Patients at thousands of hospitals face greater risks from common operations, simply because the surgical teams don't get enough practice.
Like other hospitals in thinly populated areas, Sterling Regional Medical Center does a bit of everything. The 25-bed Colorado hospital has its own heliport, delivers about 200 babies a year and admits more than 1,200 patients for a variety of conditions and procedures. Replacing worn and painful hips and knees is among them. To patients, the surgery may seem perfectly routine.
Joint replacements are anything but routine at hospitals that don't do many of them, a new U.S. News analysis shows. Sterling is among thousands of U.S. medical centers whose patients face a greater risk of death and complications because their surgical teams do too few procedures, even common ones, for doctors, nurses and technicians to maintain their skills.
These large numbers of low-volume hospitals, the analysis found, continue to put patients at higher risk even after three decades of published research have demonstrated that patients are more likely to die or suffer complications when treated by doctors who only occasionally see similar patients rather than by experienced teams at hospitals with more patients and established protocols.
Elective hip and knee replacements are a prime example. Many urban centers routinely do hundreds a year. At Sterling, the three-year total for Medicare inpatients from 2010 through 2012 was 29 hips and 52 knees. And while the death rate for these operations is about 1 in 1,000 nationally, Medicare data in the U.S. News analysis show that the relative risk of death for the hospital's elective knee replacement patients was 24 times the national average and three times the national average for hip replacement patients.
"You can save your life by picking the right place," says Leah Binder, director of the Leapfrog Group, a consortium of major employers that emphasizes safety in measuring hospital performance.
A calculation by Dr. John Birkmeyer, a surgeon who has produced pioneering research on the effect of patient volume, underscores the point. Using the U.S. News analysis, he determined that as many as 11,000 deaths nationally might have been prevented from 2010 through 2012 over the three years analyzed if patients who went to the lowest-volume fifth of the hospitals had gone to the highest-volume fifth.
The data Birkmeyer used for his calculations covered only five common procedures and conditions. If a full range of commonplace operations and medical conditions had been included, adds Birkmeyer, executive vice president for enterprise services and the chief academic officer at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, "tens of thousands" of deaths could potentially have been averted.
The analysis, conducted in collaboration with Dr Foster, a London-based global health analytics firm, unearthed low volumes and troubling outcomes at hospitals many times larger than Sterling. At 331-bed Lawnwood Regional Medical Center & Heart Institute in Ft. Pierce, Florida, the relative risk of dying following a hip replacement was nine times the national average. At 316-bed Jersey City Medical Center in New Jersey, the risk for patients who had heart bypass surgery (none involving valve replacement or repair) was four times higher than average.
Representatives from Sterling Regional and the other higher-risk hospitals highlighted in the analysis responded that they could not confirm any of the deaths. It is possible that all of the deaths occurred elsewhere, or at other hospitals, after the patients had been discharged from the facilities where they received initial care but within 30 days of their original admission. But attributing treatment-related deaths to the hospitals where patients were first admitted and adjusting for differences in each hospital's mix of patients is standard practice in analyzing health data.
Sterling spokeswoman Sara Quale said the hospital declined to comment on the specifics of the analysis because officials could not track the patients in the hospital's records. Lawnwood spokeswoman Ronda Wilburn said the hospital's "30-day post-discharge outcomes are in line with national mortality rates" posted on Medicare's Hospital Compare website. The mortality rates published there, however, reflect overall mortality, not the relative risk of death from low-volume procedures.
Joseph Scott, CEO of Jersey City Medical Center, acknowledged that the hospital may have had problems with its bypass surgery program during the years evaluated by U.S. News. "We have a different cardiac surgeon today than we did [then]," he says. "While [the findings] may be true between 2010 and 2012, we're always about continuous improvement and making things better."
The first large study showing an indisputable link between low volumes and poorer outcomes appeared in 1979 as a special report in the New England Journal of Medicine. Regardless, large numbers of hospitals continue to do small numbers of procedures. Part of the U.S. News analysis identified every hospital across the nation that operated on or treated fewer than 25 traditional Medicare inpatients from 2010 through 2012 for nearly 20 frequent procedures and conditions.
Because a single death more or less would make the calculated odds jump or plummet at these hospitals, U.S. News chose not to display their overall ratings in Best Hospitals for Common Care unless such a hospital had had five or more deaths in a procedure or condition.
Nevertheless, taken together, the risk posed by ultra-low-volume hospitals is unmistakable. In the U.S. News analysis, knee-replacement patients at the hospitals had double the national average death risk, a 25 percent higher rate of readmission because of post-discharge complications. Hip-replacement patients faced a 77 percent higher risk of death and a 25 percent higher risk of readmission.
To analyze the risks presented by hospitals with volumes high enough to allow them to be individually rated, U.S. News divided all centers that treated at least 25 patients in one or more of the operations and conditions analyzed for the project into five roughly equal bands by volume. Rates of death and complications were then calculated for each band as well as an overall rating. Hospitals in the lowest-volume quintile for knee replacement, for example, had average total volume of about 43 joints over the three years of analysis and those in the highest-volume quintile an average of 806.
Across all five operations and conditions, nearly 120,000 patients were treated at hospitals in the lowest-volume band – 39,483 for elective hip or knee replacement, 7,898 for cardiac bypass, 36,711 for heart failure patients and 34,181 for COPD.Overall, knee replacement patients who had their surgery in in the lowest-volume centers were nearly 70 percent more likely to die than patients treated at centers in the top quintile. For hip replacement patients, 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.
Few patients ask how many similar cases a hospital, let alone an individual doctor, has treated, says Dr. David Jevsevar, an orthopedic surgeon at Dartmouth-Hitchcock. "Are patients aware that they're going to a hospital that has done three of these [procedures] in the last year?" he asks. "Would they feel differently if they knew?"
Perhaps not. Most patients, doctors say, feel that the more local the care, the better. Even if other hospitals are just an hour or two away, nearby care is comfortingly familiar. It avoids negotiating with a health insurer and the expense and stress, to the patient and to family members, of out-of-town care.
A study led by Dr. Samuel finlayson of the University of Utah bears this out, showing that nearly one-fifth of patients would choose to have surgery at a local hospital with a death rate of 18 percent rather than drive two hours to a regional hospital with a death rate of 3 percent.
You must be logged in to post a comment.