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Ann Thorac Surg 1997;63:917-918
© 1997 The Society of Thoracic Surgeons
1430 Esplanade #10 Chico, CA 95926
To the Editor:
I would like to comment on Parsonnet and Bernstein's letter [1], which I interpreted to imply that high-volume cardiac surgical programs are best. My own view is that more programs with modest volumes are best because they encourage maximum interaction between patient and surgeon while still providing adequate volume to maintain technical proficiency. Analysis of California hospital Medicare data from 1990 to 1993 [2] shows that all three of the top providers in terms of in-hospital and 30-day postdischarge mortality had relatively modest volume (499, 492, and 634 cases).
Institutional resources may become strained in high-volume programs so that what is gained in the operating room may be lost in the preoperative assessment or in the inconsistencies of postoperative care. In some programs surgeons have little involvement in the care of the patient outside of the technical aspects of the operation per se. Surgeons may review angiograms for the first time while the patient is anesthetized. In short, the surgeon-patient relationship is remote and the surgeon no longer takes personal responsibility for all aspects of patient care.
Large programs promote themselves to third-party payors as models of efficiency, but I question whether the Henry Ford approach to medicine translates into optimal patient care. In the analysis cited above [2], the gap between in-hospital and 30-day postdischarge mortality was narrow in modest programs and relatively wide in large programs, and this gap further increased at 6 months and 1 year. This may reflect pressure for early (possibly premature) discharge.
I suggest that future analyses of these issues might do well to examine postdischarge results as well as in-hospital mortality. Just as a minimum volume of cardiac operations may be suggested, perhaps there is a maximum caseload beyond which our so-called efficiencies may translate into poor care for the individual patient.
References
New Jersey Pacemaker and Defibrillation Evaluation Center, Inc Newark Beth Israel Medical Center 201 Lyons Ave at Osborne Terrace Newark, NJ 07112
Reply
To the Editor:
Doctor Becker's comments regarding volume of operations versus quality are entirely appropriate and correct. In fact, if he will reexamine the data that were shown in my brief note, he will see that although the curve of outcome versus volume indicates that there is a general relationship, there were many hospitals with low volumes that had excellent results, as indicated by low mortality rates. The same is true in comparing surgeons in New Jersey, where some of the less busy surgeons have almost no surgical mortality while some of the busier ones have risk-adjusted mortality rates that are quite high. Nevertheless, this does not negate the generalization that there is a relationship between volume and quality. This generalization suggests that we should strive for a volume standard of some sort, but it is not easy to define that standard precisely.
Reducing Dr Becker's argument to an absurdity, would one expect a surgeon performing one case a month to react rapidly and appropriately upon encountering an unusual emergent problem in the course of an operation? The chance of making the right moves certainly would be better in the hands of the surgeon who does one or two cases a day. Practice makes perfect (but it does not equal perfect).
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