Hospital Volume and Surgical Mortality in the United States
John D. Birkmeyer, M.D., Andrea E. Siewers, M.P.H., Emily V.A. Finlayson, M.D., Therese A. Stukel, Ph.D., F. Lee Lucas, Ph.D., Ida Batista, B.A., H. Gilbert Welch, M.D., M.P.H., and David E. Wennberg, M.D., M.P.H.
Background Although numerous studies suggest that there is aninverse relation between hospital volume of surgical proceduresand surgical mortality, the relative importance of hospitalvolume in various surgical procedures is disputed.
Conclusions In the absence of other information about the qualityof surgery at the hospitals near them, Medicare patients undergoingselected cardiovascular or cancer procedures can significantlyreduce their risk of operative death by selecting a high-volumehospital.
Over the past three decades, numerous studies have describedhigher rates of operative mortality with selected surgical proceduresat hospitals where few such procedures are performed (low-volumehospitals).1,2,3,4 Several recent reviews suggest that thousandsof preventable surgical deaths occur each year in the UnitedStates because elective but high-risk surgery is performed inhospitals that have inadequate experience with the surgicalprocedures involved.5,6,7 As part of a broader initiative aimedat improving hospital safety, a large coalition of private andpublic purchasers of health insurance — the Leapfrog Group— is encouraging patients undergoing one of five high-riskprocedures to seek care at high-volume hospitals.8 In the laymedia, there has been an emphasis on the importance of experiencewith particular procedures,9,10 and several consumer-orientedWeb sites (e.g., http://www.healthscope.org) have begun providingpatients with information about volume at hospitals near them.
Despite the recent interest in surgical volume, many questionthe applicability of previous research on volume and outcometo current practice.11,12 First, many studies of volume andoutcome are outdated. Given that the surgical mortality associatedwith many procedures has fallen considerably since these studieswere conducted,13,14 the relative importance of the volume ofprocedures performed may be declining. Second, most publishedstudies on volume and outcome have used state-level data basesor regional populations that are served by a small number ofhigh-volume centers.6 Whether their results are broadly generalizableis uncertain. And finally, although some procedures (e.g., cardiacsurgery) have been studied extensively, the relative importanceof hospital volume to mortality with many other high-risk procedureseither has not been explored or has been studied in samplesthat were too small to permit assessment of performance at allmeaningful levels of hospital volume.
To address many of these limitations, we studied surgical mortalityin the Medicare population, which accounts for the majorityof all patients in the United States who undergo high-risk surgeryand an even larger majority of those who die after surgery.15Using current national data (from 1994 through 1999), we studiedthe importance of hospital volume to the operative mortalityassociated with six types of cardiovascular procedures and eighttypes of major cancer resections.
Methods
Subjects and Data Bases
We obtained the Medicare Provider Analysis and Review (MEDPAR)files and the denominator files from the Center for Medicareand Medicaid Services for the years 1994 through 1999. Thesefiles contain hospital-discharge abstracts for the acute carehospitalizations of all Medicare recipients covered by the hospitalcare program (Part A). Only patients covered by fee-for-servicearrangements are included in the MEDPAR file; thus, our sampleexcludes the approximately 10 percent of Medicare patients whowere enrolled in risk-bearing health maintenance organizationsduring this period. We excluded patients who were under 65 yearsof age or over 99 years of age. The study protocol was approvedby the institutional review board of Dartmouth Medical School.
We focused on the total number of each type of procedure performedat a given hospital (hospital volume), not the total numberof procedures involving Medicare recipients (Medicare volume),in order to place our results in the context of the volume standardssuggested by the Leapfrog Group8 and others. To estimate totalvolumes, we examined data from the all-payer 1997 NationwideInpatient Sample. We determined the proportion of all patientsundergoing each procedure who were covered by Medicare; theproportion ranged from 43 percent (for nephrectomy) to 75 percent(for carotid endarterectomy). To estimate the total volume atindividual hospitals, we divided the observed Medicare volume(the total number of each type of procedure performed on Medicarepatients during the six-year study period) by these procedure-specificproportions.
