Hospital standards for high-risk surgeries save lives

06/23/04

New quality criteria linked to better outcomes, fewer deaths, U-M study finds

ANN ARBOR, Mich. -- If all hospitals met the quality standards for five high-risk surgeries set by a national coalition, it would save nearly 8,000 lives each year, according to a new study from the University of Michigan Health System.

Open heart surgery alone would result in about 4,000 fewer deaths, and procedures such as angioplasty would see another 3,000 fewer deaths if all patients were treated at hospitals meeting these standards, according to the study. Results are published in the June issue of the journal Surgery.

The coalition, the Leapfrog Group, established evidence-based quality standards for five surgical procedures that hospitals must meet to be on the group's preferred list. The Leapfrog Group is a coalition of 150 large public and private employers representing more than 40 million people and aimed at improving health care quality.

Based on research showing better outcomes at hospitals that perform certain surgeries more often, the group initially set its standards to reflect surgical volumes only. New standards, revised in 2003, consider additional measures of quality, such as mortality rates. Researchers at UMHS evaluated whether patients would fare better after surgery if they were treated exclusively at hospitals that met these new criteria.

"Patients deciding where to undergo elective but high-risk surgery can substantially improve their odds of survival by selecting a hospital that meets Leapfrog safety standards," says John Birkmeyer, M.D., George D. Zuidema Professor of Surgery at the U-M Medical School and chair of the Michigan Surgical Collaborative for Outcomes Research and Evaluation. Birkmeyer conducted the study along with Justin Dimick, M.D., a UMHS surgical resident.

Leapfrog has set standards for five procedures: pancreatic surgery, esophageal surgery, open heart surgery, percutaneous coronary interventions (such as angioplasty) and abdominal aortic aneurysm repair.

Using data from the National Inpatient Sample, a random sample of 20 percent of all hospital discharges in the United States, researchers estimated the number of patients undergoing each procedure and the average mortality rates. They then estimated how many deaths would be avoided if patients were treated only at hospitals that met the new criteria.

For all five surgeries, an estimated 7,818 lives would be saved if all hospitals met the standards. The biggest benefit would be for patients undergoing open heart surgery. Standards require hospitals to perform at least 450 surgeries a year and have risk-adjusted mortality rates below the national average. If all patients were treated at the hospitals with the highest volumes and the lowest risk-adjusted mortality rates, 4,089 lives would be saved. Fully implementing similar Leapfrog standards for percutaneous coronary interventions would save 3,016 lives.

The standards for abdominal aortic aneurysm require that hospitals perform at least 50 procedures each year and give at least 80 percent of eligible patients beta-blockers before surgery. This would save 356 lives.

To meet standards for pancreatic resection, surgery to remove the pancreas, hospitals must perform 11 or more each year. Similarly, hospitals must perform at least 13 esophagectomies, surgery to remove part of the esophagus. Both procedures would see better outcomes if the standards were fully implemented, and hospitals meeting the standards for esophageal surgery would have a 5.9 percent lower mortality rate.

Full implementation of Leapfrog's standards may not be feasible for all five procedures, the researchers caution. Moving all open heart surgeries and angioplasties to the top hospitals would not be practical because the surgeries are so common. But since pancreatic resection and esophagectomies are rare, it would be possible for patients to be referred to hospitals that meet the standards. Also, any hospital could ensure appropriate patients receive beta-blockers before abdominal aortic aneurysm repair.

"Efforts should be focused on getting patients to the best hospitals as well as improving quality at all hospitals. It is not clear how many hospitals are making efforts to meet the Leapfrog standards for surgery, but there seem to be trends toward fewer patients undergoing high-risk operations in low-volume hospitals. This may reflect early success of Leapfrog and other efforts," Birkmeyer says.

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