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Previous Volume 349:2117-2127 November 27, 2003 Number 22 Next

	Full Text PDF PDA Full Text Supplementary Material Editorial by Kizer, K. W. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain.

Methods Using information from the national Medicare claims data base for 1998 through 1999, we examined mortality among all 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections. Using nested regression models, we examined the relations between operative mortality and surgeon volume and hospital volume (each in terms of total procedures performed per year), with adjustment for characteristics of the patients and other characteristics of the providers.

Results Surgeon volume was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The adjusted odds ratio for operative death (for patients with a low-volume surgeon vs. those with a high-volume surgeon) varied widely according to the procedure — from 1.24 for lung resection to 3.61 for pancreatic resection. Surgeon volume accounted for a large proportion of the apparent effect of the hospital volume, to an extent that varied according to the procedure: it accounted for 100 percent of the effect for aortic-valve replacement, 57 percent for elective repair of an abdominal aortic aneurysm, 55 percent for pancreatic resection, 49 percent for coronary-artery bypass grafting, 46 percent for esophagectomy, 39 percent for cystectomy, and 24 percent for lung resection. For most procedures, the mortality rate was higher among patients of low-volume surgeons than among those of high-volume surgeons, regardless of the surgical volume of the hospital in which they practiced.

Conclusions For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently.

Source Information

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

Address reprint requests to Dr. Birkmeyer at the Section of General Surgery, Dartmouth–Hitchcock Medical Center, Lebanon, NH 03756, or at john.birkmeyer{at}hitchcock.org.

Full Text of this Article

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Surgeon Volume and Operative Mortality
Gutow A. P., Erlebacher J. A., Hubbard S. G., Birkmeyer J. D., Kizer K. W.
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N Engl J Med 2004; 350:1256-1258, Mar 18, 2004. Correspondence

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