Minimum Volume Thresholds - Do They Apply to Late-Life Care?

The Volume-Outcome Relationship

Over the past 30 years, there has been considerable research on the relationship between surgical volume and outcomes for a variety of complex procedures. The proposed cause of the relationship is intuitively simple: practice makes perfect. Surgeons who perform high volumes of, for example, coronary artery bypass surgeries (CABG) per year are expected to have improved outcomes over surgeons who perform low volumes.



The finding that higher procedure volumes by facility and by surgeon are associated with improved outcomes has led to the development of minimum procedure requirements. These initiatives promote patient care by surgeons and facilities who meet certain volume thresholds. Guidelines published by the American Heart Association/American College of Cardiology specify the minimum number of procedures performed annually by cardiac surgeons.

Perhaps the most influential initiative has been the selective purchasing strategy of the Leapfrog Group (www.leapfroggroup.org), a large coalition of public and private purchasers of about $60 billion of health insurance annually. Members include many Fortune 500 companies such as Chrysler, Cisco Systems, Inc., IBM and Verizon. The Leapfrog Group’s mission is to trigger giant leaps forward in the safety, quality, and affordability of health care by "supporting informed healthcare decisions by those who use and pay for health care and promoting high-value health care through incentives and rewards."



As part of its “Evidence-Based Hospital Referral” guidelines, the Leapfrog Group recommends that its members contract for selected surgeries, including CABG, only with hospitals that meet minimum volume thresholds.


In line with Leapfrog’s initiatives are state regulatory policies towards the regionalization of healthcare. These projects aim to concentrate certain medical services in facilities throughout the state. The most widely adopted approach towards regionalization is state-based certificate-of need-programs. Think Florida and hospice. The goal is to distribute certain specialized procedures and services rationally and efficiently across the state.

Initially devised to restrain increasing healthcare costs, these programs have led towards concentration of specific procedures to high volume facilities. New York State is considered by many students of this issue to be a model for the successful regionalization of healthcare. One study by Hannan et al. titled “Improving outcomes of coronary artery bypass surgery in New York” showed that increasing the number of CABG procedures performed at high volume hospitals decreased the risk-adjusted mortality rates by 41 percent. Another study demonstrated the positive effect of certificate-of-need programs on percutaneous coronary intervention outcomes across a number of states. The authors showed that in states with certificate-of-need programs, Medicare patients with acute myocardial infarction were less likely to undergo revascularization procedures than patients in states without certificate-of-need programs.

So, do minimum volume thresholds have a role in improving late-life care, or put another way, is the spread of a health service innovation, like palliative care , accelerated or slowed as a result of organizational concentration? The NHPCO FY2008 National Summary of Hospice Care shows that 40% of hospices care for fewer than 25 patients per day, and that 80% of hospices care for fewer than 100 patients per day. Perhaps more to the point, almost half of this nation's hospices ADMIT less than 150 patients per YEAR (or fewer than three every week). The obvious question is, are Florida's hospices delivering better late-life care because of their volume of patients. Hard to say, because there are few agreed-upon measures of the quality of late-life care. Yet, what is widely acknowledged is that Florida's hospices make more expansive use of Hospice and Palliative Medicine (HPM) physicians. That must count for something in spreading the influence of hospice and palliative care, don't you think?

An APCO Developing in Asheville?

In a recent post (read here), I commented about the exemplary results of Asheville, North Carolina in the DAI Community Palliative Performance Profile. To learn more, we interviewed Janet Bull, MD, VP of Medical Services for a not-for-profit hospice (Four Seasons) serving the Asheville area.

Some excerpts:

"We are very heavy in physician staffing, and think that is a good real positive," with the physicians mainly out making billable visits to hospice patients and serving as attendings or consultants on about 80 percent of patients enrolled in hospice care, she explains. "They actually paid for themselves last year."

Essential to the palliative care program's success was being clear on what kinds of patients it would see -- or not see. Dr. Bull continues, "We learned early on that we can't be all things to all people. We didn't want to be a chronic pain service or post-acute, post-surgical consultants. We wanted to stay focused on serious, advanced illness, generally for patients with three years or less to live. At Four Seasons, we are all about delivering quality care and looking at measurable outcomes. We take our patient and family satisfaction surveys very seriously.The program emphasizes continuity of care across care settings. From the get-go, we saw patients where they were, and we followed them from one setting to the next."

Integrating the hospice and palliative care departments was also a priority. "Many organizations bump up against the problem of palliative care being viewed as a step-child to hospice. Here we value the great things palliative care brings, and how it complements hospice," Dr. Bull says."We consider ourselves one big team, whether palliative care or hospice, with a lot of interface between the two. Patients can flow both ways between these programs. We used an explicit strategy of building the connections between the two. Some employees serve both programs, and we share resources and administrative tasks, integrating them whenever we can," she reports. "Often at staff meetings we'll have presentations by palliative care leadership or providers, explaining their work to hospice staff. We focus on education, both internally and externally, explaining the differences between hospice and palliative care, and how they complement each other. We inform patients that hospice offers many more services than palliative care."

Seems to me that what we're seeing in Asheville is the early development of an Accountable Palliative Care Organization, led by a chief palliative care officer for the community. Surely, there are other factors contributing to Asheville's performance, but just as surely one cannot underestimate the value of a strong and well-developed medical staff of HPM specialists.

Improvisational Nature of Palliative Care , and APCOs

I'm often asked why the Accountable Palliative Care Organization (APCO) model is vital to the success of palliative care programs. There are many reasons, of course, but here's one at or near the top of my list. Currently, there is no third-party reimbursement specific to the provision of palliative care, although palliative services are often billed in other reimbursement categories, most frequently, the hospice or home health benefit, and physician or nurse practitioner consultation services (in the hospital, long-term care, or home settings). In addition, there is no regulatory structure or standard-setting body for palliative care (although JCAHO has recently introduced proposed regulations and the National Quality Forum compiled in 2006 a compendium of 38 preferred Practices in Hospital Palliative Care). (http://www.qualityforum.org/publications/reports/palliative.asp ).

The absence of targeted reimbursement and regulation is reflected nationally in the improvisational nature of palliative programs. The Accountable Palliative Care Organization (APCO) offers a structural model that improves the odds for success for a program’s sponsor. Improvisation does not have to mean trial and error, or fitful starts in a program's development.

An APCO provides the structure that brings together professionals to transfer knowledge across settings and disciplines, and the technical capacities through which staff across disciplines and settings are trained in palliative care- specific techniques and tools.APCOs have been successful models for improving delivery of chronic and end-of-life care because their characteristics encourage processes of care that are:
Timely – delivered to the right patient at the right time (early identification of patients)
Patient-centered – based on the goals and preferences of the patient and family, articulated in goals of care conversations
Beneficial and effective – demonstrably influencing important patient outcomes (place of death, intensive care utilization, transitions between settings and providers)
Accessible - available to all who are in need and who could benefit (multiple entry points into palliative care continuum, and absence of barriers related to reimbursement and prognosis).

After all, aren't these processes of care all program sponsors strive for. Yet, so many of us struggle in developing successful programs. I'd like to learn your thoughts.

Palliative Care Grand Rounds - March MMX

Read here for this month's Palliative Care Grand Rounds, a round-up of the best from the blogosphere. This month's host is Larry Beresford, who has written extensively over the years on hospice and palliative care matters.