The national decline in cardiac surgical volumes is well documented: between 2000 and 2010, annual isolated CABG volume in the U.S. declined by 95,000 cases (from 314,000 to 219,000), a drop of 30%. As a microcosm of national trends, California data reporting isolated CABG surgeries between 2005 and 2015 documents a similar trend among the state’s 125 hospitals currently licensed to provide this service. As total CABG volume has fallen, average per-hospital CABG volumes have fallen concomitantly, putting increased pressure on low volume programs to meet both internal financial performance goals and clinical and outcome expectations. Thus, low cardiac surgical volumes continue to be an issue for both hospital systems with multiple cardiac surgical providers, as well as single hospital providers who may face volume-related issues.
The Decline in California CABG Volumes Parallel U.S. Declines
California reported a decline in total CABG surgery from 21,295 discharges in 2005 to 15,278 in 2015 (see table), a decline of 6,017 or 28.3%. In 2005, 119 hospitals reported performing CABG surgery, with an average of 178 discharges. This declined to an average of 97 CABG discharges reported for 125 hospitals (6 more hospitals than in 2005!) in 2015. There were 65 hospitals in California that reported fewer than 100 CABG surgeries in 2015 ‒ frankly, more than in some entire states or regions of the country. The average CABG volume for California hospitals reporting fewer than 100 surgeries per year was 58. Clearly, the issue of low volume is widespread and increasingly relevant.
What is a Low Volume Hospital to Do?
There is no universally-accepted, recommended program minimum volume standard for CABG, valve or total cardiac surgery. However, beyond specific state-mandated minimums for licensure/certification (if present) and/or professional societal recommendations, common sense would indicate that a hospital with a total annual volume under 100 – and most certainly under 50 – is by any definition a “low volume” program.
The question becomes, can a low volume program be both relevant and insure its survival by producing excellent results? CFA believes that it can, and so do rating agencies like Truven Health Analytics Top 50 Cardiovascular Hospitals in 2017 (see Can Low Volume Cardiac Surgery Programs be Excellent? ). But it is extremely challenging. In this era of value creation and increasing data transparency, a low volume program without excellent performance can be detrimental to any hospital’s financial performance, overall reputation and market position.
We have found that many low volume programs actually provide more cost effective, clinically superior outcomes than some higher volume programs. This might seem to fly in the face of other “conventional” data showing low volume programs generally have worse, not better, outcomes. In our experience, great program-dedicated surgeons, assiduous case selection, strong teams and adherence to best practices are more important factors than gross statistics and large volumes alone relative to clinical performance and operational outcomes
CFA has written extensively on low-volume surgery programs, most specifically in its white paper, Low Volume Cardiac Surgery: Grow, Consolidate or Divest? The Need for Next Generation Assessment. We would call your attention to this document for a detailed explanation of approaches to assessing a low volume program with an eye towards taking remedial action. It would be overly simplistic to insist that every low volume program is either unnecessary or redundant in its market area, needs to be consolidated with another provider, or cannot be upgraded or salvaged with proper assistance. There are options that can be explored and strategies that can be implemented before any cardiac surgery program is deemed “unsalvageable.” You can access the CFA Low Volume Cardiac Surgery white paper.
It is important to stress that these potential program “fixes” can be attempted only after a “next generation assessment,” which correctly diagnoses the critical issues that differentiate a salvageable program from one that is fatally flawed. Having consulted with hundreds of cardiac programs over the course of my career, I can tell you from experience that if you believe the source of all problems centers on the surgeon(s), you might be wrong; there are a myriad of subtle and not-so-subtle reasons underlying overall program performance, not all of which can be laid at the feet of the surgeon(s).
All low volume cardiac surgical programs need to be aware that they are increasingly vulnerable from both outside market forces (e.g., competition, data transparency, payer scrutiny, patient expectations and experience, outside rating agencies, payment reform including bundled payment models) and internal performance expectations. An appropriate assessment of any program by an outside consultant or content expert should reveal the core issues that are preventing optimal performance. Typically, it is a myriad of issues and not just a single one that is at the root of the problem.
In conclusion, and in the face of continuing declining cardiac surgical volumes, low volume 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, and ultimately long-term success for the institution as a whole. Should attempts to revitalize a low volume program fail, this may inevitably lead to consolidation or divestiture simply due to the changing health care delivery and payer 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 firstname.lastname@example.org.
 Unfortunately, the California CCORP data does not separately track cardiac valve surgery, but “other” non-CABG cardiac procedures count for 57% of the total, which predominantly includes valves.