Know your surgeon before complex surgery.
Make sure if you have complex surgery – you go to a surgeon who has experience and has done that surgery before.
Do you need complex surgery? Some doctors may not have much practice.
The largely unregulated ability of surgeons with minimal expertise to perform high-risk procedures — particularly at hospitals that lack experience caring for significant numbers of patients — has been the subject of a touchy, long-running battle known as the volume-outcome debate.
Baltimore’s Johns Hopkins is one of three well-known hospital systems promising that their surgeons will meet minimum annual thresholds for 10 high-risk procedures.
A groundbreaking 1979 Stanford study found that patients who underwent operations at hospitals that did more ofintermittently. That finding has since been replicated repeatedly across many specialties and found to apply to surgeons as well as hospitals. Last month, a large study found that the risk of complications was far higher among surgeons who performed only one thyroid removal annually than among those who did 25 or more of the tricky procedures per year.
Recently the volume battle was started again when three important health systems — Johns Hopkins, Dartmouth-Hitchcock and the University of Michigan — pledged that they will require their surgeons and 20 affiliated hospitals to meet minimum annual thresholds for 10 high-risk procedures. The three systems have asked other hospital networks around the country to join them.
Under the terms of the volume pledge, surgeons must perform at least five pancreatic cancer surgeries annually in hospitals where 20 such operations are done each year. For knee or hip replacements, the requirement is 25 per surgeon and 50 per hospital. There are provisions for emergency surgery and for surgeons who sometimes do not meet the threshold because they were on leave; such surgeons might be required to perform a certain number of procedures under supervision.
According to John Birkmeyer, chief academic officer at Dartmouth “There is this intractableness of patients undergoing surgical care in places that have no business doing it” or performed by “hobbyists” — surgeons who infrequently perform risky surgeries, said. Birkmeyer created the pledge with Peter Pronovost, an internationally known expert who directs the Armstrong Institute for Patient Safety and Quality at Johns Hopkins.
At large teaching hospitals, Birkmeyer noted, “there are usually one or two or three surgeons who are recognized as go-to doctors” for certain procedures and do them frequently. “But there’s this tail of other surgeons who do only a few a year,” such as a shoulder surgeon who performs a handful of hip replacements or a breast cancer surgeon who occasionally attempts a Whipple.
“We decided to use volume as a pilot case, an initial foray into setting quality and safety standards,” he said. “And we wanted to do it in a way” that was not subject to the discretion of hospital officials.
As smaller community hospitals affiliate with larger ones, the questions of which surgeons should do which procedures and where are increasingly confronting health systems. Hospitals of all sizes — both large academic centers and smaller community institutions — face a variety of sometimes competing incentives: to retain lucrative surgical cases and to avoid angering surgeons, who fiercely prize autonomy and wield considerable clout because they generate substantial revenue. And while hospitals formerly reaped a financial reward if patients suffered complications and had to be readmitted, they now face penalties under the Affordable Care Act.
The Leapfrog Group, a nonprofit organization that represents large employers and purchasers of health care and seeks to advance patient safety, has focused on volume in its hospital rating system. “Volume is a really critical piece of information,” said the group’s chief executive officer, Leah Binder.
“I think every medical staff should be grappling with these volume benchmarks,” she said, endorsing the pledge. “It’s fundamental.”
Ashish K. Jha, a practicing internist and professor of health policy at the Harvard T. H. Chan School of Public Health who has written about efforts to improve medical quality, calls the pledge “very reasonable.”
Low-volume hospitals, he said, typically lack specialized teams to care for patients as well as state-of-the-art equipment and systems designed to prevent or quickly spot complications — critical factors in improving outcomes. “None of us care about volume; we care about outcomes, and volume is a surrogate” measure of outcomes, Jha noted. “Even though we’ve been talking about this for 35 years, a ton of high-risk surgery still happens among low-volume providers.”
But surgeons’ groups and the president of the Joint Commission, the Chicago group that accredits the nation’s hospitals, have criticized the pledge as simplistic and overly prescriptive. Some officials say they fear it could unfairly penalize low-volume surgeons and smaller hospitals that have good outcomes.
Although patient-safety experts and some insurance companies have long encouraged patients, especially those with serious illnesses or complex diagnoses, to seek care from experienced specialists at high-volume hospitals, there is little to prevent doctors and hospitals from doing whichever surgeries (other than organ transplants) they see fit, no matter how rarely they do them.
Many patients don’t know to ask a doctor about volume or outcomes or are unable to ferret out relevant information when choosing a surgeon or hospital. One reason, Leapfrog’s Binder said, is that much important information such as complication rates remains hidden. Hospitals report detailed data about surgical outcomes to registries for internal use, but the information is not publicly available.
A report by Leapfrog found that in 2013, one-third of hospitals that performed procedures to remove all or part of the esophagus, a demanding surgery to treat cancer, did only one or two annually, far below the level needed to achieve proficiency. A CNN investigation of an extremely low-volume Florida heart surgery program launched in 2011 found that six babies died in a two-year period, far more than expected; the program has since closed. And a U.S. News analysis last year found that Medicare patients who had knee replacements at the lowest-volume hospitals in the country were 70 percent more likely to die than those whose surgery was performed at the highest-volume centers; for hip replacement, the figure was 50 percent.
Birkmeyer states “One of our highest priorities is insuring consistent quality and safety” regardless of where a patient seeks treatment.” In the past decade, Dartmouth has grown from a single hospital in Hanover, N.H., to eight in northern New England. Baltimore-based Hopkins has affiliated with smaller hospitals in the District and suburban Maryland.
Among the most irate reactions Birkmeyer said he encountered came from about 10 surgeons affiliated with Dartmouth’s main hospital who were told they would no longer be allowed to do procedures for which they didn’t meet annual minimums. That anger and the months required to get the boards of hospitals and their executive committees to agree to the new rules may be among the reasons only three systems have signed on so far, Birkmeyer said. More than a dozen others have expressed interest.
Some surgeons say that the focus on volume is misguided.
The problem “is actually much more complicated than volume,” said David Hoyt, executive director of the American College of Surgeons. Hoyt said that the group is drafting its own guidelines that will address volume.
To Mark Chassin, president of the Joint Commission, the pledge misses the mark. “The surgeon’s contribution to the outcomes patients experience is only one component,” he said.
“Volume should never be used by an accrediting organization as a measure of quality” because it is too imperfect a measure, Chassin added.
Patients can help protect themselves, he added, by taking “as much responsibility and interest” as possible in their care.
In the view of general surgeon Linda Halderman, doctors are the best judges of their abilities. “Every surgeon has to exercise judgment of their own capabilities” and know when to refer to a more experienced colleague, said Halderman, who is based in Selma, Calif.
But Harvard’s Jha disagrees. Many surgeons, he said, tell him they “have excellent results and I’ll say, ‘How do you know? Do you actually track your outcomes?’ ” Most, he said, do not.
Read the JAMA article here: http://www.nejm.org/doi/pdf/10.1056/NEJMclde1513948
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