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May 5, 2004

Hospital Volume and Quality—Reply

Author Affiliations

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2004;291(17):2077. doi:10.1001/jama.291.17.2077-b

In Reply: I agree with Dr Mariotto that it is possible that lower-volume centers (ie, those with potentially excess capacity) may be less discriminating in their case selection. We discussed this in our article. However, assessment of the "appropriateness" of bypass for specific cases is quite challenging and was beyond the scope of our study. Second, our study indeed found that, in aggregate, higher-volume sites had lower bypass mortality risks compared with low-volume sites. However, these differences in outcome were not uniform. As we noted, many low-volume sites had outcomes that were equal to or better than those observed at high-volume sites. Thus, the informed consumer would ideally want to compare actual hospital risk-adjusted surgical outcomes as opposed to relying on a loosely associated surrogate such as case volume. Finally, I agree that there may be other advantages of centralization of surgical volumes into centers of excellence, and our study should not be seen as arguing against this. However, we support the idea that each center, whether large or small, should be measured against its peers based on its results (outcomes or economic efficiency) rather than on its size alone.

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