[Congressional Record (Bound Edition), Volume 146 (2000), Part 1]
[Extensions of Remarks]
[Pages 181-182]
[From the U.S. Government Publishing Office, www.gpo.gov]


[[Page 181]]

 LET'S STOP KILLING PATIENTS: THE NEED TO ENCOURAGE MAJOR SURGERIES TO 
                   BE DONE IN HIGH VOLUME FACILITIES

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                       Thursday, January 27, 2000

  Mr. STARK. Mr. Speaker, I have introduced legislation for Medicare to 
encourage patients to use certain hospitals that provide better 
outcomes for sophisticated surgical operations-- i.e., fewer people die 
in surgery or in recovery. In exchange for saving lives, and giving 
certain hospitals higher volume of patients, the hospitals will give 
Medicare, the taxpayer, and the beneficiary some savings. It is truly a 
win-win proposal.
  But some--mostly those who stand to lose business--oppose the idea. 
To be blunt, that puts them on the side of killing people in order to 
help their bottom line. It is, Mr. Speaker, a truly immoral position 
for so-called health care providers to take.
  And don't take my word for it. Following is a memo from a physician 
on my staff that reviews some of the academic literature on the 
subject:

     Is Quality of Care Affected by Hospital and Physician Volumes?

       It is a mark of the advancement of medicine that we have 
     come to nearly take for granted the availability of highly 
     specialized and technical diagnostic investigations, medical 
     therapies, and surgical interventions. However, when we 
     individually confront health problems we justifiably want to 
     know that our physician or hospital has adequate experience 
     to make an accurate diagnosis, to make the most informed 
     decision about what should be done and to carry out 
     sophisticated surgical procedures. The question is, do high 
     volume centers really have superior outcomes?
       Fortunately, a large body of medical literature exists on 
     the relationship between hospital volume, physician volume 
     and outcomes. Optimal results clearly require physicians with 
     specialized expertise and well-trained staff. High volume 
     centers are more likely to offer a wider range of therapeutic 
     options that result in more targeted therapy. For example, 
     the patient with angina due to narrowing of the coronary 
     arteries may be treated with medication alone, angioplasty, a 
     stenting procedure or a coronary bypass and each of these 
     options would be the optimal decision under the right 
     conditions. The cardiologist or cardiovascular surgeon who 
     has extensive experience with all of these options is likely 
     to make the best therapeutic decision. Sophisticated surgical 
     procedures demand highly-trained, close-working health teams 
     drawing upon the expertise of many health professionals 
     including anesthesiologists, nurses, rehabilitation 
     therapists, respiratory therapists, and dietitians. Stable 
     health care teams promote better collaboration, 
     communication, and continuous quality improvement based upon 
     experiential learning.
       A massive study by Hughes and colleagues in 1987 analyzed 
     503,662 case records from 757 hospitals and demonstrated a 
     statistically significant correlation between greater 
     hospital volume and better patient outcome for 8 of 10 
     surgical procedures evaluated: coronary artery bypass graft, 
     cardiac catheterization, appendectomy, hernia repair, 
     hysterectomy intestinal operations, total hip replacement, 
     and transurethral prostatectomy.
       Twenty years ago (1979) in the New England Journal of 
     Medicine, Luft and colleagues reported that mortality 
     following open-heart surgery, vascular surgery, and 
     transurethral resection of the prostate, is reduced in high 
     volume hospitals, with hospitals in which 200 or more of 
     these operations performed annually having death rates 25-41 
     percent lower than low volume hospitals. Two decades ago, the 
     authors concluded that the data supports the value of 
     regionalization for these operations.
       Numerous studies have specifically focused upon volume/
     outcome relationships in both medical and surgical 
     interventions for cardiac conditions: Jollis and colleagues 
     (1994) evaluated 217,836 Medicare beneficiaries who underwent 
     coronary angioplasty. Both in-hospital mortality and the rate 
     of coronary bypass surgery following angioplasty were higher 
     in low volume hospitals. These results indicated that if all 
     study patients had received care in high volume hospitals, 
     there would have been 381 fewer bypass operations and 300 
     fewer in-hospital deaths. These results were reproduced in 
     papers by Cameron et al (1990) and Ellis et al (1997). Hannan 
     and colleagues (1997) reported that both high hospital volume 
     and high cardiologist volume were independently correlated 
     with lower mortality following coronary angioplasty.
       Showstack and colleagues (1987) analyzed the outcomes 
     following 18,986 coronary bypass operations at 7 hospitals in 
