Why a Hospital Volume Pledge? Practice Makes Perfect
Three prominent hospital systems have taken what's become known as "the volume pledge." Johns Hopkins, Dartmouth Hitchcock, and the University of Michigan will now require their surgeons and 20 affiliated hospitals to meet minimum annual thresholds for 10 high-risk procedures, according to a recent article in Kaiser Health News. The pledge requires that each year, surgeons must perform a minimum of five pancreatic cancer surgeries in hospitals where 20 such operations are done annually, as well as 25 knee or hip replacements (with a total of at least 50 per hospital).
The pledge emanated from a long-standing debate that dates back to 1979, when a study by Stanford University found that patients had better surgical outcomes at hospitals where those procedures were performed more frequently vs where they were performed less frequently.
Succeeding studies have consistently shown that the risk for complications was much greater for surgeons who performed one thyroid removal a year, compared with those who did 25 procedures or more.
"We decided to use volume as a pilot case, an initial foray into setting quality and safety standards," John Birkmeyer, chief academic officer at Dartmouth, told Kaiser Health News. Birkmeyer, with Peter Pronovost, director of Hopkins' Armstrong Institute for Patient Safety and Quality, devised the pledge.
Not everyone thinks that volume is a good litmus test of quality outcomes. Some observers felt that more is not necessarily better, and that using numbers alone could unfairly penalize low-volume hospitals with good outcomes. Conversely, it's argued, there are high-volume hospitals with poor outcomes.
Credentialed surgeons with good records have understandably balked, which may be why only three systems have signed the pledge thus far. The article notes, however, that more than a dozen others have expressed interest.
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