The Leapfrog Initiative: a potential threat to surgical education

The Leapfrog Initiative was established in January 2000 by the Business Roundtable (BRT) in response to the Institute of Medicine report on quality and safety of medical care. The BRT is composed of chief executive officers of U.S. corporations representing more than 28 million employees. Leapfrog has proposed 3 hospital safety measures-computerized physician order entry, intensive care unit physician staffing standards and evidence-based hospital referral, which states that hospitals must meet certain volume/year criteria. Three of these criteria are pertinent to general surgery. They are abdominal aortic aneurysm (AAA) repair greater than or equal to 30/year, carotid endarterectomy (CE) greater than or equal to 100/year, and esophageal cancer surgery (ECS) greater than or equal to 7/year. Hospitals failing to meet these requirements would not be eligible to treat patients employed by BRT corporations.

Data were obtained from the Residency Review Committee (RRC) for Surgery Resident Statistics Summary for 1999 to 2001. Comparisons were made between the numbers of the Leapfrog index cases required and the actual number of cases performed by each graduating chief resident. Data from the Connecticut Hospital Association (CHA) for fiscal year 2000 were also analyzed. Outcomes for procedures at The Stamford Hospital were reviewed.

Data obtained from the RRC reveal that the mode numbers for each of the 3 evidence-based standards for each graduating chief resident in 2000 and 2001 are 5 and 3 for AAA, 15 and 17 for CE, and 0 in both years for ECS. Extrapolation using the mode for each procedure reveals that hospitals with 5 or 6 graduating chief residents may be ineligible to treat patients for AAA and CE. Hospitals with less than or equal to 5 chief residents would be excluded from performing CE. Very few institutions are performing adequate numbers of ECS. Only 4 of 31 CT hospitals would be allowed to perform AAA, and only 3 of 31 could perform CE. Only 1 Connecticut hospital performed more than 7 ECS cases in FY 2000. It is apparent that Leapfrog standards will have serious economic impact on many hospitals, as well as displacing patients to other cities for care.

Surgical chairs and program directors should be aware of the Leapfrog standards and assess their own programs and institutions for compliance. Performance improvement and outcomes data for all evidence-based standards should be reviewed.