An initiative by three major U.S. health systems aims to "minimize the number of patients who wind up getting their care by so-called 'hobbyists,' surgeons and hospitals that seldom do these procedures," says one of its chief proponents.
Leaders at Dartmouth-Hitchcock Medical Center, The Johns Hopkins Hospital and Health System, and the University of Michigan Health System are urging other systems to join their combined 20 hospitals in the "Take the Volume Pledge" campaign to place limits on surgical procedures.
The campaign aims to reduce complications linked to insufficient practice by setting minimum volume thresholds on 10 surgical procedures. The limits apply to hospitals and surgeons.
"We've gotten leaders at these organizations to draw a hard line in the sand so that no surgeon or hospital within these systems will allow those procedures unless they are meeting [certain] volumes," says John Birkmeyer, MD, a surgeon, outcomes researcher, and executive vice president for enterprise support services at Dartmouth-Hitchcock. He announced the "Take the Volume Pledge" effort this week.
John Birkmeyer, MD |
"Our intent with these thresholds is not to set such a high bar that every patient must go to one of five places for surgical care," Birkmeyer says. "What we're trying to do is minimize the number of patients who wind up getting their care by so-called 'hobbyists,' surgeons and hospitals that seldom do these procedures, certainly not enough to attain a high level of honed proficiency."
The effort's first goal is to get hospital leaders to rethink whether they should allow surgeries to be done within their organizations relatively infrequently, and by individual surgeons who rarely tackle such operations. One option may be to tie surgeon volume with staffing privileges. "We'll worry at another time about outcome differences between medium volume centers and very high volume centers," he says.
Birkmeyer adds that if all hospitals in the U.S. "applied our standards, it would prohibit half of all hospitals in the country that do these procedures from continuing to do them. But just to be fair, looking at the volume distribution of these hospitals, you would only redirect 15% of the patients to other hospitals, because there are [not] so many hospitals now doing them that just don't do very many."
Quality measurement is nearly impossible for small-volume facilities and surgeons because the sample size is too small for statistical confidence, he says. "Most of the egregiousness of this practice comes from operations performed at very, very low volume hospitals."
Birkmeyer says that hospitals and surgeons who perform certain procedures infrequently aren't always doing them just because it's lucrative, which it can for smaller organizations.
"It's less because of the survival instinct and economics of high revenue surgeries. Instead, they're just accommodating the pride and professional autonomy that surgeons believe is their due. What hospitals do care about is running afoul of their surgeons and ultimately losing those surgeons who would go somewhere else."
The pledge campaign announcement comes as U.S. News and World Report rolls out a new feature showing strong links between hospitals with high volumes and good outcomes such as fewer infections and low mortality, and hospitals with low volumes having more complications and higher mortality. The analysis uses Medicare data, and does not delve into volume for individual surgeons.
The 10 procedures were selected because of strong evidence that volume drives better outcomes, Birkmeyer says. For example, several published studies show that in rectal cancer excision, "surgeons who do very low volume have much higher odds of getting recurrent cancer."
The annual thresholds set by these three organizations are as follows:
Birkmeyer says that the time is right for many hospitals to launch such an effort as they work on mergers and acquisitions that bring smaller organizations together.
With quality ratings systems for consumers proliferating the initiative gives hospitals and surgeons a chance to take the lead.
"This is the first instance of an attempt where the provider community is trying to own this problem and lead from out front rather than be in a reactive mode," he says.