A critical evaluation of the impact of Leapfrog's evidence-based hospital referral

J Am Coll Surg. 2011 Feb;212(2):150-159.e1. doi: 10.1016/j.jamcollsurg.2010.09.027. Epub 2010 Dec 30.


Background: Evidence-based hospital referral (EBHR) is a Leapfrog group quality metric based primarily on hospital procedural volume. It has yet to be determined if EBHR has led to regionalized surgical care and whether it has improved patient outcomes.

Study design: We conducted a before and after cohort study of 13,157 adults (1994 to 2007) who underwent pancreatic or esophageal resection or abdominal aortic aneurysm (AAA) repair in Washington State. Adjusted mortality, readmission, and complication rates were assessed before and after EBHR was introduced.

Results: Hospitals meeting an EBHR volume metric in any year ranged from 2 to 6. Comparing before and after 2001 (2004 for pancreatic resection), the proportion of patients treated at hospitals meeting the EBHR volume metric for a given procedure increased for pancreatic (59.4% vs 75.7%, p < 0.001) and esophageal resection (41.5% vs 59.2%, p < 0.001), but was similar for AAA repair (16.3% vs 17.6%, p = 0.13). In general, rates of adverse events were lower at hospitals meeting an EBHR volume metric. However, across Washington State and at non-EBHR centers, rates of mortality, readmission, and complications generally did not improve in the 7 years after introduction of the EBHR initiative.

Conclusions: Although a greater proportion of pancreatic or esophageal resections were performed at hospitals meeting a given EBHR volume metric in the 7 years after Leapfrog, this shift had a negligible impact on outcomes across Washington State. It remains to be determined why regionalization for AAA repair has not occurred and why regionalization trends in pancreatic and esophageal surgery have not had the intended impact of improving overall safety outcomes.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Aortic Aneurysm, Abdominal / epidemiology
  • Aortic Aneurysm, Abdominal / surgery
  • Cohort Studies
  • Confounding Factors, Epidemiologic
  • Esophageal Neoplasms / epidemiology
  • Esophageal Neoplasms / surgery
  • Esophagectomy / statistics & numerical data
  • Evidence-Based Medicine
  • Female
  • Hospitals / statistics & numerical data*
  • Hospitals / trends*
  • Humans
  • Male
  • Middle Aged
  • Outcome and Process Assessment, Health Care
  • Pancreatectomy / methods
  • Pancreatectomy / statistics & numerical data
  • Pancreatic Neoplasms / epidemiology
  • Pancreatic Neoplasms / surgery
  • Patient Readmission / statistics & numerical data*
  • Referral and Consultation* / statistics & numerical data
  • Regional Medical Programs / trends*
  • Research Design
  • Surgical Procedures, Operative / adverse effects
  • Surgical Procedures, Operative / mortality
  • Surgical Procedures, Operative / statistics & numerical data*
  • Vascular Surgical Procedures / statistics & numerical data
  • Washington / epidemiology