Vaccination News Home Page                                            subscribe Vaccination NewsLetter

http://www.nytimes.com/2003/02/10/health/10HOSP.html?tntemail0

Study Finds Many Doctors Performing Surgery Lack Practice

By RICHARD PÉREZ-PEÑA

high proportion of the doctors who do delicate medical procedures — and many of the hospitals where they are performed — have relatively little experience at them, according to figures being released this week. Some consumer advocates say the situation may endanger patients.

Dozens of studies have shown that a patient has a much higher risk of serious injury or death at the hands of a surgeon or hospital that handles a particular procedure infrequently. Patient advocates, including the group that is releasing the new information, the Center for Medical Consumers, say the numbers point to a need for the New York State Department of Health and the hospitals themselves to limit which hospitals and doctors provide certain services.

But the agency, hospital officials and some experts in the field say the picture is far from clear, and that volume is not a reliable measure of performance.

The numbers being released cover the year 2001, and include 44 mostly common procedures. Most are surgeries, but the list also includes things like coronary artery angioplasty and colonoscopy. The figures, taken from raw data collected by the Health Department, were compiled by the Center for Medical Consumers, a nonprofit group in New York City, and are available on its Web site, www.medicalconsumers.org.

In all, the statistics represent the most detailed view New Yorkers have ever been given of the work done by individual hospitals and doctors. For each of the 44 procedures, the study lists every doctor who performed it in 2001, every hospital where it was performed and how often it was done. The registry covers hundreds of thousands of cases.

In only one area, cardiac surgery, does the state limit which hospitals can enter a particular field, a practice followed by many other states. New York issues "certificates of need" to more than 30 of New York's more than 200 hospitals, allowing them to do things like coronary artery bypass operations.

A study reported last fall in the Journal of the American Medical Association found that among the 27 states (and the District of Columbia) that require certificates of need, the death rate for bypass patients is significantly lower than in the 23 states where any hospital can perform such surgery.

"It's time for the state to seriously consider applying certificate of need to other surgeries," said Arthur Levin, director of the Center for Medical Consumers. "The volume data tells us that there are doctors and hospitals out there doing some surgeries so rarely that it could put people seriously at risk."

Dr. Mark R. Chassin has seen the issue from several angles. A former state health commissioner, he is senior vice president for clinical quality at the Mount Sinai School of Medicine, and has been a co-author of some of the studies documenting the link between surgical volume and risk.

"Should certificate of need be expanded?" he asked. "I hate to be evasive, but the answer is yes and no. You can't rely only on volume — there needs to be more research on outcomes. And as a policy matter and a political matter, it's very hard to stop places from doing something they're already doing."

Officials at several hospitals said that keeping a tighter rein on what operations surgeons can perform would require unneeded new layers of bureaucracy, and would cause internal political problems.

Department of Health officials said restricting the procedures that a hospital can perform would be unwise, in part because it would limit consumer access to those procedures. They acknowledged that there is, for many procedures, a correlation between volume and quality of care, but they added that it is dangerously easy to read too much into that.

"It doesn't automatically imply that a low-volume facility has poor outcomes," said William Van Slyke, a department spokesman. "A low-volume facility can and often does produce optimum, high-quality care."

The Center for Medical Consumers focused especially on carotid endarterectomy, a procedure to prevent strokes. About 8,000 New Yorkers have the procedure each year.

The group chose that procedure because it carries a high risk of stroke or death, it is commonplace, and the Health Department itself has sponsored research on the connection between volume and risk.

A 1998 study found that when a carotid endarterectomy was performed by a surgeon who did fewer than 5 per year at a hospital that did fewer than 100, the death rate was more than twice as high as when the doctor and hospital did it more frequently. Studies have shown even higher risks associated with low-volume surgeons and hospitals for other, less common treatments, like surgery for pancreatic cancer or esophageal cancer.

Out of more than 600 surgeons who performed carotid endarterectomies in New York in 2001, two-thirds did it fewer than 10 times, according to the figures compiled by the center. More than half the surgeons did it fewer than five times. Almost one-third did it only once.

At the other end of the spectrum, there were only 74 surgeons who did 30 or more carotid endarterectomies during the year, but they accounted for well over half the procedures.

While bypass surgery is limited to a few dozen hospitals, any hospital can perform a carotid endarterectomy, which is done less than half as often. So while 40 New York hospitals did bypass surgeries, 164 did carotid endarterectomies. Of those, 141 did it fewer than 100 times, and 49 did it fewer than 10 times.

Even among high-volume hospitals, there were a number of surgeons who did the procedure just once or twice in the year, suggesting that many hospitals do not tightly control which surgeons try it.

The findings were similar for many other common procedures. Though most colonoscopies were done by doctors who did several hundred each in 2001, almost half the doctors did only one. More than one-fourth of the surgeons who performed simple mastectomies did just one during the year, and more than half did three each or fewer.

The Health Department has long been uneasy with most public discussion or use of the mountain of data it collects on hospital procedures, which includes detailed information on each patient and the outcome of each case. The state refused to release the information for many years, until it lost a lawsuit filed by The New York Times in the 1990's. To this day, it does not make most of the information public unless requested, and then only in its raw form.

The exception is data on coronary artery bypass surgery. The department has published annual reports since 1989 on that procedure, showing not only volume, but also hospital-by-hospital death rates.

Mr. Van Slyke, the department spokesman, said it is considering publishing such reports for other procedures.

Vaccination News Home Page

ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.