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.
Weighing the Need for Surgical Volume Thresholds,