Consolidating Surgery: Another Example of Balancing Population-Level Improvements with Poignant Individual Loss

In healthcare quality circles it’s become a truism that high surgical volume is linked to improved outcomes.  If you want to have the best surgical result, the thought goes, find the surgeon who has done the most cases like yours…

Harvard’s Ashish Jha outlines the case in a recent JAMA Forum:

We have always known that volume matters. The notion is simple and intuitive: practice makes perfect; experience creates better physicians.

…For more than 2 decades, work of leading scholars has shown clearly and convincingly that volume matters. Mortality at low-volume centers for certain procedures is as much as 5 times higher than at the highest-volume centers. Such evidence has prompted quality and safety organizations to encourage patients and providers to use high-volume centers.

Jha makes the case that it’s not simply repetition that makes a high performing surgeon high-performing:

…volume matters, and it’s not just that practice makes perfect. High-volume centers likely have teams that work more effectively together, systems to identify complications early, and the ability to effectively respond to complications. They also may be more likely to have critical support programs, such as wound care, nutrition, and occupational therapy, to maximize patients’ abilities to return to their activities of daily living.

A few years ago, my colleagues and I found that when hospitals with few esophagectomy cases had more nurses, positron emission tomography scanners, and 3 clinically unrelated sets of services (lung transplant, complex oncology, and bariatric surgery) available, their outcomes were nearly as good as high-volume hospitals. And more than a decade ago, a remarkable study found that the volume of lung resections performed in a hospital was a better predictor of mortality after pancreatoduodenectomy than the volume of the pancreatoduodenectomies. These and other studies suggest that the story is a bit more complicated than “practice makes perfect.”

Jha and other make the case the volume has re-emerged as a surrogate for quality given the inherent difficulties of accurately measuring surgical outcomes.

As a side note, John D Birkmeyer and colleagues wrote a great piece in 2004 on how to measure surgical quality in the Journal of the American College of Surgeons.  They argued that volume is one of three ways to measure quality: process, outcomes were the other two.  Measuring volume is best used when the number of cases is too small to reasonably compare outcomes.  (i.e. high risk, low volume).  Here is their recommendation for how quality should be measured:

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Across the country, health systems have taken this research to heart.  Systems have increasingly restricted the types of cases that can be performed at smaller facilities and now divert them to their affiliated larger hospitals. US News noted:

Three of the nation’s top academic medical systems – Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan – say they are planning to impose minimum-volume standards that will bar hospitals in their systems from performing certain procedures unless both the hospitals and their surgeons do them often enough to keep their skill level up.

By segmenting this volume, what we’re seeing, in effect, is the evolution of “systems of care” from craft businesses. It’s a topic I wrote about a few years ago, quoting Brent James who has for years argued that healthcare must be more a system of care and less a “custom shop”.

I’ll stop here to make the somewhat cynical observation that this type of case-shuffling is primarily attractive to consolidated health systems that aren’t losing high acuity cases to competitors.  My impression has been that independent hospitals still seem more than happy to deliver low volume, high complexity cases to their friends and neighbors…  I’ll also note that consolidation of cases into one or two hospitals brings real economic efficiencies:  centralization of supplies and equipment, less inventory, etc.    It’s perhaps one of the unforeseen advantages to the merger mania in US healthcare..

Enter the messy details: The National Post just covered a tragic case that happened in November when a 70’s year old male arrived unconscious in the ED at St. Mary’s, a small hospital in Montreal.  There was an experienced vascular surgeon available to fix what turned out to be a ruptured abdominal aneurysm– but emergency surgery couldn’t be done. The surgeon had been told that he was not longer credentialed to perform aneurysm cases because St. Mary’s had too few cases: 6 per year.  They patient was transferred and died before he could be fixed.

The decision to transfer the patient fell on the heels of the establishment of consolidated “super-hospitals” in Montreal (see here for an earlier post on this move).  In April 2015, St. Mary’s became part of the West Island Integrated University Health and Social Services Centre, known by its French abbreviation, the CIUSSS de l’Ouest de l’Île.

…the decision arose from an administrative reform by Health Minister Gaétan Barrette, which empowered the CIUSSS to change the mission of St. Mary’s. It was in that context that vascular surgery was now considered “eccentric to the mission” of both St. Mary’s and the CIUSSS

[A spokesman noted] In the fall of 2015, it was decided to conclude agreements of complementarity with partner hospitals for the treatment of aortic aneurysms since St. Mary’s does only six a year, which would not permit high standards of quality to be maintained and that are found in university hospitals,”

The National Post implies that budget concerns, in addition to quality issues, drove the decision.

Three days after the man’s death, Lynn McVey, associate president and director-general of the West Island CIUSSS, informed St. Mary’s staff in a meeting that in addition to $8.6 million in cuts, the hospital had to slash another $2.5 million in operating expenses. Those spending reductions represented the steepest cuts in St. Mary’s 91-year history

The staff at St. Mary’s protested the cuts and the case:  An anonymous clinician noted: “It is unacceptable, in fact, unethical that a patient died because some bureaucrats made a bad decision to prevent a qualified surgeon from potentially saving this patient,”

It turns out, of course, that the risks of doing surgery at St. Mary’s are pretty opaque:  in the absence of a large analysis, it would be hard to draw any conclusions about the quality of care there. That’s the reason that Jha, Birkmeyer and others argue the importance of epidemiological assessments, and why the administrators at CIUSSS were right to do what they needed to do.  On the flip side, the benefits of an operation, at least to that one patient, were pretty apparent.

The argument doesn’t placate an enraged medical staff at St. Mary’s.

I’ve written about population-health thinking and how much more visible individual patient losses are compared to the often murky benefit of new healthcare policies:

Physicians have a hard time with watchful waiting and we’re hardwired to over-value the impact of missing a rare case of cancer while under-valuing the cummulative benefits of avoided testing.   It’s primal.  And, this is why recent campaigns to deemphasize prostate screening antigen testing, and routine mammography in young women have been such hard sells.  In both of these cases, population health studies are conclusive: on a aggregate basis, the side effects of  testing outweigh the benefits of catching the rare cancer.   But, tell that to the patient whose cancer you missed.    It feels better to do something, particularly when the “doing” gets safer.  

Photo: James Mutter Flikr cc


Note: Regular readers may note that Considering American Healthcare has now become American Healthcare.  My sister Nina, an experienced journalist, told me that the old title was boring and lacked punch. It’s punchier now.