Volume Matters

by Walter J. Pories, MD, FACS, and Gary M. Pratt

Dr. Pories is from East Carolina University, Greenville, North Carolina, and Mr. Pratt is from Surgical Review Corporation, Raleigh, North Carolina.

Introduction

Practice makes perfect. Pitchers and paperhangers, priests and policemen all improve their performance as they practice their skills.
And so it is with surgeons and hospitals. Institutions with greater case volumes deliver care with lower mortality and morbidity rates in cardiac surgery, orthopedics, gynecology, and even the care of strokes. In oncology, greater volumes also produce better long-term outcomes and survival.

Volume also affects outcomes in bariatric surgery. Optimum results are achieved after surgeons have a lifetime experience of 125 cases. Application of this principle is one of the mainstays of the Bariatric Surgery Centers of Excellence® (BSCOE) program of the American Society for Metabolic and Bariatric Surgery (ASMBS)—an initiative that has reduced the national mortality of bariatric surgery to 3.4 cases per 1,000 operations, about the same level as cholecystectomies—a remarkable achievement given the high operative risks associated with severe obesity. The significance of this advance comes into focus when these operative outcomes are compared to the national data for gastrectomies (6 operative deaths per 100 cases), pancreatectomies (9 operative deaths per 100 cases), and aortic repairs (6 operative deaths per 100 cases).

The effects of volume are further emphasized by the recent data from Surgical Review Corporation (SRC), the independent company that manages the BSCOE program for the ASMBS. These data reveal that institutions with volumes greater than 350 bariatric operations per year have better outcomes than those with 150 to 250 cases per year.

If we pursued these observations to a logical conclusion to assure the best outcomes and to protect the public, then one might conclude that all bariatric surgery in the world should be performed at one mammoth institution. Such a conclusion might be logical, but it is certainly not realistic.

The first obvious question is whether the issue is really volume or whether volume, per se, is a measurable indicator of a far more complex process. It is much more likely to be the latter (i.e., outcomes reflect far more than the talents of the surgeon). Patient welfare also depends greatly on the qualities of anesthesia, nursing, and other support staff. Whatever the explanation, volume matters.

What then are our options? Four approaches seem realistic:
1) Assure that surgeons are well trained when they enter practice
2) Focus not only on the surgeon, but also on the full team delivering care to the patient
3) Develop and implement carefully tested care paths and
4) Continue evaluating outcomes.

Graduating Well-Trained Surgeons
The best residency programs in the United States graduate surgeons with remarkably little focused operative experience even after five years of intense training. The minimum requirements of the American Board of Surgery (ABS) for certification, shown in Table 1, do not assure that newly certified surgeons are capable of providing safe care. What physician would be willing to undergo resection of the pancreas by a surgeon with the experience of three cases or a thyroidectomy by a colleague who had removed eight? The trainees seem to agree. More than 70 percent of the graduates pursue fellowships even after they qualify for ABS certification, finally entering practice at 33 to 35 years of age.

The approach now used by some specialties, such as plastic surgery and cardiothoracic surgery—i.e., two years of general surgical training followed by three years of focused specialty education—deserves consideration. For example, surgeons who are planning careers in minimally invasive and bariatric surgery could spend the first two years of junior residency in “general surgery” with a strong exposure to critical care, pulmonary medicine, cardiology, infectious disease, trauma, or urology, followed by three years devoted to their chosen specialty.

However, we need to consider more than just changing the length and distribution of the educational experience. There is a lot of talk about simulation, but for simulation to be useful, we need to expose our trainees to far more than picking up beans with fancy pliers. We can learn from our colleagues in anesthesia who have developed brilliant, challenging models that are fun for the learner. Other new exciting approaches are offered by James “Butch” Rosser, MD, in his new book, Playing to Win: A Surgeon, Scientist, and Parent Examines the Upside of Video Games. He also has a stake in this challenge: He is not only a surgeon, but has also undergone bariatric surgery.

Furthermore, the major focus need not be on teaching technique. Most residents who choose surgery as a career have above average eye-hand coordination. By the end of the second year, they know how to sew and staple. What they lack is knowledge, clinical judgment, and the ability to make difficult decisions. Malpractice cases rarely focus on bad technique and focus more on accusations of late diagnoses, failure to act promptly, and choosing the wrong care path. Therefore, we need to center more on these areas when teaching residents in order to overcome the need for large-volume experience.

Training the Team
Bad outcomes are often not the fault of the surgeon. In a specialty where hours make a difference, failure to inform the surgeon immediately can spell disaster. Surgical care, like a chain, is only as strong as the weakest link. A novice anesthesiologist, a dietitian offering the wrong advice, and an inadequate mental health evaluation may be as much of a hindrance as an inexperienced surgeon. The recent nurse graduate who does not recognize that tachycardia is a serious danger sign in a bariatric surgical patient and who fails to notify the surgeon is as serious a problem as a failure in technique. The hospitalist who chooses a nasogastric tube to relieve a patient after a gastric bypass is another example of well-intentioned disaster.

In short, the advantages of volume apply to the whole team as much as the surgeon. The entire team needs to be trained and the training reinforced frequently.

Checklists and “time-out” protocols, similar to the procedures used in the airline industry, offer additional approaches that can turn a disparate set of workers into a functional team.

Optimal Care Paths
One common trait of the most successful bariatric programs appears to be the routine application of care paths with which every patient is treated in a defined, stepwise manner with identical evaluations, preoperative preparations, anesthetic agents, and postoperative care—changed only if there are indications, such as allergies, to do so. Optimal care paths have proven to be the best way to assure smooth progress, early discharges, and good outcomes.

Currently, care pathways are generally grounded in the demands of lead surgeons or the experience of successful programs. Soon SRC’s Bariatric Outcomes Longitudinal Database™ (BOLD™), the nationwide database program for the documentation of bariatric surgery in BSCOE Centers, will be able to provide even better information based on national experience.

Evaluation of Outcomes
All teams do not win all of the time. Performance may vary for a number of reasons, but at least in sports, scores usually define individual and team success. The same approach is promising for the delivery of surgical care. Keeping score, as required to achieve and maintain the ASMBS BSCOE status, approval by Centers for Medicare and Medicaid Services (CMS) to perform transplantation, and cardiac scores of the Society for Thoracic Surgery (STS), provide surgical teams comparison not only with their own successes, but also with those of other centers. Differences can then be traced and problems corrected promptly and effectively.

Volume Matters
The validation that greater volumes produce better outcomes can no longer be ignored in bariatric surgery—indeed in all surgery. We have accumulated more than enough evidence that volume matters. It is high time that we respond at every level in our practices, our hospitals, our training programs, and our certification efforts. Educational processes from the 1900s no longer suffice.

To be fair, the American Board of Surgery has already provided programs with flexibility, but that is not enough. Training programs need to rise to the challenge with experimental curricula that are rigorously tested with measures of outcomes during practice. Continuing surgical education programs must offer more than lectures in big auditoria so that our colleagues who have been in practice for 15 years have the same skills as recent graduates. How can we assure that the surgeon in Keenansville, North Carolina, who has provided demanding day and night care for a decade without a chance for hands-on renewal can compete with the new surgeon in Kinston, North Carolina, who just completed her fellowship?

Yes, today volume matters. With vision, acceptance of new technologies, and a willingness to drop outmoded approaches, we can overcome the volume metric and, instead, be assured that a finishing resident will provide quality care on the first day after they receive their certificates. Just remember, any of us could be his or her first patient.

Category: Commentary, Past Articles