Ups and Downs of High Volume

Sandra Gittlen, January 7, 2016

Healthcare leaders agree that experience and expertise are essential, but some caution that the development of volume-based thresholds could have unintended effects.

This article first appeared in the December 2015 issue of HealthLeaders magazine.

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Peter Pronovost, MD

Peter Pronovost, MD, PhD, FCCM, can pinpoint the moment he knew hospitals needed to focus more attention on the role volume plays in outcomes.

Pronovost, who now serves as director of the Johns Hopkins Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, a $7.7 billion integrated global health enterprise, was caring for an elderly woman at another hospital who had had an esophagectomy that went "terribly wrong."

During the patient's final days on a breathing machine, Pronovost asked if she had been told she was at a high risk in having the procedure done there because that hospital had only done one or two of them. To his dismay, the answer was no.

Her death is just one example of why Pronovost says he began to promote volume standards and to collaborate with peers at Dartmouth-Hitchcock Medical Center and the University of Michigan Health System to create the "Take the Volume Pledge" campaign, which was announced earlier this year. All three systems and their hospitals have developed minimums on certain complex surgeries so that only surgeons who do them frequently enough to be proficient would be permitted to perform them. They aim to have the rules in place by year-end.

The pledge lists 10 procedures, including bariatric staple surgery, carotid artery stenting, and hip and knee replacement. "These are the top procedures with the strongest evidence that low volume impacts surgical outcomes," Pronovost says.

With intense pressure on providers and payers to strive for optimal outcomes, volume seems like an obvious metric. The belief is that more equals better, or practice makes perfect. Three decades of data show that volume is a clear indicator of outcomes, Pronovost says.

At Dartmouth-Hitchcock, John Birkmeyer, MD, a surgeon, outcomes researcher, executive vice president for enterprise support services, and chief academic officer, determined that for five common procedures and conditions, "as many as 11,000 deaths nationally might have been prevented from 2010 to 2012 over the three years analyzed if patients who went to the lowest-volume fifth of the hospitals had gone to the highest-volume fifth," according to U.S. News & World Report.

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