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From the Section of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Correspondence: Address correspondence to: John D. Birkmeyer, MD, Section of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756; Fax: 603-650-8030; E-mail: John.Birkmeyer{at}hitchcock.org
For such an uncommon procedure, pancreaticoduodenectomy receives an inordinate amount of attention by researchers interested in the quality of care in surgery. This may be partly attributable to the high baseline risks associated with this procedure and its usefulness as prototype for complex surgery. Mainly, however, pancreaticoduodenectomy is heavily scrutinized because mortality rates vary dramatically across providers and seem to be particularly influenced by hospital experience with this procedure.
In this issue, Kotwall et al. add to the considerable volume-outcome literature about pancreaticoduodenectomy.1Using nationally representative data from Nationwide Inpatient Sample, the authors document that a large proportion of patients continue to undergo surgery at low-volume hospitals (often performing <1 procedure per year on average). In aggregate, these patients face double-digit mortality rates, several-fold higher than those experienced by patients at high-volume centers. Echoing the results of recent population-based studies,2,3Kotwall et al. note that the dramatic volume-outcome association observed with pancreaticoduodenectomy cannot be attributed to variations in patient case mix or other hospital characteristics (e.g., teaching status).
So what can be done to eliminate the large number of unnecessary surgical deaths occurring after pancreaticoduodenectomy? The authors suggest that mortality rates at low-volume hospitals should be reviewed before these procedures are performed at such institutions. Although this idea is relatively inoffensive, it is unlikely to be effective. For obvious sample size reasons, measuring mortality at hospitals performing only one or two procedures a year will not be very informative. Would anyone feel confident about performance of a hospital with a 0% mortality rate if based on three procedures and no deaths?
A far more practical approach would be to concentrate these procedures in high-volume hospitals. Current efforts aimed at achieving this goal take several forms. The least aggressive (and likely least effective) of these are guidelines intended for professional audiences. For example, the National Cancer Policy Board recommends selective referral to high-volume centers for pancreaticoduodenectomy and esophagectomy, the two cancer procedures with the largest volume-outcome associations.4Other efforts are aimed at educating patients about the importance of volume with some procedures and giving them access to provider-specific volumes (most often on the Internet). For example, the Center for Medicare and Medicaid Services, which covers most patients undergoing high-risk surgery, may soon begin reporting procedure volumes for individual hospitals on its web site. Finally, the most aggressive effort to steer patients to higher-volume centers is being led by payers. The Leapfrog group, a large coalition of private and public purchasers representing over 30 million patients, is emphasizing minimum volume standards for five selected procedures.5Although public reporting is at the center of this effort, some Leapfrog Group participants are employing selective contracting strategies and other financial incentives to encourage the use of high-volume hospitals. Though not among the original five, pancreaticoduodenectomy has recently been added to the list of targeted procedures.
Many surgeons chafe at these volume-based referral initiatives.6Among other complaints, they criticize such policies for their potentially detrimental effects on patients and health care delivery. These include potential for increased mortality as some low-volume hospitals become very low volume; detrimental effects on quality with urgent or related procedures at low-volume hospitals; unnecessary procedures occurring as a result of provider incentives to increase their volumes; and reduced access to basic surgical care if low-volume hospitals became less able to recruit or retain surgeons. These concerns may be important for many procedures for which volume standards are being considered. However, they are not very persuasive in the case of pancreaticoduodenectomy. This procedure is predominantly elective and nondiscretionary enough that few fear an epidemic of unnecessary surgery. It is also not performed commonly enough to threaten the financial "bottom lines" of low-volume surgeons or hospitals.
To date, surgeons and their professional organizations have been consistently opposed to efforts by payers and policy makers to use volume as a lever for improving surgical quality.7 Although this position is understandable, taking this hard line may also cost surgeons their credibility as patient safety advocates. Conceding the role of volume standards for "no-brainer" procedures like pancreaticoduodenectomy may be an important first step if surgeons hope to establish a strong voice in ongoing policy debates. Surgeons may worry that agreeing to volume standards with this procedure may be a "foot in the door" for standards with other procedures. However, I would argue that the volume door is already wide open and that surgeons should be leading this important policy debate, not just reacting to it.
Acknowledgments
Dr. Birkmeyer is supported by a grant from the Agency for Health Care Policy and Research (R01 HS10141-01) and the Center for Medicare and Medicaid Services.
The views expressed herein do not necessarily represent the views of the Center for Medicare and Medicaid Services or the United States Government.
Received for publication August 22, 2002. Accepted for publication September 6, 2002.
REFERENCES
This article has been cited by other articles:
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  J. D. Birkmeyer, A. E. Siewers, N. J. Marth, and D. C. Goodman Regionalization of High-Risk Surgery and Implications for Patient Travel Times JAMA, November 26, 2003; 290(20): 2703 - 2708. [Abstract] [Full Text] [PDF]
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