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Editorial

Measuring the Quality of Surgical Outcomes in General Thoracic Surgery: Should Surgical Volume Be Used to Direct Patient Referrals?

^a Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
^b Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia

^_* Address correspondence to Dr Kozower, University of Virginia Health System, General Thoracic Surgery, PO Box 800679, Charlottesville, VA 22908-0679 (Email: bdk8g@virginia.edu).

The first 300 words of the full text of this article appear below.

	Introduction

 
Surgeons and hospitals face an increasing demand to provide evidence for the quality of care they deliver. However, considerable debate exists regarding which outcomes measures to use to reflect surgical quality [1]. Structural measures are a broad group of variables that reflect the setting in which care is delivered [2]. Volume is one important and easily quantifiable structural measure. Many studies have demonstrated an inverse relationship between the volume of hospital surgical procedures and postoperative mortality. These studies have been used to recommend the regionalization of surgical procedures using selected volume thresholds. However, the volume-outcome relationship is extremely complex, and debate continues as to how it should be used by public and private organizations caring for their patients. This policy analysis examines the evidence regarding volume as a quality indicator for general thoracic surgery and outlines potential unintended consequences of using volume to direct patient referrals.

	Support for the Volume-Outcome Relationship

 
The seminal article describing the relationship between increasing case volume and improved outcomes was published by Luft and colleagues [3] in 1979. They demonstrated that hospitals where certain complicated operations were performed 200 or more times annually had case-adjusted death rates up to 41% lower than hospitals with lower volumes. Numerous articles have supported this volume-outcome hypothesis and Birkmeyer and colleagues [4–6] have published extensive articles on this subject.

Administrative data has been used to illustrate that hospital volume is inversely related to outcome [4]. However, little was known about the possible mechanisms underlying these observed associations. Because high-volume centers tend to be larger facilities, they may have a broader range of specialists, improved technology-based services, better-staffed intensive care units, and other resources not available at smaller centers. Thus, by virtue of their size, high-volume centers may be better equipped to deliver care for . . . [Full Text of this Article]