Leapfrog Group Research Articles

Hospital commitments to address diagnostic errors: An assessment of 95 US hospitals.

Diagnostic errors are a leading cause of patient harm. In 2022, the Leapfrog Group published a report containing 29 evidence-based practices that hospitals can adopt to reduce diagnostic errors. To understand the extent to which US hospitals have already implemented these practices, we conducted a national pilot survey of Leapfrog-participating hospitals. To reduce respondent burden, we divided the 29 practices across two surveys: one focused on organizational culture and structure (Domain 1), and the second focused on the diagnostic process itself (Domain 2). A total of 95 hospitals from 23 states responded to one or both surveys. On average, hospitals reported implementing 9 of the 16 practices (56%) in Domain 1 and 8 of the 13 practices (62%) in Domain 2. The rate of practice implementation varied greatly, with some hospitals implementing as few as threepractices in their domain. The most commonly implemented practices were ensuring access to medical interpreters, continuous access to radiologists, ensuring staff and patients can report diagnostic errors and concerns, and having a formal process to identify and notify patients when diagnostic errors occur. The least implemented practices included convening a multidisciplinary team focused on diagnostic safety and quality, a CEO commitment to diagnostic excellence, conducting diagnosis-focused risk assessments, and training clinicians to optimize clinical reasoning in the diagnostic process. The findings suggest large and important implementation gaps for practices related to diagnostic excellence and can inform new initiatives to promote diagnostic excellence in US hospitals.

Digital Maturity as a Predictor of Quality and Safety Outcomes in US Hospitals: Cross-Sectional Observational Study.

This study demonstrates that digital maturity contributes to strengthened quality and safety performance outcomes in US hospitals. Advanced digital maturity is associated with more digitally enabled work environments with automated flow of data across information systems to enable clinicians and leaders to track quality and safety outcomes. This research illustrates that an advanced digitally enabled workforce is associated with strong safety leadership and culture and better patient health and safety outcomes. This study aimed to examine the relationship between digital maturity and quality and safety outcomes in US hospitals. The data sources were hospital safety letter grades as well as quality and safety scores on a continuous scale published by The Leapfrog Group. We used the digital maturity level (measured using the Electronic Medical Record Assessment Model [EMRAM]) of 1026 US hospitals. This was a cross-sectional, observational study. Logistic, linear, and Tweedie regression analyses were used to explore the relationships among The Leapfrog Group's Hospital Safety Grades, individual Leapfrog safety scores, and digital maturity levels classified as advanced or fully developed digital maturity (EMRAM levels 6 and 7) or underdeveloped maturity (EMRAM level 0). Digital maturity was a predictor while controlling for hospital characteristics including teaching status, urban or rural location, hospital size measured by number of beds, whether the hospital was a referral center, and type of hospital ownership as confounding variables. Hospitals were divided into the following 2 groups to compare safety and quality outcomes: hospitals that were digitally advanced and hospitals with underdeveloped digital maturity. Data from The Leapfrog Group's Hospital Safety Grades report published in spring 2019 were matched to the hospitals with completed EMRAM assessments in 2019. Hospital characteristics such as number of hospital beds were obtained from the CMS database. The results revealed that the odds of achieving a higher Leapfrog Group Hospital Safety Grade was statistically significantly higher, by 3.25 times, for hospitals with advanced digital maturity (EMRAM maturity of 6 or 7; odds ratio 3.25, 95% CI 2.33-4.55). Hospitals with advanced digital maturity had statistically significantly reduced infection rates, reduced adverse events, and improved surgical safety outcomes. The study findings suggest a significant difference in quality and safety outcomes among hospitals with advanced digital maturity compared with hospitals with underdeveloped digital maturity.

Hospital Rating Organizations' Quality and Patient Safety Scores: Analysis of Result Discrepancies.

