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Report: Low-Volume Hospitals Increase Mortality Risk

U.S. News analysis finds above-average deaths for common procedures

Low-volume hospitals are less prepared for common surgical procedures, putting patients at risk for serious harm, according to an analysis by U.S. News & World Report.

U.S. News studied every U.S. hospital that treated or operated on fewer than 25 traditional Medicare inpatients for several common conditions and procedures. The publication found that knee-replacement patients at these hospitals had twice the mortality risk and a 25% increased risk for readmission due to postoperative complications.

For example, at Colorado’s Sterling Regional Medical Center, a 25-bed facility that admits more than 1,200 patients annually, the mortality rate was 24 times the national average for knee replacements and three times the national average for hip replacements, according to the analysis.

John Birkmeyer, MD, executive vice president for enterprise services and the chief academic officer at Dartmouth–Hitchcock Medical Center in Lebanon, New Hampshire, used the publication’s data and projected that up to 11,000 deaths in 2009–2012 could have been avoided if patients at the lowest-volume 20% of hospitals had gone to the highest-volume 20% instead. Birkmeyer noted that his calculations applied only to five of the most common conditions and procedures, and that expanding it to the full range of common conditions and procedures would show tens of thousands of preventable deaths.

U.S. News conducted the analysis as part of a new set of rankings of hospitals for common procedures. The research found similar outcomes proportional to volume at hospitals larger than Sterling. For example, 331-bed Lawnwood Regional Medical Center & Heart Institute in Ft. Pierce, Florida, had a relative mortality risk after a hip replacement that was nine times the national average, and New Jersey’s 316-bed Jersey City Medical Center had a mortality risk that was four times the national average for heart bypass surgery.

Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, recalled a case involving a woman who had had a diseased portion of her esophagus inexpertly removed at a hospital that does only one or two esophagectomies a year. She was transferred to Johns Hopkins, but it was too late to save her. Studies have shown that mortality for the procedure is significantly lower for patients treated in hospitals that perform as few as a dozen a year. Less than 2 miles away, Pronovost said, were two hospitals that each averaged about 40 esophagectomies a year.

“She was butchered,” he told U.S News. “There’s no other word for it. Yet when I asked whether the patient was told that she was at higher risk [because of the hospital’s low volume], the answer was ‘No.’”

The lack of accountability angered Pronovost. “Who’s responsible for this?” he said. “Is it the physician? The hospital? State regulators? The Joint Commission? Where's the accountability for informing people?”

A 2013 study recommended closing or consolidating low-volume providers as a method of improving outcomes and care quality, FierceHealthcare previously reported. Moreover, research indicates that emergency department patients at high-volume EDs have a lower risk of death.

Sources: U.S. News & World Report; May 18, 2015; FierceHealthcare; May 15, 2015; and FierceHealthcare; November 15, 2013.

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