title: Observational study of the relationship between volume and outcomes using data from the National Audit of Cardiac Rehabilitation.
abstract: Cardiac rehabilitation (CR) is an evidence-based intervention delivered by a wide range of high-volume and low-volume centres; however, the extent of volume-outcome relationship is yet to be studied. There is a lack of consensus about the effect of volume on outcomes, with evidence of mixed effects in acute and chronic care. The aim of this study is, to investigate the extent of association of outcomes in CR with patient volume.
  
  
  
  Data was validated and extracted from the national audit from 2012 to 2013 for each CR centre. Volume was calculated as the total number of patients entering outpatient CR. Hierarchical multiple regression models were used to test for relationships between volume and outcomes. The outcomes included body mass index, blood pressure, psychosocial well-being, cholesterol, smoking cessation and physical activity. The analyses were adjusted for centre and patient characteristics and confounders.
  
  
  
  The number of patients included in the volume analysis was 48 476, derived from 178 CR centres. The average age per centre was 66 years with a 70% male distribution of patients enrolled. Regression analysis revealed no volume-outcome relationship, additionally no statistical significance existed.
  
  
  
  Unlike cardiac surgery this study, after accounting for staffing, age, gender and comorbidity, shows no effect of volume on outcome following CR delivered by high-volume and low-volume programmes. Based on our data there is no support for centralisation of services. Our findings and methodology can be used as a benchmark for future volume-outcome relationship studies in CR.
authors.affiliation: Department of Health Sciences , University of York , York , UK.
authors.forename: Patrick
authors.initials: P
authors.lastname: Doherty
authors.affiliation: Department of Health Sciences , University of York , York , UK.
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Harrison
authors.affiliation: British Heart Foundation , London , UK.
authors.forename: Mike
authors.initials: M
authors.lastname: Knapton
authors.affiliation: Department of Health Sciences , University of York , York , UK.
authors.forename: Veronica
authors.initials: V
authors.lastname: Dale
keywords: CORONARY ARTERY DISEASE; QUALITY OF CARE AND OUTCOMES