The Leapfrog Group, with the help of an expert panel, has identified eight high-risk surgical procedures where there is a high “volume to outcome relationship” and established minimum hospital and surgeon volume standards for each. In their Inpatient Surgery Report 2019 the results from 2,000 responding hospitals provide food for thought and reason for concern. For the 8 procedures, the vast majority of hospitals did not meet both hospital and surgeon volume criteria, meaning they had a higher likelihood of surgical errors and complications due to the low volume of procedures performed. In fact, the procedure with the highest percentage of facilities meeting both of these criteria was bariatric surgery for weight loss (38%), with Esophageal Resection and open AAA Repair both under 3%.
The report continues with an analysis of surgical appropriateness. For all high-risk procedures, hospitals are asked to report on their implementation of a hospital-wide policy which includes processes aimed at monitoring surgical necessity and preventing overuse of surgical procedures. Hospitals are asked about their progress in developing surgical appropriateness criteria based on published guidelines and other relevant factors. Once again, less than half of reporting facilities had a surgical appropriateness policy for bariatric surgery for weight loss. For all other procedures, less than one-third of reporting hospitals indicated that they have a surgical appropriateness policy in place. The report concludes that “hospitals can and should establish and enforce policies for peer-review and evidence-based standards, to assure that patients are only operated on when need is evident.”
EHC NOTE: The implications highlighted by the Leapfrog Group survey should be concerning for individual patients, payers and employers. Patients obviously deserve to have evidence-based criterion used in determining whether surgical intervention is the best option to treat their condition. This is especially true for the complex procedures considered by Leapfrog. Furthermore, especially for this subset of cases, the need for hospitals and surgeons to maintain their skill set in providing care by meeting volume thresholds has been a theme we have revisited several times in the Review.
Payers and Employers rightfully want to see their expenditures yield the best results. For complex procedures, complications can lead to significant patient suffering, increased length of stay and cost. In an article in Modern Healthcare on the subject, the AHA pushed back on a rigid volume threshold. We agree that a rigid threshold may be up for debate, but it is in the best interest of all parties to further study volume levels/surgeon experience and results for each procedure and drive complex cases to better performing centers.