Evidence-Based Hospital Referral (EHR)

Why Hospital Choice Matters
Millions of Americans undergo elective surgery every year. Many factors may influence at which hospital they choose to have surgery: recommendations from their physician, opinions of family or friends, or simply location and convenience.

For some high-risk procedures, however, the hospital where surgery is performed can mean the difference between life and death. With heart surgery, for example, studies have found more than 3-fold differences in surgical mortality rates across hospitals. Similar variation in quality has been described for non-surgical conditions as well.

One marker of how well a hospital is likely to perform is the experience of the hospital and its surgical team. In the absence of data to compare hospitals on their complications and survival rates, you can begin evaluating experience by looking at the number of high-risk treatments and procedures a hospital performs each year. Referrals to institutions with a lot of experience treating certain conditions offer the best survival odds. For example, Evidence-Based Hospital Referral (EHR) for certain conditions show strong statistical relationships between patient survival and a hospital's annual volume of such procedures.


Choosing the right hospital
In a few cases, selecting a low-risk hospital for surgery is straightforward. For example, New York and several other states regularly publish adjusted mortality rates for coronary artery bypass graft surgery (Click here for Priority Health network hospital rates -- requires Adobe Acrobat Reader). Unfortunately, similar information is not available for most other high-risk procedures and conditions. Thus, other factors must be considered. The Leapfrog Group web site (www.leapfroggroup.org) Hospital Safety Comparisons

Among the most important is surgical volume-how many procedures of a given type the hospital performs each year. More than 100 studies have demonstrated better results at high-volume hospitals with cardiovascular surgery, major cancer resections, and other high-risk procedures. For example, compared to those at high-volume hospitals (32+ procedures per year), patients undergoing abdominal aneurysm repair at low-volume hospitals are more than 50% more likely to die following surgery.

Lower surgical mortality at high-volume hospitals does not simply reflect more skillful surgeons and fewer technical errors with the procedure itself. More likely, it reflects more proficiency with all aspects of care underlying successful surgery, including patient selection, anesthesia, and postoperative care.

Choosing the right hospital is not just important in surgery. For example, babies with very low birth weight or major congenital anomalies are much more likely to survive if they are delivered and treated at large, regional neonatal intensive care units.


The Leapfrog EHR Standard
Under the advisement of national experts in quality improvement, the Leapfrog Group has adopted EHR as one of its initial Safety Standards. Conditions and volume criteria were selected after review of published research in the field and consultation with leading experts in surgery and neonatal intensive care.
Hospitals fulfilling the EHR standard will meet the criteria listed below.

¹Applies in states in which hospital licensing agency makes such a designation,

In geographical areas where scientifically rigorous, risk-adjusted hospital-specific outcomes are publicly reported, direct measures of performance will replace hospital volume as the EHR standard.

The Leapfrog Group, working in partnership with The MEDSTAT Group, will invite hospitals to record their volume with these procedures and conditions on the Leapfrog web site.

How do area hospitals do on Leapfrog safety measures such as EHR?
Go to the Leapfrog website and enter your zipcode or city to find out.

Challenges to Implementing EHR
Efforts to promote EHR could meet resistance on many fronts. In isolated rural areas, EHR could imply unreasonable travel burden for patients and their families. For this reason, the Leapfrog EHR standard will only apply to hospitals in the metropolitan areas.

Not only might patients resist EHR, but some health care providers are also likely to resist. Many low-volume hospitals may oppose giving up surgical revenue by referring patients elsewhere. They may also worry that EHR would brand them as "second-class". Some physicians may view EHR as an effort to their professional judgment and competence in referring patients.