Can Low Volume Cardiac Surgery Programs be Excellent?

If you follow CFA’s blogs, you know we have written extensively on low volume cardiac surgery programs and the challenges they face in the evolving era of value-based healthcare (refer to Low Volume Surgery Programs:  The Need for Next Generation Assessment).

  Our position is that many low volume programs are at increasing risk, and that difficult strategic and operational decisions must take place to successfully address this issue over the long-term.  

CFA has worked with many low volume programs over the years that have had excellent outcomes, by any standard measures.  But frankly, success under yesterday’s market conditions was easier, even at a lower volume, and today’s environment and the value-driven direction in which we are heading makes it much more difficult.  The “average-performing” low-volume cardiac surgical program may be doomed, but can a program that maintains a low volume perform well enough over the medium- to long-term to truly succeed and survive?  Or are they ultimately candidates for consolidation or divestiture?  These are simple questions; but ones with very complex answers.

Top Performers, but Low Volume?

I am sure you are all familiar with Truven Health Analytics’ list of Top 50 Cardiovascular Hospitals in the U.S. The 2017 list was published in Modern Healthcare, November 7, 2016.  Hospitals make the list¹ by outstanding performance in six broad areas of quality and cost measures applicable to (in this specific case) CABG surgery, including:

• Risk-adjusted inpatient mortality rates
• Complication rates
• Clinical process measures
• 30-day readmission and mortality rates
• Severity adjusted length of stay
• Average cost of care

Out of curiosity, I looked at the Community Hospital listing of fifteen hospitals and matched their cardiac surgical volumes for CY 2015, the latest year available, to see if any low-volume hospitals made the list.  The combined volume for CABG and valve surgeries, the vast majority of all “cardiac” surgeries, ranged from a hospital with a low of 46 patients to one with a high of almost 850 patients.  Three of the fifteen hospitals were what CFA would define as “low-volume” programs; with 46, 53 and 59 patients respectively.  And yet they made the 2017 list of 50 top performing cardiac hospitals in the Community Hospital category.  By Truven analysis, a hospital cardiac surgery program that performed 46 surgeries is a top 50 hospital².  (By the way, congratulations to them, they have defied the conventional wisdom and should be proud of their accomplishment.  They have likely beaten the odds by consistently tracking, monitoring and improving their clinical and operational performance through a systematic and multidisciplinary process incorporating evidence-based medicine.)  This proves that it not only can be done, but also must be done by every hospital attempting to stay competitive in an increasingly value-driven market.  Of note is the fact that two of the three low-volume hospitals were added to the list for the first time; let’s see if they continue to improve and make the list next year.  

Succeeding at Low Volume

Succeeding in improving performance to a high level, despite low volumes, is an important achievement.  It will be possible for some providers, but it cannot and should not be considered a virtual guarantee to save a program from the eventual need to seriously consider organizational options including consolidation or divestiture.  The national trends are too formidable and the market is unforgiving to even the best intentioned.

CFA estimates that there are approximately 500 hospitals in the U.S. that operate low volume cardiac surgery programs.  There are nearly 40 in California alone.  If about 30 percent are “Community” hospital programs (the same proportion as in the Truven 50 Hospital designation), then there are an estimated 150 U.S. “Community” hospitals that will need to make substantial improvements to their overall cardiac performance to be able to qualify for the “Top Hospital” list, based on Truven analyses and their definitions of what constitutes a top hospital.  If three hospitals have done it, then there is at least the opportunity for others to succeed.  We believe that, in today's value driven environment, meeting and/or exceeding cost and quality standards will drive cardiac surgery program survivability.

Improving performance and making significant efforts to achieve real progress in the typical cardiac surgery program takes focus, leadership and teamwork. This means constantly tracking data and assessing performance to address unnecessary variation, evidence-based best practice, and enhance overall patient experience.  As the average patient becomes more acutely ill, data generated from comparative databases, such as the Society of Thoracic Surgeons registry, becomes even more important to the overall performance improvement process.

CFA has worked with clients in the past that have had the specific goal of being included in the Truven (or predecessor organizations) list, and have set out to achieve that goal – to establish both a focus and tangible guidepost for performance improvement, and to achieve a perception of market leadership.  

Conclusion

Low volume cardiac surgical programs can be top performers in quality and cost measures – but they are the exception, rather than the rule.  To be the exception takes extraordinary vision, leadership, collaboration and team-building, which many hospitals are challenged to provide.  The majority of hospitals with low volume programs will need to continue to strive for performance excellence, as a means of self-preservation in the short term.  At the same time, these hospitals must recognize that ultimate long-term success for the institution as a whole may lead inevitably to consolidation or divestiture of their cardiac surgery program, simply due to the changing health care delivery and insurance markets and the need to successfully focus on attaining value-based status.

If you are interested in learning more about strategies to deal with low volume cardiac surgery programs and/or programmatic consolidation for cardiovascular or other services, please contact CFA at (949) 443-4005 or by e-mail at cfa@charlesfrancassociates.com.

Footnotes

¹ In three categories:  Teaching Hospitals with CV Residency, Teaching Hospitals without CV Residency, and Community Hospitals.

²  Recognize that this opinion is not informed by the specific mitigating local circumstances.  There are many strategic and practical reasons a hospital would want to offer a low volume program.  In some areas of the country, issues of local access, travel times and/or sole provider status may be legitimate reasons.