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Beyond Safety
Really sick patients need expertise--not just protection
U.S. News & World Report July 18, 2005
By Cory Hatch

Everybody wants a safe hospital, with few potential patient-killing errors. And everyone would like a hospital that follows basic practices--giving aspirin to heart-attack patients, for instance--that are proven to save lives. But safety and basic quality aren't enough for patients who need complicated surgery. They need the expertise available only at a handful of medical centers.

But how to find the experts? The "America's Best Hospitals" rankings are a good place to start. A patient who needs state-of-the-art prostate surgery might investigate hospitals in the cancer rankings. But these lists encompass a wide variety of procedures. What about a particularly complex and seldom-done surgery?

A few states--New Jersey, New York, and Pennsylvania--put individual surgeons' mortality rates for coronary artery bypass graft surgery (CABG) on a public website. But CABG, while fairly complicated and demanding, has become relatively commonplace. If you need a rarer and riskier type of operation, such as cancer surgery on the pancreas, you have two problems: You won't find mortality rates, and, even if you did, mortality isn't necessarily the best yardstick to use. Some operations are simply too rare for mortality statistics to prove useful.

Asking about experience with difficult surgeries may fill the void. In general, the greater the number of difficult operations a surgeon or hospital performs, the smaller the chance that patients will die. Take the removal of the cancerous part of the esophagus. According to one study, almost 19 percent of patients who went to surgeons who performed a single esophagectomy per year, or none at all, died within 30 days of the procedure. Only half that percentage died with surgeons who did at least six a year.

Seeking a higher-volume hospital or surgeon for an uncommon procedure can also give you a better shot at a problem-free recovery. Researchers found that only 26 percent of patients who needed a cancerous prostate removed and went to surgeons who do a very high volume (over 32 surgeries per year) suffered complications. But 32 percent of those who went to low-volume surgeons (fewer than 11 surgeries per year) had problems.

Despite well-documented links between either volume or mortality and patient outcomes, many doctors still rely on the surgeon's reputation instead of more-objective statistics when referring patients, often because those statistics don't exist. Arnold Milstein, medical director of the Pacific Business Group on Health, a healthcare think tank in San Francisco, argues that a good name is no substitute for real data--in fact, a good name should be based on real data. Patients and referring physicians, he says, should be able to look at objective statistics to decide which surgeon in what hospital gives the best chance for survival. But it's the same old problem: The numbers aren't made public. "It's a medical ethics question," says Milstein. "Patients are not being informed that they have a lower mortality risk elsewhere in their community."

A healthy combo. The ideal combination would be high quality plus safety. The Leapfrog Group, another patient safety and quality organization, has been pushing just that. Over 1,100 hospitals participate in a Leapfrog program that includes standards for basic safety recommendations, like computers to keep track of prescriptions and tests, as well as basic lifesaving procedures, like aspirin for CABG patients. But--and this is the key point--Leapfrog also tracks mortality or volume statistics for five high-risk surgeries, including CABG, pancreatic resection, and esophagectomy. Those hospitals that meet the volume or mortality standards for each operation get a higher rating. The data are then compiled on the Leapfrog website ( www.leapfroggroup.org ), so patients can compare hospitals side by side. It turns out to be a healthy combo. Of the 23,790 U.S. deaths attributed to these five surgeries in the year 2000, following the Leapfrog standards would have saved 7,818 lives, estimates University of Michigan surgeon and safety researcher John Birkmeyer. (Still, the Leapfrog Group's website, which highlights just a few operations at only some hospitals, is a far cry from an all-inclusive, evidence-based system.)

Even Donald Berwick, a leading advocate of safety and basic quality, says touchy surgery is about more than avoiding errors. Berwick actually looks astonished when asked if safety programs would be the first thing he'd look for when picking a hospital for complex surgery. "No," he says. "I want to go to the highest-volume place I can find and a place where I know if something goes wrong, specialists are there who can take care of me."
Copyright U.S. World & News Report 2005