The hospital volume-outcome relationship in general thoracic surgery. Is the surgeon the critical determinant?

BACKGROUND: Complex operations, such as those performed in thoracic surgery, have a hospital volume-outcome relationship. It is difficult to isolate the effect of the surgeon in this relationship since experienced thoracic surgeons tend to practice in high-volume tertiary care hospitals. An American comprehensive cancer hospital created a community outreach satellite program in thoracic surgery, and this provided a unique opportunity to study the hospital volume-outcome relationship without the confounding variable of surgeon experience.
METHODS: A retrospective review of thoracic surgical operations done over a 4-year period at a small community hospital, by a tertiary care hospital surgeon, was conducted. Operative mortality was the major outcome measure. Two high complexity operations (pneumonectomy and esophagectomy) were specifically scrutinized.
RESULTS: 486 thoracic surgical procedures (317 minor and 169 major cases) were done. There was one in-hospital death (aspiration pneumonia after esophageal stenting) and one 30-day mortality (readmission for cerebral vascular accident after lobectomy). Data,for the 10 esophagectomy patients is as follows: age - 66+/-13 years; length of stay - 12.8+/-3.4 days; anastomotic leaks - 0; operative mortality - 0. Data for the 6 pneumonectomy patients is as follows: age - 69+/-8 years; length of stay - 8.5+/-5.2 days; preoperative FEV1 - 1.6+/-0.3 litres; fistulas or empyema - 0; operative mortality - 0.
CONCLUSIONS: Despite having a very low volume of thoracic surgical cases the community hospital had crude outcomes comparable to those reported from high volume tertiary hospitals. This suggests that the surgeon may be a more important factor in the hospital volume-outcome relationship than previously thought. Nevertheless, complex thoracic surgical operations are ideally performed by an experienced surgeon, and in a high volume hospital