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Volume based privileging criteria

Credentialing Resource Center Connection, December 4, 2003

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Dear Credentialing Colleague:

I hope by now many of you have read the ground breaking article in the November 27, 2003 edition of the "New England Journal of Medicine" by Birkmeyer, et. al., entitled "Surgeon Volume and Operative Mortality in the United States."

Using Medpar data for 1998 and 1999, the authors studied mortality rates for four cardiovascular procedures (carotid endarterectomy, CABG, aortic valve replacement, and elective abdominal aortic aneurysm repair) and four cancer surgeries (lung resection, cystectomy, esophagectomy, and pancreatic resection). Using sophisticated regression analysis they determined that operative mortality correlates independently with operating surgeon volume and hospital volume for each procedure. This means that surgeons who perform one of these complex procedures more often, average a significantly lower mortality rate than do surgeons who perform these procedures less often.

This article has profound implications for your medical staff's approach to privileging for these eight procedures, as well as for other complex, high risk procedures. (Please see this week's Medical Staff Leader Connection for a discussion of the implications of this article for other medical staff related issues. Go to www.msleader.com to read the latest MS Leader Connection.)

As a credentialing leader, the best approach is to share this article with your medical executive committee (MEC) and credentials committee members to stimulate substantive discussion of its relevance for your organization. This discussion should begin with the principle that when making privileging recommendations to the board, it is the obligation of the medical staff to ensure providers demonstrate current competence for the privileges for which they are recommended. We now have an extensive research base that correlates clinical outcomes with the volume of the operating surgeon. This can, and should, usher in an era of "evidence based privileging" which includes volume as one of the criteria for evidence of competence, at least for selected, high risk procedures.

However, as with many of the issues in health care, the best course of action is not completely clear. This article does not give us evidence based minimum volume criteria for privileges for any of these procedures. Instead the authors treated volume as a continuous variable. This means they did not identify a "threshold" level of volume below which outcomes were substantially worse than for those above. Another challenge is that the author's cut off levels for low volume providers used volumes that are often not approached in community hospitals. For example, they consider surgeons who perform less than 18 carotid endarterectomies a year low volume providers. This is reasonable for academic centers, but is unrealistic for surgeons in many smaller community hospitals. It demonstrates once again the difficulties that arise in applying research from academic centers to the rest of the country.

We are not a "one size fits all country" when it comes to health care, which is why the JCAHO requires each hospital to adopt its own privileging criteria. Minimum volumes are a reasonable, and now research-supported, threshold criteria for eligibility to request privileges for selected high risk, complex procedures. Where you set that threshold should be determined after weighing the challenges and needs in your medical staff and community.

That's all for this week.

All the best,

Richard Sheff, MD

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