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THE JOURNAL OF CARDIOVASCULAR SURGERY

A Journal on Cardiac, Vascular and Thoracic Surgery


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The Journal of Cardiovascular Surgery 2000 February;41(1):153-5

language: English

The hospital volume-outcome relationship in general thoracic surgery. Is the surgeon the critical determinant?

Urschel J. D., Urschel D. M.

From the Department of Thoracic Surgical Oncology Roswell Park Cancer Institute Buffalo, New York, USA


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Background. Complex oper­a­tions, ­such as ­those per­formed in tho­rac­ic sur­gery, ­have a hos­pi­tal vol­ume-out­come rela­tion­ship. It is dif­fi­cult to iso­late the ­effect of the sur­geon in ­this rela­tion­ship ­since expe­ri­enced tho­rac­ic sur­geons ­tend to prac­tice in ­high-vol­ume ter­tiary ­care hos­pi­tals. An American com­pre­hen­sive can­cer hos­pi­tal creat­ed a com­mu­nity out­reach sat­el­lite pro­gram in tho­rac­ic sur­gery, and ­this pro­vid­ed a ­unique oppor­tu­nity to ­study the hos­pi­tal vol­ume-out­come rela­tion­ship with­out the con­found­ing var­i­able of sur­geon expe­ri­ence.
Methods. A ret­ro­spec­tive ­review of tho­rac­ic sur­gi­cal oper­a­tions ­done ­over a 4-­year peri­od at a ­small com­mu­nity hos­pi­tal, by a ter­tiary ­care hos­pi­tal sur­geon, was con­duct­ed. Operative mor­tal­ity was the ­major out­come meas­ure. Two ­high com­plex­ity oper­a­tions (pneu­mo­nec­to­my and esoph­a­gec­to­my) ­were spe­cif­i­cal­ly scru­ti­nized.
Results. 486 tho­rac­ic sur­gi­cal pro­ce­dures (317 ­minor and 169 ­major cas­es) ­were ­done. There was one in-hos­pi­tal ­death (aspi­ra­tion pneu­mo­nia ­after esoph­a­geal stent­ing) and one 30-day mor­tal­ity (read­mis­sion for cere­bral vas­cu­lar acci­dent ­after lobec­to­my). Data for the 10 esoph­a­gec­to­my ­patients is as fol­lows: age - 66±13 ­years; ­length of ­stay – 12.8±3.4 ­days; anas­to­mot­ic ­leaks – 0; oper­a­tive mor­tal­ity – 0. Data for the 6 pneu­mo­nec­to­my ­patients is as fol­lows: age - 69±8 ­years; ­length of ­stay – 8.5±5.2 ­days; pre­op­er­a­tive FEV1 - 1.6±0.3 ­litres; fis­tu­las or empye­ma – 0; oper­a­tive mor­tal­ity – 0.
Conclusions. Despite hav­ing a ­very low vol­ume of tho­rac­ic sur­gi­cal cas­es the com­mu­nity hos­pi­tal had ­crude out­comes com­par­able to ­those report­ed ­from ­high vol­ume ter­tiary hos­pi­tals. This sug­gests ­that the sur­geon may be a ­more impor­tant fac­tor in the hos­pi­tal vol­ume-out­come rela­tion­ship ­than pre­vi­ous­ly ­thought. Nevertheless, com­plex tho­rac­ic sur­gi­cal oper­a­tions are ideal­ly per­formed by an expe­ri­enced sur­geon, and in a ­high vol­ume hos­pi­tal.

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