.

4. Protect your heart

Know your risk. If you are 50 or older, your doctor should check your risk of having a heart attack or stroke. To assess your risk, use our online calculator at ConsumerReports.org/heartrisk.

Ask about beta-blockers. If you are at high risk for heart attack or stroke, ask whether you should be given beta-blockers before surgery to protect the heart from stress hormones that can trigger a too-rapid heartbeat. If you already take beta-blockers, make sure they are not stopped while you’re in the hospital.

5. Keep breathing

Talk about sleep apnea. Tell your doctor and anesthesiologist whether you have sleep apnea, which can increase the risks of anesthesia and pain medications. If you haven’t been diagnosed with sleep apnea but have been told that you snore loudly or you are unusually tired during the day, talk to your doctor about being checked for the condition.

Do deep-breathing and coughing exercises. Make sure someone teaches you those exercises when you are recovering from surgery. They can help prevent pneumonia and partial collapse of the lungs.

6. Get the right drugs

Bring a drug list. Make sure it includes over-the-counter and prescription medications, vitamins, and herbals, as well as any drug allergies.

Track your meds. The most common drug errors are inadvertent changes to existing medications. Ask your doctor about any changes to your drug regimen during your hospital stay.

For more tips on staying safe in the hospital, see our Hospital Survival Guide.

Unfortunately, hospitals often have little incentive to improve patient safety. The longer a patient stays in the hospital and the more tests and treatments he or she undergoes, the more money the hospital often makes, according to a study in the April 17, 2013, issue of the Journal of the American Medical Association.

Researchers looked at 12 institutions in a single hospital system and found that for privately insured patients, hospitals made $30,000 or more per patient when things went wrong. For Medicare patients, they also tended to make more, but it was closer to an additional $2,000.

Experts don’t think that hospitals sabotage patient safety. “In all my years of clinical practice, I never saw or heard of anyone intentionally causing a complication,” says study author William Berry, M.D., M.P.H., director of the Safe Surgery 2015 initiative at the Harvard School of Public Health. And Medicare now penalizes hospitals if readmissions are too high for some conditions. That may encourage them to pay more attention to safety.

But some hospitals may continue to avoid doing all that they can to improve patient safety. Berry says his research “sends a powerful message to policy makers about problems in the current system, but it may say something entirely different to bean counters concerned primarily with profits.”

In this its 100th anniversary year, Enloe Medical Center in Chico, Calif., made our list of high-performing hospitals. But seven years ago, it was in trouble—patient satisfaction scores had hit rock bottom, key physicians and hospital leaders had left, and patient deaths had drawn the scrutiny of state and national officials.

“It wasn’t the hospital we wanted it to be,” says Marcia Nelson, M.D., vice president of medical affairs for the nonprofit hospital. “We committed to becoming a patient-centered environment.”

She points to a yearly quality summit, where departments showcase results and choose initiatives for the coming year. “Some people think this organization-wide focus on quality is something all hospitals do,” she says. “It isn’t. It’s something special we do, and we are seeing the benefit.”

Jacqueline Birnbaum says her father chose his hospital because he was familiar with it and it had a good reputation. But as our Ratings show, that may not be enough. As health care has grown more complex, how well a hospital is regarded in the community or among medical professionals doesn’t tell you all that you need to know.

For example, Massachusetts General Hospital earned top scores in U.S. News & World Report’s 2012-2013 rankings. And it did well in heart bypass surgery ratings, based on clinical data, that we previously published. (See heart bypass surgery ratings for Massachusetts General Hospital - Division of Cardiac Surgery.) But the hospitals earned a low mark in these overall surgery Ratings, as well as low Ratings for hip replacement and carotid artery surgery. (See surgery and other hospital Ratings for Massachusetts General Hospital.)

Shahian, at Massachusetts General, says the hospital has “a robust quality-assessment program based on nationally validated methods.” He adds that the hospital often cares for complex cases and that Consumer Reports’ surgery Ratings don’t “account for the increased risk of these patients.”

Even hospitals recognized by experts as meeting a rigorous set of industry standards often don’t perform better than others. For example, complication rates for hip replacements were only somewhat lower at hospitals designated as “joint replacement Centers of Excellence,” according to a January 2013 study of 120,000 patients in the journal Medical Care. “The criteria for the Center of Excellence designation make a lot of sense, and we came into this expecting to see a difference,” lead author Mehrotra says. “The results put consumers in an awkward position of not being able to feel as confident about their choice.”

Our overall surgery Ratings are based on the percentage of a hospital’s Medicare patients who die in the hospital or stay longer than expected, for 27 kinds of surgeries combined. Click on the image at right, to see how hospitals Rated for five specific surgeries:

• knee replacement.
• hip replacement.
• back surgery.
• surgery to clear blockages in arteries that supply the heart (angioplasty).
• surgery to clear blockages in arteries that supply the brain (carortid artery surgery).

We looked at hospitals that performed the most of each of those surgeries, and identified hospitals with our highest or lowest Ratings in each procedure (listed alphabetically within procedure).

A few notable findings:

• Teaching hospitals were no better than other hospitals for hip,
  knee, and back surgeries but were better for angioplasty and carotid artery surgery.
• Specialty hospitals tended to do better overall, including for the procedures shown below.
• Scoring high in one procedure is no guarantee of success in others. St. Francis Hospital, in Roslyn, N.Y., for example, got our highest Rating for angioplasty but our lowest Rating for carotid artery surgery.

Ideally, you’d be able to peer beyond labels and subjective recommendations and look at hard numbers to see how hospitals stack up. Health care insiders do have access to some of that information.

