In May, three academic medical systems turned up the heat on a long-simmering debate about the link between surgical volumes and quality of care. Leaders from Dartmouth-Hitchcock Medical Center, the University of Michigan Health System and the Johns Hopkins Health System declared that their surgeons would need to meet annual volume thresholds for 10 high-risk procedures in order to continue performing them. Likewise, hospitals in our networks would need to perform a minimum number of these procedures every year to continue offering them.
We also challenged other hospital networks to take the "volume pledge" in the interest of patient safety and quality. Repeated studies, as well as a recent U.S. News & World Report investigation, have shown that surgeons and hospitals with greater experience in high-risk procedures have better outcomes compared to those with lower volumes.
As expected, the pledge drive has raised understandable questions and concerns. Some bristled at the suggestion that surgeons would let professional pride keep them from referring complex cases to higher-volume facilities. Others pointed out that going to a high-volume center may mean traveling hundreds of miles from home into unfamiliar surroundings and putting stress on the patient and family, potentially interfering with the recovery process. "This is great for those who live in the Northeast and have access to great insurance and a large concentration of academic institutions, but what about rural patients who barely have any health care access at all?" one commenter wrote on the popular blog KevinMD.com. Joint Commission CEO Mark Chassin says that minimum volume standards might hurt good hospitals and surgeons as well as poor ones, and reduce patient options, according to The Baltimore Sun.
A healthy debate over volume thresholds continues. Last week, articles in leading medical journals took a deeper look at the issue, giving hope that this campaign has staying power.
A Modest Proposal
The volume pledge wasn't intended to be a blanket approach. Rather, we wanted to start with multihospital networks such as ours. If a patient at one of our community hospitals needs an esophagus resection and that hospital performs less than a handful a year, why not send him or her to an affiliated hospital in our network that does them routinely?
David Urbach, a surgeon and health services researcher at the University of Toronto, observed in the New England Journal of Medicine that the negative response from the surgery community was "completely out of proportion to the modest ambition of the Pledge. Of all the possible approaches to restricting surgical care to high-volume hospitals, perhaps the least controversial ought to be a decision by a large metropolitan academic hospital system that its most complex elective surgery should be performed by the providers and hospitals that do the most of a given procedure…. If volume-based distribution of surgery cannot be accomplished in this context, then it’s probably not going to happen anywhere."
At Johns Hopkins Medicine, where we do not have a rural hospital, patients can easily access a hospital that meets the volume standards. Of course, that is not true everywhere, and these standards would need to be carefully considered in rural areas where patients might prefer to take a higher risk in exchange for staying close to home. In some cases, the surgeon may be the only one who performs the operation and may be required to do so in emergent situations. My sense is that local hospitals are best equipped to sort this out, possibly by being transparent about how many times they have performed a given high-risk procedure and discussing patients' options about where to obtain the surgery.
A Changing Health Care Landscape
In a commentary in JAMA, Justin Dimick, a professor of surgery at the University of Michigan, and Karan Chhabra, a Rutgers University medical student, explain how the changing health care marketplace may drive hospital networks to embrace the changes envisioned by the pledge, even if they don't actually adopt it.
In the traditional fee-for-service environment, requiring lower-volume surgeons and hospitals to stop performing certain procedures could result in "significant tension" and potentially economic harm to hospitals, they write.
However, Dimick and Chhabra point to two trends that may alter that dynamic. One is the growth of hospital networks through mergers and affiliations that may create a "hub-and-spoke model," in which risky procedures are concentrated in high-volume facilities.
The second shift is "the increasing financial risk hospitals encounter for poor quality and high costs," due to such programs as Medicare’s value-based purchasing and hospital readmission reduction initiatives. Smaller, lower-volume hospitals may want to shift cases to larger medical centers in their network to avoid potential penalties for poor outcomes.
"Together, these shifts have created an opportunity for a new type of surgical regionalization: that of the horizontally integrated health care delivery network voluntarily regionalizing specific surgical procedures," they write. Such a change in referral patterns would hopefully improve quality on a broad level.
