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.