Hospital volume, expressed as the average number of proceduresper year, was first evaluated as a continuous variable. To simplifythe presentation of our results, however, we also created categoricalvariables, defining five categories of hospital volume: verylow, low, medium, high, and very high. For each procedure, thehospitals were ranked in order of increasing total hospitalvolume, and then five volume groups were defined by the selectionof whole-number cutoff points for annual volume that most closelysorted the patients into five groups of equal size (quintiles).The cutoff points were established before mortality was examinedin order to avoid selecting cutoff points that could maximizethe associations between volume and outcome.17 To reflect mostaccurately the overall institutional experience with each typeof operation, we combined the replacement of aortic and mitralvalves (into the single category of heart-valve replacement)and lobectomy and pneumonectomy (into the category of lung resection)in determining hospital volume. However, the outcomes of theseprocedures were assessed separately.
Assessment of Outcomes
In creating cohorts for the analysis of outcomes, we appliedseveral restrictions in order to increase the homogeneity ofthe study samples and thus minimize the potential for confoundingby case mix. For the eight types of major cancer resections,we excluded patients without an accompanying cancer-diagnosiscode (related to the index procedure). Patients undergoing repairof an abdominal aortic aneurysm were excluded if they had adiagnosis or procedure code suggesting rupture of the aneurysm,thoracoabdominal aneurysm, or both. Patients undergoing coronary-arterybypass grafting were excluded if they simultaneously underwentvalve replacement.
Our primary outcome measure was operative mortality, definedas the rate of death before hospital discharge or within 30days after the index procedure. Because a large proportion ofsurgical deaths before discharge occurred more than 30 daysafter surgery, we decided that 30-day mortality alone wouldnot adequately reflect true operative mortality. Because thelength of stay did not vary systematically according to hospitalvolume, the inclusion of late, in-hospital deaths would notbe expected to bias our results. Moreover, associations betweenvolume and outcome were largely unchanged when we repeated ouranalyses using 30-day mortality alone.
Statistical Analysis
We used multiple logistic regression to examine relations betweenhospital volume and operative mortality, with adjustment forcharacteristics of the patients.18 We used the patient as theunit of analysis, with volume measured at the hospital level.We first fitted separate models for each procedure against thelogarithm of volume to establish the general form of the relation.We then fitted models against the quintiles of volume for eachprocedure.
We adjusted for age group (65 to 69 years, 70 to 74 years, 75to 79 years, 80 to 84 years, or 85 to 99 years), sex, race (blackor nonblack), and their interactions, as well as the year ofthe procedure, the relative urgency of the index admission (elective,urgent, or emergency), the presence of coexisting conditions,and mean income from Social Security.18 This last measure wasassessed at the ZIP Code level (on the basis of the 1990 Censusfile) because patient-level information on socioeconomic statusis not available.
Coexisting conditions were identified with the use of informationfrom the index admission and any other admissions that had occurredwithin the preceding six months. Relative to low-volume hospitals,high-volume hospitals treat a larger number of patients whohave been transferred or referred from other centers. To minimizethe possibility of bias due to the identification of more previousadmissions (and thus more coexisting conditions) at high-volumecenters, we excluded information on coexisting conditions identifiedat previous admissions that occurred within two weeks beforethe index hospitalization. For the purposes of risk adjustment,coexisting conditions (identified by their appropriate ICD-9-CMcodes) were compiled into a Charlson score (the number of coexistingconditions, weighted according to their relative effects onmortality),19,20 which was modified to exclude conditions thatwere likely to reflect either the primary indication for surgeryor postoperative complications.21,22 We also explored two alternativeapproaches to incorporating coexisting conditions into our risk-adjustmentmodels: including Charlson scores with weights derived empiricallyfor each procedure and including coexisting conditions individuallyby inserting into each model each condition that was presentin at least 2 percent of the patients. Because all three approachesyielded virtually identical results, we report only those fromthe model that used the Charlson score with published weights.19
We used overdispersed binary logistic models to adjust for clusteringof deaths within hospitals.23 The net effect was to increasethe width of the confidence intervals between 2 percent (cystectomy)and 44 percent (lobectomy), with a mean increase of 25 percent.We computed adjusted mortality rates on the basis of the averagevalues of the characteristics of the patients by back-transformingpredicted mortality from the logistic model. Our final risk-adjustmentmodels had intermediate discriminative ability, with C statisticsranging from 0.60 (for pneumonectomy) to 0.71 (for nephrectomy).All P values are two-tailed.
Because the Medicare files used for this analysis reflect theuse of procedures among patients with fee-for-service arrangementsfor health care, we may have underestimated hospital volumein regions of the country that had a high penetration of Medicaremanaged care during the study period (mainly southern Californiaand the Southwest). For this reason, we repeated our analysesafter restricting our data set to hospital-referral regionswith a penetration of Medicare managed care of less than 10percent. Because the adjusted odds ratios for death associatedwith hospital volume changed negligibly as a result of thisrestriction, these data are not presented.
