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

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.

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.

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.

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