Surgery referrals don't improve state's outcomes
NEW YORK (Reuters Health) - Initiatives aimed at getting more surgery patients sent to hospitals where they have the best chance of surviving may not be accomplishing their goals, at least in Washington State, according to a recent study.
The authors say that the program, which is based on referring patients preferentially to hospitals that score high on measures related to patient safety, "has not had its intended impact" and needs further evaluation.
Previous research has suggested that patients who need surgery have better outcomes if they get treated at a hospital that has a lot of experience performing their specific surgery. That's led some policy groups - including the Leapfrog Group, a nonprofit that represents healthcare employers - to try to increase the number of patients treated at hospitals that have experience with their condition.
But the current research suggests that efforts to shift patients toward so-called "high-volume" hospitals might not be effective at saving lives on a state-wide scale.
In their research, Dr. Nader Massarweh, of the University of Washington in Seattle, and colleagues looked specifically at three procedures: surgery for a dangerous ballooning (called an aneurysm) of the largest artery in the abdomen, and procedures that remove part of the pancreas or esophagus, often in people with cancer.
For each of those procedures, the Leapfrog Group has created performance measures and designated which hospitals are "regional centers" - those where surgeons have a lot of experience with each procedure - and made a goal of getting more patients treated at those hospitals.
According to the results, the rates of aneurysm surgery at high-volume versus low-volume hospitals did not change after Leapfrog began its initiative. And patients survived aneurysm surgery at about the same rate at both kinds of hospitals.
For surgeries on the pancreas and esophagus, however, the percentage of surgeries done at high-volume hospitals jumped when Leapfrog implemented its initiative to have patients preferentially referred to those hospitals.
In the years before 2001, when Leapfrog made recommendations on the best places to get esophageal surgery, about 42 percent of these procedures were done at high-volume hospitals, compared to 59 percent afterwards.
Leapfrog's initiative for surgeries on the pancreas began in 2004. In the years before that, 59 percent of patients had pancreas surgery at a high-volume center, compared to 76 percent in the years following.
For both of those procedures, patients were generally more likely to survive after being treated at high-volume hospitals in the years before and after Leapfrog's initiative. For example, close to 14 percent of patients getting surgery on the esophagus at a high-volume hospital after 2001 died within a year of the surgery, compared to 24 percent of those treated at low-volume hospitals.
Despite the improvements in the number of patients seeking treatment at high-volume hospitals for surgeries on the esophagus and pancreas, there was no overall difference in how many patients died after both procedures across Washington State before and after the launch of Leapfrog's initiative.
The authors said they couldn't be sure why that was the case, but it might have to do with which kind of patients were changing where they got treated.
The authors "didn't really see much of a shift in the composition of patients treated at low-volume hospitals," Massarweh told Reuters Health.
"The question that I think is important to address is: who are the patients that are shifting their care to high-volume centers?" Massarweh said. "In truth, if it's a low-risk surgical patient who's seeking care at a high-volume center ... then we may not see as much benefit as we would if the high-risk patients are the ones that go there."
The challenge, Massarweh said, is figuring out how to identify those patients that could benefit most from being treated at a hospital with lots of experience, and making sure they end up there. Another problem is that low-income, high-risk patients may also have difficulty traveling to the best hospitals.
Massarweh added that not every surgery can be done at a high-volume hospital, and the authors note in the Journal of the American College of Surgeons that the initiative may have a negative impact on smaller hospitals where surgeons are also needed.
Leah Binder, the CEO of the Leapfrog group, said there could be many explanations for the findings but emphasized that the study shows that Washington needs to work harder at referring patients to the hospital where they have the best chance of having a good outcome.
"The bottom line is, we need to figure out how to get people to regional (high-volume) centers," she told Reuters Health. She also added that since the study was conducted, Leapfrog has "evolved its standard" for how it evaluates hospitals that do esophagus and pancreas surgeries.
Binder said that if everyone in a state went to high-volume hospitals for surgeries, that state should have a lower mortality rate overall. And in spite of the lack of state-wide success shown in this study, she said that the information Leapfrog provides is most important for individual patients to educate themselves about hospital differences before they decide where to get surgery.
"Any consumer who thinks this is something that's just a lot of wonkishness needs to pay attention," Binder said. "This is really an issue of saving your own life."
SOURCE: bit.ly/hZpK0j Journal of the American College of Surgeons, February 2011.
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