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Understanding the Volume-Outcome Relationship

Kevin G. Billingsley, MD; Arden M. Morris, MD, MPH; Jason A. Dominitz, MD, MHS; Barbara Matthews, MBA; Sharon Dobie, MD; William Barlow, PhD; George E. Wright, PhD; Laura-Mae Baldwin, MD, MPH

Arch Surg. 2007;142(1):23-31.

Hypothesis  Although numerous studies have demonstrated an association between surgical volume and improved outcome in cancer surgery, the specific structures and mechanisms of care that are associated with volume and lead to improved outcomes remain poorly defined. We hypothesize that there are modifiable surgeon and hospital characteristics that explain observed volume-outcome relationships.

Design  Retrospective cohort study.

Setting  Surveillance, Epidemiology, and End Results cancer registry areas.

Patients  Patients aged 66 years and older, diagnosed and surgically treated for stage I, II, or III colon cancer between 1992 and 1996 (n = 22 672).

Main Outcome Measures  Thirty-day postoperative mortality and 30-day postoperative procedural interventions, including reoperation and image-guided percutaneous procedures.

Results  Surgeon volume, but not hospital volume, is a significant predictor of postoperative procedural intervention (adjusted odds ratio for very high–volume surgeons vs low-volume surgeons, 0.79; 95% confidence interval, 0.64-0.98). In the unadjusted analyses, high hospital volume (odds ratio, 0.67; 95% confidence interval, 0.56-0.81) and very high hospital volume (odds ratio, 0.65; 95% confidence interval, 0.54-0.79) is associated with lower postoperative mortality. Postoperative procedural intervention is not a significant mediator of the relationship between hospital volume and mortality. A single variable—the presence of sophisticated clinical services—was the most important explanatory variable underlying the relationship between hospital volume and mortality.

Conclusions  Very high surgeon volume is associated with a reduction in surgical complications. However, the association between increasing hospital volume and postoperative mortality appears to derive mainly from a full spectrum of clinical services that may facilitate the prompt recognition and treatment of complications.

Author Affiliations: Department of Surgery, Oregon Health and Science University, Portland (Dr Billingsley); Department of Surgery, University of Michigan School of Medicine, Ann Arbor (Dr Morris); and Division of Gastroenterology, VA Puget Sound Health Care System (Dr Dominitz), and Department of Family Medicine (Drs Matthews, Dobie, Wright, and Baldwin), University of Washington School of Medicine, and Cancer Research and Biostatistics (CRAB) (Dr Barlow), Seattle, Wash.

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