Over the long consulting careers of CFA's Principals, the relationship between cardiovascular procedural volume and quality outcomes has continually merited examination.
Multiple studies have addressed the issue for a wide range of cardiovascular procedures. It is intuitive-isn't it?-that higher volume cardiovascular programs produce better outcomes, and vice versa?
Researchers, professional societies (through evidence-based practices), payers and the media have all addressed the issue, in some cases setting guidelines and standards for minimum volumes at both the program and physician operator level. In certain states, falling below a minimum volume standard can trigger a clinical audit and could result in program decertification. Unfortunately, we all know that "volume equals quality" just isn't that simple-it is complex and heavily nuanced.
A recent example of research into this issue was published in the Journal of the American Medical Association in November 2009. The article examined the association of hospital primary angioplasty volume with quality and outcome. One of its authors, Dr. Deepak L. Bhatt of the Cleveland Clinic, concluded that the mortality from small, medium and large volume providers does not differ considerably. Other markers of quality were also studied, such as door-to-balloon times and length of stay. He further concluded that,
"As common sense would suggest, certainly there is a level where volume does matter, but in the contemporary era, that threshold may vary. The best measure of outcome is outcome."
Dr. Bhatt's conclusion is surprising simple, yet profound: the best measure of outcome is outcome. In this era of pay for performance, bundling payments, rewarding specific levels of outcome metrics, demand for increasingly transparent results and heightened public expectations, hospitals need to pay strict attention to Dr. Bhatt's simple conclusion and make it work for their program.
CFA recommends that hospitals (and individual physician operators) whose CV service line volume of a key procedure falls below generally accepted minimum volume indicators take the following actions:
For further information, CFA refers you to Association of Hospital Primary Angioplasty Volume in ST-Segment Elevation Myocardial Infarction with Quality and Outcomes, published in JAMA, November 25, 2009; 302(20); 2207-2213. (http://jama.ama-assn.org/content/vol302/issue20/index.dtl)