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J Thorac Cardiovasc Surg 2009;137:10-12
© 2009 The American Association for Thoracic Surgery

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Esophagectomy volume threshold as a criterion for centers of excellence: Causation or cause, strategy or strategem?

^a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
^b Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio

Received for publication June 26, 2008; accepted for publication June 30, 2008.

^_* Address for reprints: Thomas W. Rice, MD, Cleveland Clinic, 9500 Euclid Ave/Desk F24, Cleveland, OH 44195. (Email: ricet@ccf.org).

The first 300 words of the full text of this article appear below.

	Introduction

 

See related article on page 23.

 

	Prologue

 
Outcomes ranking, number of stars received, and designation of excellence by a host of watchdog organizations, government agencies, insurers, and national societies have captivated and captured every hospital, program, and department chair. The cause is to promote higher-quality, yet lower-cost, medical care (value). The pivotal target of this cause was hospital mortality after coronary artery bypass grafting—a high-cost, commonly performed, rather uniform, routine operation. Esophagectomy is, in contrast, uncommon, complex, and performed for a spectrum of esophageal diseases, both benign and malignant. Groups such as Leapfrog¹ believe that esophagectomy should not be a cottage industry but rather regionalized, much like surgery for congenital heart disease. Their strategy to effect change in surgical practice is to set a threshold (lower bound) for number of operated cases that must be performed each year to qualify for the coveted designation "Center of Excellence." They promote their strategy as "evidence-based hospital referral."

It is important to recognize that implicit in this strategy is a direct cause-and-effect relation (causation) between patient outcome and number of cases performed in a hospital or by a surgeon per year, and not merely an association between hospital mortality and volume. The theory behind the strategy is that regionalization will further increase the volume of Centers of Excellence and, thereby, decrease mortality (we have called this neutralization of the effect of low volume²). Although this theory may turn out to be fact, and in any event, regionalization may be philosophically compelling for good reasons, Meguid and colleagues³ in this issue of the Journal of Thoracic and Cardiovascular Surgery question the fundamental evidence for this volume threshold, challenging the theory behind the strategy. Implicit in their discussion is that a volume threshold for esophagectomy as a criterion for a Center . . . [Full Text of this Article]

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The effect of volume on esophageal cancer resections: What constitutes acceptable resection volumes for centers of excellence?

Robert A. Meguid, Eric S. Weiss, David C. Chang, Malcolm V. Brock, and Steven C. Yang
J. Thorac. Cardiovasc. Surg. 2009 137: 23-29. [Abstract] [Full Text] [PDF]