A Critical Evaluation of the Impact of Leapfrog's Evidence-Based Hospital Referral

• Published in: Journal of the American College of Surgeons Vol. 212; no. 2; pp. 150 - 159.e1
• Main Authors: Massarweh, Nader N., MD, MPH, Flum, David R., MD, MPH, FACS, Symons, Rebecca G., MPH, Varghese, Thomas K., MD, MS, FACS, Pellegrini, Carlos A., MD, FACS
• Format: Journal Article Conference Proceeding
• Language: English
• Published: New York, NY Elsevier Inc 01-02-2011; Elsevier
• Subjects: Adult; Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal - epidemiology; Aortic Aneurysm, Abdominal - surgery; Biological and medical sciences; Cohort Studies; Confounding Factors (Epidemiology); Esophageal Neoplasms - epidemiology; Esophageal Neoplasms - surgery; Esophagectomy - statistics & numerical data; Evidence-Based Medicine; Female; General aspects; Hospitals - statistics & numerical data; Hospitals - trends; Humans; Male; Medical sciences; Middle Aged; Miscellaneous; Outcome and Process Assessment (Health Care); Pancreatectomy - methods; Pancreatectomy - statistics & numerical data; Pancreatic Neoplasms - epidemiology; Pancreatic Neoplasms - surgery; Patient Readmission - statistics & numerical data; Public health. Hygiene; Public health. Hygiene-occupational medicine; Referral and Consultation - statistics & numerical data; Regional Medical Programs - trends; Research Design; Surgery; Surgical Procedures, Operative - adverse effects; Surgical Procedures, Operative - mortality; Surgical Procedures, Operative - statistics & numerical data; Vascular Surgical Procedures - statistics & numerical data; Washington - epidemiology; Washington; AAA; Comprehensive Hospital Abstract Reporting System; evidence-based hospital referral; Leapfrog; EBHR; LF; CHARS; abdominal aortic aneurysm; Evaluation; Treatment; Hospital; Evidence-based medicine; Surgery; Evidence-based practice
• ISSN: 1072-7515; 1879-1190
• DOI: 10.1016/j.jamcollsurg.2010.09.027

Background Evidence-based hospital referral (EBHR) is a Leapfrog group quality metric based primarily on hospital procedural volume. It has yet to be determined if EBHR has led to regionalized surgical care and whether it has improved patient outcomes. Study Design We conducted a before and after cohort study of 13,157 adults (1994 to 2007) who underwent pancreatic or esophageal resection or abdominal aortic aneurysm (AAA) repair in Washington State. Adjusted mortality, readmission, and complication rates were assessed before and after EBHR was introduced. Results Hospitals meeting an EBHR volume metric in any year ranged from 2 to 6. Comparing before and after 2001 (2004 for pancreatic resection), the proportion of patients treated at hospitals meeting the EBHR volume metric for a given procedure increased for pancreatic (59.4% vs 75.7%, p < 0.001) and esophageal resection (41.5% vs 59.2%, p < 0.001), but was similar for AAA repair (16.3% vs 17.6%, p = 0.13). In general, rates of adverse events were lower at hospitals meeting an EBHR volume metric. However, across Washington State and at non-EBHR centers, rates of mortality, readmission, and complications generally did not improve in the 7 years after introduction of the EBHR initiative. Conclusions Although a greater proportion of pancreatic or esophageal resections were performed at hospitals meeting a given EBHR volume metric in the 7 years after Leapfrog, this shift had a negligible impact on outcomes across Washington State. It remains to be determined why regionalization for AAA repair has not occurred and why regionalization trends in pancreatic and esophageal surgery have not had the intended impact of improving overall safety outcomes.