The relationship between surgical volumes, patient outcomes and hospital expenses has been the topic of research dating back to a 1979 study in the New England Journal of Medicine that first recognized this link—yet it remains a subject health policy experts are grappling with. There aren't any federal guidelines, but with the increased scrutiny of quality-of-care under the ACA, providers are looking at minimum volume standards as a way to meet performance metrics.
Three large medical centers recently announced plans to limit low-volume surgeries—slated to go into effect before the end of this year—representing the first coordinated effort to place limits on hospitals and surgeons. Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine and the University of Michigan Health System will be participating in the new program, whose rules cover 10 procedures. These surgeries have been repeatedly shown in research studies to have a higher risk when performed at low-volume hospitals, and include bariatric surgery, esophagus surgery, lung cancer surgery and joint replacement.
What the data say
A recent analysis by U.S. News found that patients who had knee-replacement surgery at the lowest-volume fifth of hospitals were 70% more likely to die than those who had the same surgery at the highest-volume fifth. "Low-volume hobbyists are bad for patients and we have to stop them," said John Birkmeyer, surgeon and chief academic officer at Dartmouth-Hitchcock Medical Center. He and Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University, worked together with surgeons at both centers to draft the new guidelines.
Minimum volume standards were first set in 2000 by the Leapfrog Group (a voluntary program that supports informed health decisions) for several high-risk surgeries because data indicated a link between high surgical mortality and low volume procedures. Dr. Birkmeyer acknowledged the benefits of the group's standards in a 2002 study. However, the standards were largely ignored—perhaps due to financial pressures at low-volume hospitals.
A new report by the LeapFrog Group, Predicting Patient Survival in High-Risk Surgeries, found that the survival rates for four high-risk procedures at 1,500 U.S. hospitals vary significantly and do not meet the group's standard for each procedure. The 2014 survey analyzed pancreatectomy, esophagectomy, repair of abdominal aortic aneurysm and aortic valve replacement.
"Every year, millions of Americans undergo surgery, and this report clearly demonstrates that the choice of hospital is one of the most important decisions a patient can make," said Leapfrog CEO Leah Binder.
The report also provides a call-to-action for hospitals to work toward better and more consistent surgical outcomes. "There is a notable financial burden on the U.S. healthcare system when less-than-optimal care is delivered. By every measure, these findings warrant attention and immediate action," said Jennifer Schneider, chief medical officer for Castlight Health, which analyzed the survey data.
Does limiting volumes work?
Binder is optimistic about the three medical centers' plans to limit low volume surgeries. "It's a promising, bold move. I hope other hospitals across the country follow," she told U.S. News. She may get her wish: Massachusetts General Hospital and Brigham and Women's Hospital are considering adopting the new standards but said they need more time to deliberate.
Not everyone is on board with the minimum volume standards. According to Dr. Mark Chassin, president, and CEO of The Joint Commission, setting such limits "will reduce supply and indiscriminately remove both good and bad performers" and is "not a prescription for improvement." Chassin suggested instead that hospitals establish a surgeon credentialing criteria to track their performance.
Many are also concerned that higher-volume hospitals may struggle with the influx of patients sent by lower-volume hospitals who can no longer perform certain procedures—possibly impacting quality of care at those facilities.
Another consideration: Binder told U.S. News that the new standards "can't account for surgeons who do unnecessary procedures."
The University of Michigan Health System said a detailed plan for implementing the new standards must still be worked out at the three hospital systems. "But, we agree that the standards are important for patient safety and will lead to fewer complications and better outcomes," said Shantell Kirkendoll, senior communication representative.