Elsevier

Surgery

Volume 135, Issue 6, June 2004, Pages 569-575
Surgery

Surgical outcomes research
Potential benefits of the new Leapfrog standards: effect of process and outcomes measures

https://doi.org/10.1016/j.surg.2004.03.004Get rights and content

Abstract

Objective

The Leapfrog Group standards for evidence-based hospital referral underwent significant revision in 2003. In addition to other changes, risk-adjusted mortality and process of care measures now augment or replace volume standards for some procedures. The objective of this study was to estimate the potential benefits of these newly expanded standards.

Methods

Leapfrog's 2003 standards were based on minimum volume standards alone for 2 operations (esophagectomy, pancreatectomy), volume standards and a process measure (perioperative beta blockade) for 1 operation (abdominal aortic aneurysm repair), and volume standards coupled with risk-adjusted mortality rates for 2 operations (coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI]). We used data from the 2000 Nationwide Inpatient Sample to determine eligible surgical populations, volume–outcome associations, and risk-adjusted hospital mortality rates for the 5 operations. A recent meta-analysis was used to estimate the effectiveness of perioperative beta-blocker use.

Results

Approximately 23,790 patients died in 2000 in the United States undergoing 1 of the 5 procedures. We estimate that full implementation of the Leapfrog standards would have averted 7818 of these deaths: CABG (4089), PCI (3016), elective abdominal aortic aneurysm repair (356), esophageal resection (180), and pancreatic resection (177). For CABG and PCI, standards based on risk-adjusted mortality rates would save at least 5 times more lives than those based on volume criteria alone.

Conclusions

Widespread implementation of the 2003 Leapfrog standards for evidence-based referral could avert a large number of surgical deaths. For some procedures, standards comprised of process of care or direct outcome measures would be more effective than those based on volume alone.

Section snippets

Changes in the Leapfrog standards

Effective January 1, 2004, pancreatic resection was added to the list of procedures targeted for EHR, based on evidence demonstrating very strong volume–outcome associations with this procedure. Given new reports showing little hospital volume effect for carotid endarterectomy, this procedure was removed.8., 9., 10. CABG, PCI, elective AAA repair, and esophagectomy are still included. The revised EHR standards also provide “partial credit” for hospitals with intermediate procedure volumes

Number of patients potentially affected

We first estimated the annual number of US patients undergoing each of the 5 procedures, which ranged from 678,296 (PCI) to 4350 (esophagectomy) (Table II). Based on 2000 NIS data, approximately 95% of these procedures were performed in hospitals located in nonrural areas. The proportion of patients treated in hospitals not fully adherent to the Leapfrog standards varied according to procedure, from 46% of patients with PCI to 74% with esophagectomy.

Efficacy of the EHR standards

We then estimated potential mortality

Discussion

The addition of process and outcomes measures to volume standards significantly increases the potential benefits of the Leapfrog Group's EHR initiative. In this analysis, we estimate that 7818 lives could be saved with EHR compared with 2581 in our previous analysis of the standards based on volume alone.3 The majority of the increase in lives saved can be attributed to more precise classification of high-quality centers using risk-adjusted mortality for CABG and PCI, which are by far the 2

References (23)

  • Healthcare Cost and Utilization Project (HCUP-9). Nationwide Inpatient Sample, Release 9

    (2000)
  • Cited by (0)

    Supported by the Business Roundtable, the sponsor of the Leapfrog Group.

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