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:
Jha makes the case that it's not simply repetition that makes a high performing surgeon high-performing:
Jha and other make the case the volume has re-emerged as a
given the inherent difficulties of accurately measuring surgical outcomes.
As a side note, John D Birkmeyer and colleagues
in 2004 on how to measure surgical quality in the Journal of the American College of Surgeons. They argued that
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:
Across the country,
. 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:
By segmenting this volume,
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
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
: 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 National Post implies that budget concerns, in addition to quality issues, drove the decision.
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
:
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Photo: James Mutter Flikr cc
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