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Why Surgical Volumes Should Be Public

Her voice cracked with strain. I could imagine the woman at the other end of the line shaking, overcome with remorse about the hospital where her husband had had esophageal surgery. Might he still be alive, she asked me, if they had chosen a different hospital?

The couple had initially planned to have the procedure done at a well-known medical center, but when she went online to do her homework, she discovered that the hospital’s patient safety scores were poor. Another hospital in her community had stronger patient safety ratings, so they decided to have the procedure there.

It made sense. Why wouldn’t they go to a safer hospital?

What she didn’t know was that multiple studies over several decades have shown outcomes are better when procedures are handled by surgeons and hospitals with higher volumes, and while the well-known hospital had performed the procedure her husband needed many times during the previous year, the hospital they chose had done one.

That information was neither publicly available nor discussed with the couple.

The patient’s wife also hadn’t realized that the accuracy of some patient safety ratings can be poor, in large part because they use data from Medicare billing rather than clinical documentation. These are not distinctions average consumers can be expected to know.

Initially, the surgery seemed to go well. But two days later, the man developed a rapid heart rate, shortness of breath and dangerously low blood pressure. A breathing tube had to be inserted. The cause was a leak where the surgeon had sutured the esophagus. After a long stay, the patient was transferred to a different hospital, where he later died.

The widow called me because her husband’s tragedy was similar to one I wrote about in 2012 in which a woman died in my ICU after an unsuccessful esophageal resection at a nearby hospital that had done exactly one such procedure during the previous year. Why, the widow wanted to know, is information on patient volumes still not broadly available?

A stunningly large number of high-risk surgeries are performed by hospitals that individually do hardly any. In a study of cancer procedures in California, 63 percent of hospitals performing esophageal surgery and 48 percent of those performing bladder surgery did just one or two a year. And a high-volume hospital within 50 miles was available for about 70 percent of these cases.

In 2015, U.S. News reporter Steve Sternberg examined the volume-outcome connection in several common procedures. Among his findings: At hospitals with ultra-low volumes, knee-replacement patients had twice the national average risk of death. For hip replacement patients, the risk was 77 percent higher.

What should we do?

Last year, prompted by Sternberg’s reporting, three health systems – Johns Hopkins Health System, University of Michigan Health System and Dartmouth-Hitchcock Medical Center — made the “Volume Pledge.” We all agreed to require our surgeons and hospitals to meet modest minimums for each of 10 procedures — for example, 40 lung resections per hospital and 50 knee replacements per hospital in the past year.

The announcement produced strong reactions and healthy dialogue within the healthcare community. Critics pointed out that the pledge might work for large health systems or academic medical centers, but not in a rural area where patients may be hundreds of miles from a high-volume hospital. And some surgeons argued that volume is a poor surrogate for outcomes — we should report mortality instead. This may sound great in theory, but it’s not practical scientifically. It would take decades to collect enough cases for a precise mortality estimate at a hospital that does one or two cases of a given procedure a year.

The debate over the Volume Pledge will continue to simmer. Yet in encouraging health systems to adopt it, we may have created a distraction from the fundamental and patient-centered issue that is more important: When patients are considering a surgeon and a hospital for a procedure, they are entitled to know how many the surgeon and hospital have performed. Armed with this data, and in dialogue with their surgeon, family and others, they can make informed decisions.

Hospitals could make their volumes transparent. At Johns Hopkins, we have been working to make hospital-level volume data public. We are starting by posting volumes for the 10 surgeries on our Volume Pledge list on a web page where we share a variety of patient safety and quality performance measures. We hope to post by early December for Johns Hopkins Hospital and Johns Hopkins Bayview Center in Baltimore and to add our three community hospitals — Howard County General Hospital, Sibley Memorial Hospital and Suburban Hospital — at a later date. We will also add more procedures over time.

If patients are to have ready access to this information for all hospitals, this effort also must be led by those who issue ratings, rankings and scorecards for healthcare quality.

No doubt there are challenges in making this data transparent on a broad scale. The field would need to agree on a taxonomy of surgeries so hospitals’ volumes can be compared apples to apples. For example, “lung surgery” might include different operations. Which ones require similar technical skills, and which can we group together? Professional societies could help play a role in making these decisions.

Some may argue that patients may misinterpret the numbers, or not know how to evaluate them. How do you weigh the risk of going to a hospital that has performed 20 esophageal surgeries (which puts them in the lowest 25 percent of all hospitals) the previous year versus another that has done 40?

But let’s not overcomplicate things. The benefit to patients is not in selecting the hospital that has done 20 cases of a procedure versus another that’s done 19. It is in avoiding, if possible, hospitals that rarely do it at all.

If hospitals aren’t ready to impose a Volume Pledge, there is no good excuse for all of us not to take a Volume Transparency Pledge. Patients deserve to know the numbers.

