title: Which Kind of Provider's Operation Volumes Matters? Associations between CABG Surgical Site Infection Risk and Hospital and Surgeon Operation Volumes among Medical Centers in Taiwan.
abstract: BACKGROUND
  Volume-infection relationships have been examined for high-risk surgical procedures, but the conclusions remain controversial. The inconsistency might be due to inaccurate identification of cases of infection and different methods of categorizing service volumes. This study takes coronary artery bypass graft (CABG) surgical site infections (SSIs) as an example to examine whether a relationship exists between operation volumes and SSIs, when different SSIs case identification, definitions and categorization methods of operation volumes were implemented.
  
  
  METHODS
  A population-based cross-sectional multilevel study was conducted. A total of 7,007 patients who received CABG surgery between 2006 and 2008 from 19 medical centers in Taiwan were recruited. SSIs associated with CABG surgery were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) codes and a Classification and Regression Trees (CART) model. Two definitions of surgeon and hospital operation volumes were used: (1) the cumulative CABG operation volumes within the study period; and (2) the cumulative CABG operation volumes in the previous one year before each CABG surgery. Operation volumes were further treated in three different ways: (1) a continuous variable; (2) a categorical variable based on the quartile; and (3) a data-driven categorical variable based on k-means clustering algorithm. Furthermore, subgroup analysis for comorbidities was also conducted.
  
  
  RESULTS
  This study showed that hospital volumes were not significantly associated with SSIs, no matter which definitions or categorization methods of operation volume, or SSIs case identification approaches were used. On the contrary, the relationships between surgeon's volumes varied. Most of the models demonstrated that the low-volume surgeons had higher risk than high-volume surgeons.
  
  
  CONCLUSIONS
  Surgeon volumes were more important than hospital volumes in exploring the relationship between CABG operation volumes and SSIs in Taiwan. However, the relationships were not robust. Definitions and categorization methods of operation volume and correct identification of SSIs are important issues for future research.
authors.affiliation: Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan.
authors.forename: Tsung-Hsien
authors.initials: TH
authors.lastname: Yu
authors.affiliation: Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan.
authors.forename: Yu-Chi
authors.initials: YC
authors.lastname: Tung
authors.affiliation: Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan.
authors.forename: Kuo-Piao
authors.initials: KP
authors.lastname: Chung
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000368:Aged; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D038801:International Classification of Diseases; D008297:Male; D055361:Multilevel Analysis; D012307:Risk Factors; D066231:Surgeons; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000209:etiology*; D013624:Taiwan / Q000453:epidemiology