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ABSTRACT

Background Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is disputed.

Methods Using information from the national Medicare claims data base and the Nationwide Inpatient Sample, we examined the mortality associated with six different types of cardiovascular procedures and eight types of major cancer resections between 1994 and 1999 (total number of procedures, 2.5 million). Regression techniques were used to describe relations between hospital volume (total number of procedures performed per year) and mortality (in-hospital or within 30 days), with adjustment for characteristics of the patients.

Results Mortality decreased as volume increased for all 14 types of procedures, but the relative importance of volume varied markedly according to the type of procedure. Absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals ranged from over 12 percent (for pancreatic resection, 16.3 percent vs. 3.8 percent) to only 0.2 percent (for carotid endarterectomy, 1.7 percent vs. 1.5 percent). The absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals were greater than 5 percent for esophagectomy and pneumonectomy, 2 to 5 percent for gastrectomy, cystectomy, repair of a nonruptured abdominal aneurysm, and replacement of an aortic or mitral valve, and less than 2 percent for coronary-artery bypass grafting, lower-extremity bypass, colectomy, lobectomy, and nephrectomy.

Conclusions In the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.

Source Information

From the Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vt. (J.D.B., E.V.A.F., H.G.W.); the Department of Surgery, Dartmouth–Hitchcock Medical Center, Lebanon, N.H. (J.D.B.); the Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, N.H. (J.D.B., T.A.S., H.G.W., D.E.W.); the Center for Outcomes Research and Evaluation, Maine Medical Center, Portland (A.E.S., F.L.L., I.B., D.E.W.); and the Department of Surgery, University of California, San Francisco (E.V.A.F.).

Address reprint requests to Dr. Birkmeyer at the Veterans Affairs Outcomes Group (111B), Veterans Affairs Medical Center, White River Junction, VT 05009, or at john.birkmeyer{at}dartmouth.edu.

Full Text of this Article

Related Letters:

Volume and Outcome
Barone J. E., Risucci D. A., Savino J. A., Nallamothu B. K., Saint S., Eagle K. A., Senkowski C. K., Kocs D. M., Rowe A. K., Deming M. S., Bohmer R., Edmondson A., Pisano G., Ghertner J. L., Babson W. W. Jr., Birkmeyer J. D., Finlayson E. V.A., Epstein A. M.
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N Engl J Med 2002; 347:693-696, Aug 29, 2002. Correspondence

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