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(Circulation. 2004;110:784-789.)
© 2004 American Heart Association, Inc.

Original Articles

Is the Impact of Hospital and Surgeon Volumes on the In-Hospital Mortality Rate for Coronary Artery Bypass Graft Surgery Limited to Patients at High Risk?

Chuntao Wu, MD, PhD; Edward L. Hannan, PhD; Thomas J. Ryan, MD; Edward Bennett, MD; Alfred T. Culliford, MD; Jeffrey P. Gold, MD; O. Wayne Isom, MD; Robert H. Jones, MD; Barbara McNeil, MD, PhD; Eric A. Rose, MD; Valavanur A. Subramanian, MD

From University at Albany (C.W., E.L.H.), State University of New York, Albany, NY; Boston University School of Medicine (T.J.R.), Boston, Mass; St. Peter’s Hospital (E.B.), Albany, NY; New York University Medical Center (A.T.C.), New York, NY; Montefiore Medical Center (J.P.G.), Bronx, NY; New York Hospital-Cornell (O.W.I.), New York, NY; Duke University Medical Center (R.H.J.), Durham, NC; Harvard Medical School (B.M.), Boston, Mass; Columbia-Presbyterian Medical Center (E.A.R.), New York, NY; and Lenox Hill Hospital (V.A.S.), New York, NY.

Correspondence to Chuntao Wu, MD, PhD, University at Albany, State University of New York, One University Place, Rensselaer, NY 12144-3456. E-mail ctw09{at}health.state.ny.us

Received November 14, 2003; de novo received February 17, 2004; revision received April 13, 2004; accepted April 15, 2004.

Background— Restriction of volume-based referral for CABG surgery to high-risk patients has been suggested, and earlier studies have reached different conclusions regarding volume-based referral for low-risk patients.

Methods and Results— Patients who underwent isolated CABG surgery in New York from 1997 through 1999 (n=57 150) were separated into low-risk and moderate-to-high-risk groups with a predicted probability of in-hospital death of 2% as the cutoff point. The provider volume-mortality relationship was examined for both groups. For annual hospital volume thresholds between 200 and 600 cases, the adjusted ORs of in-hospital mortality for high-volume to low-volume hospitals ranged from 0.45 to 0.77 and were all significant for the low-risk group; for the moderate-to-high-risk group, ORs ranged from 0.62 to 0.91, and most were significant. The number needed to treat at higher-volume hospitals to avoid 1 death was greater for the low-risk group (a range of 114 to 446 versus 37 to 184). As the annual surgeon volume threshold increased from 50 to 150 cases, the ORs for high- to low-volume surgeons increased from 0.43 to 0.74 for the low-risk group; for the moderate-to-high-risk group, ORs ranged from 0.79 to 0.86. Compared with patients treated by surgeons with volumes of <125 in hospitals with volumes of <600, patients treated by higher-volume surgeons in higher-volume hospitals had a significantly lower risk of death; in particular, the OR was 0.52 for the low-risk group.

Conclusions— For both low-risk and moderate-to-high-risk patients, higher provider volume is associated with lower risk of death.

Key Words: bypass • mortality • risk factors

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