This post first appeared on U.S. News & World Report

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Ronald GrafMichel AccadJohn IrvinemeltootsPatientzorro Recent comment authors
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Ronald Graf
Member

If anyone agrees that healthcare could benefit from transparency in ALL aspects I just posted a petition to HHS Sec. Tom Price to lease Healthcare.gov as a central publishing house one accepted price of every product and service by code offered by every provider by code, and thus end insurance network negotiated pricing. Health insurance would work like others except with coverage maximums by code, creating policy tiers. In addition, every bill should be accompanied by a feedback link that allows anonymous and relevant feedback on outcomes. This would provide the context behind other published statistics, like volumes, that could… Read more »

Michel Accad
Member

The main potential problem with a minimum volume requirement is that it might incentivize surgeons and institutions to perform more operations than they would otherwise. The last thing patients need is yet another metric to occupy the back of the mind of their doctors.

meltoots
Member
meltoots

Nice try. Johns Hopkins not have enough patients to make your Volume pledge? This is a typical ivory tower academic tactic to try to gain market share and political advantage. The vast majority of surgeons do procedures that they have training and comfort in doing. These big academic institutions always try this awkward way of trying to say they are better because they do 50 instead of 20. I have see MANY academic surgeons that do NOT operate well, spend all day traveling, speaking and never actually doing front line work. Also Peter, tell me how much front line work… Read more »

Patientzorro
Member
Patientzorro

Facility volumes are important, but I’d argue even that is not enough. Put yourself in the patient’s shoes for a second. Say I need to have a relatively “simple” procedure: a hernia repair for example. Wouldn’t I want to have access to how many procedures/hours my surgeon has for the specific procedure they’re proposing for me, as a proxy for experience (because that matters) benchmarked against other surgeons. I’d also want complication rates and recurrence rates specific to that surgeon. I’d also want to know if I am being quoted complication rates that are actually his/hers, vs some literature of… Read more »

Barry Carol
Member
Barry Carol

I’m interested in data for the individual surgeon as well, especially for the particular procedure I’m about to have if I’m the patient. However, my understanding is that a lot of the simpler procedures like hernia repair, appendix removal, gallbladder removal, etc. are done by general surgeons. If all or most of the procedures they do fall into the relatively simple or less complicated category, maybe their overall complication and infection rates might be sufficiently meaningful. I don’t know. Maybe one of the doctors can speak to that. On the other hand, for procedures done by specialists including heart, brain,… Read more »

Allan
Member
Allan

The idea behind surgical volume is probably in the back of everyone’s mind, especially large medical centers that have the volume and recognize such an idea can provide additional business to their centers. I like the idea for specific treatments. I also like the idea of avoiding institutions that will never produce adequate numbers so I support the idea to a degree. However, medicine is moving so fast today that I believe the new technologies such as video in the operating room and robotics might lead to an alternate pathway. I can’t read the future, so I believe we have… Read more »

Steve2
Member
Steve2

I remain skeptical about robots. I think it is mostly a technology looking for a niche. Maybe the tech just needs to be better, but as of right now I am not convinced it gives much better care, and it certainly costs a lot. (Neat optics though and fun to watch on the screen for a while.) That aside, even with robots numbers matter. Are there other numbers that also matter? Sure. One of the ortho guys in our area is(was) 4th in the state in the number of total knees. Also second in the percentage of joint infections (for… Read more »

Allan
Member
Allan

Remain skeptical all you wish Steve. Robotics are here and will advance further though you are correct that they are in their infancy. Perhaps you should review what is being done today both for the civilian population and the military. Technology is moving very quickly.

I’m glad that you mentioned the additional costs to families when patients travel long distances for care.

Steve2
Member
Steve2

What is your experience with robots at your hospital? After lots of years our experience is that their use is pretty limited. The tech will have to get a lot better. Not skeptical about robots in general, son works with the Google car guys, but haven’t seen it pan out so well in medicine.

Steve

pjnelson
Member
pjnelson

The risks associated with esophageal surgery are profound. I would hope that the surgeon had explained their experience and the basis of the surgeon’s apparent low experience history. However, its likely that the stability of the person’s health and its healthcare continuity before the surgery could also be a contributing factor. Correspondingly, did his Primary Physician have a role in the surgeon/hospital decision process? If esophageal cancer was involved (a very poor prognosis with or without surgery), was an oncologist involved? And, was the surgeon/hospital decision process attempting a one time commitment to a cure, rather than palliative procedure? .… Read more »

Barry Carol
Member
Barry Carol

As a patient, I think it would be very useful to know the minimum number of surgeries per year or per month the experts think need to be done in order for both the hospital and the individual surgeon to keep their skills sharp. If the minimum for a particular procedure is, say, 50 per year, how much better off will I be if I go to a surgeon that does 100 or 200? Presumably, I should avoid the hospitals and surgeons that do fewer than 35 or 40. We patients shouldn’t be afraid to travel a few hundred miles… Read more »