In the USA, multiple organizations rate hospitals based on quality and patient safety data, but few studies have analyzed and compared the rating results. Compare the results of different US hospital-rating organizations. Observational data analysis of US acute care hospital ratings. Four rating organizations: Hospital Compare® (HC), Healthgrades® (HG), The Leapfrog Group® (Leapfrog), and US News and World Report® (USN). We analyzed the level of concordance (similar ranking), discordance (difference of 1 or more rankings), and severe discordance (difference of two or more rankings), as well as differences and correlations between the scores. From Feb 1 to Oct 3, 2023, we analyzed data from 2,384 hospitals. In Leapfrog, there were 688 hospitals (29%) with Grade A, 652 (27.3%) with B, 885 (37.1%) with C, 153 (6.4%) with D, and 6 (0.3%) with F. For HC, 333 hospitals (14%) had five stars, 676 (28.4%) four, 695 (29.2%) three, 502 (21.4%) two, and 171 (7.2%) one-star. In ratings between HC and Leapfrog, discordance was 70%, and severe discordance was 25.1%. USN ranked 469 hospitals (19.7%). Within the USN-ranked hospital group, there was a 62% discordance and 19.8% severe discordance between HC and Leapfrog. The analysis of orthopedic procedures from HG and USN showed discordance ranging from 48 to 61.2%. The rating organizations' reported metrics were highly discordant. A hospital's ranking by one organization frequently did not correspond to a similar ranking by another. The methodology and included timeline and patient population can help explain the differences. However, the discordant ratings may confuse patients and customers.

Low-Volume Elective Surgery and Outcomes in Medicare Beneficiaries Treated at Hospital Networks

Minimum volume standards have been advocated as a strategy to improve outcomes for certain surgical procedures. Hospital networks could avoid low-volume surgery by consolidating cases within network hospitals that meet volume standards, thus optimizing outcomes while retaining cases and revenue. The rates of compliance with volume standards among hospital networks and the association of volume standards with outcomes at these hospitals remain unknown. To quantify low-volume surgery and associated outcomes within hospital networks. This cross-sectional study used Medicare Provider Analysis and Review data to examine fee-for-service beneficiaries aged 66 to 99 years who underwent 1 of 10 elective surgical procedures (abdominal aortic aneurysm repair, carotid endarterectomy, mitral valve repair, hip or knee replacement, bariatric surgery, or resection for lung, esophageal, pancreatic, or rectal cancers) in a network hospital from 2016 to 2018. Hospital volume for each procedure (calculated with the use of the National Inpatient Sample) was compared with yearly hospital volume standards for that procedure recommended by The Leapfrog Group. Networks were then categorized into 4 groups according to whether or not that hospital or another hospital in the network met low-volume standards for that procedure. Data were analyzed from February to June 2023. Receipt of surgery in a low-volume hospital within a network. Primary outcomes were postoperative complications, 30-day readmission, and 30-day mortality, stratified by the volume status of the hospital and network type. The secondary outcome was the availability of a different high-volume hospital within the same network or outside the network and its proximity to the patient (based on hospital referral region and zip code). In all, data were analyzed for 950 079 Medicare fee-for-service beneficiaries (mean [SD] age, 74.4 [6.5] years; 621 138 females [59.2%] and 427 931 males [40.8%]) who underwent 1 049 069 procedures at 2469 hospitals within 382 networks. Of these networks, 380 (99.5%) had at least 1 low-volume hospital performing the elective procedure of interest. In 35 137 of 44 011 procedures (79.8%) that were performed at low-volume hospitals, there was a hospital that met volume standards within the same network and hospital referral region located a median (IQR) distance of 29 (12-60) miles from the patient's home. Across hospital networks, there was 43-fold variation in rates of low-volume surgery among the procedures studied (from 1.5% of carotid endarterectomies to 65.0% of esophagectomies). In adjusted analyses, postoperative outcomes were inferior at low-volume hospitals compared with hospitals meeting volume standards, with a 30-day mortality of 8.1% at low-volume hospitals vs 5.5% at hospitals that met volume standards (adjusted odds ratio, 0.67 [95% CI, 0.61-0.73]; P < .001). Findings of this study suggest that most US hospital networks had hospitals performing low-volume surgery that is associated with inferior surgical outcomes despite availability of a different in-network hospital that met volume standards within a median of 29 miles for the vast majority of patients. Strategies are needed to help patients access high-quality care within their networks, including avoidance of elective surgery at low-volume hospitals. Avoidance of low-volume surgery could be considered a process measure that reflects attention to quality within hospital networks.

