This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Social Bookmarking   What's this?

The Role of Surgeon Volume

Edward L. Hannan, PhD; Albert L. Siu, MD, MSPH; Dinesh Kumar, MS; Harold Kilburn, Jr, MA; Mark R. Chassin, MD, MPP, MPH

JAMA. 1995;273(3):209-213.

Abstract
Objective.
—To examine the longitudinal relationship between surgeon volume and in-hospital mortality for coronary artery bypass graft (CABG) surgery in New York State and to explain changes in mortality that occurred over time.

Design.
—Observation of clinically risk-adjusted operative mortality over time.

Setting.
—All 30 New York State hospitals in which CABG surgery was performed for 1989 through 1992.

Patients.
—All 57187 patients undergoing isolated CABG surgery in New York State in 1989 through 1992 in the 30 hospitals.

Main Outcome Measures.
—Actual, expected, and risk-adjusted mortality.

Results.
—Risk-adjusted in-hospital mortality decreased for all categories of surgeons. Low-volume surgeons (50 operations per year) experienced a 60% reduction in risk-adjusted mortality in the 4-year period, whereas the highest-volume surgeons (>150 operations per year) experienced a 34% reduction. The percentage of patients undergoing CABG surgery by low-volume surgeons decreased from 7.6% in 1989 to 5.7% in 1992, a 25% decrease.

Conclusions.
—The overall decline in risk-adjusted mortality could not be explained by shifts in patients away from low-volume surgeons to high-volume surgeons. The proportionately larger decrease in risk-adjusted mortality for low-volume surgeons could not be explained by changes in patient case mix or by improvements in the performance of surgeons with persistently low volumes. Part of the decrease was a result of the exodus of low-volume surgeons with high risk-adjusted mortality (in all years studied), the markedly better performance of surgeons who were new to the system (especially in 1991 and 1992), and the performance of surgeons who were not consistently low-volume surgeons (especially in 1992).

(JAMA. 1995;273:209-213)

Author Affiliations
From the State University of New York, University at Albany (Dr Hannan and Mr Kumar), and the New York State Department of Health, Albany (Drs Hannan, Siu, and Chassin and Messrs Kumar and Kilburn).

Footnotes
Reprint requests to Department of Health Policy and Management, University at Albany School of Public Health, 135 Western Ave, 203 Husted Hall, Albany, NY 12203 (Dr Hannan).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Measuring, Monitoring, And Managing Quality In Germany's Hospitals
Busse et al.
Health Aff (Millwood) 2009;28:w294-w304.
ABSTRACT | FULL TEXT  

Policy Research: Using Evidence to Improve Healthcare Delivery Systems
Ross and Gross
Circulation 2009;119:891-898.
FULL TEXT  

Regulation, measurements and incentives. The experience in the US and UK: does context matter?
Hamblin
The Journal of the Royal Society for the Promotion of Health 2008;128:291-298.
ABSTRACT  

Improving Quality of Care in Cardiac Surgery: Evaluating Risk Factors, Processes of Care, Structures of Care, and Outcomes
Shroyer et al.
SEMIN CARDIOTHORAC VASC ANESTH 2008;12:140-152.
ABSTRACT  

Predictors of Physical Therapy Clinic Performance in the Treatment of Patients With Low Back Pain Syndromes
Resnik et al.
ptjournal 2008;88:989-1004.
ABSTRACT | FULL TEXT  

The Frequency and Cost of Complications Associated With Coronary Artery Bypass Grafting Surgery: Results from the United States Medicare Program
Brown et al.
Ann. Thorac. Surg. 2008;85:1980-1986.
ABSTRACT | FULL TEXT  

Volume-outcome relationships in coronary artery bypass graft surgery patients: 5-year major cardiovascular event outcomes.
Lin et al.
J. Thorac. Cardiovasc. Surg. 2008;135:923-930.
ABSTRACT | FULL TEXT  

Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care
Fung et al.
ANN INTERN MED 2008;148:111-123.
ABSTRACT | FULL TEXT  

