'Vast Majority' of Hospitals Don't Meet Volume Thresholds for High-risk Surgeries

Volume has long been considered one of the key metrics for predicting surgical success.

The "vast majority" of hospitals do not meet minimal hospital or surgeon volumes for eight high-risk procedures, or policies in place to monitor the appropriateness of surgeries, with rural hospitals lagging far behind uban hospitals, a new analysis from The Leapfrog Group shows.

Less than 3% of the 2,000 hospitals who took part in the voluntary survey met the volume thresholds for two of the high-risk procedures: open abdominal aortic aneurysm repair, and esophageal resection for cancer. Adequate volumes for bariatric surgery were achieved by 38% of the hospitals, Leapfrog found.     

"It's clear from this report that patients should be very careful before they choose a hospital for one of these high-risk procedures," Leapfrog CEO and President Leah Binder said in prepared remarks.

"Beyond the disturbing findings in this report, patients should worry even more about hospitals that decline to report this information at all, because candor and transparency is the necessary first step to improvement," she said.

This year's report is the first time that Leapfrog has included a volume metric for surgical procedures and whether hospitals monitored for surgical necessity.

Volume has long been considered one of the key metrics for predicting surgical success, although some studies suggest that surgical specialty is a better gauge of successful outcomes.   

Erica Mobley, Leapfrog's director of operations, said "higher patient volumes does not necessarily mean higher quality, but lower volume is not adequate for patient safety."

"Hospitals and surgeons that do a very low number of a given procedure per year cannot hone the techniques and skills necessary to successfully perform these complex and high-risk procedures," she said.

In 2015, a U.S. News & World Report study estimated that as many as 11,000 deaths could have been prevented if patients who went to the lowest-volume hospitals went instead to the highest-volume hospitals.

Patient volumes are a key argument for proponents of certificate of need laws, who note that an unregulated, free-market approach to specialty care dilutes the overall quality of care.  

"The reality is that in healthcare, particularly when it comes to highly specialized care, like transplants, NICU procedures or open-heart surgery, procedure volume is critical in order to have positive patient outcomes," John D. Couris, president and CEO of Tampa General Hospital, said in a recent HealthLeaders opinion piece.

"Research continues to demonstrate that the more times a hospital performs a surgery or other procedures, the better the outcomes, the better the patient care and the lower the cost," Couris said.  "High-volume thresholds ensure proficiency in skill by the physicians, which, in return, reduces the amount of medical errors."

"Without CON in place, we are now more likely to experience an increase in hospitals where providers perform complex procedures less often, maybe only a handful of times," he said.  

Mobley said the Leapfrog analysis didn’t specifically evaluate certificate of need laws or compare results to areas in which CON laws are in place.

"That said, any efforts that can help to ensure that hospitals and surgeons perform an adequate volume of surgeries per year will ultimately improve surgical safety for patients," she said. "Health systems in particular can help remediate this problem by consolidating surgical services for a high-risk procedure into a single facility rather than having multiple hospitals perform the same surgery only a handful of times each year."

Not surprisingly, the report also shows that urban hospitals consistently outperform rural hospitals across all eight high-risk procedures. No rural hospital met Leapfrog's volume standard for five of the eight procedures.

Mobley said the problem is that "hospitals and surgeons are performing surgeries when they shouldn’t be."

"Hospitals and surgeons without adequate, ongoing experience with a particular procedure should refer the patient to a different facility and physician that perform more of this surgery rather than doing it themselves at that location," she said. "This isn’t always an easy conversation, but it is critical in order to provide patients with the safest care."