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May 19, 2015

Three top health systems will impose minimum-volume standards for 10 surgeries

Daily Briefing

Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan this week announced plans to set minimum-volume standards that prevent hospitals in their systems from performing certain procedures if the hospital and its surgeons do not perform them frequently enough to maintain high skill levels, U.S. News & World Report reports.

The issue with low-volume surgeries

Research has long shown that undergoing a surgical procedure at a hospital where the procedure is rarely performed has an adverse effect on outcomes. Last week, a U.S. News analysis found that knee-replacement patients who underwent surgery at the lowest-volume fifth of hospitals were 70% more likely to die than those who underwent the procedure at the highest-volume fifth.

"Low-volume hobbyists are bad for patients and we have to stop them," says John Birkmeyer, a surgeon and chief academic officer at Dartmouth-Hitchcock.

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Details of the new rules

Birkmeyer and Johns Hopkins patient safety expert Peter Pronovost drafted the new rules, which are slated to go into effect before the end of 2015 at up to 20 hospitals across the three systems. According to Birkmeyer, the standards are "very conservative" and apply to 10 procedures, including bariatric surgery, esophagus surgery, lung cancer surgery, and joint replacement.

Birkmeyer says special rules will cover emergency procedures, new surgeons, and surgeons who have been away from the OR for health reasons or while on sabbatical. Surgeons looking to obtain, regain, or expand their privileges may have to perform supervised procedures to boost their volumes.

The new standards represent the first coordinated attempt to limit hospitals and surgeons who have long been allowed to perform any procedures within the scope of their training. "It's a promising, bold move. I hope other hospitals across the country follow," says The Leapfrog Group's Leah Binder.

Massachusetts General Hospital and Brigham and Women's Hospital, as well as their sister institutions in the Partners Healthcare system, also are considering implementing the new standards.

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Leaders of the standards effort recognize that there is likely to be opposition and challenges to the effort. For example, higher-volume hospitals in the systems may struggle with an influx of patients sent by lower-volume hospitals who can no longer perform certain procedures.

"There are going to be strong critics of this," Pronovost says, adding, "We just have to be ready for that" (Sternberg, U.S. News, 5/19).

The takeaway: Three top health systems are leading the first coordinated effort to limit low-volume surgical procedures, which have long been linked to poor outcomes for patients.

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