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The Effect of Provider Case Volume on Cancer Mortality: Systematic Review and Meta-Analysis

¹Associate Professor of Surgery, University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia
²Health Technology Assessment Evaluator, Monash Institute of Health Services Research, Melbourne, Victoria, Australia
³Professorial Fellow, Monash Institute of Health Services Research, Melbourne, Victoria, Australia
⁴Information Specialist, Monash Institute of Health Services Research, Melbourne, Victoria, Australia
Professor of Medicine, Monash Medical Center, Melbourne, Victoria, Australia
Associate Professor and Senior Biostatistician, Centre for Research Excellence in Patient Safety, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

Corresponding author: Russell L. Gruen, MBBS, PhD, Level 4, 89 Commercial Road, Melbourne, Victoria, 3004, Australia; r.gruen{at}alfred.org.au

DISCLOSURES: Supported by the Victorian Government Department of Human Services. Russell Gruen's work is supported by a National Health and Medical Research Council Career Development Award. The authors report no conflicts of interest.

The authors systematically reviewed the association between provider case volume and mortality in 101 publications involving greater than 1 million patients with esophageal, gastric, hepatic, pancreatic, colon, or rectal cancer, of whom more than 70,000 died. The majority of studies addressed the relation between hospital surgical case volume and short-term perioperative mortality. Few studies addressed surgeon case volume or evaluated long-term survival outcomes. Common methodologic limitations were failure to control for potential confounders, post hoc categorization of provider volume, and unit of analysis errors. A significant volume effect was evident for the majority of gastrointestinal cancers; with each doubling of hospital case volume, the odds of perioperative death decreased by 0.1 to 0.23. The authors calculated that between 10 and 50 patients per year, depending on cancer type, needed to be moved from a "low-volume" hospital to a "high-volume" hospital to prevent 1 additional volume-associated perioperative death. Despite this, approximately one-third of all analyses did not find a significant volume effect on mortality. The heterogeneity of results from individual studies calls into question the validity of case volume as a proxy for care quality, and leads the authors to conclude that more direct quality measures and the validity of their use to inform policy should also be explored. CA Cancer J Clin 2009;59:192–211. © 2009 American Cancer Society.

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