Implementing a health-system–wide antibiotic stewardship program in ambulatory surgery centers

Background: In 2016, the CDC released the Core Elements of Outpatient Antibiotic Stewardship, which extended the requirements previously released for hospital facilities and nursing homes to the outpatient setting. Several regulatory agencies focused on outpatient antimicrobial use. However, The Joint Commission and the Ambulatory Surgery Center (ASC) Leapfrog Group excluded ambulatory surgery centers from their medication management standards and questions. Due to the public health and patient safety benefits of implementing an antimicrobial stewardship program (ASP) and increasing regulatory interest in the matter, the Hospital Corporation of America (HCA) Ambulatory Surgery Division formally launched a nationwide ASP for its ambulatory surgery centers in March 2021. Methods: HCA is a large healthcare system with 146 ASCs in 16 states in 2021. The structure of the ASCs are local surgery centers with a medical director, a nurse responsible for infection prevention, and a pharmacist at a regional level. The types of surgeries vary based on location and ASC site. In 2019, a multidisciplinary team formed the corporate planning committee. The program was modeled after the CDC Core Elements and The Joint Commission’s requirements for an ASP. Each ASC was asked to build a local ASP team, led by a local physician and a regionally based pharmacist. In addition, a stewardship goal was established to update all preoperative antibiotic surgical-site infection prophylaxis order sets. The corporate committee provided educational resources, including evidence-based guidelines for appropriate antibiotic selection for surgical-site infections. They collected antibiotic cost per case as a baseline metric to track and analyze. Pediatric, ophthalmic, and gastrointestinal endoscopic procedures were excluded from the program. Results: From January 1, 2020, through December 31, 2021, including only centers that were operational during this period and excluding single specialty endoscopy centers, antibiotic cost per case decreased annually from $2.38 to $1.84 (t = 4.157; P &lt; .005), and the postoperative infection rate also declined from 0.370 to 0.304 (t = 2.079; P = .040). Conclusions: Our findings suggest that implementing a health-system–wide outpatient antibiotic stewardship program in the ambulatory surgery center setting is feasible and may contribute to decreased antibiotic cost per case and improved postoperative surgical site infection rates.Disclosures: None

Development of the Leapfrog Group's Bar Code Medication Administration Standard to Address Hospital Inpatient Medication Safety.

Medication errors are the most common type of error in hospitals and reflect a leading cause of avoidable harm to patients. Bar code medication administration (BCMA) systems are a technology designed to help intercept medication errors at the point of medication administration. This article describes the process of developing, testing, and refining a standard for BCMA adoption and use in U.S. hospitals, as measured through the Leapfrog Hospital Survey. Building on the published literature and an expert panel's collective experience in studying, implementing, and using BCMA systems, the expert panel recommended a standard with 4 key domains. Leapfrog's BCMA standard provides hospitals with a "how-to guide" on what best practice looks like for using BCMA to ensure safe medication administration at the bedside.

Minimum Volume Standards for Surgical Care of Early-Stage Lung Cancer: A Cost-Effectiveness Analysis

BackgroundMultiple stakeholders have advocated for minimum volume standards for complex surgical procedures. The Leapfrog Group recommends that patients with non–small cell lung cancer (NSCLC) receive surgical resection at hospitals that perform at least 40 lung resections annually. However, the cost-effectiveness of this paradigm is unknown. MethodsA cost-effectiveness analysis was performed on 90-day and 5-year horizons for patients with clinical stage I NSCLC undergoing surgical resection at hospitals stratified by Leapfrog standard. Model inputs were derived from either the literature or a propensity score–matched cohort using the National Cancer Database. For the 5-year horizon, we simulated using a Markov model with 1-year cycle. Incremental cost-effectiveness ratio (ICER) was calculated to evaluate cost-effectiveness. ResultsFor the 90-day horizon, resection at a Leapfrog hospital was more costly ($25 567 vs $25 530) but had greater utility (0.185 vs 0.181 quality-adjusted life-years), resulting in an ICER of 10 506. Similarly, for the 5-year horizon, resection at a Leapfrog hospital was more costly ($26 600 vs $26 495) but more effective (3.216 vs 3.122 quality-adjusted life-years), resulting in an ICER of 1108. When the costs for long-distance travel, lodging, and loss of productivity for caregivers were factored in, the ICER was 20 499 during the 5-year horizon for resection at Leapfrog hospitals. Using a willingness-to-pay threshold of $50 000, resection at a Leapfrog hospital remained cost-effective. ConclusionsReceiving surgery for clinical stage I NSCLC at hospitals that meet Leapfrog volume standards is cost-effective. Payers and policymakers should consider supporting patient and caregiver travel to higher volume institutions for lung cancer surgery.

Making Healthcare Safe: The Story of the Patient Safety Movement

Making Healthcare Safe: The Story of the Patient Safety Movement

ANCC Pathway to Excellence® now included in the Leapfrog Hospital Survey

ANCC Pathway to Excellence® now included in the Leapfrog Hospital Survey

Access to High-Volume Hospitals for High-Risk Cancer Surgery for Racial and Ethnic Minoritized Groups.

