Ann Thorac Surg 2008;85:1840-1841. doi:10.1016/j.athoracsur.2007.10.019
© 2008 The Society of Thoracic Surgeons
Correspondence
Hospital Volume as a Quality Standard in Lung Cancer Surgery: An Unfinished Debate
Wilson W.L. Li, MD,
Bas A.J.M. de Mol, MD, PhD
Department of Cardiothoracic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
(Email: b.a.demol{at}amc.uva.nl).
To the Editor:
We read with great interest the article by Sundaresan and associates [1], proposing quality standards for centers performing thoracic surgical oncology. Regarding lung cancer surgery, the authors attempted to set hospital volume criteria, recommending a target of 150 anatomic pulmonary resections per year for level 1 centers, and at least 50 per year for level 2. We have two comments. First of all, the title of the article states that these standards are meant for countries with single-payer healthcare systems, as implemented in Canada, the Netherlands, and most European countries. However, most of their evidence originates from database studies derived from the United States, where such a universal health care system is absent. As previously emphasized in a review by Urbach and associates [2], the healthcare system in the United States could promote competition between hospitals and providers, overexposing any possible variations in quality of care. Indeed, while most United States-based publications have found an association between higher hospital volume and lower hospital mortality after lung cancer surgery, this relationship has yet to be confirmed in European reports. In our own volume-outcome study using data from the Amsterdam Cancer Registry with 1,815 patients, we also failed to find such an association (data submitted for publication).
Secondly, in a recent supplement from The Annals of Thoracic Surgery [3], the Quality Measurement Task Force assembled by the Society of Thoracic Surgeons has published guidelines on quality measurement in adult cardiac surgery. They propose that quality assessments should assess each of Donabedian's three domains of quality: (1) structure, (2) process, and (3) outcomes. For thoracic surgical oncology, Sundaresan and associates [1] have set only standards for structural features and organization of thoracic surgical oncology. However, we believe that outcome-related endpoints are the most important to patients, and these should form an essential part in assessment of quality of care. Although the authors suggest that the implementation of their standards will result in better patient outcomes, their structural standards for quality are no substitute for properly case mix-adjusted outcome measures such as surgical resection rate, hospital mortality, rate of (neo)adjuvant therapy, and ultimately, long-term survival. We eagerly await the efforts to formulate benchmarks and standards to assess process- and outcome-related quality of care after lung cancer surgery.
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References
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- Sundaresan S, Langer B, Oliver T, Schwartz F, Brouwers M, Stern H, Expert Panel on Thoracic Surgical Oncology Standards for thoracic surgical oncology in a single-payer healthcare system Ann Thorac Surg 2007;84:693-701.[Abstract/Free Full Text]
- Urbach DR, Croxford R, MacCallum NL, Stukel TA. How are volume-outcome associations related to models of health care funding and delivery?. A comparison of the United States and Canada. World J Surg 2005;29:1230-1233.[Medline]
- Shahian DM, Edwards FH, Ferraris VA, et al. Society of Thoracic Surgeons Quality Measurement Task Force Quality measurement in adult cardiac surgery: part 1: conceptual framework and measure selection Ann Thorac Surg 2007;83(Suppl 4):S3-S12.[Free Full Text]
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- Sudhir Sundaresan, Tom Oliver, Farrah Schwartz, Hartley Stern, Bernard Langer, and Melissa Brouwers
Ann. Thorac. Surg. 2008 85: 1841-1842.
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