Results
Between 1994 and 1999, approximately 2.5 million Medicare patientsunderwent 1 of the 14 cardiovascular or cancer-related proceduresthat we studied. The criteria used to define the five strataof hospital volume varied markedly according to procedure, reflectingthe relative frequency with which each is performed (Table 1).Medicare volume and total volume for the 14 procedures werehighly correlated at the hospital level (overall correlationcoefficient, 0.97).
Table 1. Distribution of Patients and Hospitals among Quintiles of Volume for the 14 Procedures.
The age and sex of the patients did not vary consistently amongstrata of hospital volume (Table 2). However, for most of the14 procedures, black patients were more likely to undergo surgeryat a lower-volume hospital. For most procedures, Charlson scorestended to be slightly higher at higher-volume hospitals. However,patients were more likely to be admitted nonelectively at lower-volumehospitals. This trend was more apparent with respect to severalcancer-related resections (e.g., esophagectomy) than with respectto cardiovascular procedures.
Table 2. Characteristics of the Patients According to Hospital Volume.
When it was assessed as a continuous (logarithmic) variable,hospital volume was related to both observed and adjusted operativemortality rates for all 14 procedures (P<0.001 for all trends).In terms of odds ratios for death, adjustment for characteristicsof the patients attenuated the associations between volume andoutcome moderately for carotid endarterectomy, colectomy, gastrectomy,esophagectomy, and pulmonary lobectomy (Table 3). Risk adjustmenthad negligible effect with respect to the other procedures.
Table 3. Operative Mortality Rates and Their Association with Hospital Volume.
In terms of absolute differences in adjusted mortality rates,the importance of hospital volume varied markedly accordingto the type of procedure (Figure 1 and Figure 2). For example,for pancreatic resection, adjusted mortality rates at very-low-volumehospitals were 12.5 percent higher than at very-high-volumehospitals (16.3 percent vs. 3.8 percent) (Figure 2A). Relativelylarge differences in risk were also observed for esophagectomy(11.9 percent) and pneumonectomy (5.4 percent). Absolute differencesin adjusted mortality rates between very-low-volume and very-high-volumehospitals were between 2 percent and 5 percent for gastrectomy,cystectomy, repair of a nonruptured abdominal aortic aneurysm,and aortic- and mitral-valve replacement, and the differenceswere less than 2 percent for coronary-artery bypass grafting,lower-extremity bypass, colectomy, lobectomy, and nephrectomy.The absolute difference in mortality between very-low-volumeand very-high-volume hospitals was smallest for carotid endarterectomy(1.7 percent vs. 1.5 percent).
Figure 1. Adjusted In-Hospital or 30-Day Mortality among Medicare Patients (1994 through 1999), According to Quintile of Total Hospital Volume for Peripheral Vascular Procedures (Panel A) and Cardiac Procedures (Panel B).
P<0.001 for all procedures. The outcomes for aortic-valve and mitral-valve replacement were stratified according to the total volume of heart-valve replacements. Values above the bars are the percent mortality.
Figure 2. Adjusted In-Hospital or 30-Day Mortality among Medicare Patients (1994 through 1999), According to Quintile of Total Hospital Volume for Resections of Gastrointestinal Cancer (Panel A) and Resections of Other Cancers (Panel B).
P<0.001 for all procedures. The outcomes for lobectomy and pneumonectomy were stratified according to the total volume of lung resections. Values above the bars are the percent mortality.
Relations between volume and outcome in the intermediate strataof hospital volume also varied widely according to the typeof procedure (Figure 1 and Figure 2). For several types of procedure(including coronary-artery bypass grafting, valve replacement,and pancreatic resection), mortality declined monotonicallywith each stratum of increasing hospital volume. For others(including elective repair of an abdominal aortic aneurysm,gastrectomy, and pneumonectomy), differences in mortality weremost apparent at the extremes of volume, whereas hospitals inthe intermediate-volume strata had similar mortality rates.