Risk Stratification and Comorbidity
Ferraris et al.
Card Surg Adult 2008;3:199-246.
FULL TEXT  

Reevaluation of the Volume-Outcome Relationship for Pediatric Cardiac Surgery
Gauvreau
Circulation 2007;115:2599-2601.
FULL TEXT  

Contemporary Impact of State Certificate-of-Need Regulations for Cardiac Surgery: An Analysis Using the Society of Thoracic Surgeons' National Cardiac Surgery Database
DiSesa et al.
Circulation 2006;114:2122-2129.
ABSTRACT | FULL TEXT  

Do Cardiac Surgery Report Cards Reduce Mortality? Assessing the Evidence
Epstein
Med Care Res Rev 2006;63:403-426.
ABSTRACT  

Association Between Surgeon and Hospital Volume in Coronary Artery Bypass Graft Surgery Outcomes: A Population-Based Study
Wen et al.
Ann. Thorac. Surg. 2006;81:835-842.
ABSTRACT | FULL TEXT  

The Italian CABG Outcome Study: short-term outcomes in patients with coronary artery bypass graft surgery
Seccareccia et al.
Eur. J. Cardiothorac. Surg. 2006;29:56-62.
ABSTRACT | FULL TEXT  

Should Coronary Artery Bypass Grafting Be Regionalized?
Nallamothu et al.
Ann. Thorac. Surg. 2005;80:1572-1581.
FULL TEXT  

The Relation Between Surgeon Volume and Outcome Following Off-Pump vs On-Pump Coronary Artery Bypass Graft Surgery
Glance et al.
Chest 2005;128:829-837.
ABSTRACT | FULL TEXT  

Public Reporting and Case Selection for Percutaneous Coronary Interventions: An Analysis From Two Large Multicenter Percutaneous Coronary Intervention Databases
Moscucci et al.
J Am Coll Cardiol 2005;45:1759-1765.
ABSTRACT | FULL TEXT  

The Big Chill: The Deleterious Effects of Public Reporting on Access to Health Care for the Sickest Patients
Turi
J Am Coll Cardiol 2005;45:1766-1768.
FULL TEXT  

Is Hospital Procedure Volume a Reliable Marker of Quality for Coronary Artery Bypass Surgery? A Comparison of Risk and Propensity Adjusted Operative and Midterm Outcomes
Zacharias et al.
Ann. Thorac. Surg. 2005;79:1961-1969.
ABSTRACT | FULL TEXT  

The Volume-Quality Relationship of Mental Health Care: Does Practice Make Perfect?
Druss et al.
Am. J. Psychiatry 2004;161:2282-2286.
ABSTRACT | FULL TEXT  

Consumer-Driven Health Care: Lessons From Switzerland
Herzlinger and Parsa-Parsi
JAMA 2004;292:1213-1220.
ABSTRACT | FULL TEXT  

The legacy of Bristol: public disclosure of individual surgeons' results
Keogh et al.
BMJ 2004;329:450-454.
FULL TEXT  

Is the Impact of Hospital and Surgeon Volumes on the In-Hospital Mortality Rate for Coronary Artery Bypass Graft Surgery Limited to Patients at High Risk?
Wu et al.
Circulation 2004;110:784-789.
ABSTRACT | FULL TEXT  

Impact of regionalisation of cardiac surgery in Emilia-Romagna, Italy
Nobilio et al.
J. Epidemiol. Community Health 2004;58:97-102.
ABSTRACT | FULL TEXT  

Procedural Volume as a Marker of Quality for CABG Surgery
Peterson et al.
JAMA 2004;291:195-201.
ABSTRACT | FULL TEXT  

Surgeon Volume and Operative Mortality in the United States
Birkmeyer et al.
NEJM 2003;349:2117-2127.
ABSTRACT | FULL TEXT  

The Effect of Clustering of Outcomes on the Association of Procedure Volume and Surgical Outcomes
Panageas et al.
ANN INTERN MED 2003;139:658-665.
ABSTRACT | FULL TEXT  