The American College of Surgeons, for example, analyzes hospital data as part of its National Surgical Quality Improvement Program (NSQIP). “It allows hospitals to gauge how they’re doing compared to other hospitals, and to target specific areas for improvement,” says Clifford Ko, M.D., director of the Division of Research and Optimal Patient Care at the American College of Surgeons.

But most NSQIP data are off-limits to the public. When asked how consumers are supposed to evaluate the quality of their hospital, Ko responded that there really isn’t a good answer. “It can be a difficult thing for consumers to evaluate the quality of their hospital,” he says, “because there are so many possible ways to look at it and present the information.”

Use our hospital Ratings. See a list of the surgery Ratings for 2,463 hospitals nationwide. Subscribers can get more detailed information through our full hospital Ratings. Once there, click on:

• Your state for an overview of how hospitals performed in our Safety Score, which includes information from surgical and nonsurgical patients, as well as Ratings on other measures, such as readmissions, bloodstream infections, and communication about drugs.

• A hospital’s name for even more details, including its Rating for five surgeries: back surgery, hip and knee replacements, and surgeries to clear blockages in the arteries in the heart (angioplasty) or neck (carotid artery surgery).

• What’s Behind Our Ratings for a detailed description of our methodology.

Consider other sources. Good sources include Hospital Compare, state health departments, and the Leapfrog Group, a nonprofit organization that collects data on hospital quality for employer members and their employees.

Know what insurance covers. Verify which hospitals are in your plan’s network (and be aware that even if a hospital is in the network, doctors who practice there may not be); the difference between in-network and out-of-network costs, such as deductibles or coinsurance; and whether your procedure requires pre-authorization.

Get firsthand experiences. Anecdotal experiences aren’t always reliable, but it can help to talk to friends and family members (especially those who work in hospitals) about their stay.

For more details, see How To Choose A Hospital. And for advice on picking a surgeon, see How To Choose A Doctor.

“Dad always consulted Consumer Reports before buying anything,” Birnbaum says. She wishes these hospital Ratings had been available when her father had surgery in 2009. “People need to know this information,” she adds.

Thanks to health care reform, hospitals are encouraged to move to electronic record keeping, which will make it easier to track data. And some professional organizations—such as those that focus on eye surgery, heart surgery, and joint replacement—are starting to make information available. The American College of Surgeons, for example, now publishes some of its NSQIP data on the government’s Hospital Compare website. And the Society of Thoracic Surgeons now makes information on heart bypass surgery available for many hospitals and surgical groups. And we now include that information in our heart surgery Ratings.  

But all of those cases involve voluntary reporting, and some are limited to a small number of hospitals. As Berry and his Harvard colleagues help hospitals institute safer surgery practices, one of their biggest frustrations is getting that information to consumers.

“If you have ever been a patient, then you have been on the wrong side of the power equation,” Berry says. “Now is really the time to bring the consumer’s voice into the discussion about quality.”

Consumers Union, the policy arm of Consumer Reports, aims to do just that through its Safe Patient Project. It works with patient advocates to highlight the things that can go wrong in hospitals and to urge state and federal governments, as well as hospital administrators, to take steps necessary to improve patient safety. Safe Patient Project goals include:

• Expanding public reporting by hospitals on surgical-site infections. That’s now required nationally only for colon surgery and abdominal hysterectomy.
• Requiring federally funded hospital safety projects to publicly report their results.
• Establishing a standardized way for patients to report medical errors.

Medical harm is all too common in hospitals, but you might not hear much about it from patients themselves. For one thing, many victims and their families, understandably, don't want to talk publicly about painful memories. And even if they do, they may be prevented from speaking out by gag orders or sealed legal settlements.

That's unfortunate, says Lisa McGiffert, director of Consumers Union's Safe Patient Project. "The best cure for medical harm is full disclosure," she says.

Before you tell your story, follow these steps to protect yourself:

Get prompt medical attention. A trusted primary care doctor, for example, can help you decide how to proceed. Or see an independent doctor for another look. If you suspect a friend or family member is in danger, call a meeting with all of her or his doctors.

Get a copy of your medical records. They belong to you and can help you and your other doctors understand what happened, and what needs to happen. Your physician, or the hospital's records department, can help you obtain a complete copy, including medical summaries, doctor and nursing notes, test results, and diagnostic images. Note that you might have to pay for copies. If you believe that someone died from hospital harm, ask for an autopsy, to determine the most likely cause of death. Hospitals don't always do them automatically, but the person's next of kin or the legally responsible party can request one. Because autopsies help doctors learn more about illness and ways to improve medical care, autopsies are usually performed without charge. Although you have the right to pay for an independent one on your own.

Report the problem. Only about 14 percent of medical harm events are reported by hospital staff, according to federal estimates. Make sure you tell your version of events to the hospital. Then contact:

• Your local or state health department.

• Your state's Medicare Quality Improvement Organization, if you are a Medicare patient.

Don't pay. "You shouldn't have to pay for a mistake or its consequences," says John Santa, M.D. medical director of Consumer Reports Health. For example, patients shouldn't be billed for treatment related to hospital error, such as treating a broken hip after a preventable fall in the hospital.

Consider hiring a lawyer. Medical malpractice has a high standard of proof, and attorneys might reject your case. But a lawyer can also help you negotiate with hospitals over medical bills or compensation agreements, even if you aren't considering legal action.

Tell others about your experience. If you have been harmed in the hospital, we encourage you to consider sharing your story with our Safe Patient Project. Consumers Union's advocates use those patient experiences to help push for legislative and regulatory changes.

This article appeared in the September 2013 issue of Consumer Reports magazine.

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