Dartmouth-Hitchcock, Johns Hopkins, University of Michigan to limit low-volume surgeries

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Three of the nation's top academic medical systems – Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan – are planning to bar hospitals in their systems from performing low-volume procedures, according to U.S. News & World Report.

The move, they hope, will contribute to lowering an estimated 1,300 patient deaths nationwide each year attributed to mistakes associated with surgeries conducted too infrequently at medical facilities.

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The minimum standards will apply to up to 20 hospitals in the three systems and are expected to go into effect before the end of the year. They represent the first coordinated effort to place limits on hospitals and on surgeons.

The announcement follows a May 18 report by U.S. News that shows certain procedures are riskier for patients when done at hospitals and by surgeons who perform them infrequently.

As a starting point, the three centers have agreed on a list of 10 procedures, including bariatric surgery, lung cancer surgery, esophagus surgery and joint replacement.

The link between risk and low-volume has long been known, having been reported in the New England Journal of Medicine in 1979. However, action has been stymied by patients' desire to be treated closer to home and by hospitals' reluctance to give up profitable procedures, according to U.S. News.

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Nearly 30 percent of hospitalizations involve surgery, and those operations make up almost 50 percent of a hospital's revenue, said U.S. News, referring to an analysis by the Agency for Healthcare Research and Quality.

Two flagship Harvard University teaching hospitals in the Partners Healthcare system, Massachusetts General Hospital and Brigham and Women's Hospital, and their sister institutions  are considering the new standards but are not ready to sign on without more deliberation, according to the report.

Approximately 1.3 million people in the U.S each year undergo the 10 procedures on the minimums list and about 264,000 of those patients are treated in hospitals with below-average volume, according to Dartmouth-Hitchcock surgeon and Chief Academic Officer John Birkmeyer.

If patients treated in those hospitals were in more experienced hands, he said, more than 1,300 deaths could be averted each year.

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“We see this within our own health system, when surgeons whose primary interests are elsewhere do that [operation] just because it showed up on their doorstep,” Birkmeyer said.

Birkmeyer helped to draft the new standards with Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University, in consultation with surgeons at both institutions.

Dartmouth-Hitchcock and Johns Hopkins decided to act after Birkmeyer and Pronovost were asked to comment on the findings from the U.S. News analysis.

“Within two weeks, we got consensus on something that hasn't been acted on in 30 years," Pronovost said. “Not just consensus – people realized that this is something we have to do, the direction in which we have to go.”

Opposition is expected.

One concern is that many higher-volume hospitals are already full and don't have the capacity to care for a major influx of patients from smaller community hospitals.

The CEOs and boards at both Dartmouth and Johns Hopkins have agreed to adopt the new standards, but each hospital's medical executive committee, which represents the physician leadership, must also sign on.

“There are going to be strong critics of this,” Pronovost said. “We just have to be ready for that.”

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Overall, U.S. News found knee-replacement patients who had their surgery in the lowest-volume fifth of the centers were nearly 70 percent more likely to die than patients treated at centers in the highest-volume fifth.

For hip replacement, the risk was nearly 50 percent higher. Patients with congestive heart failure and chronic obstructive pulmonary disease had a 20 percent increased risk of dying.

The analysis was conducted as part of a new set of hospital ratings, Best Hospitals for Common Care, launched on May 20, that enables users to identify local hospitals that do the best job of caring for patients whose needs are relatively commonplace.

Twitter: @SusanMorseHFN