To select the eight procedures, Leapfrog reviewed hundreds of studies conducted in the last 10 years and looked at guidance from Leapfrog's National Inpatient Surgery Expert Panel. It chose procedures that have a strong relationships between volume and patient outcomes, according to Matt Austin, assistant professor at the Johns Hopkins Armstrong Institute.
The eight procedures Leapfrog include in its report are:
- Bariatric surgery for weight loss;
- Carotid endarterectomy;
- Esophageal resection for cancer;
- Lung resection for cancer;
- Mitral valve repair and replacement;
- Open abdominal aortic aneurysm repair;
- Pancreatic resection; and
- Rectal cancer surgery.
In the analysis, the researchers examined data from its 2018 Leapfrog hospital Survey looked at the share of hospitals that met Leapfrog Group's:
- Hospital minimum volume standard for procedures performed; and/or
- Surgeon minimum volume standard for physician privileging at the hospital.
The analysis encompasses the 1,326 hospitals that performed one of the eight procedures.
Most hospitals fall short of volume requirements
The analysis found that the vast majority of the hospitals analyzed for the survey did not meet the minimum volume requirements for surgeons or hospitals for the eight procedures.
Hospitals were most likely to meet the volume requirements for bariatric surgery, according to the analysis. Specifically, the analysis found that for:
- Bariatric surgery, 68.4% of hospitals met the facility standard, 51.5% met the surgeon standard, and 38% met both standards;
- Carotid endarterectomy, 63% of hospitals met the facility standard, 25.3% met the surgeon standard, and 16.2% met both;
- Esophageal resection for cancer, 7% of hospitals met the facility standard, 17.9% met the surgeon standard, and 2.6% met both;
- Lung resection for cancer, 22.4% of hospitals met the facility standard, 17.1% met the surgeon standard, and 5.6% met both;
- Mitral valve repair and replacement, 28.4% of hospitals met the facility standard, 18.7% met the surgeon standard, and 7.1% met both;
- Open abdominal aortic aneurysm repair, 9.7% of hospitals met the facility standard, 19.5% met the surgeon standard, and 2.5% met both;
- Pancreatic resection for cancer, 19.3% of hospitals met the facility standard, 16.6% met the surgeon standard, and 5.4% met both; and
- Rectal cancer surgery, 26.5% of hospitals met the facility standard, 18.2% met the surgeon standard, and 5.6% met both.
The report found that rural hospitals were most likely to fall short of the volume requirements for the procedures. For instance, zero rural hospitals met the standards for five of the eight procedures.
Further, Leah Binder, President and CEO of the Leapfrog Group, noted that 75% of hospitals overall had not established appropriateness criteria for procedures aside from bariatric surgery for weight loss, for which 44% of hospitals had criteria.
"No hospital and no surgeon should do only one or two of these procedures a year ever. The evidence is abundant: that’s not safe for patients," Binder said in a release. "Sometimes protecting patients means helping patients find a more appropriate place to have their surgery. That’s not always easy, but it’s the right thing to do."
In addition, James Rickert, an orthopedic surgeon and president of the Society for Patient Centered Orthopedics, said the number of low-volume centers performing high-risk surgeries "is worse than [he] thought."
However, the American Hospital Association (AHA) called Leapfrog's volume requirements "arbitrary."
"There remains no definitive research about the exact volumes of procedures at which patient outcomes will improve significantly," said Nancy Foster, VP of quality and patient safety policy at AHA. "Attributing surgical expertise solely to the number of procedures performed ignores the other important and effective strategies for improving safety," she said.
But Binder said that while Leapfrog is "not saying that a surgeon or a hospital that does a higher volume is therefore higher quality … if a surgeon or a hospital does a lower volume of these surgeries than our standard, that is not adequate for safety" (Castellucci, Modern Healthcare, 7/18; Frellick, Medscape, 7/18; Leapfrog Group release, 7/18; Leapfrog Group report, 7/18).