print page | send as email | email editor

A patient lies sedated under surgical drapes as Dr. Rafael Williams performs an arthroscopic shoulder surgery Aug. 19 at St. John's Medical Center. NEWS&GUIDE PHOTO / PRICE CHAMBERS

View our entire photo gallery >>

First of two parts –Eds.

Colonoscopies, surgeries of the stomach and Cesarean-section births are among the most common inpatient operations at St. John’s Medical Center during the last three years, data from the hospital show.

Data on outpatient surgeries – those done without an overnight stay – revealed biopsies from colonoscopies and other tests that could lead to cancer diagnosis as the most common. The information from St. John’s surgery rooms comes from the years 2006 to 2008.

The numbers can provide insight into what the hospital is equipped to do and educate consumers, said Barbara Rudolph of health care watchdog The Leapfrog Group.

Rudolph is responsible for surveys for the group’s consumer Web site, which allows hospitals to voluntarily post their safety and procedural data. Only two hospitals in Wyoming – Platte County Memorial in Wheatland and Torrington Community Hospital – participate.

All medical centers should be providing information about patient volumes and procedure outcomes, Rudolph said.

“Hospitals ought to be giving it so we can make better choices,” she said.

Providing access to hospital data, results of procedures and quality rates is an increasing trend, albeit slow growing, experts say. National groups have been trying to track data for years, pulling together information from on-site inspections, government data and voluntary hospital reporting. The idea is to provide material for patients to do their homework.

Health Grades, The Joint Commission, Medicare’s Hospital Compare and The Leapfrog Group all have Web sites that provide the public free access to look up hospital ratings when it comes to certain surgeries and procedures.

Health Grades, a health care ratings organization, provides hospital ratings from one to five stars for about a dozen procedures including hip fracture repairs and spine and back surgeries. St. John’s is rated for some of the procedures depending on if it is classified as a “high volume” hospital.

The Joint Commission posts general hospital results online following on-site inspections. Hospitals pay for inspections.

Following an inspection, The Joint Commission lists accreditation scores regarding general departments and surgeries, such as “eye surgery” and “emergency room.” St. John’s received the gold seal of approval after a surprise on-site inspection last fall.

Hospital Compare focuses on Medicare patient results from a handful of procedures, such as those to the back and neck and operations on lower and upper extremities. St. John’s is listed in some of the information about outcome results, such as treatment for pneumonia.

The Leapfrog Group is an organization that promotes transparency and encourages hospitals to report performance data so employers and their employees who pay for medical care can make better decisions.

The organization used a 1999 report by the Institute of Medicine for its focus, which is to reduce preventable medical mistakes. In the report, the IOM found that up to 98,000 Americans die every year from preventable medical errors made in hospitals.

Leapfrog founders reward hospitals that provide their outcomes by giving the public access to the data and directing consumers to participating hospitals with high marks.

The Leapfrog Web site provides patient safety results, including infection rates and whether the hospital has adequate resources for procedures. The catch is that hospitals have to agree to report them. St. John’s does not.

“Up until now the consumer hasn’t had much information to go on,” said Rudolph, who is director of Leapfrog’s Leaps and Measures Department. “It’s only recently that consumers have even had access to that information.”

That’s changing, she said.

Five states – New York, New Jersey, Massachusetts, Pennsylvania and California – now require that hospitals report statistics and outcomes on certain procedures.

Having data available doesn’t hurt anything, said new St. John’s CEO Pam Maples Maher, who replaced Jim Schuessler this month.

“There’s no harm,” she said. “It lets patients know what we can do and services we provide.”

She said she hopes primary care physicians know what St. John’s does well and can refer patients accordingly.

Kinds of surgeries

St. John’s classifies surgeries in three categories: scheduled, urgent and emergency. Eighty percent are scheduled, and many of these are elective, or a surgery that is a patient’s choice to have. The rest are mostly emergency.

Physicians do twice as many outpatient surgeries compared to inpatient procedures requiring at least an overnight stay so staff can monitor recovery.

Colonoscopies and procedures related to colonoscopies top the list among inpatient and outpatient surgeries. A colonoscopy is usually considered an outpatient procedure, but a patient having complications or having the procedure along with another surgery requiring an overnight stay are classified as inpatient.

More than 1,600 colonoscopies, or an average of 533, were recorded in total for outpatient and inpatient at St. John’s from 2006 to 2008.

Many of St. John’s other operations are orthopedic, or related to the bone and skeletal system, Surgical Service Director Tina Romaine said. Other more common procedures are gastrointestinal, gynecological and ear, nose and throat.

Doctors perform 150 to 220 surgeries per month, Romaine said. Most operations are generally planned for the five-day-a-week, 12-hours-a-day schedule, St. John’s Chief of Nursing and Risk Manager Kathleen Music said.

During scheduled hours, St. John’s always has enough staff to run the three operating rooms. Staff is on-call in 24- to 48-hour shifts. Staff members must agree to 20-minute response, Romaine said.

“The majority are scheduled, but staff are around to accommodate in emergency and after-hours situations,” Romaine said.

