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Complications more likely when doctors don't do enough surgeries, study says

"People should be clamoring for change and yet there isn't that kind of public discussion about something that has an enormous impact,"  said Dr. Peter Pronovost.
"People should be clamoring for change and yet there isn't that kind of public discussion about something that has an enormous impact,"  said Dr. Peter Pronovost. (Lloyd Fox, Baltimore Sun)

Patients who have complex surgeries at hospitals where the procedures are not performed regularly put themselves at greater risk for complications including death, according to new research by U.S. News & World Report.

The data released earlier this month shows the complication rate for five common procedures was significantly higher at so-called low-volume hospitals.

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About 11,000 deaths might have been prevented nationally if patients who had gone to the lowest-volume hospitals went to the highest volume hospitals instead, according to analysis of the data by Dr. John Birkmeyer from Dartmouth-Hitchcock, who has studied the effects of patient volume.

To combat the problem, Dartmouth-Hitchcock has joined forces with The Johns Hopkins Hospital and the University of Michigan Health System to develop volume standards to help determine which doctors and hospitals can perform certain complicated surgeries. The plan would set voluntary standards for doctors that would apply to 20 hospitals in the three systems and could become a national model for other hospital networks.

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But Birkmeyer and other patient advocates argue more needs to be done to address what they say has turned into a longstanding systemic problem backed up by years of evidence and research.

"People should be clamoring for change and yet there isn't that kind of public discussion about something that has an enormous impact," said Dr. Peter Pronovost, an expert on patient quality and safety at Johns Hopkins.

The Joint Commission, the not-for-profit that accredits hospitals and other health care institutions, said they agree studies have shown a relationship between low volumes and worse outcomes for certain procedures, but called the U.S. News analysis flawed.

It did not look at how sick a patient was before the surgery so did not give an accurate portrayal of the extent of the problem, said Dr. Mark Chassin, the commission's CEO. For example, he said, previous heart attacks make a cardiac bypass procedure riskier.

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Chassin said that setting minimum standards would hurt good surgeons and hospitals, as well as bad ones, and reduce options for patients. One bad surgery at a low-volume hospital could skew its quality of care.

"You can't just shut down low-volume programs," Chassin said. "The best approach is to get them to be better."

In the U.S. News analysis, knee-replacement patients treated at the lowest-volume hospitals were nearly 70 percent more likely to die than patients at the highest-volume hospitals, according to the U.S. News data. Lowest-volume hospitals perform a surgery less often than 80 percent of other hospitals, while highest-volume hospitals perform it more often than the other 80 percent.

The risk was nearly 50 percent higher for those who got hip replacements. Patients with congestive heart failure and chronic obstructive pulmonary disease had a 20 percent increased risk of dying.

The analysis is part of a new set of hospital ratings released by U.S. News that ranks hospitals based on common procedures. It looked at Medicare data for bypass surgery without valve repair or replacement, elective hip and knee replacement, congestive heart failure and chronic obstructive pulmonary disease.

It is not the first time the correlation between surgery volume and outcome has been made. The first of reams of research on the issue was first published in the New England Journal of Medicine in 1979.

What was most concerning for the researchers at U.S. News was that little has changed since then, said Steve Sternberg, a U.S. News senior writer who worked on the analysis.

"The relationship was still evident," Sternberg said. "And it appeared that very little had been done about that."

Patient advocates say patients don't think to ask their doctor or hospital how many times they have performed a procedure. They typically choose the hospital that is most convenient to where they live and trust their doctors know what they are doing.

"We need people to get more information about the specific place where they are getting surgery," said Lisa McGiffert, who heads up the Safe Patient Project at Consumers Union, a consumer advocacy group.

The Safe Patient Project advises people to ask as much as they can about their surgeons and the hospitals where they seek care, but say more transparency and oversight is needed.

McGiffert argued there's no incentive for doctors and hospitals to voluntarily regulate themselves. She supports a disclosure system run by an independent group and said benchmarks need to be set so patients know how many surgeries it takes for a physician to become well-practiced.

"This is serious business, and something needs to happen, and absolutely a voluntary system is not going to cut it," McGiffert said.

Pronovost also does not believe self-reporting works, particularly if it would hurt a hospital's bottom line.

"Even though there is this evidence, in many cases you are asking hospital boards to vote against their financial interest," Pronovost said.

Complicated surgeries are more lucrative than more common surgeries. The Leapfrog Group publishes an annual survey that names the hospitals that meet its standards, but only 20 percent of U.S. hospitals provide needed information to the organization, which represents employers that provide health benefits and pushes to improve patient safety, care quality and affordability.

The Joint Commission's Chassin said the ongoing hospital consolidation could improve outcomes as smaller hospitals consolidate with larger ones and adapt their standard of care.

He also pointed to a program in New York that helped reduce deaths from cardiac surgery. Under that program, hospitals had to apply to establish or expand cardiac programs. The goal was to create high-volume, high-quality programs that were located throughout the state.

Under their plan to improve outcomes in their systems, Hopkins and the other two institutions will set criteria for 10 procedures that studies have shown to be riskier when performed at low-volume hospitals. For example, it might require surgeons to have enough experience under their belt before performing certain complicated procedures.

Pronovost believes the accountability program for transplant surgeries could be used as a model for creating a system for all hospitals. Only hospitals that meet standards of excellence created by the Centers for Medicare and Medicaid Services can perform the procedures. The hospitals are monitored closely and can't perform transplants anymore if they don't meet certain standards.

"Something more needs to be done," he said.

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