Interpreting the Volume-Outcome Relationship in the Context of Cancer Care (2001) / Chapter Skim
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Interpreting the Volume-Outcome Relationship in the Context of Cancer
Interpreting the Volume-Outcome Relationship in the Context of Cancer
Pages 1-12
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These findings prompted the National Cancer Policy Board (board) to recommend in its 1999 report Ensuring Quality Cancer Care that cancer care is optimally delivered in systems of care that Ensure that patients undergoing procedures that are technically difficult to perform and have been associated with higher mortality in lower-volume settings receive care at facilities with extensive experience (i.e., high-volume facilities)
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TlIE VOLUMENUTCOME RELATIONSHIP IN THE CONTEXT OF HEALTH CARE QUALITY MEASUREMENT The National Cancer Policy Board concluded in its 1999 report Ensuring Quality Cancer Care that, based on the best available evidence, some individuals with cancer do not receive care known to be effective for their conditions. The magnitude of the problem is not known, but the board believes it is substantial.
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In the absence of good data on processes of care, data about outcomes (e.g., mortality, functional status) that include risk adjustment using detailed clinical data (usually available only in the medical chart or specialized databases)
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Although there is a statistically significant Bend confiIIning improved outcomes with higher volume, providers in Me intermediate-volume group are sometimes ~ndisting~shable from either low- or high-volume providers. FIGURE 1 Impact of hospital volume on operative mortality for major cancer surgery among Medicare beneficiaries.
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, for example, statewide clinical databases are available for cardiac surgery that allow analyses of outcomes by both individual surgeons and hospitals. Cancer registries are available for surveillance purposes, but they usually lack sufficient clinical information for quality-of-care studies (IOM, 2000b)
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Selective referral programs might be difficult to implement for infrequently performed procedures because of the limited number of hospitals that have high volumes of these procedures: in 1997, an estimated 37 hospitals nationwide performed seven or more esophagectomies and 85 hospitals had this volume of pancreatectomies.
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estimated that in 1997, 27 deaths associated with esophagectomy and pancreatectomy performed in lowvolume hospitals could have been averted with care in a high-volume hospital. NATIONAL CANCER POLICY BOARD RECOMMENDATIONS It is often difficult to judge when to implement policies based on research findings.
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Examples of such applications include the following: 1. Public and private health care purchasers' use of quality indicators (e.g., selective referral programs, consumer education)
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This could be accomplished through a systematic and comprehensive examination of the relationship for both surgical and nonsurgical interventions, using existing data resources (e.g., AHRQ's HCUP database, state hospital discharge files, cancer registries, ACS-CoC's and the American Cancer Society's National Cancer Data Base)
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HCllP includes states' hospital discharge data, a valuable data source for health services research, but the database has certain limitations (e.g., lacks detailed clinical data, is not longitudinal, provides
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Operationalizing volume-based quality indicators will require agreement on the definition of the conditions and procedures to be included in the measure (e.g., ICD-9 codes) ; volume thresholds or cutpoints to identify highand low-volume hospitals, standard methods to measure and monitor hospital volume (e.g., annual or biannual measurement, effects of hospital mergers and affiliations on categorization)
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