The national death rate from knee replacement surgery is about one in a thousand. But patients are three times more likely to die if they have their knee replaced at a hospital that doesn’t perform that surgery frequently.
Now three leading healthcare systems, including Dartmouth-Hitchcock, are putting restrictions on their surgeons.
Locally, the changes will impact Dartmouth's main campus, plus its satellite hospitals: New London, Cheshire Medical Center and Mt. Ascutney in Vermont. Nationally, patient advocates hope other hospitals will follow the move is raising skepticism in one group: surgeons.
The tangled gut
So how bad can things get? Dr. John Birkmeyer at Dartmouth-Hitchcock in New Hampshire says a patient came to him after bariatric surgery at a small hospital – a hospital that didn’t perform that operation often. Before sewing up this patient, the surgeon had messed up the plumbing. This patient’s gut flowed in a circle.
"Well the food would come in through the esophagus," says Birkmeyer, "go down through a loop of intestine, and rather than continuing downstream, the food would come backwards up through another piece of intestine and back up into the bypass part of the stomach."
And consider the stats for pancreatectomies. One third of Medicare patients who have their pancreas removed do so at a hospital that performs that surgery only once or twice each year. Yet most of those patients would only have to drive an extra 30 minutes to get to a high-volume hospital, and most would be willing to do so.
A recent analysis of Medicare data by U.S. News and World Reports found low-volume hospitals put patients at risk in a big way. Birkmeyer says that analysis indicates up to 11,000 patients died at these facilities from 2010 to 2012.
"Surgeons would never disclose the fact those risks are a function of not just the procedure itself, but who’s doing it," says Birkmeyer.
Holding surgeons accountable
The U.S. News report prompted Dartmouth, John’s Hopkins and the University of Michigan to announce they will stop letting low-volume surgeons perform ten complex surgeries: knee and hip replacements, some cancer and thoracic operations, and bariatric surgery. For the most part, these aren’t emergency procedures.
The 30-or-so years of data suggesting risky surgeries are way riskier in the hands of some? It all really ticks off a lot of surgeons. Dr. Tyler Hughes, a surgeon in rural Kansas, has seen this play out online, where he moderates a social media platform for the American College of Surgeons, a trade association.
"I think there’s a lot of work going on trying to, if you’ll pardon the pun, cut away that cowboy mentality," says Hughes. "Because ultimately this isn’t about us, the surgeon; it’s about the patient."
Bruised egos aside, here’s another question: Just because you’re licensed to do a surgery, should you? As in, doesn’t this call into question the way surgeons are certified?
"Uh, no I do not think that," says Dr. Frank Lewis, the executive director of the American Board of Surgery, which certifies 30,000 surgeons.
Lewis says all this data really reflects on hospitals, not the surgeons who work there.
"There’s been very, very little data that relates to individual surgeons and how they might differ from each other," says Lewis.
A life-saving decision
Yet Birkmeyer – the doctor who undid the tangled gut – tested this idea too. In one study he filmed 20 surgeons at work, and found high-volume surgeon’s hands were fluid and confident, while the low-volume docs were herky-jerky.
Some patients will always prefer the closest hospital. Still, Birkmeyer says they should have an informed choice.
"It’s hard for me to imagine a patient that would react poorly to a health system deciding that only experienced, proficient surgeons will be doing operations," says Birkmeyer.
Dartmouth, Johns Hopkins and the University of Michigan estimate if high-volume hospitals exclusively did the ten surgeries on their list, it would save 1,300 lives nationwide per year.