1. “Medically Ready Force…Ready Medical Force”
Managing the Challenge of the Relationship between Low Volume Surgery and Quality ~ AMSUS ~ Paul R. Cordts, MD, FACS Military Health System Functional Champion Defense Health Agency December 2016
“Medically Ready Force…Ready Medical Force”

2. Agenda Background MHS Volume Data MHS Quality Data
Mitigation Strategies
Public Reporting of Volumes
Summary

3. Military Health System (MHS) Overview
The MHS is a large healthcare system whose mission is to provide optimal health services in support of our nation’s military mission.
$48B organization
Serves over 9.4M beneficiaries
Payer and provider
Facilities
55 Hospitals (41 in US)
373 Clinics (315 in US)
251 Dental Clinics (201 in US)
253 Veterinary Facilities (198 in US)
The MHS Quadruple Aim – better health, better care, lower cost, and readiness – reflects the system’s vision of providing a coordinated continuum of preventive and curative services while supporting the Services’ warfighter needs.
MHS Quadruple Aim

4. Leapfrog Surgeon Volume Factsheet
Volume and Mortality
Studies have demonstrated that high volume facilities and surgeons have considerably lower mortality rates than their lower volume counterparts.
Pancreatectomy for cancer: low volume hospitals have 4x mortality rate of highest volume hospitals
Vascular surgery: higher operator volume correlates with lower rate of mortality and complications
Lung cancer resection: mortality rates are significantly higher in low volume facilities, and 2x higher in non-teaching facilities
Leapfrog Surgeon Volume Factsheet

5. Minimum Procedure Volumes
Minimum procedure volume guidelines addressing the importance of surgeon volume have been developed in an effort to improve patient safety.
American College of Surgeons: set minimum volume standards in its credentialing process for “Centers of Excellence” in bariatric surgery
Aetna and Blue Cross: developed annual volume standards for surgeries such as transplants, bariatric, orthopedic, and spinal surgery
The Leapfrog Surgical Volume Standard4
Johns Hopkins, University of Michigan, and Dartmouth-Hitchcock Medical Center: decided to establish “minimum volume standards”

6. Health systems set minimum volume standards
Procedure
Minimum hospital annual volume
Bariatric staple surgery 40
Esophagus cancer resection 20
Lung cancer resection
Pancreatic cancer resection
Rectal cancer resection 15
Carotid artery stenting 10
Complex abdominal aortic aneurysm repair
Mitral valve repair
Hip replacement 50
Knee replacement
Three prominent healthcare systems
Dartmouth-Hitchcock Medical Center
Johns Hopkins Medicine
University of Michigan Hospital
Sets minimum volume standards for hospitals (and physicians) in their system

7. Complex Procedures Procedure Surgeon Volume-Outcome Association?
Hospital Volume-Outcome Association?
Sources
Esophageal Cancer Resection
N/A (no study identified)
Weak (mortality); None (LOS and complications)
Kozower and Stukenborg (2012); Meguid et al (2009)
Lung Cancer Resection
N/A
Weak (longer term mortality); None (inpatient mortality)
Rosen et al (2014); Kozower and Stukenborg (2011); Cheung et al (2009)
Pancreatic Cancer Resection
Strong (mortality, LOS)
Swanson et al (2014); Hollenbeck et al (2007)
Rectal Cancer Resection
Weak (mortality)
Etzioni et al (2014); Baek et al (2013); Ho et al (2006)
Carotid Artery Stenting
Modest (mortality and complications)
Weak (mortality, stroke, AMI)
Badheka et al (2014); Modrall et al (2014); Sidawy et al (2009)
AAA Repair
Modest (mortality)
None
Modrall et al (2011); McPhee et al (2011); LaPar et al (2012)
Mitral Valve Repair
Kidher et al (2010); Gammie et al (2007)

9. 13 Years of Continuous Learning

10. Deployment Effect Skills eroded after 6 months (perceived)
1-6 months to re-acquire complete comfort
3-6 month deployments best
Ideal time between deployments not asked
Most discomfort with cognitive skills (not technical)

11. Military Surgeon Case Volumes

12. DRAFT - PREDECISIONAL

13. MHS Performance: Mortality and Morbidity
July '12-June '13
July '13-June '14
Jan '14-Dec '14
Jan '15-Dec '15
Mortality
Morbidity
Medical Center 1 *
Community Hospitals *
Exceeds Standards 1
Meets Standards
Needs Improvement
Data Unavailable

14. Low Volume High Acuity Surgical Procedures based on NSQIP – MHS vs. CIV
Complication Rates
Complication
Rate
AAA
BAR
CEA
COL
ESO
LUN
PAN
PRO
THA
TKA
AVE
MHS(%)
1.65
1.2
1.5
0.5
1.8 2
1.3
1.1
1.4
CIVIL(%)
2.1
1.7
2.6
1.9
1.6
Survival Rates
Survival
Rate 
AAA
BAR
CEA
COL
ESO
LUN
PAN
PRO
THA
TKA
AVE
MHS(%)
100
99.9
98.3 99
99.4 94
99.8
98.7
CIVIL(%)
86.2
96.7
96.4
98.6 98
99.3
97.3
Takeaways:
Represents 85% of complex surgical cases performed in MHS (MTFs >5 years with NSQIP)
Complication/survival rates comparable to civilian rates.
Procedure Index:
AAA = abdominal aortic aneurysm; BAR = bariatric surgery; CEA = carotid stenting; ESO = esophagectomy; LUN = lung cancer resection
PAN = pancreatic cancer surgery; PRO = rectal cancer surgery; THA = total hip arthroplasty;
TKA = total knee arthroplasty; AVE = average

16. Mitigation Strategies
Facility capabilities:
24/7 ICU coverage with critical care trained nurses
24/7 Interventional Radiology capability
24/7 in-house skilled provider(s) to reduce risk of Failure to Rescue
Surgeon/surgical team capabilities:
Part-time practice in, or rotation to, high volume facilities
Inform recapture strategy with KSAs required of expeditionary surgeon/team
MTFs attain Trauma Center designation
Enhanced MSMs as a readiness platform

17. From ProPublica Surgeon’s Scorecard

18. From ProPublica Surgeon’s Scorecard

19. Summary
Professional societies, insurance plans and some healthcare systems do consider volume
Healthcare systems may regionalize specific high risk procedures and those requiring advanced technology
Factors other than volume play a role in patient outcome
Increasing demand for public reporting of volumes
Must ensure “Ready Medical Force”, while ensuring Patient Safety, robust training programs and volume/complexity of procedures to maintain staff proficiency