[Congressional Record Volume 146, Number 32 (Tuesday, March 21, 2000)]
[Extensions of Remarks]
[Pages E361-E362]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

                            BETTER RESULTS''


                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                        Tuesday, March 21, 2000

  Mr. STARK. Mr. Speaker, the March 1 issue of the Journal of the 
American Medical Association contains further documentation of life-
saving importance: if you are going to have surgery, have it in a 
hospital that does a lot of it: your chances of survival and good 
health are much better.
  Put another way: avoid hospitals that can't do the procedure in their 
  As public policy makers, we should encourage, in every way possible, 
our constituents and Medicare beneficiaries to seek out the high volume 
hospitals and avoid the low volume hospitals. The President's Medicare 
reform proposals move us in that direction.
  It really is a matter of life and death.
  The JAMA article follows:

                  High-Risk Surgery--Follow the Crowd

                        (John D. Birkmeyer, MD)

       Each year a large number of patients die following elective 
     surgery. In the Medicare population alone, 17,000 patients 
     died in 1995 after undergoing 10 types of elective 
     procedures, such as coronary artery by-pass surgery, carotid 
     endarterectomy, and lung resection.\1\ Quality improvement 
     initiatives at the local and regional levels may be important 
     for reducing mortality at individual hospitals,\2, 3\ but, 
     for many procedures, choosing at which hospitals surgery is 
     performed may be equally important for improving surgical 
     References at end of article.
       The idea of concentrating high-risk surgical procedures in 
     high-volume hospitals is not new. Since seminal work by Luft 
     et al \4\ 2 decades ago, large, population-based studies have 
     consistently demonstrated better outcomes at high-volume 
     centers for cardiovascular surgery, major cancer resections, 
     solid organ transplantation, and other high-risk 
     procedures.\5, 8\ Lower surgical mortality at high-volume 
     hospitals does not simply reflect the presence of more 
     skillful surgeons and fewer technical errors with the 
     procedure itself. More likely, it reflects more proficiency 
     with all aspects of care underlying successful surgery, 
     including patient selection, anesthesia, and postoperative 
       In this issue of the Journal, Dudley and colleagues \9\ are 
     among the first to estimate how many lives could be saved by 
     regionalization (``selective referral'') at the population 
     level. Based on careful review of the extensive volume-
     outcome literature, they used explicit criteria to identify 
     the single highest-quality study for each surgical procedure 
     or clinical condition that could be considered for 
     regionalization. (The volume-outcome literature is too 
     heterogeneous for formal meta-analysis.) Statistically 
     significant relationships between hospital volume and 
     mortality were identified for 10 procedures and 1 medical 
     condition (care for patients which human immunodeficiency 
     virus infection/acquired
       Two cautions are necessary in interpreting the findings of 
     this study. First, the authors' estimates of the benefits 
     likely to be achieved by regionalization are no more reliable 
     than the volume-outcome studies on which they are based. Much 
     of this literature is outdated or skewed by results from a 
     small number of national referral centers. Additional 
     generalizable, population-based studies are needed. Second, 
     analysis of California data may overestimate the decrease in 
     mortality rates likely to be achieved by regionalization 
     elsewhere. Because California has few restrictions on where 
     surgical care may be delivered, more patients may be

[[Page E362]]