Do hospitals with low mortality rates in coronary artery bypass also perform well in valve replacement?
Goodney et al.
Ann. Thorac. Surg. 2003;76:1131-1137.
ABSTRACT | FULL TEXT  

Is the hospital volume-mortality relationship in coronary artery bypass surgery the same for low-risk versus high-risk patients?
Glance et al.
Ann. Thorac. Surg. 2003;76:1155-1162.
ABSTRACT | FULL TEXT  

Impact of Hospital-Related Factors on Outcome After Treatment of Cerebral Aneurysms
Berman et al.
Stroke 2003;34:2200-2207.
ABSTRACT | FULL TEXT  

Do Hospitals and Surgeons With Higher Coronary Artery Bypass Graft Surgery Volumes Still Have Lower Risk-Adjusted Mortality Rates?
Hannan et al.
Circulation 2003;108:795-801.
ABSTRACT | FULL TEXT  

Predictors of Readmission for Complications of Coronary Artery Bypass Graft Surgery
Hannan et al.
JAMA 2003;290:773-780.
ABSTRACT | FULL TEXT  

Use of Continuous Quality Improvement to Increase Use of Process Measures in Patients Undergoing Coronary Artery Bypass Graft Surgery: A Randomized Controlled Trial
Ferguson et al.
JAMA 2003;290:49-56.
ABSTRACT | FULL TEXT  

The Quality of Quality Measurement in U.S. Nursing Homes
Mor et al.
Gerontologist 2003;43:37-46.
ABSTRACT | FULL TEXT  

The volume-outcome relationship: from Luft to Leapfrog
Shahian and Normand
Ann. Thorac. Surg. 2003;75:1048-1058.
ABSTRACT | FULL TEXT  

Should Volume Standards for Cardiovascular Surgery Focus Only on High-Risk Patients?
Goodney et al.
Circulation 2003;107:384-387.
ABSTRACT | FULL TEXT  

Risk Stratification and Comorbidity
Ferraris and Ferraris
Card Surg Adult 2003;2:187-224.
FULL TEXT  

Large Employers' New Strategies in Health Care
Galvin and Milstein
NEJM 2002;347:939-942.
FULL TEXT  

Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature
Halm et al.
ANN INTERN MED 2002;137:511-520.
ABSTRACT | FULL TEXT  

Achieving And Sustaining Improved Quality: Lessons From New York State And Cardiac Surgery
Chassin
Health Aff (Millwood) 2002;21:40-51.
ABSTRACT | FULL TEXT  

Health Care Report Cards: Implications for Vulnerable Patient Groups and the Organizations Providing Them Care
Davies et al.
Journal of Health Politics, Policy and Law 2002;27:379-400.
ABSTRACT  

Volume and Outcome -- It Is Time to Move Ahead
Epstein
NEJM 2002;346:1161-1164.
FULL TEXT  

Public Profiling of Clinical Performance
Naylor
JAMA 2002;287:1323-1325.
FULL TEXT  

Cardiac surgery report cards: comprehensive review and statistical critique
Shahian et al.
Ann. Thorac. Surg. 2001;72:2155-2168.
ABSTRACT | FULL TEXT  

Hospitals Without Eye Surgery: Are Minimum Standards of Care Being Met for Patients With Ocular Injury?
Margo
Arch Ophthalmol 2001;119:1851-1853.
FULL TEXT  

Hidden Barriers to Improvement in the Quality of Care
McNeil
NEJM 2001;345:1612-1620.
FULL TEXT  

Association Between Hospital and Surgeon Procedure Volume and Outcomes of Total Hip Replacement in the United States Medicare Population
Katz et al.
JBJS 2001;83:1622-1629.
ABSTRACT | FULL TEXT  

Improving The Quality Of Health Care: Who Will Lead?
Becher and Chassin
Health Aff (Millwood) 2001;20:164-179.
ABSTRACT | FULL TEXT  

