A recent article in U.S. News & World Report discusses the relationship between the volume of surgeries and the success of outcomes. The conclusion was simple: hospitals that routinely perform certain procedures have better outcomes than hospitals that seldom perform the same procedures.
This is not a novel proposition. For decades, evidence has shown that mortality is lower and outcomes are better for patients who undergo surgical procedures in hospitals that have more experience performing the surgeries. As such, at least when it comes to surgeries, quantity does seem to improve quality. According to the Armstrong Institute, for example, “as many as 11,000 lives of Medicare patients could have been saved between 2010 and 2012 if patients received treatment at the highest-volume fifth of the hospitals instead of the lowest-volume fifth.”
This is truly troubling. The question then becomes – should standards be in place to prevent doctors and hospitals from performing specific procedures if such procedures are not regularly performed by them? After all, the evidence tells us that experience matters in reducing morbidity and mortality. But more importantly, can we trust our health care providers to police themselves in deciding which surgeries to perform or not perform?
I, for one, am very skeptical of the idea of self-policing. First, money is the primary reason why self-policing won’t work. Surgical procedures are very profitable if not the most profitable for hospitals. A simple hip replacement can cost as much as thirty thousand dollars, not including pre-operative and post-operative care. While hospitals should have their patients’ best interests in mind, they are also businesses that will do what they can to bring in revenue.
Second, many community hospitals and young or growing health care systems have strong incentives to broaden their services in order to compete with other health care providers. For example, if the demand for bariatric surgery is great, a community hospital that seldom performs such surgeries may have a strong incentive to advertise and offer bariatric surgery in order to increase volume overtime.
Third, on an individual level, I believe it will be difficult to tell physicians what procedures they can or cannot perform. My experience with surgeons has been that they are often too eager and to confident to perform any surgery as long as it is in the realm of what they generally know how to do.
Fourth, physicians are not particularly good at telling each other what to do. There has been quite a bit of discussion recently about why doctors stay silent about mistakes their colleagues made. A major reason is that doctors are colleagues, and they often depend on each other for business. This rationale applies to self-policing. I find it difficult to believe that a physician who collaborates with another physician would be willing to demand restrictions on that physician’s surgical practice.
Therefore, if the evidence suggests that it is prudent to impose limitations on surgeries dependent on volume, such limitations should be instituted by entities without a vested interest or bias and with the power to enforce the limitation. Perhaps the Joint Commission or the Centers for Medicare and Medicaid Services are well-suited for the task.