High-volume hospitals have been associated with better outcomes for high-risk cancer surgeries, although concerns exist concerning inequitable access to these high-volume hospitals. We assessed tendencies in access to high-volume hospitals for 4 (lung, pancreatic, rectal, esophageal) high-risk cancer surgeries for Black and Hispanic patients in the National Cancer Database. Hospitals were classified as high volume according to Leapfrog Group volume thresholds. Odds of accessing high-volume hospitals increased over time for Black and Hispanic patients for 3 surgeries, but Black patients had lower probabilities of undergoing a pancreatectomy, proctectomy, or esophagectomy at high-volume hospitals than non-Black patients (eg, 2016 pancreatectomy rate: 49.0% [95% confidence interval (CI) = 45.4% to 52.5%] vs 62.3% [95% CI = 61.1% to 63.5%]). Although for Hispanics the gap narrowed for lung resection and pancreatectomy, these populations continued to have lower probabilities of accessing high-volume hospitals than non-Hispanic patients (eg, 2016 pancreatectomy: 48.8% [95% CI = 44.1% to 53.5%] vs 61.6% [95% CI = 60.5% to 62.8%]). Despite increased access to high-volume hospitals for high-risk cancer surgeries, ongoing efforts to improve equity in access are needed.

Surgical Residency Programs Should Leverage Recent Advances in National Policy, Real-World Data, and Public Opinion to Improve Post-Surgery Opioid Prescribing.

Surgical Residency Programs Should Leverage Recent Advances in National Policy, Real-World Data, and Public Opinion to Improve Post-Surgery Opioid Prescribing.

Equity360: Gender, Race, and Ethnicity: Our "Best Hospitals" Rank Poorly in Health Equity.

Equity360: Gender, Race, and Ethnicity: Our "Best Hospitals" Rank Poorly in Health Equity.

Short and Long-term Outcomes Among High-Volume vs Low-Volume Esophagectomy Surgeons at a High-Volume Center

To determine associations between surgeon volume and esophagectomy outcomes at a high-volume institution. All esophagectomies for esophageal cancer at our institution from August 2005 to August 2019 were reviewed. Cases were divided by surgeon into low, <7 cases/year, vs high volume, ≥7 cases/year, based on Leapfrog Group recommendations. Surgeons remained 'high-volume' after one year of ≥7 cases. Demographics, comorbidities, course of care, and long-term outcomes were compared. In total, 1029 cases were evaluated; 120 performed by low-volume surgeons vs 909 by high-volume surgeons. Never-smokers, atrial fibrillation, and clinical Stage IVa patients were associated with high-volume surgeons. Other demographics were similar. Low-volume surgeons did more open cases, 45.8% vs 14.5%, P < 0.01. Low-volume surgeons had more complications than high-volume surgeons (71.7% vs 57.6%, P < 0.01), specifically Grade II and III (59.2% vs 46.8%, P=0.01, and 44.2% vs 27.0%, P <0.01). No differences were seen in anastomotic leak rate, 90-day mortality, recurrences, 5-year overall survival (46.7% low-volume vs 49.3% high-volume, P=0.64), or 5-year disease-free survival (35.7% low-volume vs 42.2% high-volume, P=0.27). In multivariable logistic regression for Grade III or higher complications, high-volume surgeons had an odds ratio of 0.56 (95% confidence interval 0.36-0.87) for complications. Our study found higher rates of open esophagectomies and complications in low-volume esophagectomy surgeons compared to high-volume surgeons at the same, high-volume institution. However, low-volume surgeons were not associated with worse survival outcomes compared to high-volume surgeons. Low-volume esophagectomy surgeons may benefit from mentoring and support to improve perioperative outcomes; these efforts are underway at our institution.

Hospital Volume Counts for Ruptured Abdominal Aortic Aneurysm Repair: Evolving Data from a Meta-Analysis

Kontopodis et al.1 provide a contemporary perspective on the volume outcome relationship with ruptured abdominal aortic aneurysm (AAA) repair. To date, several publications have examined centre and surgeon volume association with both elective and non-elective AAA repair outcomes. The importance of this issue is underscored by the fact that professional societies and watchdog organisations endorse specific and often conflicting volume thresholds for elective repair, presumptively to serve as proxies for high quality care, without recommendations for ruptured presentations (European Society for Vascular Surgery: surgeon ≥ 10, centre ≥ 30 procedures/year; International Consortium of Vascular Registries: surgeon not applicable, centre ≥ 13–16; Society for Vascular Surgery: surgeon not applicable, centre ≥ 10; Leapfrog Group: surgeon ≥ 10, centre ≥ 15).

