Are outcomes volume sensitive?

Dear Medical Staff Leader:

By now many of you have read the groundbreaking article in the November 27, 2003 edition of the "New England Journal of Medicine" entitled "Surgeon Volume and Operative Mortality in the United States." The authors of this article used 1998 and 1999 Medpar data to study the mortality rate for four cardiovascular procedures (carotid endarterectomy, CABG, aortic valve replacement, and elective abdominal aortic aneurysm repair) and four cancer surgeries (lung resection, cystectomy, esophagectomy, and pancreatic resection).

By using sophisticated regression analysis, the authors determined that operative mortality correlates independently with operating surgeon volume and hospital volume for each procedure, which means that surgeons who frequently perform one of these complex procedures average a significantly lower mortality rate than do surgeons who infrequently perform such procedures.

This article has significant implications for your medical staff and hospital. (Please go to www.credentialinfo.com on Friday to see this week's "Credentialing Connection" for a discussion of the article's implications on privileging.)

The article supports the contention that, on average, better results are achieved for high risk, complex procedures in referral centers compared to community hospitals. The authors contend that the study's results support a strategy of regionalization for select, high risk, complex procedures. In other words, third party payers and perhaps the government would only allow high volume referral centers to perform these procedures-- an approach supported by the Leapfrog group.

Share this article with your medical executive committee, senior hospital management group, and governing board to stimulate important discussion. This discussion should focus on a "downstream analysis" of potential hospital, government, and payer decisions. Should your hospital adopt minimum volume threshold criteria that physicians must meet before applying for privileges for selected high risk, complex procedures? Will your organization even offer these procedures? If the hospital stops performing these procedures, what will be the impact on the hospital's financial health and ability to continue serving your community long term? What would such a decision mean for the income of surgeons in your community and your ability to recruit and retain good quality surgeons? Remember, the focus of this discussion should always be on helping the hospital fulfill its mission of providing quality medical care.

That's all for this week.

All the best,

Rick Sheff, MD