Discussion
In this large, national study, higher-volume hospitals had loweroperative mortality rates for six types of cardiovascular proceduresand eight types of major cancer resections. However, the absolutemagnitude of the relation between volume and outcome variedmarkedly among the types of procedures. Dramatic differencesin mortality between very-low-volume and very-high-volume hospitalswere observed for pancreatic resection and esophagectomy (morethan 12 percent, in absolute terms), whereas relatively smalldifferences in mortality (1 percent or less) were found for3 of the 14 procedures examined in our analysis. These findingssuggest the relative importance of hospital volume for individualpatients who are considering where to undergo various procedures.From the public health perspective, however, one must also considerthe total number of patients who undergo each procedure. Forexample, in the case of coronary-artery bypass grafting (forwhich volume had a moderate effect but which is very common),314 deaths would be averted in the United States each year ifthe mortality rate at very-low-volume hospitals were reducedto the rate at very-high-volume centers. Conversely, in thecase of pancreatic resection (for which volume had a very largeeffect but which is performed infrequently), lowering the mortalityrate at very-low-volume centers to that observed at very-high-volumecenters would avert only 32 deaths annually.
We believe that our results reflect real differences in thequality of surgery between high-volume and low-volume hospitals.First, the effect is large. For some procedures, mortality atlow-volume centers was several times as high as at high-volumehospitals — a difference that is too great to be attributedto chance or unmeasured confounding. Second, relations betweenvolume and outcome are remarkably consistent over time and acrossstudies. According to one recent structured review of the literature,123 of 128 analyses involving 40 different procedures (96 percent)found lower mortality at high-volume hospitals (differenceswere statistically significant in 80 percent of these analyses).5Only 4 of the 128 (3 percent) found higher mortality rates athigh-volume hospitals, but none of these findings were statisticallysignificant. And finally, the link between surgical volume andmortality is clinically plausible. Although the mechanisms underlyingthe relations between volume and outcome have not been fullycharacterized, high-volume hospitals may have more surgeonswho specialize in specific procedures, more consistent processesfor postoperative care, better-staffed intensive care units,and greater resources, in general, for dealing with postoperativecomplications.
Our analysis has several limitations. First, because we studiedonly Medicare patients, our results may not be generalizableto patients under 65 years of age. However, there is no evidencethat age affects the relations between volume and outcome. Second,our measure of volume was imperfect. We estimated total hospitalvolume by extrapolating from Medicare volume, not by directmeasurement. Although Medicare and total volumes are highlycorrelated at the hospital level, there probably remains somedegree of misclassification of hospital-volume status, whichwould tend to bias our analysis toward the null hypothesis (noeffect of volume on outcome). Third, because our primary goalwas to estimate the potential effect of referral policies thatfocus exclusively on volume, we did not attempt to adjust forcharacteristics of the provider that are likely to be highlycorrelated with volume. Analyses that aimed to assess the independenteffect of hospital volume would need to account for other variablesthat may influence mortality, including hospital size and teachingstatus, the volume of procedures performed by a particular surgeon,and staffing patterns in the intensive care unit.24,25,26,27
Finally, because we relied on administrative data, we may nothave accounted adequately for differences in case mix amongstrata of hospital volume. Administrative data are limited intheir ability to differentiate patients according to the severityof illness.21,22,28,29 Age and the prevalence of coexistingconditions did not vary substantially according to hospitalvolume in our data set. However, even for conditions for whichthe procedure itself is almost always elective, patients atlower-volume hospitals were more likely to have been admittednonelectively. Conversely, patients at higher-volume hospitalswere more likely to have had recent nonelective admissions elsewhere.Although these findings raise the possibility of unmeasureddifferences in case mix among hospitals, we do not believe thatconfounding is a likely explanation for our main findings.
Many may object to such initiatives aimed at concentrating selectedsurgical procedures in high-volume hospitals. They may rightlypoint out that procedure volume is an imperfect proxy for quality— that some low-volume hospitals have excellent outcomes,whereas some high-volume hospitals have poor outcomes. Unfortunately,most patients facing high-risk surgery have no way of knowingthe relative quality of the hospitals near them. Although severalstates currently have public reporting systems in place,30,31these efforts are largely restricted to reporting on cardiacsurgery. Most other procedures are not performed frequentlyenough to allow assessment of procedure-specific mortality atthe level of the individual hospital. Thus, in the absence ofbetter information about surgical quality, patients undergoingmany types of procedures can substantially improve their oddsof survival by selecting a high-volume hospital near them.
Supported by a grant (R01 HS10141-01) from the Agency for HealthcareResearch and Quality. Dr. Birkmeyer is also supported by a CareerDevelopment Award from the Veterans Affairs Health ServicesResearch and Development program. The views expressed hereindo not necessarily represent the views of the Department ofVeterans Affairs or the United States Government.
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.
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Volume and Outcome
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