Leapfrogging quality – can anyone play?

Second of two parts

Leapfrog as a child’s game is a benign thing, involving children leaping, and laughing, and falling in happy heaps. As a national initiative to improve care in American hospitals, however, it represents a potential threat to the survival of small hospitals, urban and rural, for whom the Leapfrog Initiative is not a game, but a real threat to be flattened.

The Leapfrog Initiative is a national effort by some of America’s biggest businesses to push hospitals into adopting specific steps to improve patient care. The initiative’s proponents estimate that three of these steps together could annually prevent 58,000 hospital patient deaths due to medical errors. The Leapfrog Initiative will ultimately steer patients of its member businesses toward hospitals that adopt these steps and away from those that do not “play.”

The specific steps, and the Leapfrog Initiative’s economic model of forcing hospital adoption of them, could ultimately diminish quality of care at small hospitals. Each of the Leapfrog Initiative’s quality steps may be good medicine for individual hospital care; the question for small and rural hospitals is whether the Leapfrog Initiative’s medicine for health care amounts to a fatal overdose for them.

The steps each pose a challenge:

1. Computerized physician order entry (CPOE) – this system, in which physicians enter their orders into a computer instead of scrawling them on sheets of paper, should reduce medication errors in hospital patients. The challenge of the computerized order entry pill, one that most modern American businesses have already swallowed, is its multi-million-dollar cost. Despite that, CPOE is one Leapfrog step that every hospital should take.

2. Evidence-based referral (EBR) – high-risk surgical procedures are referred only to those doctors and hospitals that do many of them, so their patients theoretically have fewer complications and better outcomes. Small hospitals that have surgeons who do those high-risk procedures, but probably not a certain threshold number, would lose those patients and that business as employers steered their employees to bigger hospitals with higher volumes.

EBR poses a particular threat to small hospitals. There is no cadre of surgeons out there trained just to practice in small hospitals where only low-risk surgical procedures are done. Surgeons who cannot do procedures they like to do because the local Leapfrog businesses are sending patients who need those procedures out of town may either leave the hospital or not even consider coming to it in the first place. Getting and keeping good surgeons is a challenge for small hospitals, especially in rural areas, and the loss of even one can be devastating. A hospital without a good general surgeon, for example, has a hard time even being a hospital. The patients leave, the relatively lucrative business of general surgery leaves, and the tapestry of hospital medical care starts to unravel.

Most frightening of all, when the general surgeon leaves there may be no one to take care of general surgical emergencies such as trauma, which arrive unexpectedly in the emergency department. Evidence-based referral sounds good, and may be the right approach for some patients, but perhaps not for the critically ill patient who will not survive transfer to another hospital and for whom there is no surgeon left in town to haul the patient back from the brink.

3. Intensive care physician staffing in the Intensive Care Unit (ICU) – a hospital’s intensive care unit is staffed with specialists in intensive care medicine, with those specialists in the hospital during the day and rapidly available at night. The problem for small hospitals is that such specialists are in short supply, are very expensive, and most want to practice in larger hospitals. If the presence of ICU specialists is a requirement for the care of ICU patients, most small hospitals will ultimately have to transfer ICU patients to larger hospitals and perhaps close their ICUs.

What is a small hospital without an intensive-care unit and without surgeons who do high-risk procedures? In America, not many of us know the answer to that question, because there are few such hospitals. Even the federally supported concept of critical access hospitals is less restricted than this. Can such a hospital meet the needs of a small community, especially the emergent needs and those of patient care close to home? Are the patients of a small community better off getting theoretically better care for complicated procedures at urban medical centers if the price is less care available when they are in a medical crisis close at home?

Those are some of the fundamental, and unanswered, questions posed by the Leapfrog Initiative. Its vision of how hospital quality should be improved may be incompatible with the survival of many of the small hospitals that are the backbone of medical care in the communities they serve. However, given the orientation of the Leapfrog Initiative businesses to the urban centers and large hospitals where most of their employees get care, and the economic motivation behind the Initiative, America’s small hospitals may be on their own when it comes to answering those questions.

A model that establishes big hospital islands of high-quality health care far apart in a sea of inadequate small hospital resources may, in the long run, primarily save lives of the lucky, urban, insured and well-connected. What about the rest of us?

Do we just take a flying Leap?

Erik Steele, D.O. is a physician in Bangor, an administrator at Eastern Maine Medical Center, and is on the staff of several hospital emergency rooms in the region.