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J Thorac Cardiovasc Surg 2008;135:1306-1312
© 2008 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Effect of procedural volume on outcome of coronary artery bypass graft surgery in Japan: Implication toward public reporting and minimal volume standards

Departments of Healthcare Quality Assessment and Cardiothoracic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan, the Department of Cardiothoracic Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan, and Hyogo Medical College, Hyogo, Japan

Received for publication May 22, 2007; revisions received October 21, 2007; accepted for publication October 26, 2007.

^_* Address for reprints: Hiroaki Miyata, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. (Email: hiroaki.miyata{at}gmail.com).

Background: Since the Japanese government updated the medical practice laws, each hospital has to submit procedural volume from April 2007 and may sometime in the future have to submit some outcome indicators. It is very important to examine whether procedural volume is accurate and appropriate.

Methods: We analyzed 4581 procedures from 36 centers between 2003 and 2005 by clinical database. The effect of hospital volume on each outcome was tested by a hierarchical mixed-effects logistic regression model, covering clinical risk factors, procedural year, clinical processes, and hospital volume/surgeon volume as a fixed effect and random intercepts for sites.

Results: Logistic regression model revealed a significant association between hospital bypass graft volume and 30-day mortality (P < .05) and operative mortality (P < .01). Surgeon procedural volume, however, did not have a significant effect on those outcomes. The effect of hospital procedural volume was associated with better outcomes in most patient subgroups: age younger than 65 years (P < .05), age 65 years and older (P < .01), low risk (P = .58), and high risk (P < .01).

Conclusion: In Japan, high-volume compared with low-volume providers had better outcomes. As for public reporting in Japan, hospital-based evaluation might be more credible than surgeon-based evaluation. Although minimal volume standards might be effective to improve quality to some extent, volume has limitations as a marker of quality because of its wide range of variance.

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