Many Hospitals Not Meeting Standards for High-Risk Surgeries, Survey Shows

Marcia Frellick

July 18, 2019

The vast majority of hospitals in the United States fall short of minimum hospital or surgeon volume safety standards for eight high-risk procedures, according to the first such report by The Leapfrog Group, a national nonprofit healthcare watchdog.

Leapfrog analyzed reported volumes on the high-risk procedures to evaluate which hospitals and surgeons performed enough of them to minimize patient harm or death. The voluntary survey also asked whether each hospital actively monitors the surgeries to confirm whether each is necessary.

Findings on these measures pointed to alarmingly poor performance across the board and red flags for patient safety.

The analysis comes from findings of the 2018 Leapfrog Hospital Survey and included 1326 hospitals nationwide where at least one of the eight high-risk surgeries was performed in 2018.

How Procedures Were Chosen

The eight procedures were identified based on an intensive review of hundreds of studies conducted over the past decade, as well as guidance from Leapfrog's National Inpatient Surgery Expert Panel. From this analysis, Leapfrog set evidence-based standards for the minimum number of surgeries each hospital and each surgeon should perform. 

Leapfrog contracts with the Johns Hopkins Armstrong Institute for Patient Safety and Quality, which provides scientific guidance for the Leapfrog Hospital Survey.

The procedures were those with a strong relationship between volume and patient outcomes, Matt Austin, PhD, assistant professor at the Armstrong Institute, Baltimore, Maryland, told reporters during a telephone briefing.

He said that for the survey hospitals were allowed to submit 12-month data or an average for 24 months.

Open abdominal aortic aneurysm repair and esophageal resection for cancer were the two procedures for which the fewest hospitals met the standard (less than 3% fully met the standards for each).

Bariatric surgery (38%) had the highest rate for which both surgeons and hospitals met the minimum volume standards.

Percentage of Hospitals That Fully Met Hospital, Surgeon Volume Standards

High-Risk Procedure Met Both Standards, %
Bariatric surgery for weight loss 38.0
Carotid endarterectomy 16.2
Esophageal resection for cancer 2.6
Lung resection for cancer 5.6
Mitral valve repair and replacement 7.1
Open abdominal aortic aneurysm repair 2.5
Pancreatic resection for cancer 5.4
Rectal cancer surgery 5.6

Leah Binder, president and CEO of The Leapfrog Group, told reporters during the briefing, "Surgeons themselves need — as part of their privileges for the hospitals — to show they have performed the minimum number of the surgeries, whether they perform them at that hospital or not."

"We are not saying that a surgeon or a hospital that does a higher volume is therefore higher quality. What we are saying, however, is that if a surgeon or a hospital does a lower volume of these surgeries than our standard, that is not adequate for safety," she said.

The report found that rural hospitals were particularly more likely to fall below volume standards for the procedures. In five of the eight procedures, for example, no rural hospitals fully met the volume standard.

Three out of four hospitals do not have appropriateness criteria for procedures, Binder noted, except for bariatric surgery for weight loss, for which 44% of hospitals have the criteria, which she said, is "deeply concerning."


James Rickert, MD, an orthopedic surgeon in Bloomington, Indiana, and president of the Society for Patient Centered Orthopedics, told Medscape Medical News the number of low-volume centers performing high-risk surgeries highlighted by the report "is troubling" and said "the problem is worse than I thought."

Financial considerations are likely influencing decisions to do the surgeries, he said.

"It's very difficult for any institution to turn away business," he said. "Those are really big surgeries with a lot of revenue."

"Patients should definitely be asking surgeons how many of these procedures they do and asking hospitals how many of these are done at [their] institution," he said. "If you're a person in rural America, you really have to ask careful questions."

Holding hospitals accountable for the numbers done at their institutions is important, he said, because staff and nonsurgeon providers also need to be well-trained and prepared to do the surgeries.

Rickert said the thresholds for safety are in-line with industry standards.

"I didn't feel the bar was set too high," he said.

He noted that for several of the surgeries the safety threshold for number of surgeries a surgeon performed was less than one per month. For rectal cancer surgery, the safety threshold for surgeons is only six per year.

Many Hospitals Declined to Reveal Data

The survey includes large numbers of hospitals who declined to provide information on the number of surgeries performed or whether they had an appropriateness evaluation system in place.

Rickert noted that may indicate the problem is even worse than revealed in the report because those who didn't respond are more likely to be those who had lower numbers of surgeries.

He added that hospitals should have a policy in place for referring low-volume surgeries so the decision is not left up to the physician.

The choice of hospital for high-risk surgeries can be deadly. A 2015 analysis by US News led to a report that showed as many as 11,000 deaths in the United States might have been prevented over 3 years if patients who went to the lowest-volume hospitals had their procedure at the highest-volume hospitals.

"For hospitals and hospital systems, we advise them to work hard to concentrate the volume for these procedures in facilities that have adequate volume," Binder said.

For all eight high-risk surgeries except bariatric, fewer than one third of reporting hospitals said they have a surgical appropriateness policy in place. For bariatric surgery, 45% said they had such a policy.

That has direct consequences, Rickert said.

"About a third of major surgeries are considered unnecessary or inappropriate," he said, "and without oversight from the institution where it's being done, it's hard to correct that problem."

Individual hospital results are available and searchable on the Leapfrog website.

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