Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative.

BACKGROUND: As part of a broader effort aimed at improving hospital safety, a large coalition of employers, the Leapfrog Group, will soon require hospitals caring for their employees to meet volume standards for 5 high-risk surgical procedures. We estimated the potential benefits of full nationwide implementation of these volume standards. METHODS. Using data from Nationwide Inpatient Sample and other sources, we first estimated the total number of each of the 5 procedures-coronary-artery bypass graft, abdominal aortic aneurysm repair, coronary angioplasty, esophagectomy, and carotid endarterectomy-performed each year in hospitals in US metropolitan areas. (Leapfrog exempts hospitals in rural areas to avoid access issues.) We then projected the effectiveness of volume standards (in terms of relative risks of mortality) for each procedure using data from a published structured literature review. RESULTS: With full implementation nationwide, the Leapfrog volume standards would save 2581 lives. Of the procedures, volume standards would save the most lives with coronary-artery bypass graft (1486), followed by abdominal aortic-aneurysm repair (464), coronary angioplasty (345), esophagectomy (168), and carotid endarterectomy (118). In our estimates of the number of lives saved, we considered assumptions about how many patients would be affected and the effectiveness of volume standards (ie, strength of underlying volume-outcome relationships with each procedure). CONCLUSIONS: If the Leapfrog volume standards are successfully implemented, employers and health-care purchasers could prevent many surgical deaths by requiring hospital volume standards for high-risk procedures.

Operative mortality with elective surgery in older adults.

CONTEXT: For patients considering elective major surgery, information about operative mortality risks is essential for careful decision making. Because available information is often limited to educated guesses or optimistic data from case series, we examined surgical mortality by using nationwide data. PRACTICE PATTERN EXAMINED: Operative mortality in 1.2 million patients in the Medicare system who were hospitalized between 1994 and 1999 for major elective surgery (six cardiovascular procedures and eight major cancer resections). DATA SOURCE: MEDPAR file of the National Medicare claims database for patients 65 years of age and older. OUTCOMES: Operative mortality, defined as death within 30 days of the operation or death before discharge. RESULTS: Overall operative mortality varied widely according to procedure. Procedures associated with relatively low mortality risk included carotid endarterectomy (1.3%) and nephrectomy (2.3%). Overall mortality was greater than 10% for other procedures, such as mitral valve replacement (10.5%), esophagectomy (13.6%), and pneumonectomy (13.7%). In general, mortality risk increased with age. Operative mortality for patients 80 years of age and older was more than twice that for patients 65 to 69 years of age. CONCLUSION: Population-based operative mortality for major surgery varies by procedure and patient age and is considerably higher than that typically reported in case series and trials.