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J Thorac Cardiovasc Surg 2009;137:1139-1140
© 2009 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr J. William Gaynor (Philadelphia, Pa). I would like to congratulate Dr Welke and his coinvestigators for a very important and interesting study. They have used data from the STS congenital database to investigate the relationship between center-based surgical volume and outcome as assessed based on hospital mortality. This is an important and controversial topic because center volume has been used as a quality measure.

Dr Welke and colleagues' study shows that volume alone is a poor predictor of outcome. However, after adjustment for patient factors and case complexity, they did identify a complex relationship between surgical volume and outcomes.

There is no relationship between volume and outcome for low-complexity cases. However, for complex cases, particularly the Norwood procedure, there was a significant relationship between increasing surgical volume, particularly in very large centers of greater than 350 patients a year, and improved outcomes.

This study complements and supports a previous study by Dr Welke and his colleagues, which was presented at the STS meeting earlier this year. In that study they used an administrative data set and showed that surgeons in centers with a large annual case volume performed more complex cases with better results than those in smaller centers.

Use of case volume as a quality metric is obviously controversial. Previous studies with administrative databases have been criticized because of the lack of data quality and the lack of adequate risk stratification.

The current study Dr Welke and his colleagues used the best available clinical database and the best available risk stratification to identify this relationship between volumes and clinical outcomes.

The goal of the STS database is quality improvement. We have now identified a relationship that some centers might not want to see; that is, there appears to be a relationship, . . . [Full Text of this Article]