For patients facing high-risk operations, an alarm on hospital surgical volumes

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Would a major league baseball team start a pitcher who played only once in the season for the deciding game of the World Series? Would passengers want to be aboard a jet whose pilot flew just once a year? Would any high-end sports car owner let a mechanic under the vehicle’s hood if she fixed that model one time every 365 days?

If rigorous tasks benefit from regular, quality practice — and they do — then why do hospitals allow low-volume surgeons to undertake procedures they rarely perform? That’s a tough question posed by new research from the Leapfrog Group, a national nonprofit organization seeking to improve the quality and safety of American health care.

Leapfrog, working with medical experts, identified eight high-risk surgeries and sought to estimate from rigorous published research the correlation between how often surgeons perform these and their procedures optimal outcomes.

The vast majority of U.S. hospitals fall short of the group’s optimal surgical volumes in the risky operations, with Leah Binder, president and CEO of The Leapfrog Group, observing: “It’s clear from this report that patients should be very careful before they choose a hospital for one of these high-risk procedures.” She added: “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. 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.”

The American Hospital Association criticized the Leapfrog study, saying research has not established that surgeons, by performing any procedure for a specified number of times in a given period, were safer and had better outcomes for patients.

Leapfrog issued its warning about surgeons and the volumes of their procedures based on its 2018 survey of more than 2,000 hospitals. Not all hospitals responded with surgical volume information. The eight complex and high-risk procedures Leapfrog focused on were:

  • bariatric surgery, for obese patients to lose weight;
  • carotid endarterectomy, which cleans out blockages from crucial arteries in the neck that supply the brain;
  • esophageal resection for cancer;
  • lung resection for cancer;
  • mitral valve repair and replacement in the heart;
  • open abdominal aortic aneurysm repair;
  • pancreatic resection for cancer;
  • and rectal cancer surgery.

Independent experts interviewed about the Leapfrog report expressed concern about its findings, saying the group had not set its standards too high and that it was troubling that hospitals with low numbers of surgeries were allowing surgeons to tackle complex procedures that they only rarely performed.

That’s not good for patients, nor is it safe, they said. It may reflect institutions and practitioners putting a drive for profits ahead of their patients. Leapfrog noted that rural hospitals may struggle more than, say, major academic medical centers, in surgical volumes, especially with complex procedures.

But the group said hospitals should not hesitate to refer patients to places where they get the best care they can afford. For their patients’ sake, hospitals also must step up and more of them need to increase their candor about their surgical volumes, so patients can make good decisions about their care. Patients have a fundamental right to informed consent. This means they are told clearly and fully all the important facts they need to make an intelligent decision about what treatments to have, where to get them, and from whom.

In my practice, I see the harms that patients suffer while seeking medical services, including damage inflicted on them in difficult procedures that are botched by surgeons with insufficient training, skill, experience, and diligence. Most doctors may be careful, caring, and compassionate. But surgeons, who are legend as medical swashbucklers, should not defy common sense and put their patients at risk by tackling nonemergency operations they don’t perform with regularity to gain mastery, much less comfort.

Surgical volume isn’t the only measure that matters to patients. But as I have written in my book, The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst, it is vital for patients to be tough and to ask a prospective surgeon questions such as:

  1. “Do I really need any surgery?” (A busy surgeon – and busy means a lot of doctors have confidence in this surgeon — will be more candid than a surgeon with time on his hands to tell you that waiting might be the most prudent thing to do.)
  2. “What is the exact procedure that you would recommend for a family member if they had the same thing I have?” (You need to make sure the surgeon and you are both talking about the exact kind of procedure proposed for you, not some close cousin.)
  3. “Who would you ask to do the operation on a close family member of yours if you couldn’t?”
  4. “How often do you do this kind of procedure?” You want to hear: “Every week” (and if you hear “a few times a year” or less, you want to drop this surgeon).
  5. “Is there anyone at your institution (in your partnership, in my town, etc.) who does these procedures more than you do? If so, would you mind if I speak to him or her?” (A defensive response to this question is a red flag.)
  6. “How long have you been doing this procedure?” (Be careful with this one, because some surgeons can honestly say “years” but have less experience in volume of cases than a fresh-faced young surgeon who has just finished rigorous sub-specialty training at a major teaching hospital with several cases every week. The more important focus is volume of recent cases.)”

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
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