The Volume-Outcome Relationship: From Luft to Leapfrog

Department of Thoracic and Cardiovascular Surgery, Lahey Clinic, Burlington, Massachusetts 01805, USA.
The Annals of Thoracic Surgery (Impact Factor: 3.63). 04/2003; 75(3):1048-58. DOI: 10.1016/S0003-4975(02)04308-4
Source: PubMed

ABSTRACT Numerous reports have documented a volume-outcome relationship for complex medical and surgical care, although many such studies are compromised by the use of discharge abstract data, inadequate risk adjustment, and problematic statistical methodology. Because of the volume-outcome association, and because valid outcome measurements are unavailable for many procedures, volume-based referral strategies have been advocated as an alternative approach to health-care quality improvement. This is most appropriate for procedures with the greatest outcome variability between low-volume and high-volume providers, such as esophagectomy and pancreatectomy, and for particularly high-risk subgroups of patients. Whenever possible, risk-adjusted outcome data should supplement or supplant volume standards, and continuous quality improvement programs should seek to emulate the processes of high-volume, high-quality providers. The Leapfrog Group has established a minimum volume requirement of 500 procedures for coronary artery bypass grafting. In view of the questionable basis for this recommendation, we suggest that it be reevaluated.

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    • "If high hospital volume reduces patient mortality then a case can be made for closing small hospitals and regionalizing care. (Shahian, 2003, Birkmeyer, 2002) On the other hand, if " selective referral " explains the relationship between volume and outcome then regionalization could actually worsen outcomes if the wrong hospitals are chosen for expansion. The benefits of regionalization must also be weighed against the cost of transporting patients over long distances, (Birkmeyer, 2003) so knowing the magnitude of the " practice makes perfect " effect is important. "
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    • "In addition, Hand and colleagues (1991) found that urban hospitals with more poorly insured patients were associated with late diagnoses of breast cancer. Higher volume hospitals, particularly the volume of specific procedures, seem to show better patient outcomes, indicating the presence of more practiced care providers (Allareddy, Allareddy, & Konety, 2007; Shahian & Normand, 2003). And, ethnic minorities were more likely to receive care in lower volume hospitals and were less likely to be referred to specialists in high-volume hospitals compared with white patients (Trivedi, Sequist, & Ayanian, 2006). "
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    • "A cost to regionalization is the effect it has on access to surgery for patients (Norton et al. 1998; Shahian and Normand 2003). Centralization of surgery services has the potential of increasing travel times for many patients, especially in rural areas. "
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