Maher has worked at numerous hospitals throughout her career, many of comparable size to St. John’s. She also worked with the American Hospital Association and its members as regional executive.

She looked over the list of top 10 surgeries.

In 2008, the top 10 inpatient surgeries were stitches/sutures (612) as part of other surgeries, endoscopic polypectomy of large intestine (338), colonoscopy (291), biopsy of esophagus, stomach, and/or duodenum (218), repair of obstetric laceration (211), low cervical Cesarean section (139), biopsy of large intestine (123), polypectomy of rectum (123), laparoscopic cholecystectomy (112) and operation on skin (108).

Inpatient surgeries recorded for 2006 and 2007 showed similar numbers and procedures in the top 10.

“I think this is pretty standard to me,” she said. “You end up doing a lot of these at a hospital this size.”

St. John’s internists recommend the procedures and screenings, which are then done by the hospital’s general surgeons, she said.

“These are not esoteric kinds of cases,” she said. “We would expect these kinds of surgeries.”

Music said she’d be concerned if there were fewer than those recorded.

“I’d be worried that we were missing some screening opportunities,” she said.

Cancer screenings important in county

Colonoscopies and breast and prostate biopsies topping the surgery lists are helpful in detecting cancer, which is the leading cause of death in Teton County. Cancer deaths are followed by heart disease, unintentional injuries and suicide, according to the county health department’s community health report released earlier this year.

For the nation as a whole, heart disease is the leading cause of death, followed by cancer, according to the national Centers for Disease Control and Prevention.

Incidence rates for cancer in Teton County were 542 per 100,000 people, compared with 439 for the state and 460 for the rest of the country.

The rate of breast cancer incidences in Teton County was 134 per 100,000 people, compared with 101 for Wyoming and 124 for the rest of the U.S.

Prostate cancer incidence rates are also higher here by comparison. Teton County had an incidence rate of more than 204 per 100,000. Wyoming’s rate is 137, and the national rate is 147.

Preventative care is more routine in Teton County than in the rest of the state, said county heath manager Terri Gregory.

“It is pretty well known that people are more health conscious, have screenings and are alert to any symptoms they might have,” she said.

Birth-related surgeries on the rise

The increase in births at St. John’s in recent years also shows a rise in surgeries related to deliveries and complications. St. John’s obstetricians and surgeons delivered 332 babies in 2003. That number grew to 530 in 2008.

So far in 2009, the number of births is 242. The 43 babies born in May accounted for 18 percent of hospital inpatient numbers.

The number of Cesarean sections also has risen. In 2006, doctors performed 100 C-sections. By 2008, that number was 139.

In 2007, 24 percent of births at St. John’s, or 129, were by C-sections. That is less than the national average, which is 31.8 percent for C-section births, according to statistics from the federal Centers for Disease Control and Prevention.

Both rates are still significantly higher than the World Health organization recommendations that say the best outcomes for mothers and babies occur at C-section rates of 5 percent to 10 percent.

Numbers from obstetric laceration repairs, resulting from tears during vaginal delivery, also climbed in those three years. St. John’s repaired 192 tears in 2006 and 211 last year.

Is St. John’s on the right track?

A hospital St. John’s size should be handling normal deliveries, acute situations and unexpected trauma, Leapfrog’s Rudolph said.

“The hospital should respond to the community,” she said after learning of the top operations at St John’s.

Births and accidents are what a rural hospital like St. John’s should put at the top of its priority list.

Surgeries that require expertise, such as coronary bypass, should be referred elsewhere, she said.

St. John’s does not perform cardiovascular surgeries.

Generally speaking, Rudolph said other surgeries, such as laparoscopic gall bladder procedures, seem like easy surgeries, but have a fair number of complications if the physician is not used to them.

Looking at the data, St. John’s recorded 112 of these procedures under the clinical name “laparoscopic cholecystectomy” in 2008.

Some professional organizations have put a number on how many surgeries a hospital’s surgical team should perform as a standard to be proficient, Rudolph said.

“If they do a poor job, the rate of mortality could be quite high,” Rudolph said.

For instance, The American College of Surgeons sets that number at 120 for bariatric surgery, a gastric bypass, she said.

St. John’s counts 16 for this kind of surgery for 2008. The hospital did not provide an accounting of surgical outcomes with the data.

Insurance payers, such as the federal Medicare program, also set standards as to what they will pay for at certain hospitals. The reason is that they want the best outcome for patient recovery and for the cost, she said.

Rick Wade, spokesman for American Hospital Association, said St. John’s should do what the community needs.

St. John’s should provide a full line of services. He noted the oncology department and its quality care as an unusual asset to small, rural hospital.

Primary care is important, he said.

And when a hospital begins to add procedures or new operations it has to be able to ensure that it has the equipment, skills, physicians and nurses to do them right, he said. St. John’s should be doing its maintenance to set priorities and ensure safety.

“They should be periodically evaluating all their services,” he said.

Next week: A look at St. John’s operations only performed a few times a year and the community hospital’s role in providing them.

Download a PDF of the complete list of surgeries from 2008 here.