Having more high-risk procedures performed at high-volume hospitals appears to be lowering surgical deaths, but other factors also are at play, according to a report by University of Michigan Health System researchers published in the New England Journal of Medicine.
Surgery mortality rates decline: U. of Mich. report
The researchers identified Medicare patients ages 65 to 99 who had had one of eight cancer or cardiovascular operations between 1999 and 2008: an esophagectomy, a pancreatectomy, lung resection, a cystectomy (bladder removal), the repair of abdominal aortic aneurysm (AAA), coronary-artery bypass grafting (CABG), a carotid endarterectomy or an aortic-valve replacement. The study noted that six of these had been identified by the Leapfrog Group coalition of large employers as operations in which higher-volume hospitals had better outcomes.
According to the report, more than 3.2 million Medicare patients underwent one of these procedures during the period studied, with the volume of the four cancer procedures and AAA repair increasing "substantially" while hospital volumes for CABG and carotid endarterectomy declined "sharply."
For all procedures, risk-adjusted mortality rates fell between 8% and 36%. Declines in mortality associated with pancreatic cancer surgeries (67%); cystectomies (37%) and esophagectomies (32%) were the result of the procedures being performed in higher volumes at hospitals, according to the report. The report also noted that, for most procedures studied, additional factors—such as the use of less invasive surgical approaches—were responsible for lower mortality rates. Less-invasive approaches helped account for a 60% decline in mortality for AAA repair, according to the report.
"Other efforts, such as public reporting initiatives and regional quality-improvement collaboratives, may also have played a role in declines in mortality," the report's authors wrote. "The fact that mortality for all eight procedures declined during the 10-year study period suggests that there are factors common to all these procedures that contributed to mortality reduction. Technological advances and the use of checklists in the operating room and improvements in perioperative care, particularly intensive care, have most likely enhanced operative safety."
Moreover, after the National Institutes of Health's publication in 1999 of the patient-safety manifesto To Err is Human, hospitals may be increasingly focused on improving their patient-safety cultures, the authors noted, and pay-for-performance programs and initiatives to drive compliance with evidence-based practices related to perioperative care may have contributed to declining mortality rates for the procedures studied too.
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