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December 15, 2008

Volume and Outcome: Equipoise at Last

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Copyright 2008 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2008

Arch Surg. 2008;143(12):1235. doi:10.1001/archsurg.143.12.1235-a

Dr Ricciardi and colleagues1 are to be congratulated on their enquiry into the true relationship between volume and outcome. In addition to providing a concise synopsis of recent changes in cardiothoracic practice, they explore the impact of specific-procedure volume on in-hospital mortality (an indisputably robust end point). Considering that most studies to date have been intrinsically flawed,2 the present article adds evidence and equipoise to an otherwise misleading knowledge base. It congratulates smaller hospitals (a refreshing sentiment in an era of centralization) and recognizes their contribution to global surgical care. The authors understand the limitations of using volume as a sole base of comparison and allude to the fact that surgeon lifetime experience may be more important than current hospital throughput. This was highlighted by a minimal change in outcome when a hospital shifted from the high- to low-volume group, an angle previously unexplored in the ongoing debate. The international surgical community has much to learn from well-designed, adequately powered trials such as this one.

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