Relationship of hospital size, case volume, and cost for coronary artery bypass surgery: Analysis of 12,774 patients operated on in Massachusetts during fiscal years 1995 and 1996
Shahian et al.
J. Thorac. Cardiovasc. Surg. 2001;122:53-64.
ABSTRACT | FULL TEXT  

Relationship Between Annual Volume of Patients Treated by Admitting Physician and Mortality After Acute Myocardial Infarction
Tu et al.
JAMA 2001;285:3116-3122.
ABSTRACT | FULL TEXT  

Problems for clinical judgement: 4. Surviving in the report card era
Tu et al.
CMAJ 2001;164:1709-1712.
ABSTRACT | FULL TEXT  

Statewide reporting of coronary artery surgery results: A view from California
Harlan
J. Thorac. Cardiovasc. Surg. 2001;121:409-417.
FULL TEXT  

Intussusception: Hospital Size and Risk of Surgery
Bratton et al.
Pediatrics 2001;107:299-303.
ABSTRACT | FULL TEXT  

Commentary: Public Disclosure in the Health Field: Is There a Relevant Option?
Weil
American Journal of Medical Quality 2001;16:23-33.
ABSTRACT  

Relation Between Hospital Primary Angioplasty Volume and Mortality for Patients With Acute MI Treated With Primary Angioplasty vs Thrombolytic Therapy
Magid et al.
JAMA 2000;284:3131-3138.
ABSTRACT | FULL TEXT  

Influence of Hospital Procedure Volume on Outcomes Following Surgery for Colon Cancer
Schrag et al.
JAMA 2000;284:3028-3035.
ABSTRACT | FULL TEXT  

Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy
O'Neill et al.
Neurology 2000;55:773-781.
ABSTRACT | FULL TEXT  

Predictive accuracy study: comparing a statistical model to clinicians' estimates of outcomes after coronary bypass surgery
Ivanov et al.
Ann. Thorac. Surg. 2000;70:162-168.
ABSTRACT | FULL TEXT  

Clinical Performance Measurement--A Hard Sell
Jencks
JAMA 2000;283:2015-2016.
FULL TEXT  

The Public Release of Performance Data: What Do We Expect to Gain? A Review of the Evidence
Marshall et al.
JAMA 2000;283:1866-1874.
ABSTRACT | FULL TEXT  

Public disclosure of performance data: learning from the US experience
Marshall et al.
Qual Saf Health Care 2000;9:53-57.
FULL TEXT  

Some Things Have Not Changed
Clever
ANN INTERN MED 2000;132:85-89.
ABSTRACT | FULL TEXT  

Excellence and low case volume: an example of the inapplicability of volume-based credentialing
Early and Roberts
Ann. Thorac. Surg. 2000;69:146-150.
ABSTRACT | FULL TEXT  

Alabama Coronary Artery Bypass Grafting Cooperative Project: baseline data
Holman et al.
Ann. Thorac. Surg. 1999;68:1592-1598.
ABSTRACT | FULL TEXT  

Public reporting of surgical mortality: a survey of New York State cardiothoracic surgeons
Burack et al.
Ann. Thorac. Surg. 1999;68:1195-1200.
ABSTRACT | FULL TEXT  

Commentary
Hannan
Med Care Res Rev 1999;56:363-372.
 

The Relation between Volume and Outcome in Health Care
Hannan
NEJM 1999;340:1677-1679.
FULL TEXT  

Volume-Outcome Relationships In Cardiovascular Operations: New York State, 1990-1995
Sollano et al.
J. Thorac. Cardiovasc. Surg. 1999;117:419-430.
ABSTRACT | FULL TEXT  

Hospital Volume and Patient Outcomes in Major Cancer Surgery: A Catalyst for Quality Assessment and Concentration of Cancer Services
Hillner and Smith
JAMA 1998;280:1783-1785.
FULL TEXT  

