In their article, Sheetz et al1 provide an interesting method of evaluating surgeon outcomes for a specific complex operation relative to similar procedures. Rather than focusing solely on surgeon or hospital volume for a single procedure to determine a threshold for competency and safety, the authors assessed surgeon volume for related procedures in an attempt to provide a more comprehensive evaluation of expertise. In essence, the authors argue for the consideration of a halo effect when assessing volume-based credentialing; that is, individual surgeon outcomes for a specific procedure such as pancreaticoduodenectomy (PD) are associated with that individual surgeon’s volume for related complex hepatopancreatobiliary (HPB) operations. In turn, for those surgeons performing PD who do not meet established volume thresholds owing to their practice location or patient population, the authors suggest that a higher volume of other complex HPB procedures in their practice should be considered in the credentialing process.1 These data were somewhat surprising, given that Nathan et al2 had previously argued that the surgeon volume-outcomes association was very specific. Using the State Inpatient Databases for Florida, Maryland, and New York, Nathan and colleagues2 noted that all apparent nonspecific benefits of increased surgeon volumes of HPB procedures were explained by increased volumes of the specific primary procedure in question. For example, although overall HPB and hepatic resection surgeon volume initially appeared to be associated with mortality benefits after pancreatic resection, additional analyses revealed that the apparent benefits were actually explained by the fact that surgeons with high volumes of total HPB cases and hepatic resections also tended to have high volumes of pancreatic resection. In turn, Nathan et al2 argued that high-volume surgeon expertise in one area of HPB surgery did not translate into improved outcomes for other HPB procedures.
Low-volume, high-risk procedures such as PD have traditionally presented challenges to credentialing and quality committees in low-volume centers. Balancing the need to provide access to care with the potential for worse outcomes in these centers is difficult, because there is a strong volume-outcome association for many of these complex surgical procedures. The Leapfrog Group,3 a national nonprofit organization focused on improving quality and patient safety in US health care, has identified 8 high-risk procedures and the recommended hospital and surgeon volume for each. Meeting these volume thresholds is clearly associated with better outcomes and lower mortality rates. In fact, when 3 metrics (Leapfrog minimum volumes, hospital safety grade A, and Magnet recognition) were evaluated in association with outcomes after a variety of complex cancer operations in patients covered by Medicare, the only metric associated with lower odds of serious complications or mortality was the Leapfrog volume criteria.4 For pancreatic resections for cancer, Leapfrog recommended minimum annual volume for the hospital and for surgeon credentialing of 20 and 10 cases, respectively.3 Other complex gastrointestinal tract, vascular, and cardiac procedures have similar hospital and surgeon minimum volume requirements and pose similar credentialing challenges in low-volume centers. Despite strong evidence that low-volume surgeons have worse outcomes for specific operations, efforts to regionalize this type of specialized care has remained a challenge. Patients want to receive care close to home and are still more likely to have surgery at low-volume centers if they can travel a shorter distance or if they reside in a rural location.5 This reality requires us to develop other ways to assess competency and improve outcomes after these types of procedures. Alternatives to the Leapfrog criteria have been investigated, including exporting practices from high-volume centers to low-volume centers.6 Similar approaches include direct collaboration from a surgeon at a high-volume center or sharing of best practices and care paths to decrease variation in care. In 1 study,7 high-volume HPB surgeons provided on-site mentorship for the preoperative, intraoperative, and postoperative care of patients undergoing HPB procedures that, after 2 years, resulted in low-volume centers achieving comparable outcomes to those of the high-volume centers.
It is important to note that hospital credentialing for high-risk procedures is a local process that is typically not based on volume alone. Although there is merit in evaluating outcomes for a group of similar procedures (eg, colon resections, anastomotic bariatric procedures, and laparoscopic solid organ resections), it is often unclear to the credentialing committee which procedures to bundle and what volume defines competency. In practice, core and advanced credentialing requirements are determined by recommendations from the individual departments with supporting evidence from society guidelines, relevant literature, and credentialing standards at other similar institutions, as well as the surgeon’s training and experience, all while considering the number of clinicians and volume of procedures at the institution. At our institution, PD is a core privilege in surgical oncology as well as general and gastrointestinal tract surgery. As such, PD is only subject to an initial focused professional practice evaluation at 6 months and ongoing professional practice evaluation; there is, however, no ongoing volume requirement to maintain the privilege. The focused professional practice evaluation includes a random sampling of core privileges that may or may not include operations such as PD. This level of oversight is common but may be insufficient in some centers. The role of monitoring safety and adverse events then falls on the quality officer for the department or division and is more often reactive than proactive. At large academic medical centers such as ours, volume is rarely an issue when it comes to initial credentialing or renewal of privileges. In the present study, however, most surgeons performed 2 or fewer PDs a year. The credentialing and quality committees at these institutions must use information other than volume alone to decide whether this is a procedure that surgeons or their institution should be offering. Studies like the one by Sheetz and colleagues1 are necessary to provide this information. The data may help us understand what criteria to apply or bundle to provide appropriate credentialing and to ensure the safe delivery of care without unnecessarily restricting patient access. Volume-outcome associations for high-risk procedures will undoubtedly continue to be reported and used as part of the criteria for credentialing surgeons. The use of other innovative methods to determine a surgeon’s skill and safety are necessary, because credentialing does not necessarily always equate to competency.
Published: April 29, 2020. doi:10.1001/jamanetworkopen.2020.3888
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Needleman BJ et al. JAMA Network Open.
Corresponding Author: Timothy M. Pawlik, MD, PhD, MPH, Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Suite 670, Columbus, OH 43210 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Needleman reported serving on the advisory board for and receiving equity from RevMedica outside the submitted work. Dr Brethauer reported being a consultant for GI Windows Corp and receiving a speaker honorarium from Medtronic plc outside the submitted work. No other disclosures were reported.
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Needleman BJ, Brethauer SA, Pawlik TM. Assessing a Surgeon’s Competency for High-Risk Procedures: Should We Be Looking at the Bigger Picture? JAMA Netw Open. 2020;3(4):e203888. doi:10.1001/jamanetworkopen.2020.3888
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