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Hospital Procedure Volume Should Not Be Used as a Measure of Surgical Quality
Damien J LaPar*, Irving L Kron, David R Jones, George J Stukenborg*, Benjamin D Kozower*
University of Virginia, Charlottesville, VA

Objectives: The Agency for Healthcare Research and Quality and the Leapfrog Group use hospital procedure volume as a quality measure for pancreatic resection (PR), abdominal aortic aneurysm repair (AAA), esophageal resection (ER), and coronary artery bypass grafting (CABG). However, controversy exists regarding the strength and validity of the evidence for the volume-outcome association. The purpose of this study was to re-evaluate the volume-outcome relationship for these procedures.
Methods: Discharge data for 261,412 patients were extracted from the 2008 Nationwide Inpatient Sample. The relationship between hospital procedure volume and mortality was rigorously assessed using hierarchical general linear modeling with restricted cubic splines, adjusted for patient demographics, comorbid disease, elective procedure status, and for correlated events within hospitals.
Results: Unadjusted mortality included PR (4.7%), AAA (12.7%), ER (5.8%), CABG (2.2%), and a majority were elective operations. Hospital procedure volume was not a significant predictor of mortality for any of the four procedures (Table). Strong predictors of mortality included age, elective procedure status, renal failure, and malnutrition (p<0.001). Each of the models demonstrated excellent performance in estimating the probability of death.
Conclusions: Hospital procedure volume is not a significant independent predictor of mortality for the performance of pancreatectomy, AAA repair, esophagectomy or CABG. Procedure volume by itself should not be used as a proxy measure for surgical quality. Patient mortality risk is primarily attributable to patient level characteristics.
ProcedurenSurgery volume Likelihood RatiopModel Performance
c statisticR2
Pancreatectomy19,1994.100.250.890.37
AAA repair15,2710.01>0.990.890.44
Esophagectomy4,7641.730.630.950.58
CABG222,1780.270.960.810.16


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