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

Categories: Uncategorized

15 replies »

  1. 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 easily be supplied if mandated. This would also produce statistical scientific data for use by CDC, FDA and other NIH scientists. Here is my link: https://www.change.org/p/hhs-secretary-of-tom-price-one-published-pricing-healthcare

  2. You are free to comment about all things at all times.

    You are not free to attack another physician’s character on this blog.

    Driven apparently by your own sense of injustice and belief that academic medicine has unfair advantages. (Note: academic medicine has a set of serious cultural + institutional problems that are separate from what is being discussed here and that sorely need to be addressed. ) Peter Pronovost has an excellent reputation and has done a great deal of important work in patient safety. His contribution speaks for itself.

    Surgical volume can just as easily used to evaluate the experience of two physicians in Florida, two private surgical centers in New Jersey or two hospitals in Los Angeles.

    You can be critical of this post. And you are encouraged to be.

    We will be equally critical of what you write.

    / j

  3. Did you see this web page? I find it interesting that the big great Johns Hopkins does 8 total knee and 10 total hip replacements per year, which is a dreadfully small amount. They add a caveat that those that are done there are performed because the patient is not stable, etc. What TKA or THA is not stable as these are entirely elective procedures? They cannot transfer 3.3 miles up the road to Bayview? Should Johns Hopkins NOT be doing ANY TKAs or THAs if they are doing less than 10? Isn’t that the crux of his article? They set minimum at 50. Aren’t those patients at high risk for failure/poor outcomes? Funny how its OK for them to do under the minimum but not ok for others. Typical JH tries to excuse itself for low volumes with a nonsensical explanation. Couldn’t all hospitals then come up with explanations for low volume? Also, consideration should be that JH as an institution should not be doing TKA or THA as the nursing PT and other staff have very little experience with the care of a TKA/THA patient.

  4. 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.

  5. Excuse me John, but what scrutiny are you speaking about? This is a very typical article made by academicians that feel they are superior. I cannot comment as a front line MD that practices in a nonacademic center? I cannot be critical of this post? I cannot ask Peter if he feels that he can start a central line but we don’t ask him how many he does? Or that what the magic number he has to reach to feel he is not dangerous? There is another side to this story. Snarky or not. I cannot be directly critical or is that too snarky? Why the threat to walk back?

  6. Probably a good idea to walk back the snark, Toots.

    This doesn’t stand up to scrutiny.

    Without context, data is meaningless.

  7. 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.


  8. 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 do you do? Are you a full time front line MD? Should we trust your abilities if you do not practice full time in a critical care unit? Are you spending your day blogging and speaking and doing meetings and not caring for patients? Or do you feel trained enough to still work? Just checking….

  9. 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.

  10. 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, spine, back, hip and knee replacement surgery, etc., I would like to access data for the particular procedure the patient is about to have at the individual surgeon as well as the hospital level.

    At the same time, several years ago, I saw some data regarding heart surgeons in Boston. Their outcomes were rated either better than expected, as expected or worse than expected. Of 54 surgeons for which data was available, outcomes were rated as expected for 52 of them, better than expected for one and worse than expected for one. That suggests that patients would be in good hands with all but one of them.

  11. 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 a similar procedure performed by someone else. Sure, hospital level quality metrics are important, but I’d imagine there is likely to be intra facility surgeon variation at many hospitals. I want to know the data profile of the guy/gal that’s cutting me open. This is where the “consumer” metrics largely fall short. You cannot get anywhere close to building this type of picture, at least to the best of my knowledge. I imagine it will only be a matter of time until such detail is available. The next barrier will be coupling enhanced patient education to actually understand such data and use it to make decisions that are meaningful when choosing a hospital and/or surgeon.

  12. 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 high volume surgeons). Would be nice if people knew both of those numbers.

    That said, what people like Peter probably won’t know, I doubt he has ever worked in a critical access hospital, or not recently, is that for a lot of patients these numbers are irrelevant. They don’t have the resources, be it financial or family to travel further away for some of these procedures. A lot of the older people just refuse to be shipped off to the big tertiary care center. They “know” that people go there to die, which is partially true. So, I am not sure we have a perfect answer here. I think, just my preference, that we probably shouldn’t do esophagectomies at the little hospitals, regardless of concerns about traveling. They just don’t have the capabilities (most of them) to do things well. For things like total knees, I think I can see making a case for accepting some higher risk, as long as the patient accepts that risk. But, YMMV.


  13. 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 to be careful in too strongly promoting such things less we inhibit innovation and destroy the marketplace of ideas.

    There are many negatives to the proposed idea as there are with any idea along and they exist alongside of many possible unintended consequences. I suppose the surgical procedure in question would be one of the major determinant factors spurring its use or disuse. There are many other factors involved as we do not all live adjacent to such large academic centers. I won’t list the many reason knowing in advance that we are dealing with tradeoffs and in general ‘practice makes perfect’ so higher numbers should (not a guarantee) lead to better results. Today most people are familiar with many such centers that exist throughout the country. Some people avail themselves of these centers with or without their own physician’s suggestion and some don’t. There are good reasons for either choice, but I wouldn’t put all my eggs in one basket.

    One other item, “ultra-low volumes” means few patients avail themselves of those hospitals. That by itself diminishes, but doesn’t eliminate the problem. “ultra-low volume” might be demonstrating that today people and physicians are already accessing higher volume institutions.

  14. 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?
    During 40 years of Primary Healthcare, I really don’t remember any person with progressive esophageal cancer that had much quality of life. I suspect Barry and I share the same view.

  15. 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 if necessary to go to a hospital that knows what it’s doing. The other issue is what happens if the hospitals and surgeons who handle the highest risk cases have lower mortality or safety scores as a result. If I’m a high risk case, maybe nobody will operate on me. If I have a reasonable chance of surviving the procedure, what then?