Relationship Between Provider Volume and Mortality for Carotid Endarterectomies in New York State
Hannan et al.
Stroke 1998;29:2292-2297.
ABSTRACT | FULL TEXT  

Center-Specific Graft and Patient Survival Rates: 1997 United Network for Organ Sharing (UNOS) Report
Lin et al.
JAMA 1998;280:1153-1160.
ABSTRACT | FULL TEXT  

Patients treated by cardiologists have a lower in-hospital mortality for acute myocardial infarction
Casale et al.
J Am Coll Cardiol 1998;32:885-889.
ABSTRACT | FULL TEXT  

Using Outcomes to Make Inferences about Nursing Home Quality
Spector and Mukamel
Eval Health Prof 1998;21:291-315.
ABSTRACT  

Rolling Down the Runway: The Challenges Ahead for Quality Report Cards
Epstein
JAMA 1998;279:1691-1696.
ABSTRACT | FULL TEXT  

Pediatric Cardiac Surgery: The Effect of Hospital and Surgeon Volume on In-hospital Mortality
Hannan et al.
Pediatrics 1998;101:963-969.
ABSTRACT | FULL TEXT  

The Risks of Risk Adjustment
lezzoni
JAMA 1997;278:1600-1607.
ABSTRACT  

Declines in Hospital Mortality Associated with a Regional Initiative to Measure Hospital Performance
Rosenthal et al.
American Journal of Medical Quality 1997;12:103-112.
ABSTRACT  

Coronary Angioplasty Volume-Outcome Relationships for Hospitals and Cardiologists
Hannan et al.
JAMA 1997;277:892-898.
ABSTRACT  

Coronary Artery Bypass Grafting Volume and Mortality
Pett et al.
Ann. Thorac. Surg. 1996;62:941-943.
FULL TEXT  

Influence of Cardiac-Surgery Performance Reports on Referral Practices and Access to Care -- A Survey of Cardiovascular Specialists
Schneider and Epstein
NEJM 1996;335:251-256.
ABSTRACT | FULL TEXT  

Benefits and Hazards of Reporting Medical Outcomes Publicly
Chassin et al.
NEJM 1996;334:394-398.
FULL TEXT  

Operator-Specific Outcomes : A Call to Professional Responsibility
Califf et al.
Circulation 1996;93:403-406.
FULL TEXT  

Volume Requirements for Cardiac Surgery Credentialing: A Critical Examination
Crawford et al.
Ann. Thorac. Surg. 1996;61:12-16.
ABSTRACT | FULL TEXT  

No Continuous Relationship Between Veterans Affairs Hospital Coronary Artery Bypass Grafting Surgical Volume and Operative Mortality
Shroyer et al.
Ann. Thorac. Surg. 1996;61:17-20.
ABSTRACT | FULL TEXT  

Outcome as a Function of Annual Coronary Artery Bypass Graft Volume
Clark
Ann. Thorac. Surg. 1996;61:21-26.
ABSTRACT | FULL TEXT  

Relationship Between the Volume of Craniotomies for Cerebral Aneurysm Performed at New York State Hospitals and In-Hospital Mortality
Solomon et al.
Stroke 1996;27:13-17.
ABSTRACT | FULL TEXT  

BUN as a Risk Factor for Mortality After Coronary Artery Bypass Grafting
Hartz et al.
Ann. Thorac. Surg. 1995;60:398-404.
ABSTRACT | FULL TEXT  

Volume and outcome in coronary artery bypass graft surgery: true association or artefact?
Sowden et al.
BMJ 1995;311:151-155.
ABSTRACT | FULL TEXT  

The STS Cardiac Surgery National Database: An Update
Clark
Ann. Thorac. Surg. 1995;59:1376-1380.
ABSTRACT | FULL TEXT  

Report Cards on Cardiac Surgeons -- Assessing New York State's Approach
Green and Wintfeld
NEJM 1995;332:1229-1233.
FULL TEXT  

WHY IS CABG MORTALITY FALLING?
JWatch General 1995;1995:7-7.
FULL TEXT