[Congressional Record Volume 146, Number 32 (Tuesday, March 21, 2000)]
[Extensions of Remarks]
[Pages E361-E362]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
LIFE AND DEATH: IT'S YOUR CHOICE IN SURGERY OR ``HIGH VOLUME EQUALS
BETTER RESULTS''
______
HON. FORTNEY PETE STARK
of california
in the house of representatives
Tuesday, March 21, 2000
Mr. STARK. Mr. Speaker, the March 1 issue of the Journal of the
American Medical Association contains further documentation of life-
saving importance: if you are going to have surgery, have it in a
hospital that does a lot of it: your chances of survival and good
health are much better.
Put another way: avoid hospitals that can't do the procedure in their
sleep.
As public policy makers, we should encourage, in every way possible,
our constituents and Medicare beneficiaries to seek out the high volume
hospitals and avoid the low volume hospitals. The President's Medicare
reform proposals move us in that direction.
It really is a matter of life and death.
The JAMA article follows:
High-Risk Surgery--Follow the Crowd
(John D. Birkmeyer, MD)
Each year a large number of patients die following elective
surgery. In the Medicare population alone, 17,000 patients
died in 1995 after undergoing 10 types of elective
procedures, such as coronary artery by-pass surgery, carotid
endarterectomy, and lung resection.\1\ Quality improvement
initiatives at the local and regional levels may be important
for reducing mortality at individual hospitals,\2, 3\ but,
for many procedures, choosing at which hospitals surgery is
performed may be equally important for improving surgical
quality.
---------------------------------------------------------------------------
References at end of article.
---------------------------------------------------------------------------
The idea of concentrating high-risk surgical procedures in
high-volume hospitals is not new. Since seminal work by Luft
et al \4\ 2 decades ago, large, population-based studies have
consistently demonstrated better outcomes at high-volume
centers for cardiovascular surgery, major cancer resections,
solid organ transplantation, and other high-risk
procedures.\5, 8\ Lower surgical mortality at high-volume
hospitals does not simply reflect the presence of more
skillful surgeons and fewer technical errors with the
procedure itself. More likely, it reflects more proficiency
with all aspects of care underlying successful surgery,
including patient selection, anesthesia, and postoperative
care.
In this issue of the Journal, Dudley and colleagues \9\ are
among the first to estimate how many lives could be saved by
regionalization (``selective referral'') at the population
level. Based on careful review of the extensive volume-
outcome literature, they used explicit criteria to identify
the single highest-quality study for each surgical procedure
or clinical condition that could be considered for
regionalization. (The volume-outcome literature is too
heterogeneous for formal meta-analysis.) Statistically
significant relationships between hospital volume and
mortality were identified for 10 procedures and 1 medical
condition (care for patients which human immunodeficiency
virus infection/acquired
Two cautions are necessary in interpreting the findings of
this study. First, the authors' estimates of the benefits
likely to be achieved by regionalization are no more reliable
than the volume-outcome studies on which they are based. Much
of this literature is outdated or skewed by results from a
small number of national referral centers. Additional
generalizable, population-based studies are needed. Second,
analysis of California data may overestimate the decrease in
mortality rates likely to be achieved by regionalization
elsewhere. Because California has few restrictions on where
surgical care may be delivered, more patients may be
[[Page E362]]
undergoing high-risk surgery in low-volume hospitals there.
In 1 study, 65% of coronary artery bypass graft operations
performed in California in 1989 occurred at low-volume
hospitals (<200 procedures/year).\10\ In New York State,
which has stricter Certificate of Need regulations based in
part on volume criteria, only 20% of these procedures were
performed at low-volume hospitals that year.\10\ More
information is needed about how other high-risk procedures
are being delivered in other parts of the country.
Concentrating surgery in selected referral centers would
facilitate the monitoring of outcomes at individual
hospitals. Many high-risk procedures are performed too
infrequently to achieve statistical precision with mortality
rates, particularly at low-volume hospitals. For example,
what inferences could be made about outcomes at a hospital
performing 3 esophagectomies a year? By concentrating
selected procedures in a relatively small number of high-
volume hospitals, it would be more feasible to measure
outcomes aside from mortality, such as nonfatal
complications, patient functional status, and costs. The
ability to monitor surgical outcomes systematically would
make hospitals more accountable and create ideal platforms
for quality improvement initiatives.
