Is volume related to outcome in health care? A systematic review and methodologic critique of the literature.
OBJECTIVE
To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them.


METHODS
The authors searched MEDLINE from January 1980 to December 2000 for English-language, population-based studies examining the independent relationship between hospital or physician volume and clinical outcomes. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies.


METHODS
Of 272 studies reviewed, 135 met inclusion criteria and covered 27 procedures and clinical conditions.


METHODS
Two investigators independently reviewed each article, using a standard form to abstract information on key study characteristics and results.


RESULTS
The methodologic rigor of the primary studies varied. Few studies used clinical data for risk adjustment or examined effects of hospital and physician volume simultaneously. Overall, 71% of all studies of hospital volume and 69% of studies of physician volume reported statistically significant associations between higher volume and better outcomes. The strongest associations were found for AIDS treatment and for surgery on pancreatic cancer, esophageal cancer, abdominal aortic aneurysms, and pediatric cardiac problems (a median of 3.3 to 13 excess deaths per 100 cases were attributed to low volume). Although statistically significant, the volume-outcome relationship for coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery, and orthopedic procedures was of much smaller magnitude. Hospital volume-outcome studies that performed risk adjustment by using clinical data were less likely to report significant associations than were studies that adjusted for risk by using administrative data.


CONCLUSIONS
High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of these findings is complicated by the methodologic shortcomings of many studies. Differences in case mix and processes of care between high- and low-volume providers may explain part of the observed relationship between volume and outcome.
Halm
Ethan A
EA
Mount Sinai School of Medicine, Department of Health Policy, Box 1077, One Gustave L. Levy Place, New York, NY 10029, USA. ethan.halm@mountsinai.org
Lee
Clara
C
Chassin
Mark R
MR
D003695:Delivery of Health Care / Q000592:standards*; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D017063:Outcome Assessment, Health Care; D010820:Physicians / Q000706:statistics & numerical data*; D012107:Research Design; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data; D014481:United States