We'll have to see if the changes that they envision will come to pass. In the meantime, we need more large medical systems such as ours to commit to this straightforward step to improve quality that is envisioned by the pledge. And while we want all patients to have access to the most experienced surgical teams, we recognize that the formula for change may need to be tailored to the specific circumstances of some rural and community hospitals.
It is important that we as care-givers have the honesty to refer a client to a safer option, when necessary and more so, when it is available. We realized how our own team improved and refined the algorithm for handling placenta accreta in view of the spate of referrals which in turn helped gain more experience.
There is wisdom in this approach. Today with communication made easier, it is imperative we network to help save more lives
As a patient, this gives me visions of doctors pressured to work beyond their best speed level, without sleep, urged to do more of what they don't do best, and more surgeons doing 2-AT A TIME.
My California primary once urged me to go to "the best.'" That surgeon takes summers off. Low volume.
Instead I got the one the nurses refer to as "He does fancy." He did "fancy" on me, and it took quite a while. And his post-op care was as wonderful as the surgery. Low volume.
Fewer surgeries does not always mean more risk.
I fear a rush to simple numbers, ignoring the complex procedural and support staff needed to keep quality in higher volume. I fear doctors over their heads to get more surgeries.
And I fear the loss of "fancy."
Margaret: Thank you for your thoughtful comment. I’m glad to hear about your great experience with your surgeon. The thresholds that our three medical systems have set are conservative and intended to prevent surgeries by physicians and hospitals whose volumes in a given high-risk procedure are in the 20th percentile or lower. When possible, we do not want our surgeons and teams to perform procedures in which they are relatively inexperienced. That said, if your surgeon specializes in one of the 10 procedures that we have targeted, he probably would exceed our thresholds even if he does take off during the summer and without performing two at a time (which I do not endorse).
The article did not mention which procedures. Since many emergencies are not able to be transferred, I would prefer that my surgeon have the training to do the procedures, even if that means he is not performing ten of them in a month! When it comes to elective procedures, past studies show that the greater than 500 bed and less than 100 bed facilities prove to be the best for patient outcomes. I felt my patients were watched better in the smaller hospitals. But, when my own mother was transferred to a hospital two hours away, because of political affiliations, when there was a good facility, a half of an hour away, we see other factors that enter in. The "big hospital" neglected to watch my high diabetic mother after a cervical resection for stage 1A or 1B cancer, years after a supra-cervical hysterectomy. She was found unresponsive with a BP of 60 systolic the morning of the fourth post-operative day. Most hospitals, nowadays, allow family to stay in the room. As a surgeon, I wanted to stay with my mother. But, the "big hospital" could not allow that! The outcome may have been no different. But, in the closer hospital, I would have been allowed to stay in the room. I still find it unacceptable that the simple surgical resection of the cervix was sent two hours away. There were general surgeons, AND gynecological surgeons, associated with this small town hospital, where I once practiced. (I had excellent outcomes from a wide variety of operations done there, including a large rupturing aortic aneurysm, missed at the regional hospital in the area. The guy was starved to death from a superior mesenteric artery syndrome that had pinched off his distal duodenum. He looked like an Auschwitz survivor, when he showed up rupturing his abdominal aortic aneurysm.) But, the same hospital referred my mother two hours away from her home. That two hour drive, to go to her, was very stressful. When it happened, the drive was almost unbearable. People are left with poor coverage because small town general surgeons are being more poorly trained with the new training rules. Most people do not realize that half of the time gynecologists spend in residency is for OB training. The general surgeons are better suited to deal with cancers that might be invasive into surrounding tissues. Doctor referrals from FP specialists result in wrongly directed referrals, as well. They are ignorant to the surgical training that their own surgeons have. I spent five years in training, learning gynecological procedures, as well. Had one FP refer a patient with acute appendicitis down the road to the regional hospital. With my training, the lady would have ended up with an appendectomy. In stead, she received a total hysterectomy after seeing the gynecologist! I saw that as ignorance at its best! Petty medical politicians (and administration bozos) have ruined the practice of medicine in our rural hospitals. But, karma is going to bite them all in the behind! I am retired and disabled from a spinal cord injury. I don't swim with the sharks, any more!
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