Minimum volume standards
What you don't know can kill you
In 2015 three major academic medical centers made a pledge to impose minimum volume standards that would eliminate hospitals with low volumes from performing certain high risk procedures. This was done in order to enhance quality and reduce both morbidity and mortality associated with these high risk procedures
This pledge was not uniformally endorsed and was criticized by many as self-serving
The fact that minimum required numbers of procedures as a mandate for credentialing has been well-established for years and those who perform procedures especially more complex ones more frequently have better outcomes has been well-established for years. Minimum numbers of procedures for cardiology, stroke centers, and myriad other procedures are routinely required for both certification and reimbursement but not for other major procedures like cancer surgery. Frankly even simple procedures when done in greater volume often have the best outcomes. Take for instance hernai repair center in Canada, Shouldice Hospital. It comes as no surprise that Congressman Rand Paul traveled out of the country for his surgery.
GREED TRUMPS SAFETY
It seems intuitive that institutions would only perform procedures which they can do at the highest level of competence but tragically this is not the case. Many of these procedures generate large amounts of revenue for hospitals which they are reluctant to forgo. They rarely reveal these facts to the patients and the lack of informed consent about their higher complication rate is likely both a violation of informed consent and immoral. The horrific story of St Marys Medical center in Florida made national headlines with triple the death rate for pediatric cardiac surgery which continued (all the time getting paid) until the press excoriated the institution.
More lawsuits should be brought against institutions that continue to perform surgeries which they cannot justify based on low volume. My experience on committees for safety and quality identified institutions performing procedures with disproportionately high complication rates. The most telling was one where open bariatric surgery was performed and patients were not even aware that the procedure can be performed much more safely laparoscopically. The untold suffering and unnecessary deaths that resulted remain uncounted and unrecognized.
The arguments against maintaining volume pledges and minimum required procedures to maintain competency are exceptionally weak. Staying local for the convenience of friends and relatives is trumped by the reduced complication rates and deaths at high volume centers.
It is important that patients specifically query their physicians with regard to the volume of procedures they perform and their complication rates. In this way an informed and engaged patient can be their best advocate Further, soliciting a second opinion from another clinician can only enhance your knowledge and care.
A recent article in JAMA surgery once again highlights the disproportionate outcomes for discretionary high-risk cancer surgery when performed at low volume centers. This is unconscionable. This practice should not be allowed to be continued.
In the accompanying invited commentary points out the fact that low volume centers are allowed in other countries where there is centralization of complex surgery by law and enforced by healthcare financing. This approach should be adopted in the United States. The term "Lyft therapy" is used in the invited commentary, meaning that a simple car ride to a more experienced center will have a much more salutary effect than any other intervention including chemotherapy or radiation.
The marketplace has failed us when institutions put profit over patient safety. We should follow the lead of other countries which prohibit low volume institutions from billing for procedures. The time for intervention through legislation and regulation is now.
copyright nicolasargy 2019