     California. They also found that higher volume hospitals had 
     lower in-hospital mortality and concluded that the greatest 
     improvement in average outcomes following bypass surgery 
     would be achieved by closing low volume surgical units.
       The significance of high physician volumes in determining 
     outcome is highlighted by a series of papers examining 
     patient outcomes following myocardial infarction: Jollis and 
     colleagues (1996) examined mortality following MI for 220,535 
     Medicare patients and reported that patients treated by 
     cardiologists were 12 percent less likely to die within one 
     year than those treated by a primary care physician. 
     Similarly, Casale and colleagues (1998) reported that 
     following MI, treatment by a cardiologist resulted in a 17 
     percent reduction in hospital mortality. In addition, 
     patients of all physicians who treated high volumes of 
     patients with MI, had an 11 percent reduction in mortality. 
     Nash and colleagues (1997) reported that not only mortality 
     following MI was reduced by cardiologist's care, but also 
     that these patients had a shorter length of hospital stay 
     than those receiving care by primary care physicians. Both 
     Thiemann et al and Chen et al in this year's New England 
     Journal of Medicine also reported lower mortality following 
     MI in higher volume hospitals or following admission to one 
     of ``America's Best Hospitals'' for cardiology (as determined 
     by U.S. News and World Report).
       Children requiring surgical repair of congenital heart 
     defects face a much lower risk of death when operated on in a 
     hospital that performs more than 300 similar surgical 
     procedures annually (Jinkins et al, 1995). Hannan and 
     colleagues (1992) reported the identical relationship between 
     hospital volume and mortality following abdominal aortic 
     aneurysm surgery.
       Cancer surgery frequently involves complex procedures which 
     require special expertise. Accordingly, a number of studies 
     have examined volume-outcome relationships following complex 
     surgical oncologic procedures. Begg and colleagues (1998) 
     analyzed the case reports of 5013 patients in the 
     Surveillance, Epidemiology, and End Results (SEER)-Medicare 
     linked database including patients who underwent 
     pancreatectomy, esophagectomy, pneumonectomy, liver resection 
     or pelvic exenteration for cancers of the pancreas, 
     esophagus, lung, colon, rectum and genitourinary tract. 
     Higher hospital volume was associated with lower mortality 
     for all surgical procedures except for pneumonectomy. The 
     most striking results were for esophagectomy and for 
     pancreatectomy where operative mortality rose from 3.4% to 
     17.3% and 5.8% to 12.9% respectively in low-volume vs. high-
     volume hospitals. The pancreatectomy results were reproduced 
     this year by Simunovic et al. (1999).
       It has been suggested that national referral centers be 
     developed for pancreaticoduodenectomy, also known as the 
     Whipple procedure. Hospital volume was found to strongly 
     influence both perioperative risk and long-term survival 
     following the Whipple procedure as reported by Birkmeyer and 
     colleagues (1999). The relationship between hospital volume 
     and outcome of hepatic resection for hepatocellular carcinoma 
     were analyzed by Choti et al (1998) and Glasgow et al (1999). 
     The mortality rate rose from 1.5% to 7.9% in procedures 
     performed in high volume vs. low volume hospitals. Moreover, 
     Glasgow reported that three quarters of patients with liver 
     cancer were treated at low volume hospitals with a record of 
     3 or fewer hepatic resections per year.
       The identical volume-outcome relationships have been 
     reported for renal diseases. The Agency of Health Care Policy 
     and Research recently sponsored a study regarding referrals 
     and specialty care within the Medicare system. Avon (1999), 
     reported that when patients with renal failure received late 
     referral to a kidney specialist (nephrologist), their risk of 
     death was 33% higher. Pediatric renal transplantation has 
     also been scrutinized for volume-outcome relationships. 
     Schurman and colleagues (1999) reported superior survival of 
     the transplanted kidney in high volume centers performing 
     more than 100 transplants annually.
       Research supporting a strong relationship between high 
     hospital/physician volumes and improved patient outcomes 
     spans two decades and multiple medical specialties. Both 
     medical and surgical care at institutions with lower levels 
     of experience clearly increases the risk of poorer outcomes 
     including death, in a diverse range of medical conditions. A 
     review of the literature demonstrates that there is strong 
     evidence to support the development and implementation of 
     Centers of Excellence for a range of medical and surgical 
     conditions.


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[[Page 182]]

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