In medicine, substitute for experience

If you need a risky, complicated surgery, would you go to a hospital or surgeon who had performed the procedure only a time or two before?

Most people would say no, but the evidence indicates otherwise. Patients do go to doctors and hospitals that have seldom performed the procedures they need. Yet, for almost 40 years, study after study has shown that patients’ death rates were significantly lower for surgeries done at hospitals that were experienced in the procedure.

The same is true for physicians. In March, for example, a large study of patients undergoing thyroid surgeries found that they had an 87 percent increase in the odds of a complication if their surgeon had previously performed only one thyroid surgery but only a 3 percent chance if the surgeon had performed between 21 and 25 surgeries.

“The number of surgeries a doctor or hospital performs has a major impact on your likelihood of surviving or thriving,” says Leah Binder, president and CEO of The Leapfrog Group, a Washington, D.C., organization, which supports the use of transparent data to improve hospital safety and outcomes.

“It’s frankly dangerous to go to a surgeon or a hospital that does one or two a year of what you need,” Binder told me. “Unfortunately, it happens in rural hospitals a lot. These hospitals should recommend you go to a bigger hospital that has more experience” performing the more complicated procedures.

Binder would be the first to admit that finding hospitals and doctors who have done a lot of any particular procedure is not easy. Most of what we know comes from Medicare data, but insurers have oodles of data, too. “We have the data,” Binder said. “It just hasn’t been made public.”

Governments have been slow to require transparency, and a Supreme Court decision in March has made it less likely that will change any time soon.

The court ruled that states could not force insurers, employers, providers, medical facilities or government agencies to submit information on price, quality and use of services to a database run by a state. Without such a reporting requirement, state efforts to construct what’s called an “all claims” database could show an incomplete picture, making it hard for patients to find those surgeons and hospitals that had the most experience treating their particular illness.

That’s why last fall’s announcement from three large, prominent hospital systems — Johns Hopkins, Dartmouth-Hitchcock and the University of Michigan — was so significant. The three systems pledged that their 20 affiliated hospitals would require the surgeons to meet minimum annual thresholds for performing 10 high-risk procedures including cardiovascular, gastrointestinal and joint-replacement surgeries.

The thresholds vary by procedure. They range from 10 per hospital and five per surgeon for carotid stenting, to 50 per hospital and 25 per surgeon for hip and knee replacement.

Self-policing may be the best hope at the moment, but such thresholds are not universally popular in the medical industry. Doctors who don’t do many such procedures don’t want to lose business. Neither do the hospitals that grant them privileges. Doctors themselves argue for using quality-based standards instead. But volume, a surrogate for outcomes, may be the best measure we have at the moment, according to many health safety experts.

How do patients get those magic volume numbers? Volume is one metric in The Leapfrog Group’s ratings. Consumers’ Checkbook and Consumer Reports have some data on volume in their ratings. And, of course, it’s crucial that you talk with your doctor and hospital about how much expertise they have doing the kind of procedure you need.

Be prepared for a hospital to argue that “for many patients, the best possible surgery is closest to home,” as Dr. Tyler Hughes, a surgeon at a very small hospital in McPherson, Kansas, and a director of the American Board of Surgery, did recently in a story published by Kaiser Health News.

I asked Binder about that because I’ve heard that argument many times. “You can stay at home,” she said, “but know the risks.”

One risk might be that the hospital with the best volume for your needs is not in your insurer’s network because insurers don’t always choose the providers with the best quality and safety records. What do you do, then? Pay the out-of-network price, prohibitively expensive for almost everyone, or take your chances? Binder thinks most people would pay more to have a much higher chance for survival. Should they even have to make that choice? Our mixed-up, contradictory healthcare system has yet to solve that one.

Trudy Lieberman, a journalist for more than 40 years, is a contributing editor to the Columbia Journalism Review, where she blogs about health care and retirement at cjr.org. She can be reached at trudy.lieberman@gmail.com.