How Much is Enough? Public Perception of Minimum Surgeon Volumes

Abstract

Background

A large body of literature supports an association between surgical volumes and outcomes. Research on this subject has resulted in attempts to quantify minimum volume standards for specific surgeries. However, the extent to which the public takes interest in or is able to interpret surgical volume information is not known.

Methods

We designed a 38-question online survey to assess respondents’ knowledge and beliefs about minimum surgical volume standards, and other factors influencing choice of surgeon. Participants, recruited through Amazon Mechanical Turk, an online crowdsourcing marketplace, were specifically asked to estimate minimum volume standards for four different operations (hernia repair, knee replacement, mitral valve repair, and Whipple) and to assess the implications of specific surgeon volumes for decision-making in two hypothetical scenarios.

Results

Among 2024 participants, 81% attested that surgeons should be subject to minimum volume standards. A small minority (19%) reported having prior knowledge of a link between surgeon volumes and outcomes. Respondents’ mean estimates for appropriate minimum annual volumes across four operations were directly correlated with surgical complexity (5 for inguinal hernia repair, 25 for Whipple), while published minimum standards fall with increasing surgical complexity (25 for hernia repair, 5 for Whipple). These findings were validated by participants’ stated intentions: 55% would proceed with a hernia repair by a surgeon with annual volume of 25, while 13% would proceed with a Whipple when annual volume was 5.

Conclusion

The concept of minimum surgical volumes is intuitively important to the lay public. However, the general public’s skewed expectations of minimum volume standards demonstrate an inability to interpret surgical volume numbers meaningfully in clinical settings without appropriate context.

Appendix 1: Survey

Research Project Information Sheet: Public Perception of Surgeon Volumes and Outcomes.

Thank you for taking our survey.

This research project is being conducted by the General Surgery Department at Dartmouth-Hitchcock Medical Center and the Geisel School of Medicine at Dartmouth College, Hanover, NH, USA. It is a study designed to collect public opinion regarding surgeon experience and other factors to consider when choosing a surgeon. No prior knowledge about surgery or health care is required, just your thoughts and opinions regarding these topics.

Your participation is voluntary and involves completion of an online survey that should take about 10 min.

The information will be collected anonymously and will be maintained confidentially. As this survey will not collect any identifying information, none will be used in any presentation or paper written about this project.

Important Note Before You Begin:

This survey is not designed to see how accurately you can respond to certain questions. Instead, our hope is to learn about your perceptions and opinions about these topics. As such, we'd ask that you complete the survey based on what you think (rather than, for example, looking something up or asking someone else); your thoughts are just what we are interested in, and can only learn from you.

Thank you!

• 1. How old are you?

• 18-29

• 30-39

• 40-49

• 50-59

• 60-69

• 70-79

• 80 or older

• 2. What is your gender?

• Male

• Female

• Non-binary

• 3. Have you ever had surgery before?

• No

• Yes, within the past 5 years

• Yes, more than 5 years ago

If “Yes, more than 5 years ago” is chosen, display q4.

• 4. What operation did you have? (If you have had more than one surgery, please describe the most recent one.)

• 5. Let's say you did need to undergo an operation. How important would you consider each of the following characteristics in selecting a surgeon to operate on you? (Using a three-point Likert scale: not important at all, somewhat important, very important)

• Impression from your initial consultation with surgeon

• Family or friend's opinion of the surgeon

• Online testimonial reviews of the surgeon

• Surgeon background (i.e. where s/he trained, board certifications)

• How specialized your surgeon is

• Choose "not important at all"*

• Number of years the surgeon has been in practice

• How many of that specific operation the surgeon performs each year

• Surgeon's complication rate for the surgery you need

• 6. How important would you consider each of the following characteristics in selecting a hospital at which to have the surgery?

• Personal hospital preference

• Distance the hospital is from your home

• Where your insurance coverage applies

• Hospital's complication rate for the surgery you need

• 7. Please indicate the extent to which you agree or disagree with the following statements. (Using a four-point Likert scale: disagree strongly, disagree somewhat, agree somewhat, agree strongly)

• In order to be permitted to operate at all, a surgeon should be required to perform a minimum number of total operations each year.

• In order to be permitted to perform a specific operation, a surgeon should be required to perform a minimum number of that operation each year.

• 8. For each of the following four surgeries, what do you think should be the minimum number a surgeon should perform per year to be allowed to perform the operation on you? Please enter a numeric response in the box provided.

• Hernia repair surgery

• A minimally complex surgery to fix a bulging of the abdominal contents into the groin. Patients typically go home the same day of their surgery and postoperative complication rate is less than 1%.

• Knee replacement surgery

• A moderately complex surgery to replace an arthritic knee joint with an artificial one. Patients typically spend 1–2 days in the hospital following this surgery and the postoperative complication rate is about 2%.

• Open heart surgery to repair a damaged valve

• A complex surgery that involves opening the chest to access the heart and repair a valve. The heart must stop beating during this procedure so the operation can be performed on a motionless and bloodless field, requiring a device known as a heart-lung bypass machine. Patients typically spend 4-7 days in the hospital following this surgery and postoperative complication rate is about 2%.

• Pancreatic cancer resection surgery

• A highly complex surgery, also known as a Whipple procedure, that involves removal of part of the pancreas, intestines, and stomach to remove pancreatic cancer. Patients typically spend 7–10 days in the hospital following this surgery and postoperative complication rate is about 40%.

• 9. From the following options, please choose "other" and type in "blue."*

• Red

• Orange

• Yellow

• Other:

Please answer the following questions based on this scenario.

