Brian K. Yorkgitis, PA-C, DO
Throughout my career, I have committed to serving patients in a safety-net hospital. The ability to care for all who need care is a great reward. Last summer, I happened to be on call for every summer holiday: Memorial Day, Fourth of July, and Labor Day. I was receiving
requests for transfer from hospitals that often do not send certain diagnoses to our facility. After several requests, I began asking; “Does your specialist not handle this type of case?” The answers were often similar: “We do not have anyone on call for the holiday,” “the OR is too busy for the holiday,” and other seemingly analogous answers. We have a policy to accept all in need and I accepted every patient. After all, these patients were falling through the cracks of the holiday and needed a safety net to catch them.
On any other day, these patients would receive their healthcare at their originating facility but for varying reasons required transfer to the safety-net hospital. I wondered if their reason for not choosing the safety-net hospital first was because they thought it provided lower-quality care compared with their first choice.
Working at safety-net hospitals over the past 16 years, I realized that often, complex patients are transferred to our facility once they have reached the limit of their initial facility’s capabilities. This always struck me as odd—wouldn’t you want to choose the facility that can care for any curveball thrown at it in case you have a rocky course? That is exactly what these hospitals do; hit those curveballs when the count is full. With increased scrutiny on quality of care, I have noticed that complex patients are being transferred to our facilities more often. Unfortunately, most quality measures can only risk-adjust for a few variables rather than the whole patient picture. This creates a selection bias when safety-net hospitals are sampled. The question I always have is whether a transferred patient should be included in the quality metrics. It’s like blaming a losing game on the relief pitcher who takes the mound in the 9th inning.
So, I began looking at the literature for quality measures for these hospitals. Examining esophagectomies, one of the most complex and high-risk surgical procedure performed, Gurien and colleagues found that compared with a national sample, patients treated at a safety-net hospital had fewer complications and reoperations along with a shorter hospital length of stay.1 Dhar and colleagues showed that treatment and survival after resection of pancreatic cancer (another complex and high-risk surgery) was equivalent at safety-net hospitals and non-safety-net hospitals.2
Won and colleagues examined the quality of two of the most common surgical procedures, appendectomy and cholecystectomy. Patients undergoing appendectomies at safety-net hospitals had similar morbidity and cost to those at non-safety-net hospitals. Not surprisingly, safety-net hospitals more often took care of patients with complicated cases of appendicitis, including rupture, while achieving the same morbidity as for patients with less complicated disease treated at non-safety-net hospitals.3 When looking at cholecystectomy, safety-net hospitals performed similarly in regards to morbidity but achieved the same quality with lower costs.4
The literature is also riddled with opposite results. The playing field is not often level. Social determinants of health are known to play a vital role in outcomes but most studies fail to include all aspects of this key factor. If we were able to capture all the aspects of social determinants, would the safety-net hospitals look even better?
If safety-net hospitals are good enough on a holiday, one might say they are better than their comparison, as they stand ready each day to catch any patient any time. Showing up for the game is the first step at winning. I know I would want my parachute to work every time, not just on non-holidays.
1. Gurien LA, Tepas JJ, Lind DS, et al. How safe is the safety net? Comparison of Ivor-Lewis esophagectomy at a safety-net hospital using the NSQIP database.
J Am Coll Surg. 2018;226(4):680-683.
2. Dhar VK, Hoehn RS, Young K, et al. Equivalent treatment and survival after resection of pancreatic cancer at safety-net hospitals.
J Gastrointest Surg. 2018;22(1):98-106.
3. Won RP, Friedlander S, Lee SL. Outcomes and costs of managing appendicitis at safety-net hospitals.
JAMA Surg. 2017;152(11):1001-1006.
4. Won RP, Friedlander S, de Virgillo C, Lee SL. Addressing the quality and cost of cholecystectomy at a safety net hospital. Am J Surg. 2017;214(6):1030-1033.
Brian K. Yorkgitis practices in the Division of Acute Care Surgery at the University of Florida-Jacksonville. The views expressed in this blog post are those of the author and may not reflect AAPA policies.