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We thank Drs Hogan and Winter for their letter regarding our article. As the authors point out, though our data demonstrate relatively small but persistent differences in mortality between high- and low-volume hospitals, the data, more importantly, reveal a narrowing of this mortality difference. Low-volume hospitals appear to be catching up to high-volume facilities in terms of rates of postoperative mortality, most likely owing to improvements in quality among many low-volume providers. In analyzing our data, it became clear that procedure volume should not be considered to the exclusion of clinical, economic, and social factors when selecting a treatment facility. Patients may well accept a tiny reduction in life expectancy or survival for the convenience, familiarity, and other benefits of a low-volume hospital. It is therefore imperative that we account for patient preferences in care, rather than assigning patients to providers or facilities based on volume alone. As Drs Hogan and Winter point out, smaller hospitals do provide significant contributions to global surgical care and our work demonstrates that results at such hospitals can be excellent.
Ricciardi R, Baxter NN. Volume and Outcome: Equipoise at Last—Reply. Arch Surg. 2008;143(12):1235. doi:10.1001/archsurg.143.12.1235-b