The Development and Piloting of the Ambulatory Electronic Health Record Evaluation Tool: Lessons Learned.

Substantial research has been performed about the impact of computerized physician order entry on medication safety in the inpatient setting; however, relatively little has been done in ambulatory care, where most medications are prescribed. To outline the development and piloting process of the Ambulatory Electronic Health Record (EHR) Evaluation Tool and to report the quantitative and qualitative results from the pilot. The Ambulatory EHR Evaluation Tool closely mirrors the inpatient version of the tool, which is administered by The Leapfrog Group. The tool was piloted with seven clinics in the United States, each using a different EHR. The tool consists of a medication safety test and a medication reconciliation module. For the medication test, clinics entered test patients and associated test orders into their EHR and recorded any decision support they received. An overall percentage score of unsafe orders detected, and order category scores were provided to clinics. For the medication reconciliation module, clinics demonstrated how their EHR electronically detected discrepancies between two medication lists. For the medication safety test, the clinics correctly alerted on 54.6% of unsafe medication orders. Clinics scored highest in the drug allergy (100%) and drug-drug interaction (89.3%) categories. Lower scoring categories included drug age (39.3%) and therapeutic duplication (39.3%). None of the clinics alerted for the drug laboratory or drug monitoring orders. In the medication reconciliation module, three (42.8%) clinics had an EHR-based medication reconciliation function; however, only one of those clinics could demonstrate it during the pilot. Clinics struggled in areas of advanced decision support such as drug age, drug laboratory, and drub monitoring. Most clinics did not have an EHR-based medication reconciliation function and this process was dependent on accessing patients' medication lists. Wider use of this tool could improve outpatient medication safety and can inform vendors about areas of improvement.

Modeling Patient Access to High-Volume Surgeons for Carotid Endarterectomy

Multiple studies demonstrate an association between surgeon, hospital volume, and the outcomes of “high-risk” surgery, such as carotid endarterectomy (CEA). These findings have resulted in the creation of surgeon volume standards. The Leapfrog Group, for example, recommends an annual surgeon volume threshold of 10 CEAs per year. In this study, we link Medicare data to high-accuracy geolocation and navigation data sets to evaluate variation in accessibility to high-volume surgeons (HVSs) and develop models for predicting the impact of changes to the surgical workforce.

National Trends in the Safety Performance of Electronic Health Record Systems From 2009 to 2018

Despite the broad adoption of electronic health record (EHR) systems across the continuum of care, safety problems persist. To measure the safety performance of operational EHRs in hospitals across the country during a 10-year period. This case series included all US adult hospitals nationwide that used the National Quality Forum Health IT Safety Measure EHR computerized physician order entry safety test administered by the Leapfrog Group between 2009 and 2018. Data were analyzed from July 1, 2018 to December 1, 2019. The Health IT Safety Measure test, which uses simulated medication orders that have either injured or killed patients previously to evaluate how well hospital EHRs could identify medication errors with potential for patient harm. Descriptive statistics for performance on the assessment test over time were calculated at the overall test score level, type of decision support category level, and EHR vendor level. Among 8657 hospital-years observed during the study, mean (SD) scores on the overall test increased from 53.9% (18.3%) in 2009 to 65.6% (15.4%) in 2018. Mean (SD) hospital score for the categories representing basic clinical decision support increased from 69.8% (20.8%) in 2009 to 85.6% (14.9%) in 2018. For the categories representing advanced clinical decision support, the mean (SD) score increased from 29.6% (22.4%) in 2009 to 46.1% (21.6%) in 2018. There was considerable variation in test performance by EHR. These findings suggest that despite broad adoption and optimization of EHR systems in hospitals, wide variation in the safety performance of operational EHR systems remains across a large sample of hospitals and EHR vendors. Hospitals using some EHR vendors had significantly higher test scores. Overall, substantial safety risk persists in current hospital EHR systems.

