Although hospitals improved slightly on the Leapfrog Group's minimum volume standards for high-risk procedures, most still struggle to comply, according to new data.
Less than a quarter of hospitals that voluntarily completed Leapfrog's 2019 Hospital Survey fully met the standard for all eight high-risk procedures with the exception of bariatric surgery for weight loss, which had 48.1% of hospitals in compliance. The results are slightly better from 2018 when less than 16.2% of hospitals met the full standards for seven of the procedures and just 38% complied with the bariatric surgery standard.
"It's good news we are seeing improvement … however the very bad news is performance nationally is still abysmal," Leapfrog Group CEO Leah Binder said. "Patients and employers need to look closely at this data before they identify centers of excellence or choose a facility for surgery."
The eight high-risk procedures were selected by a Leapfrog panel of patient safety experts that found a strong correlation between patient outcomes and the number of times the procedure was performed. The eight procedures are bariatric surgery for weight loss, carotid endarterectomy, esophageal resection for cancer, lung resection for cancer, open aortic procedures, mitral valve repair and replacement, pancreatic resection for cancer and rectal cancer surgery. One of the procedures, open aortic procedures, replaced abdominal aortic aneurysm repair from the 2018 survey in response to ICD-10 code changes, Binder said.
The American Hospital Association opposes the Leapfrog Group's standards.
"Surgical expertise goes well beyond the number of procedures performed and Leapfrog's approach ignores other important strategies to improving care," said Nancy Foster, AHA's vice president of quality and patient safety policy, in a statement.
She added, as she previously said when the Leapfrog Group released its report last July, that there is no research about the exact volumes of procedures to perform that will improve patient outcomes and therefore any attempt to do so is "arbitrary."
In response, Binder said the standards are based on the input from several patient experts. Additionally, they are minimum standards deemed safe for patients and they aren't intended to indicate quality is better, she said.
Leapfrog Group determines a hospital is in full compliance with its standards if it meets both facility-wide volumes and individual surgeon volumes. Surgeon volumes are determined if the hospital gives privileges to a physician who meets or exceeds Leapfrog's numbers. Binder said surgeon volumes are determined that way because doctors can perform the same procedure at multiple facilities.
Hospitals are more likely to meet one part of the standard rather than both parts, the report shows. For instance, 61.2% of 1,163 hospitals met Leapfrog's facility volume standard for carotid endarterectomy but just 35% of hospitals met the surgeon volume standard.
Binder said it's unclear why that's the case and she's hoping research will be done to explore the reasons.
The longer hospitals participated in the Leapfrog survey also influenced their compliance with the standards, according to the report. Hospitals that participated in Leapfrog's 2018 Hospital Survey did better on the standards for five of the procedures in the 2019 survey. For instance, 4.7% of hospitals reporting for the first time met the standard for pancreatic resection surgery compared to 9.7% of hospitals that reported in 2018 as well.
"Transparency has had a galvanizing effect on hospitals and certainly with this volume standard we are seeing it," Binder said. "Hospitals are recognizing their own shortcomings in this area and we are seeing some progress, which is good."
Policies to determine if a procedure should be performed on a patient also aren't widespread at hospitals, the report found.
While more than 71% of the hospitals reported they had a multidisciplinary tumor board in place to review the four cancer surgeries, just 32.1% had an appropriateness policy in place for open aortic procedures while 60.5% had such policies for bariatric surgery for weight loss.
Leapfrog determines a hospital has met the standard for the four non-cancer procedures if they report having an appropriateness policy created by surgical staff.
"We know that inappropriate care is a major driver of poor health outcomes and waste," Binder said. "We really think that hospitals need to step up and be more aggressive about ensuring when a procedure is performed it's done on a patient who needs it."
The results on the minimum volume standards are available to the public and Binder said health plans and employers should adopt them to make network decisions and to determine centers of excellence.
The influence of health plans is evident when looking at bariatric surgery for weight loss, Binder said. Nearly 50% of hospitals comply with Leapfrog's standard for that procedure likely because health plans have implemented more restrictions on where members can get it.
"We would also like to see hospitals immediately set new policies that ensure that their surgeons and OR teams have the experience necessary to perform each of these procedures," she said.