Better patient outcomes with high surgical volume

Main Category: Transplants / Organ Donations
Article Date: 22 Dec 2003 - 0:00 PDT

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Standards may evolve to reflect the impact that individual surgeons have on reducing surgical risk.

In perhaps the medical equivalent of being on the cover of both Time and Newsweek, John D. Birkmeyer, MD, managed to get reports relating to the effect of surgical volume on patient outcome in both the Journal of the American Medical Association and the New England Journal of Medicine during the same week.

Dr. Birkmeyer said he hoped the studies and the publicity they received would help end any arguments about whether there is a relationship between surgical volume and patient outcome, and that patients, health plans and referring physicians would use this information when deciding where surgeries should be performed.

The NEJM report indicated that surgeon volume may be more significant than hospital volume, something Dr. Birkmeyer said might affect health care purchasing strategies of employer organizations such as the Leapfrog Group.

Meanwhile, the JAMA study indicated that referring patients to regional, high-volume centers for certain cancer surgeries would not significantly increase travel times for patients or families.

'The debate should really move past whether the impact of volume is real or not,' Dr. Birkmeyer said. 'Maybe there is less impact on certain procedures, but it's ridiculous to assert that it doesn't matter.'

He said primary care physicians should have a clinical sense of when volume matters and when it doesn't.

This information could be comforting for patients who are especially anxious about upcoming surgery and are looking to lower risks, he said.

'They shouldn't be sweating it for patients with gallstones or groin hernias,' Dr. Birkmeyer said. 'But I think referring doctors should carry in their minds a half-dozen to 10 operations in which a patient's risk is going to depend on volume.'

In the NEJM report, for example, surgeon volume had a significant effect on outcomes for abdominal aortic aneurysm repair, aortic valve replacement, coronary artery bypass grafting, esophagectomy and pancreatic resection.

A professor of surgery at the University of Michigan, Ann Arbor, Dr. Birkmeyer did his research while at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H. But his position as chair of the Leapfrog Group's expert panel might carry the greatest significance for the studies' impact.

Leapfrog, a coalition of more than 145 Fortune 500 companies representing 34 million health plan enrollees, has made 'evidence-based hospital referral' one of the pillars of its patient safety program.

Originally based solely on hospital volume, the standards were revised by Leapfrog earlier this year, and Dr. Birkmeyer predicts that further refinements will reflect the NEJM findings that the volume of individual surgeons might have more of an impact on outcomes than a hospital's total volume.

'I always asserted that the hospital or system was the major factor, so it was a little bit of a surprise to me to see how individual surgeon volume trumped hospital volume,' Dr. Birkmeyer said.

'So the standards for the Leapfrog Group are likely to evolve over the next year to reflect this, and what I picture is a lowering of the hospital-volume bar, but with an addition of a standard of how the caseload is distributed among lower- and higher-volume surgeons.'

No time for timidness

In the NEJM study, Dr. Birkmeyer and colleagues used information from the Medicare claims database on nearly 475,000 patients who underwent one of eight cardiovascular or cancer-related surgeries between 1998 and 1999. Data showed that mortality rates were lower for high-volume surgeons, particularly in regard to lung and pancreatic resections.

In an accompanying editorial, National Quality Forum CEO Ken Kizer, MD, said the evidence 'is especially convincing,' and wondered why -- in view of the many lives that could be saved -- most health plans were being 'so timid' about initiating volume-based strategies.

'At a minimum, the sum of the evidence should compel purchasers and health plans to adopt a default position of selective avoidance of very-low-volume providers in all but exceptional circumstances,' he wrote.

In an interview with American Medical News, Dr. Kizer acknowledged that more research was needed but that it also was time to act.

'There's enough information out there so that purchasers, payers and health plans should be acting on this more than they have,' he said, adding that surgical volume also should be part of any informed consent discussions doctors have with patients.

In the JAMA study, Dr. Birkmeyer and colleagues concluded that, if patients were directed to higher-volume hospitals for esophagectomy and pancreatic resection, it would add fewer than 30 minutes to the travel time for most patients and, in some cases, actually decrease travel time.

'We are sure that most patients would rather travel up to 30 minutes extra to have their surgery at a hospital that has more experience,' said Leapfrog Executive Director Suzanne Delbanco, PhD, in a prepared statement.

'It is fascinating that the study found that a quarter of the patients studied are currently traveling past higher-volume hospitals and could receive higher quality health care closer to home

People from all over the country go to the University of Pittsburgh Medical Center for liver transplants or to the University of Maryland Medical Center in Baltimore for pancreas transplants, Dr. Kizer said, so driving 30 minutes more for a lung resection or coronary artery bypass grafting isn't unreasonable.

He also suggested that future studies could explore what makes a high-volume hospital or surgeon perform better than those at the low end, and where the curve starts to change in relation to different procedures.

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