Variation in outcome of surgical procedures

Abstract

Evidence regarding the relationship between outcome and the number (volume) of patients treated at individual hospitals or by individual surgeons is reviewed and the interplay of other factors such as hospital characteristics, population profiles and referral preferences examined. An inverse relationship between mortality rate and hospital volume has repeatedly been found and, while there have been similar findings for surgeon volume, these results have been less consistent. What is certain is that wide variation in outcome does occur. What is less clear is whether the relationship to volume is a causal one or whether it is due to other factors such as those mentioned above. Despite there being a great deal that we do not understand about these relationships, considerable action has been taken as a result of the studies reported here, in the USA in particular. This has taken the form of rationalization of services, publication of hospital mortality rates and the setting of minimum numbers of specific procedures that should be performed each year by individual surgeons. Understanding of this area should be much greater before rationalization is considered in the name of higher quality and before mortality rates according to hospital or surgeon are published.

Surgeon Volume Versus Morbidity and Cost in Patients Undergoing Pancreaticoduodenectomy in an Academic Community Medical Center

“…However, despite many reports demonstrating improved outcomes when PD is performed at highvolume institutions by high-volume surgeons, there remains a debate in the literature regarding the feasibility and appropriateness of this concept. [21][22][23][24][25][26][27][28][29] Complications following PD can be devastating or even deadly and occur even in the most advanced programs. The ability to predict outcomes, or to at least stratify risk, would be immensely helpful for practitioners, administrators, and patients.…”

Conventional models overestimate the statistical significance of volume–outcome associations, compared with multilevel models

“…This volume-outcome effect is large, consistent across different surgical procedures, study designs, and outcome measures, and persists after adjustment for differences in preexisting patient risk [1][2][3]. The published evidence is so convincing that observers and health policy makers have recommended at least some degree of regionalization of complex surgical procedures to highvolume centers [4,5].…”

Funnel Plots and Their Emerging Application in Surgery

“…It has long been believed that institutions, or indeed surgeons, that undertake greater numbers of particular operations achieve improved surgical outcomes over 'low-volume' institutions. 15 This has precipitated service reconfiguration in the UK, with centralization of specialist services and, similarly in the US, selective referral to high-volume institutions driven by proponent groups such as Leapfrog. 16 The Leapfrog group has placed emphasis on a point cut-off for volume of procedures, such as esophagectomy, coronary artery bypass grafting, and elective abdominal aortic repair that should be undertaken by an institution with the aim of reducing the annual death rate for patients undergoing these procedures.…”