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April 28, 2016

Inside the fierce debate over surgical volume standards

Daily Briefing

Experts disagree over whether surgeons who perform only a low volume of certain procedures should be barred from performing any of those procedures at all, Sandra Boodman reports for the Washington Post.

Last May, Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan became the first three health systems to "Take the Volume Pledge." The systems agreed to set minimum-volume standards that prevent their hospitals from performing 10 procedures if the hospital and its surgeons do not perform them frequently enough to maintain high skill levels.

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

A growing debate

But in the months since, no additional hospitals or health systems have signed onto the pledge, although more than a dozen have expressed interest. Meanwhile, the debate over the link between surgical volume and surgical quality has become increasingly important as more small hospitals affiliate with larger systems, forcing leaders to decide which facilities—and surgeons—are best equipped to perform certain procedures.

On one side of the debate are some rating organizations, including the Leapfrog Group, that are beginning to take volumes into account when the evaluate hospital safety. "I think every medical staff should be grappling with these volume benchmarks," says the group's CEO, Leah Binder. "It's fundamental."

Ashish Jha, a professor of health policy at the Harvard T. H. Chan School of Public Health, agrees. "None of us care about volume; we care about outcomes, and volume is a surrogate" measure of outcomes, he explains.

Such stakeholders note that research has long shown that undergoing a surgical procedure at a hospital where it is rarely performed tends to result in worse outcomes. Last year, a U.S. News & World Report analysis found that knee-replacement patients who underwent surgery at the lowest-volume fifth of hospitals were 70 percent more likely to die than patients at the highest-volume fifth.

But other groups, such as the Joint Commission, say volumes are too blunt a metric to use as a proxy for quality. "Volume should never be used by an accrediting organization as a measure of quality," says Mark Chassin, president of the Commission. "The surgeon's contribution to the outcomes patients experience is only one component."

Similarly, Kevin Bozic, who heads the committee on research and quality for the American Academy of Orthopaedic Surgeons, argues that each facility and surgeon is unique. "There's room to improve in low-volume and high-volume hospitals," says Bozic, chair of the department of surgery at the University of Texas at Austin's Dell Medical School.

What's the relationship between surgical volumes, costs, and quality in CV?

In addition, some doctors say sticking with only high-volume providers can harm patients. "For many patients, the best possible surgery is closest to home," says Tyler Hughes, a surgeon at the 25-bed McPherson Hospital and director of the American Board of Surgery.

And a new study, published this week in the journal Applied Health Economics and Health Policy, calls into question the notion that higher volumes always lead to higher quality care. The study authors argue that previous research has used flawed, simplistic statistical models. As a result, medical literature may have overestimated the degree to which volumes promote better outcomes, the authors say.

Ultimately, Jha says the key is to base evaluations of quality on data. Many surgeons may say they "have excellent results," he notes. But when Jha asks them if they "actually track [their outcomes]," most, he says, do not (Boodman, Washington Post/Kaiser Health News, 4/25; Ferguson, FierceHealthcare, 4/26; Rice, "Vital Signs," Modern Healthcare, 4/27).

Assess where you stand on surgical services

With OR revenues critical to the success of your organization, assuming you have the tools to run an effective OR will not suffice. The necessity for vision setting, communication, and surgeon engagement is an ever-rising bar that many hospitals are not hitting.

We've compiled a comprehensive checklist that helps you assess whether or not your surgery department has the resources it needs to maximize volumes and improve OR efficiency.


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