Experience Counts with Risky Surgery

Study finds death rates much lower at high-volume hospitals

TUESDAY, Nov. 25, 2003 (HealthDayNews) -- Medically, advice to people who face high-risk surgery is easy to give, a new study finds: Go to hospitals where the skills have been honed by doing a lot of the procedures.

Politically and economically, however, the issue is more tangled, says Dr. John D. Birkmeyer, an associate professor of surgery at Dartmouth-Hitchcock Medical Center and lead researcher on the study.

The results are set forth simply: "For many surgical procedures, operative mortality rates are substantially lower at hospitals that perform them more frequently," the report says. Results appear in the Nov. 26 issue of the Journal of the American Medical Association.

But that finding steps on some delicate toes, Birkmeyer says. "There are a number of vested interests on both sides of the aisle," he says. "Surgery is a dominant profit center at most hospitals, and hospitals, particularly smaller hospitals, have an interest in policies that shunt operations elsewhere."

On the other side of the issue are the organizations that pay for surgery, most notably Medicare, and the Leapfrog Group, founded just three years ago, when an Institute of Medicine report said that tens of thousands of Americans die every year from preventable medical mistakes. Leapfrog now advises 145 health benefit providers, including Fortune 500 corporations, which have more than 34 million American enrollees.

The new study looked at two operations that are potentially risky: removal of part or all of the pancreas and removal of part or the entire esophagus. The researchers say they chose those operations because they are almost always scheduled well in advance and because there are relatively few of them, meaning regionalization -- limiting surgery to high-volume hospitals -- would not affect large numbers of people.

But the findings are also true of many other surgical procedures, Birkmeyer says.

Medicare data on 15,796 people who had one of the two procedures between 1994 and 1999 showed the difference between very low-volume and very high-volume hospitals. The death rate for the pancreas operation was 16 percent in low-volume hospitals and 4 percent in high-volume hospitals. The comparable rates for esophagus surgery was 8 percent for high-volume hospitals, 20 percent for low-volume hospitals.

And having the high-risk operations done in high-volume hospitals would not be a major inconvenience for most people, the study finds. For three-quarters of all patients, the extra travel time to get to a hospital with relatively high volume would be less than 30 minutes.

But getting to the highest-volume hospitals (16 or more pancreas operations, 19 or more esophagus operations a year) would mean an additional hour or more of travel time for more than 50 percent of patients. The increase would be greatest for people living in sparsely populated rural areas.

That's where politics steps in. In these areas, a few votes can make a big difference.

"This is absolutely a political issue," Birkmeyer says. "The controversy is over whether we should simply focus on giving patients access to the data and let them make their own decisions or essentially forcing some operations to be limited to a smaller number of hospitals."

The advice-only strategy appears to winning out. Choosing her words carefully, Susan Delbanco, executive director of the Leapfrog Group, says, "We are delighted that centralizing surgery in highest-volume centers will not inconvenience patients to any great extent. 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."

Delbanco picks up on one study finding: "a quarter of the patients studied are currently traveling past higher volume hospitals and could receive higher quality health care closer to home."

But right now, she says, "Leapfrog is working with employers to raise awareness with their employees and about our patient safety recommendations and the importance of making informed decisions."

More information

Hospital patient safety data is provided by the Leapfrog Group and the National Patient Safety Foundation.

SOURCES: John D. Birkmeyer, M.D., associate professor of surgery, Dartmouth-Hitchcock Medical Cehnter, Lebanon, N.H.; Suzanne Delbanco, executive director, Leapfrog Group, Washington, D.C.; Nov. 26, 2003, Journal of the American Medical Association
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