SHOULD OPERATIONS BE REGIONALIZED - EMPIRICAL RELATION BETWEEN SURGICAL VOLUME AND MORTALITY

This study examines mortality rates for 12 surgical procedures of varying complexity in 1498 hospitals to determine whether there is a relation between a hospital's surgical volume and its surgical mortality. The mortality of open-heart surgery, vascular surgery, transurethral resection of the prostate, and coronary bypass decreased with increasing number of operations. Hospitals in which 200 or more of these operations were done annually had death rates, adjusted for case mix, 25 to 41 per cent lower than hospitals with lower volumes. For other procedures, the mortality curve flattened at lower volumes. For example, hospitals doing 50 to 100 total hip replacements attained a mortality rate for this procedure almost as low as that of hospitals doing 200 or more. Some procedures, such as cholecystectomy, showed no relation between volume and mortality. The results may reflect the effect of volume or experience on mortality, or referrals to institutions with better outcomes, as well as a number of other factors, such as patient selection. Regardless of the explanation, these data support the value of regionalization for certain operations. (N Engl J Med 301:1364–1369, 1979) THERE is wide acceptance of the hypothesis that, other things being equal, the quality of care improves with the experience of those providing it. If true, surgical mortality rates should be lower in hospitals performing higher volumes of a given procedure. Also, the “experience effect” should be more pronounced in more complex procedures. The “experience curve,” or “learning curve,” describing a logarithmic decline in unit costs as a function of cumulative production experience, has been widely recognized and well documented in industrial economics.1 2 3 The experience hypothesis — if true — would have important implications for the organization of medical care. © 1979, Massachusetts Medical Society. All rights reserved.