If there was a wonder drug to save the lives of infants with serious heart abnormalities, doctors would be sure to prescribe it. Parents would insist that their children get it. The company that invented it would get rich.
But there already is something that can have as dramatic an impact on these young lives as a blockbuster pill: having complex heart surgery performed in a high-volume hospital.
Surgical volume — the number of certain procedures that a hospital performs each year — has far greater impact on whether these patients, most of whom are infants or children, survive than infection rates, readmissions or other publicly reported measures. As U.S. News' Steve Sternberg reported, the risk of dying was 26 percent lower if a complex congenital heart operation was performed at a high-volume hospital rather than at low- and medium-volume hospitals. Yet, few parents know to ask about volumes, let alone know how to find and evaluate the data.
Heart surgery is not the only procedure for which numbers matter. Although the analyses aren't flawless, more than 40 years of research has shown that for most complex procedures, patient outcomes are better when the hospital and surgeon perform them more frequently. And the evidence that this is true continues to pile up. In May, a study of mitral valve replacement — a complex heart procedure for adults — found that survival rates were significantly higher when the surgeon had performed the procedure at least 25 times a year. These surgeons also were far more likely to repair the valve, a preferable result to replacing it, and they needed to re-operate far less frequently.
Intuitively, such findings make sense. Surgeons need more opportunities to hone their technical skills, and hospitals use higher volumes to install the care teams, systems, processes and specialized equipment to ensure patients do well.
Unfortunately, volume data is not readily available to patients. The studies are stashed in medical journals, and the volumes statistics hidden in databases, many of them closed to the public. How do we ensure they have this potentially life-saving information?
Certainly, there are technical issues. For instance, patients and families need to know whether a volume-outcome relationship exists for a given procedure, or whether a procedure is considered routine or high-risk in the first place. They need to know what number of surgeries qualify as "high volume." And they need to find data that allow them to fairly compare hospitals.
There are complexities to achieving this reality. But they are surmountable, and none are as strong as the ethical arguments for making these data transparent. Despite signs of change, it is moving nowhere near fast enough for the one in four patients who die needlessly.
From government, we need public reporting of volume data for high-risk surgeries. We also need the Centers for Medicare and Medicaid Services to partner with physician societies to create a taxonomy of surgeries, so that comparisons are truly apples-to-apples.
Some state and local governments are taking the lead on reporting. For example, Maryland Health Care Commission plans to post hospital volumes for 10 high-risk surgeries.
From professional societies, we need greater transparency. These organizations collect detailed data from hospitals about surgeries, which can then be used to analyze and report on volumes, mortality, complications and other patient outcomes. By posting its data publicly, The Society of Thoracic Surgeons made it possible for U.S. News to investigate the issue. It even issues star ratings for hospitals in different types of surgeries. More professional societies should do something similar.
From hospitals, we need to tell patients and the public how frequently we perform certain high-risk procedures in those cases where volume is a strong predictor of quality. This includes allowing the data we report to professional societies to be public, and proactively sharing our volume data. Last year at Johns Hopkins Medicine, we began posting surgical volumes for 10 high-risk surgeries on our website, covering procedures performed at our two academic medical campuses. We plan to add data for our community hospitals.
While few hospitals are independently reporting volume data, the Leapfrog Group, a consortium of large employers seeking to improve quality of care, has added hospital volume for 10 surgeries to its Leapfrog Hospital Survey, and will begin publicly reporting those results next year.
Multi-hospital health systems might also seek to regionalize care — increasing volumes by designating hospitals as the place for a given high-risk procedure. This could allow them to set in place the teams, resources and systems to excel in these surgeries.
From payers, we need help directing patients to better outcomes, by steering them to high-volume centers and surgeons — or at least avoiding ultra-low volume hospitals. In a study of cancer procedures in California, more than 63 percent of hospitals performing esophageal surgery did just one or two a year. Yet a high-volume hospital was within 50 miles of those patients about 70 percent of the time.
Perhaps the greatest barriers in making volume data public may come from my own "tribe": physicians and hospital leaders. Though these data are not perfect, I hope they embrace the ethical obligation to finally make this information available to patients. Recently, after giving the commencement address at the St. Louis University School of Medicine and observing the graduation, I was struck by a sentence in the Hippocratic Oath that the students somberly read: "I will not be ashamed to say I know not, nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery."
As I listened, I wondered when a physician's view of professionalism might include calling on colleagues when he or she did not have deep experience in a procedure. Some physicians say they believe the volume-outcome link, yet seem to think their personal performance is an exception.
As an industry, health care has the chance to make a change that is as powerful as a blockbuster medicine. We've already discovered it: surgical volumes. The challenge is coming up with the courage and political will to bring it to patients.
Disclosure: The Johns Hopkins University Armstrong Institute for Patient Safety and Quality, which Dr. Pronovost serves as the director, analyzed STS data on congenital heart surgery for U.S. News without compensation. The two Johns Hopkins Medicine pediatric cardiac surgery programs are medium-volume hospitals with "as expected" performance.
This post was first published in U.S. News & World Report.
More Posts on Surgical Volumes
- "Why Surgical Volumes Should Be Public" (12/16/16)
- "Weighing the Need for Surgical Volume Thresholds" (10/15/2015)
- "Can Hospitals Police Themselves to Avoid Too-Risky Surgeries?" (6/8/2015)
- "See One, Do One, Harm One?" (6/11/2012)