     undergoing high-risk surgery in low-volume hospitals there. 
     In 1 study, 65% of coronary artery bypass graft operations 
     performed in California in 1989 occurred at low-volume 
     hospitals (<200 procedures/year).\10\ In New York State, 
     which has stricter Certificate of Need regulations based in 
     part on volume criteria, only 20% of these procedures were 
     performed at low-volume hospitals that year.\10\ More 
     information is needed about how other high-risk procedures 
     are being delivered in other parts of the country.
       Concentrating surgery in selected referral centers would 
     facilitate the monitoring of outcomes at individual 
     hospitals. Many high-risk procedures are performed too 
     infrequently to achieve statistical precision with mortality 
     rates, particularly at low-volume hospitals. For example, 
     what inferences could be made about outcomes at a hospital 
     performing 3 esophagectomies a year? By concentrating 
     selected procedures in a relatively small number of high-
     volume hospitals, it would be more feasible to measure 
     outcomes aside from mortality, such as nonfatal 
     complications, patient functional status, and costs. The 
     ability to monitor surgical outcomes systematically would 
     make hospitals more accountable and create ideal platforms 
     for quality improvement initiatives.
       How can the proportion of elective but high-risk procedures 
     being performed in high-volume hospitals be increased? The 
     least intrusive approach may be to focus on educating 
     patients about the importance of hospital volume for specific 
     procedures and to recommend that patients acquire this 
     information from the hospital that they are considering for 
     surgery. Although many hospitals do not have data on their 
     own procedure-related morbidity and mortality rates, all 
       More active strategies also could be implemented. Leaders 
     of large, integrated health plans could designate referral 
     centers for selected procedures and enforce their appropriate 
     use. Professional societies also could take a role in 
     regionalization. For example, the American College of 
     Surgeons Committee on Trauma has established regional trauma 
     networks, encouraging referral of the most severely injured 
     trauma patients to designated trauma centers that meet 
     established process and volume criteria.\11\ Through 
     reimbursement mechanisms, large payers (both government and 
     private) have substantial leverage to limit surgery to high-
     volume hospitals. For example, the Health Care Financing 
     Administration is currently exploring the development of 
     exclusive contracts with ``centers of excellence'' for 
     cardiac surgery and total joint replacement for Medicare 
     patients.\12\ In addition, through the Certificate of Need 
     process, states can reduce the proportion of surgery being 
     performed in low-volume hospitals by limiting the 
     proliferation of new surgical centers.\13\
       Many would argue that regionalizing high-risk surgery would 
     have adverse effects, particularly in rural areas. For 
     patients living far from referral centers, elective surgery 
     could create unreasonable logistical problems for patients 
     and their families. With excessive travel burdens, some 
     patients may even decline surgery altogether.\14\ 
     Regionalizing surgery also could interfere with continuity of 
     care because many aspects of postoperative care, including 
     dealing with the late complications or other sequelae of 
     surgery, would be left to local physicians who were not 
     involved with the surgery. Regionalization could reduce 
     access to health care for rural patients by threatening the 
     financial viability of local hospitals or their ability to 
     recruit and retain surgeons. Even if regionalization had no 
     effect on the availability of local clinicians, it could 
     reduce their proficiency in delivering emergency care that 
     must be handled locally. For example, the local general 
     surgeon no longer allowed to perform elective repair of 
     abdominal aortic aneurysms could be less prepared for 
     emergency surgery involving a ruptured aneurysm.
       However, these problems may not be as important as they 
     were once assumed to be. Most low-volume hospitals are not 
     located in sparsely populated rural areas; they are more 
     commonly located in hospital-dense metropolitan areas, often 
     in close proximity to high-volume referral centers.\10\ In 
     the analysis by Dudley et al,\9\ 75% of California patients 
     undergoing surgery at low-volume centers in 1997 would have 
     needed to travel fewer than 25 additional miles to the 
     nearest high-volume hospital. In fact, 25% of patients 
     traveled farther to undergo surgery at a low-volume hospital. 
     These data suggest that a substantial degree of 
     regionalization could occur without separating patients and 
     surgeons or surgical centers by prohibitive distances.
       With any regulatory attempt to regionalize high-risk 
     surgery, policy makers need to be ready for a political 
     firestorm. Many low-volume hospitals, already under
       Although some physicians and some institutions would resist 
     regionalization, the potential benefits for patients are too 
     large to ignore. Given the current ad hoc approach to 
     delivering high-risk surgery, it seems that almost any effort 
     aimed at concentrating these procedures in high-volume 
     hospitals would be an improvement.


     \1\ Birkmeyer JD, Lucas FL, Wennberg DE. Potential benefits 
     of regionalizing major surgery in Medicare patients, 
     Effective Clin Pract. 1999;2:277-283.
     \2\ O'Connor GT, Plume SK, Olmstead EM, et al, for The 
     Northern New England Cardiovascular Disease Study Group. A 
     regional intervention to improve the hospital mortality 
     associated with coronary artery bypass graft surgery. JAMA. 
     \3\ Hannan EL, Kilburn H Jr, Racz M, et al. Improving the 
     outcomes of coronary artery bypass surgery in New York State. 
     JAMA. 1994;271:761-766.
     \4\ Luft HS, Bunker JP, Enthoven AC. Should operations be 
     regionalized? the empirical relation between surgical volume 
     and mortality. N Engl J Med. 1979; 301:1364-1369.
     \5\ Houghton A. Variation in outcome of surgical procedures. 
     Br J Surg. 1994;81:653-660.
     \6\ Flood AB, Scott WR, Ewy W. Does practice make perfect? I: 
     the relation between hospital volume and outcomes for 
     selected diagnostic categories. Med Care. 1984;22:98-114.
     \7\ Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of 
     hospital volume on operative mortality for major cancer 
     surgery. JAMA. 1998;280:1747-1751.
     \8\ Wennberg DE, Lucas FL, Birkmeyer JD, Bredenberg CE, 
     Fisher ES. Variation in carotid endarterectomy mortality in 
     the Medicare population: trial hospitals, volume, and patient 
     characteristics. JAMA. 1998;279:1278-1281.
     \9\ Dudley RA, Johansewn KL, Brand R, Rennie DJ, Milstein A. 
     Selective referral to high-volume hospitals: estimating 
     potentially avoidable deaths. JAMA. 2000;283:1159-1166.
     \10\ Grumbach K, Anderson GM, Luft HS, Roos LL, Brook R. 
     Regionalization of cardiac surgery in the United States and 
     Canada: geographic access, choice, and outcomes. JAMA. 
     \11\ American College of Surgeons Committee on Trauma. 
     Resources for the Optimal Care of the Injured Patient: 1999. 
     Chicago, Ill: American College of Surgeons; 1998.
     \12\ Health Care Financing Administration. Medicare 
     Participating Heart Bypass Center Demonstration Project; 
     Extramural Reseasrach Report. Baltimore, Md: Health Care 
     Financing Administration; September 1998.
     \13\ Arnold J. Mendelson D. Evaluation of the Pennsylvania 
     Certificate of Need Program. Falls Church, Va: Lewin-ICF; 
     \14\ Finlayson SR, Birkmeyer JD, Tosteson AN, Nease RF Jr. 
     Patient preferences for location of care. Med Care.