While more hospitals are meeting minimum volume standards, the majority are still electing to perform high-risk procedures without meeting the volume standards required to do so safely.

That’s the consensus of independent national healthcare watchdog, The Leapfrog Group, which outlined its findings in its report, Safety In Numbers: Hospital Performance on Leapfrog's Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey.

"Research is clear that patients undergoing high-risk surgeries have a higher likelihood of experiencing errors, complications and even death at a hospital that performs a lower volume of these procedures," Erica Mobley, vice president of administration of The Leapfrog Group, told HCB News. "Both surgeons and hospitals need adequate, ongoing experience with that specific procedure in order to be able to operate safely. The Leapfrog standard isn’t looking to see how many procedures a hospital can do as an indicator of quality; it looks at whether a hospital and surgeon are doing enough procedures to be safe."

Overtreatment or low-value care costs the U.S. healthcare system $75.7 billion to $101.2 billion, according to a retrospective literature study that was published in October 2019 in JAMA.

More than 2,100 hospitals — representing 70% of U.S. hospital beds — participated in the 2019 Survey, which used final hospital data from the 2019 Leapfrog Hospital Survey, the flagship initiative of The Leapfrog Group. The eight surgeries included in the Survey were identified by Leapfrog's National Inpatient Surgery Expert Panel as procedures for which there is a strong volume-outcome relationship. They include bariatric surgery for weight loss; carotid endarterectomy; esophageal resection for cancer; lung resection for cancer; open aortic procedures; mitral valve repair and replacement; pancreatic resection for cancer; and rectal cancer surgery.

A higher percentage of hospitals met Leapfrog’s minimum volume standards in 2019 than in 2018, with 70 percent having implemented protocols to monitor appropriateness for cancer procedures. Compliance for appropriateness of other high-risk operations evaluated in the survey ranged from 32-60%, depending on the procedure. Such efforts potentially protect patients from undergoing unnecessary procedures.

Esophageal resection for cancer and pancreatic resection for cancer ranked the lowest among hospitals that met the volume standard for patient safety, at less than 3% and 8%, respectively. Hospitals were most likely to meet the safety standard for bariatric surgery for weight loss, at 48 percent.

In addition, the vast majority of rural hospitals did not perform these high-risk procedures, and those that did were less likely than other hospitals to meet the volume standard for patient safety.

"If a hospital and/or surgeon is not able to perform the designated minimum number of surgeries per year, as established in literature, to be able to do so safely, the surgeon should have a conversation with the patient about other facilities where they may be able to seek care," said Mobley. "Most importantly, if a hospital cannot ensure that they will perform an established minimum number of designated procedures, it should not electively perform those surgeries. Likewise, the hospital should not grant privileges to surgeons who do not perform a minimum volume of a specific surgery each year."

She adds that hospitals must "implement an appropriateness policy to assess whether a high-risk procedure is necessary and ensure patients are not receiving surgeries they may not need. For cancer surgeries, this includes having a multidisciplinary tumor board prospectively review cases. For other procedures, hospitals should develop appropriateness criteria based on published evidence and surgeon input. Finally, hospitals should have a policy to help patients find another hospital and/or surgeon if they do not have adequate volumes to perform the procedure safely."

Leapfrog has publicly reported since 2018 on the ability of hospitals to meet minimum volume standards for safety of eight high-risk procedures.