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(Circulation. 2003;107:384.)
© 2003 American Heart Association, Inc.

Brief Rapid Communications

Should Volume Standards for Cardiovascular Surgery Focus Only on High-Risk Patients?

From the VA Outcomes Group (P.P.G., J.D.B.), Department of Veterans Affairs Medical Center, White River Junction, Vt; Department of Surgery (P.P.G., J.D.B.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; and Center for Outcomes Research and Evaluation (F.L.L.), Maine Medical Center, Portland.

Correspondence to Philip P. Goodney, MD, VA Outcomes Group (111B), Department of Veteran Affairs Medical Center, White River Junction, VT 05009. E-mail philip.goodney{at}hitchcock.org

Background— Payers and policy makers are attempting to concentrate selected cardiovascular procedures in high-volume centers. A recent analysis of coronary artery bypass grafting (CABG), however, suggests that volume-based referral initiatives should focus only on high-risk patients.

Methods and Results— Using the national Medicare database (1994 to 1999), we studied the operative mortality in patients undergoing 4 cardiovascular procedures (CABG, aortic valve replacement, mitral valve replacement, and elective abdominal aortic aneurysm repair). We defined 2 categories of patient risk: high-risk (patients in the highest 25th percentile of predicted risk on the basis of a logistic regression model) and low-risk (patients in the lowest 75th percentile). We then compared operative mortality in patients undergoing surgery at very-high volume hospitals (VHVH, highest 20th percentile of procedure volume) and very-low volume hospitals (VLVH, lowest 20th percentile of procedure volume). Absolute differences in operative mortality between VLVH and VHVH were somewhat larger in high-risk patients. However, volume-related differences in mortality were also significant for low-risk patients undergoing one of the 4 procedures. In relative terms, the effect of hospital volume was similar in both high- and low-risk patients. For high- and low-risk patients, the relative risk (RR) of mortality between VHVH and VLVH were nearly equal for CABG (RR=0.78 for low-risk patients, RR=0.77 for high risk patients), aortic valve replacement (0.73 versus 0.76), mitral valve replacement (0.73 versus 0.74), and abdominal aortic aneurysm repair (0.51 versus 0.54).

Conclusions— Although the merits of volume-based referral initiatives can be debated on many grounds, there seems to be little rationale for restricting these initiatives to high-risk patients.

Key Words: cardiovascular diseases • surgery • mortality • risk factors

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