Let's say you've been diagnosed with an inguinal hernia, a bulging out of the abdominal contents into the groin. These hernias are common (occurring in 4% of those 45 years and older) and can be repaired by a basic operation. The risk of complication from this surgery is low (less than 1%) and includes pain, bleeding at the site of the suture, recurrence, infection, and testicular complications.

• 10. Please indicate the extent to which you agree or disagree with the following statements. (Using a four-point Likert scale: disagree strongly, disagree somewhat, agree somewhat, agree strongly)

• In order to operate on me, I would need my surgeon to have performed a minimum number of hernia surgeries each year.

• I would feel comfortable asking my surgeon how many hernia repairs s/he does each year.

• 11. Your primary care provider has referred you to a surgeon for your hernia repair. You think to ask this surgeon how many hernia repairs she does per year and s/he tells you 25. What are you likely to do next?

• Proceed with surgery

• Ask the surgeon if that is considered an adequate number

• Do research to decide if that is an adequate number

• Ask someone in health care if that is an adequate number

• Seek out a different surgeon

If “seek out a different surgeon is chosen,” display q 12.

• 12. What is the greatest distance you would be willing to travel from your current hospital to seek out a different surgeon?

• Unwilling to travel at all

• Seek out a different surgeon locally

• Drive 50 miles

• Drive 150 miles

• Fly to another part of the country

Please answer the following questions based on this NEW scenario.

Now, consider if you were diagnosed with pancreatic cancer, a rare (occurring in 1–10 per 100,000 people) but deadly cancer. Only 5% of people are alive 5 years after diagnosis. It can be treated surgically with a major operation known as a Whipple procedure during which parts of the pancreas, stomach, gallbladder, common bile duct, and lymph nodes are removed. The risk of complications from this surgery is high (up to 40%) and includes pancreatic leakage, slowed digestion, internal bleeding, and infection.

• 13. Please indicate the extent to which you agree or disagree with the following statements. (Using a four-point Likert scale: disagree strongly, disagree somewhat, agree somewhat, agree strongly)

• In order to operate on me, I would need my surgeon to have performed a minimum number of Whipple surgeries each year.

• I would feel comfortable asking my surgeon how many Whipple repairs she/he does each year.

• 14. Your primary care provider refers you to a surgeon for your Whipple surgery. You think to ask this surgeon how many Whipples she does per year and she/he tells you 5. What are you likely to do next?

• Proceed with surgery

• Ask the surgeon if that is considered an adequate number

• Do research to decide if that is an adequate number

• Ask someone in health care if that is an adequate number

• Seek out a different surgeon

If “seek out a different surgeon” is chosen, display q 15.

• 15. What is the greatest distance you would be willing to travel from your current hospital to seek out a different surgeon?

• Unwilling to travel at all

• Seek out a different surgeon locally

• Drive 50 miles

• Drive 150 miles

• Fly to another part of the country

The following questions were displayed only to those who said they had had an operation in the last 5 years.

• 16. Earlier you mentioned you've had surgery within the past 5 years. What operation did you have? (If you have had more than one surgery, please describe the most recent one.)

• 17. Before your most recent surgery, did you ask your surgeon directly how many of the operation you needed she/he typically performs each year?

• Yes

• No

• 18. Before your most recent surgery, did you learn how many of the operation you needed your surgeon typically performs each year (whether or not you had asked)?

• Yes

• No

• 19. Using any number from 0 to 10, where 0 is the worst surgeon possible and 10 is the best surgeon possible, what number would you use to rate your care from the surgeon who performed your most recent operation?

End of surgery follow up questions.

• 20. Have you heard, in the news or elsewhere, about a relationship between annual number of surgeries performed (often called volume) and results of surgery (often called outcomes)?

• Yes.

• No.

• 21. Do you have any professional medical training?

• Physician (MD or DO)

• Associate Provider (APRN or PA)

• Nurse (RN, LPN, or equivalent)

• Nurse Aide or Medical Assistant (LNA, CNA, MA, or equivalent)

• Paramedic, EMT, or equivalent

• Other, please specify

• None

Finally, we'd like to ask just a little bit more about you…

• 22. How would you describe your race and ethnicity? (You may choose more than one.)

• Hispanic or Latino

• White

• Black or African American

• Asian (includes East Asian, Southeast Asian, and Indian)

• American Indian or Alaska Native

• Native Hawaiian or Pacific Islander

• Other

• 23. What is the highest level of education you have completed?

• Less than high school diploma/GED

• High school diploma/GED

• Some college, no degree

• College degree

• Advanced degree

• 24. Which of the following best approximates the size of the city or town where you live?

• Urban (>50,000)

• Suburban (10,000 - 50,000)

• Rural (<10,000)

• 25. What type of health insurance do you have?

• None

• Employer-based health insurance

• Private health insurance

• Medicare

• Medicaid

• Other, please specify

• 26. Which of the following best describes your level of employment?

• Employed full-time

• Employed part-time

• Unemployed

• Retired

• Student

• Unable to work

• 27. What is your annual total household income before taxes?

• Less than $25,000

• $25,000–$100,000

• Over $100,000

• N/A or prefer not to say

• 28. If you have any additional thoughts about surgery, choosing a surgeon, requiring a minimum number of surgeries, or anything related, we'd welcome you to share them here.

You've reached the end of the survey! Thanks for taking it. Once you click the arrow at the bottom of this page, your responses will be submitted and you will receive your MTurk validation code.