Quality and Volume – Are They Related?
Rahul K. Shah, MD George Washington University School of Medicine Children’s National Medical Center, Washington, DC Do surgeons who do more cases of one type have superior results than other surgeons? It is one of the most contentious questions about the case volume of surgeons and their outcomes. Intuitively, one would answer – of course! This, indeed, may be one of the historical justifications for specialization within medicine and why and how our healthcare provider system has evolved to hospitals of different triage abilities and physicians with such in-depth content expertise. A significant body of literature supports the claim that high-volume hospitals have superior outcomes compared to other hospitals. There is also data that for specific surgeons this relationship holds true for higher volume surgeons. It is worth noting an article1 from the Johns Hopkins Medical Institutions that explores the relationship of surgeon and hospital volume to the short-term outcomes in laryngeal cancer surgery care. This article is pertinent to discuss, as much of the literature regarding volume of surgeons and hospitals and their relationship to outcomes is not germane to otolaryngologists. As a surgical specialty with some of the most complex cases (head and neck reconstructions, skull base approaches, etc.) and with significant volume (approaching 40 percent at some major medical centers), it is imperative that the quality/outcome/volume relationship is explored for otolaryngology. The article’s authors, Gourin, et al., evaluate this relationship in short-term outcomes of laryngeal cancer care vis-à-vis surgeon and hospital volume. The article is an exceptional use of existing state databases, which provide macro-level data on surgical volume and hospital outcomes. The intent of the column this month is not to discuss whether patients should have laryngeal cancer care at high volume hospitals or not — this is well-addressed by the article we reference below. Rather, my aim is for otolaryngologists to begin contemplating where quality, outcomes, and volume intersect. This question has significant implications for our specialty in terms of physician workforce; reimbursement; expectations of the government in relation to quality outcomes; and for maintenance of certification. The power of aggregate data obtained via national datasets is the ability to identify trends that may be lost in smaller institutional series. The danger is that if we are not the ones mining the data, then others, with presumably less understanding of the disease process, will do it for us. The result will be attempts via reimbursement, pay for performance, or legislation to affect the scope of what we can practice. Gourin, et al., should be commended for objectively looking at outcomes for a complex disease process. With the availability of mega-data sets, which are easily obtained and accessed, healthcare professionals have the ability to ask profound questions similar to the one posed by Gourin, et al. Their study used a state-level database; it would be of interest to see if their findings are supported by a nationwide sampling and the further relationships that would be exposed by such a perspective. Where patient safety and quality improvement initiatives end up in otolaryngology is really up to us. With the myriad data that exist and the significant public pressure upon us, it is incumbent on us that we examine our outcomes in our institutions, and, on a macro-level, demonstrate that, indeed, we are providing the highest level of care. In the last five years, many major medical centers have begun publishing their outcomes in an attempt to be transparent and show how their results benchmark to others. The next iteration of this is to use the macro-level data as shown by Gourin, et al., to compare our own institution’s outcomes to the national benchmarks. The quality/volume/outcomes relationship continues to be contentious, however, we can expect that the availability of macro-level data will provide insight which was previously not available. Reference Gourin CG, Forastiere AA, Sanguineti G, Koch WM, Marur S, Bristow RE. Impact of surgeon and hospital volume on short-term outcomes and cost of laryngeal cancer surgical care. Laryngoscope. 2011 Jan;121(1):85-90. Dr. Shah serves the AAO-HNS/F as the Chair of the Patient Safety and Quality Improvement Committee. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.
Rahul K. Shah, MD
George Washington University School of Medicine
Children’s National Medical Center, Washington, DC
Do surgeons who do more cases of one type have superior results than other surgeons? It is one of the most contentious questions about the case volume of surgeons and their outcomes. Intuitively, one would answer – of course! This, indeed, may be one of the historical justifications for specialization within medicine and why and how our healthcare provider system has evolved to hospitals of different triage abilities and physicians with such in-depth content expertise.
A significant body of literature supports the claim that high-volume hospitals have superior outcomes compared to other hospitals. There is also data that for specific surgeons this relationship holds true for higher volume surgeons.
It is worth noting an article1 from the Johns Hopkins Medical Institutions that explores the relationship of surgeon and hospital volume to the short-term outcomes in laryngeal cancer surgery care. This article is pertinent to discuss, as much of the literature regarding volume of surgeons and hospitals and their relationship to outcomes is not germane to otolaryngologists.
As a surgical specialty with some of the most complex cases (head and neck reconstructions, skull base approaches, etc.) and with significant volume (approaching 40 percent at some major medical centers), it is imperative that the quality/outcome/volume relationship is explored for otolaryngology. The article’s authors, Gourin, et al., evaluate this relationship in short-term outcomes of laryngeal cancer care vis-à-vis surgeon and hospital volume. The article is an exceptional use of existing state databases, which provide macro-level data on surgical volume and hospital outcomes.
The intent of the column this month is not to discuss whether patients should have laryngeal cancer care at high volume hospitals or not — this is well-addressed by the article we reference below. Rather, my aim is for otolaryngologists to begin contemplating where quality, outcomes, and volume intersect. This question has significant implications for our specialty in terms of physician workforce; reimbursement; expectations of the government in relation to quality outcomes; and for maintenance of certification.
The power of aggregate data obtained via national datasets is the ability to identify trends that may be lost in smaller institutional series. The danger is that if we are not the ones mining the data, then others, with presumably less understanding of the disease process, will do it for us. The result will be attempts via reimbursement, pay for performance, or legislation to affect the scope of what we can practice.
Gourin, et al., should be commended for objectively looking at outcomes for a complex disease process. With the availability of mega-data sets, which are easily obtained and accessed, healthcare professionals have the ability to ask profound questions similar to the one posed by Gourin, et al. Their study used a state-level database; it would be of interest to see if their findings are supported by a nationwide sampling and the further relationships that would be exposed by such a perspective.
Where patient safety and quality improvement initiatives end up in otolaryngology is really up to us. With the myriad data that exist and the significant public pressure upon us, it is incumbent on us that we examine our outcomes in our institutions, and, on a macro-level, demonstrate that, indeed, we are providing the highest level of care.
In the last five years, many major medical centers have begun publishing their outcomes in an attempt to be transparent and show how their results benchmark to others. The next iteration of this is to use the macro-level data as shown by Gourin, et al., to compare our own institution’s outcomes to the national benchmarks. The quality/volume/outcomes relationship continues to be contentious, however, we can expect that the availability of macro-level data will provide insight which was previously not available.
Reference
- Gourin CG, Forastiere AA, Sanguineti G, Koch WM, Marur S, Bristow RE. Impact of surgeon and hospital volume on short-term outcomes and cost of laryngeal cancer surgical care. Laryngoscope. 2011 Jan;121(1):85-90.
Dr. Shah serves the AAO-HNS/F as the Chair of the Patient Safety and Quality Improvement Committee. Please email the Academy at qualityimprovement@entnet.org to engage us in a patient safety and quality discussion that is pertinent to your practice.