Should volume standards for cardiovascular surgery focus only on high-risk patients?

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.

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).

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.