How many times did he do that operation? Volume as a quality proxy in health care

Filed Under: Costs, Patients, Providers

Cleveland Clinic doctor ratings
Cleveland Clinic doctor ratings

Summary: It’s hard to judge quality in health care. What’s best: a good outcome? Good hospital experience? Shorter wait times? Less money spent for better results? It’s one of the toughest nuts to crack, along with price transparency. But there are some simple measures that can be used, including the very simple one of frequency or volume: how many times did someone do a thing, and does that mean they’re better at doing it than people who did it less? Quite possibly, as Cheryl Clark wrote recently in Health Leaders media: “After a decade in which physicians and observers focused on processes and outcomes, the pendulum is swinging back toward viewing volume as the best barometer of hospital quality.”

 


 

“Welcome back, Procedural Volume,” she wrote.

“Your popularity as a way to measure hospital quality—that the more procedures a hospital or doctor does, the lower risk of complications and vice versa—has been on the wane. But now you’re trending back up. Good for you.”

“Here’s why:

“On Wednesday, U.S. News & World Report published, as part of its annual Best Hospitals report, a special new set of ratings that evaluate hospital performance in five common surgical procedures and medical conditions. The expanded report, Best Hospitals for Common Care, found that patients who receive these procedures at low-volume hospitals have a much higher risk of death or complications, while patients at higher-volume facilities have a reduced risk.

“On Tuesday, Dartmouth-Hitchcock Medical Center, The Johns Hopkins Hospital and Health System, and the University of Michigan Health System announced their “Take the Volume Pledge” program. They will restrict their 20 hospitals and surgeons from performing any of 10 procedures if they don’t do a minimum amount per year. They also encourage other hospitals to adopt similar policies, perhaps as a condition for granting physician staff privilege.

“The Centers for Medicare & Medicaid Services has begun posting on a new Hospital Compare tab the number of Medicare beneficiaries who received care for any of 64 medical conditions or surgeries at various levels of complexity. The idea is that an especially fragile patient may require a hospital with experience treating a more complex case.”

It’s easy to collect, so why isn’t it more available?

What’s interesting about volume or frequency data is that it’s fairly easily collected. It doesn’t require complex algorithms or patient questionnaires about their experiences. Volume or frequency are not, of course, a perfect measure of skill, because a high-volume provider could easily be botching those procedures. But as a proxy for quality, it’s not bad. (Unless, of course, the high number of procedures means that one provider is the lead billing provider for a several-doctor practice, or a high-volume provider is committing fraud.)

By this, I don’t mean to say that complex algorithms are bad, or that other data beyond frequency isn’t important. Of course it’s important to know if a hospital has a higher rate of hospital-induced infections, or of readmissions.

Likewise, the patient experience information is important: Would you recommend this hospital or provider to someone else? Was your nursing staff attentive?

But collecting this type of information is hard, and there’s always the question of whether the quality of the hospital food or the manner of the staff should be judged, or whether it’s the quality of care. And the administration of patient satisfaction surveys like Press-Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is mysterious and erratic, according to various reports.

In New York State, some volume metrics

New York state, where I live, used to collect volume for a handful of procedures. I used that information when I was looking for an orthopedic surgeon to repair a broken leg. I had a little bit of time to shop around, and was able to find a listing of orthopedic surgeons who performed this type of operation, with the number of times they had done it. Several surgeons I was considering were on the list, and the one who had been recommended to me (a friend of a friend) had an impressive number of such operations. Ultimately I chose him, and his work (as far as I know) was excellent — though his bedside manner left a great deal to be desired, and he had little faith in physical therapy as part of the recovery process, things the frequency listing would not have revealed.

Since then, New York has stopped collecting frequency for all but a few procedures, as I understand, because of budget limitations. But couldn’t they start?

I blogged about that in 2011, but the listing is no longer visible on the web.

Here’s one New York report that includes frequency, but it’s only on cardiac surgery and angioplasty.

Here’s original data for cardiac surgery by surgeon in New York State. Here’s data for percutaneous coronary intervention by surgeon in New York State.

Cleveland Clinic ratings

Other rankings or assessments continue to develop. An interesting one is Cleveland Clinic’s, where ratings by patients are made public online. Their CEO, Toby Cosgrove, explains the system here.

I took a quick look at it, and it certainly does show reviews — but should we worry that all the doctors are at least 4.5 out of 5? Does that mean that, as in Lake Wobegon, all the children are above average? If Cleveland Clinic is keeping the ratings, are they also monitoring and removing unacceptable ones?

Here’s one negative one, with a three-star rating out of a possible five:

“From a surgical standpoint, excellent work on my wounds, appreciate the delicacy and difficulty. Preparation before and after surgery, horrendous. Very poor communicaton written and verbal. Was not properly prepared for the issues with a drain, numbness, and lymph node drainage issues still experiencing 8 weeks out. I think Dr Gastman is an excellent surgeon and is well meaning. However, there needs to be better patient education through the entire process. There should be individualized specialists like physical therapy, lymphodema specialists, involved to help direct healing and side effects of lymph node removal. As a patient it is scary to have Cancer and not know how far it has spread, especially when you are relatively young, very healthy, and a parent of a young child. A little empathy, education, and preparation of what one is going to experience can make the negative situation a positive care model.”

The same doctor got five stars and “very knowledgeable” from another patient.

Aggregate total: 4.5 out of 5 stars.

In any case, the art and science of measuring quality continues to be a hot topic. Clark adds a quote from John Birkmeyer, MD, a surgeon, outcomes researcher, and executive vice president for enterprise support services at Dartmouth-Hitchcock: “There is a pendulum swing back toward paying attention to the volume/outcome story now.”

Her full story: “Welcome Back, Volume—the Original Quality Measure.”