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J Thorac Cardiovasc Surg 2008;135:1202-1209
© 2008 The American Association for Thoracic Surgery

Expert Commentary

Low-volume coronary artery bypass surgery: Measuring and optimizing performance

^a Department of Surgery, Center for Quality and Safety, and the Institute for Health Policy, Massachusetts General Hospital, and Harvard Medical School, Boston, Mass
^b Department of Health Care Policy, Harvard Medical School, and the Department of Biostatistics, Harvard School of Public Health, Boston, Mass

Received for publication November 9, 2007; accepted for publication December 18, 2007.

^_* Address for reprints: David M. Shahian, MD, Center for Quality and Safety, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. (Email: dshahian@partners.org).

The first 300 words of the full text of this article appear below.

	Introduction

 

See related article on page 1306.

 

In the current issue of the Journal, Miyata and colleagues¹ describe the relationship between coronary artery bypass grafting (CABG) procedural volume and outcome in Japan. In reality, however, there are no high-volume programs in this study. What the authors have actually provided us is the most extensive study of low-volume and extremely low-volume CABG surgery in the literature. It complements previous studies from the United States that include some programs with low volumes, and it provides a striking counterpoint to New York studies that are weighted toward the high end of the volume spectrum.

This report illustrates the potential for good performance at low volumes, as well as the statistical challenge of accurately measuring performance when sample sizes are small. It raises a number of unresolved issues in the ongoing volume–outcome debate, at least as applied to CABG surgery. For example, some payers and other stakeholders continue to promote best-practice volume requirements that are increasingly beyond the grasp of many programs, particularly as overall CABG volumes decrease nationally. Is this appropriate policy given the available outcomes data? Because many lower-volume programs function at a high level, can the public be protected while at the same time not penalizing such excellent programs? Is there a rational lower volume limit for CABG surgery programs? Are there better ways to measure performance that are less compromised by small sample sizes? Are there specific process and structural approaches that might promote optimal functioning of small programs?

	Is Low-volume CABG Surgery a Performance Problem or a Measurement Problem?

 
CABG is unique: it is a mature, standardized procedure that is performed more frequently than any other complex operation and that has also been scrutinized more thoroughly. Notwithstanding the general validity of the volume–outcome relationship for a number of medical conditions and surgical procedures, data from a variety of sources . . . [Full Text of this Article]

Related Article

Effect of procedural volume on outcome of coronary artery bypass graft surgery in Japan: Implication toward public reporting and minimal volume standards

Hiroaki Miyata, Noboru Motomura, Yuichi Ueda, Hikaru Matsuda, and Shinichi Takamoto
J. Thorac. Cardiovasc. Surg. 2008 135: 1306-1312. [Abstract] [Full Text] [PDF]

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