How can the proportion of elective but high-risk procedures
being performed in high-volume hospitals be increased? The
least intrusive approach may be to focus on educating
patients about the importance of hospital volume for specific
procedures and to recommend that patients acquire this
information from the hospital that they are considering for
surgery. Although many hospitals do not have data on their
own procedure-related morbidity and mortality rates, all
hospitals
More active strategies also could be implemented. Leaders
of large, integrated health plans could designate referral
centers for selected procedures and enforce their appropriate
use. Professional societies also could take a role in
regionalization. For example, the American College of
Surgeons Committee on Trauma has established regional trauma
networks, encouraging referral of the most severely injured
trauma patients to designated trauma centers that meet
established process and volume criteria.\11\ Through
reimbursement mechanisms, large payers (both government and
private) have substantial leverage to limit surgery to high-
volume hospitals. For example, the Health Care Financing
Administration is currently exploring the development of
exclusive contracts with ``centers of excellence'' for
cardiac surgery and total joint replacement for Medicare
patients.\12\ In addition, through the Certificate of Need
process, states can reduce the proportion of surgery being
performed in low-volume hospitals by limiting the
proliferation of new surgical centers.\13\
Many would argue that regionalizing high-risk surgery would
have adverse effects, particularly in rural areas. For
patients living far from referral centers, elective surgery
could create unreasonable logistical problems for patients
and their families. With excessive travel burdens, some
patients may even decline surgery altogether.\14\
Regionalizing surgery also could interfere with continuity of
care because many aspects of postoperative care, including
dealing with the late complications or other sequelae of
surgery, would be left to local physicians who were not
involved with the surgery. Regionalization could reduce
access to health care for rural patients by threatening the
financial viability of local hospitals or their ability to
recruit and retain surgeons. Even if regionalization had no
effect on the availability of local clinicians, it could
reduce their proficiency in delivering emergency care that
must be handled locally. For example, the local general
surgeon no longer allowed to perform elective repair of
abdominal aortic aneurysms could be less prepared for
emergency surgery involving a ruptured aneurysm.
However, these problems may not be as important as they
were once assumed to be. Most low-volume hospitals are not
located in sparsely populated rural areas; they are more
commonly located in hospital-dense metropolitan areas, often
in close proximity to high-volume referral centers.\10\ In
the analysis by Dudley et al,\9\ 75% of California patients
undergoing surgery at low-volume centers in 1997 would have
needed to travel fewer than 25 additional miles to the
nearest high-volume hospital. In fact, 25% of patients
traveled farther to undergo surgery at a low-volume hospital.
These data suggest that a substantial degree of
regionalization could occur without separating patients and
surgeons or surgical centers by prohibitive distances.
With any regulatory attempt to regionalize high-risk
surgery, policy makers need to be ready for a political
firestorm. Many low-volume hospitals, already under
Although some physicians and some institutions would resist
regionalization, the potential benefits for patients are too
large to ignore. Given the current ad hoc approach to
delivering high-risk surgery, it seems that almost any effort
aimed at concentrating these procedures in high-volume
hospitals would be an improvement.
REFERENCES
\1\ Birkmeyer JD, Lucas FL, Wennberg DE. Potential benefits
of regionalizing major surgery in Medicare patients,
Effective Clin Pract. 1999;2:277-283.
\2\ O'Connor GT, Plume SK, Olmstead EM, et al, for The
Northern New England Cardiovascular Disease Study Group. A
regional intervention to improve the hospital mortality
associated with coronary artery bypass graft surgery. JAMA.
1996;275:841-846.
\3\ Hannan EL, Kilburn H Jr, Racz M, et al. Improving the
outcomes of coronary artery bypass surgery in New York State.
JAMA. 1994;271:761-766.
\4\ Luft HS, Bunker JP, Enthoven AC. Should operations be
regionalized? the empirical relation between surgical volume
and mortality. N Engl J Med. 1979; 301:1364-1369.
\5\ Houghton A. Variation in outcome of surgical procedures.
Br J Surg. 1994;81:653-660.
\6\ Flood AB, Scott WR, Ewy W. Does practice make perfect? I:
the relation between hospital volume and outcomes for
selected diagnostic categories. Med Care. 1984;22:98-114.
\7\ Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of
hospital volume on operative mortality for major cancer
surgery. JAMA. 1998;280:1747-1751.
\8\ Wennberg DE, Lucas FL, Birkmeyer JD, Bredenberg CE,
Fisher ES. Variation in carotid endarterectomy mortality in
the Medicare population: trial hospitals, volume, and patient
characteristics. JAMA. 1998;279:1278-1281.
\9\ Dudley RA, Johansewn KL, Brand R, Rennie DJ, Milstein A.
Selective referral to high-volume hospitals: estimating
potentially avoidable deaths. JAMA. 2000;283:1159-1166.
\10\ Grumbach K, Anderson GM, Luft HS, Roos LL, Brook R.
Regionalization of cardiac surgery in the United States and
Canada: geographic access, choice, and outcomes. JAMA.
1995;274:1282-1288.
\11\ American College of Surgeons Committee on Trauma.
Resources for the Optimal Care of the Injured Patient: 1999.
Chicago, Ill: American College of Surgeons; 1998.
\12\ Health Care Financing Administration. Medicare
Participating Heart Bypass Center Demonstration Project;
Extramural Reseasrach Report. Baltimore, Md: Health Care
Financing Administration; September 1998.
\13\ Arnold J. Mendelson D. Evaluation of the Pennsylvania
Certificate of Need Program. Falls Church, Va: Lewin-ICF;
1992.
\14\ Finlayson SR, Birkmeyer JD, Tosteson AN, Nease RF Jr.
Patient preferences for location of care. Med Care.
1999;37:204-209.
____________________