Potential benefits of the new Leapfrog standards: effect of process and outcomes measures

The Leapfrog Group standards for evidence-based hospital referral underwent significant revision in 2003. In addition to other changes, risk-adjusted mortality and process of care measures now augment or replace volume standards for some procedures. The objective of this study was to estimate the potential benefits of these newly expanded standards.

Leapfrog's 2003 standards were based on minimum volume standards alone for 2 operations (esophagectomy, pancreatectomy), volume standards and a process measure (perioperative beta blockade) for 1 operation (abdominal aortic aneurysm repair), and volume standards coupled with risk-adjusted mortality rates for 2 operations (coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI]). We used data from the 2000 Nationwide Inpatient Sample to determine eligible surgical populations, volume-outcome associations, and risk-adjusted hospital mortality rates for the 5 operations. A recent meta-analysis was used to estimate the effectiveness of perioperative beta-blocker use.

Approximately 23,790 patients died in 2000 in the United States undergoing 1 of the 5 procedures. We estimate that full implementation of the Leapfrog standards would have averted 7818 of these deaths: CABG (4089), PCI (3016), elective abdominal aortic aneurysm repair (356), esophageal resection (180), and pancreatic resection (177). For CABG and PCI, standards based on risk-adjusted mortality rates would save at least 5 times more lives than those based on volume criteria alone.

Widespread implementation of the 2003 Leapfrog standards for evidence-based referral could avert a large number of surgical deaths. For some procedures, standards comprised of process of care or direct outcome measures would be more effective than those based on volume alone.