Tuesday, December 4, 2018

How many of those have you done?

When your choice of hospitals is limited, there is the inherent problem of any monopoly, with little incentive to provide better service or lower prices, but when there are multiple hospitals in a community, another problem arises. As I note in Prescription for Bankruptcy, when there are several hospitals in a city competing, the temptation is strong for every hospital to provide all services – particularly the high-prestige, high reimbursement services. Every hospital “must” have its own high-tech imaging equipment, even when fewer units would be adequate to serve the community. This is one reason why so many more CT and MRI scans are done in the U.S. compared to Canada – in most cities in the U.S., the tests can be done same-day or the next with no backlog of patients needing the service. While this may be touted as a good feature of the American system, a great many of the tests done are of little value and may even result in over-treatment.
More important from a patient’s perspective is the duplication of surgical and other interventional treatments. As in most fields, the more often a surgeon or hospital does something, the better they get at it. For procedures that are very commonly done, it may be possible for every hospital or surgeon to do them well. I would not worry about the volume of cases that he or she had done when a surgeon suggested an appendectomy. For more complex procedures, however, it does become quite critical to your health. A study reported in the journal Stroke in May 2015 looked at carotid endarterectomy, a procedure in which a surgeon opens a blocked artery in the neck, allowing better blood flow to the brain. They found a definite increased death rate in patients operated on by a surgeon who had done fewer than ten cases in the prior year. Another study, reported in Surgery in 2013, looked at operations on the thyroid for Graves disease, an overactive thyroid. While the impact of hospital volume was less dramatic, there was a significant increase in complications when the surgery was done by less-experienced surgeons. More recently, a study published in JAMA Cardiology on October 31, 2018 looked at outcomes among patients having their aortic valve replaced. By far the lowest 30-day mortality was found in hospitals with the highest number of cases done. Another looked at outcomes and hospital volume in patients having complex repairs of abdominal aortic aneurysms (Annals of Surgery 2018) and found peri-operative death rates correlated with surgical volume: the death rates at low, medium and high-volume centers were 9%, 4.9% and 3.9%.
Even as “bread and butter” a hospital function as labor and delivery shows this phenomenon. A study reported in The American Journal of Obstetrics and Gynecology in December 2012 looked at outcomes among newborns delivered in California hospitals. They only looked at full-term, normal birth weight babies, as most agree that when obstetric complications are anticipated, referral to a specialty center is needed. They looked at asphyxia among newborns, and divided hospitals into four categories based on numbers of deliveries. This life-threatening complication ranged from 9/10,000 births at the highest volume centers to 18 at the lowest.
The bottom line for you: if anyone suggests you need a complex procedure, carefully study how often the surgeon and hospital have done it!
For policy makers, consideration needs to be given to incentivizing hospitals to consolidate complex procedures at fewer hospitals.

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