Correlation of Proposed Surgical Volume Standards for Complex Cancer Surgery with Hospital Mortality

Minimum case volume thresholds for complex cancer operations have been proposed by the Leapfrog Group. There has been no formal study of how these standards correlate with actual hospital mortality. The National Cancer Database was used to identify patients undergoing operations for esophageal, lung, pancreatic, and rectal cancer between 2013 and 2015. Recommended annual hospital case volume was used to divide hospitals into those meeting a minimum volume threshold (VT) and those below it. Hospitals in the highest quartile of adjusted hospital mortality were designated as poor performing hospitals (PPHs). Sensitivity, specificity, negative predictive value, and positive predictive value of current minimum VTs to predict PPHs were calculated. The proportion of hospitals meeting minimum VTs varied from 7% for esophagectomy to 27% for rectal operations. Proposed minimum VTs had a sensitivity of 69% to 93%, specificity of 7% to 27%, and area under the curve of 0.59 to 0.65 for identifying PPHs. Although the negative predictive value varied from 72% to 79%, the positive predictive value was only 24% to 26%. Optimal minimum VTs to identify PPHs were lower than those currently proposed-esophagus was 4 vs 20, lung was 21 vs 40, pancreas was 7 vs 20, and rectum was 8 vs 16. Even under these idealized volume cutoffs, the best performing procedure-specific model (esophagus) had an area under the curve of 0.68. Although proposed minimum VTs are reasonably good at identifying PPHs, they misclassify 3 of 4 hospitals below the minimum VT as PPHs and 1 of 4 PPHs as meeting the minimum VT. Use of case volume cutoffs alone does not correlate well with actual hospital mortality.

Can Public Reporting Cure Healthcare? The Role of Quality Transparency in Improving Patient–Provider Alignment

In the past two decades, government and private organizations have ramped up efforts to measure and publicly report clinical outcomes, a practice known as “public reporting.” For example, in 2005 the Center for Medicare and Medicaid Services launched the website Hospital Compare with share outcome data. Other sites, including CalHospitalCompare.org , the ProPublica Surgeon Scorecard, the Compare Hospitals site by the Leapfrog Group, and the hospital-rating websites of Healthgrades, Consumer Reports, Yelp, and U.S. News, have provided similar information. Despite making more and more information available, empirical evidence suggests that the reality of public reporting has fallen short of the promise. In “Can Public Reporting Cure Healthcare? The Role of Quality Transparency in Improving Patient-Provider Alignment” S. Saghafian and W. J. Hopp use a model of the impact of quality transparency via public reporting to generate insights into why previous efforts have been less than fully successful and to suggest ways in which future efforts can be more effective.

Does one size fit all? An evaluation of the 2018 Leapfrog Group minimal hospital and surgeon volume thresholds for lung surgery

BackgroundIn 2018, the Leapfrog Group set minimum annual lung cancer surgery hospital and surgeon volume thresholds of 40 and 15, respectively. We examined whether outcomes associated with these Leapfrog Group volume thresholds are comparable for patients at the extremes of age and comorbidities. MethodsWe assessed lung cancer patients undergoing lobectomy or pneumonectomy in the New York and Florida State Inpatient Databases for 2007 to 2013. Multivariate logit models evaluated in-hospital mortality, complications, and prolonged length of stay. Median surgeon and hospital volumes were compared between “younger-healthier” (age 18-60 years, Elixhauser Comorbidity Index <1) and “older-sicker” patients (age >77 years, Elixhauser Comorbidity Index >3). ResultsThe 27,841 patients included 13,277 men (48%). The median patient age was 69 years (interquartile range, 61-77), and mortality was 2.1%. Patients treated by both low-volume surgeons (<15 annual cases) and at low-volume hospitals (<40) had the greatest risk of mortality (2.5%), except for the cohort of younger-healthier patients (mortality <2%). Mortality for older-sicker patients was highest for high-volume surgeons (12%), although higher hospital volume was protective. Increasing hospital volume was associated with decreased mortality (odds ratio [OR], 0.997; 95% confidence interval [CI], 0.995-0.998; P = .0103), complications (OR, 0.998; 95% CI, 0.997-0.999; P < .001), and prolonged length of stay (OR, 0.998; 95% CI, 0.997-1.00; P = .01); similarly, higher surgeon volume was associated with decreased mortality (OR, 0.997; 95% CI, 0.99-1.00; P = .03), complications (OR, 0.997; 95% CI, 0.994-1.00; P = .02), and prolonged length of stay (OR, 0.991; 95% CI, 0.986-0.995; P < .01). ConclusionsHospital volume has a greater effect on morbidity and mortality than surgeon volume especially for older-sicker patients, suggesting that Leapfrog Group volume guidelines should emphasize hospital volume over surgeon volume and may be less relevant for younger-healthier patients.