Society of Surgical Oncology Presidential Address: Volume, Outcome, and Surgical Specialization

The opportunity to address you today is a singular privilege, one that I do not take lightly. Many of you are mentors, colleagues, trainees, friends, and family who have shaped this talk through your personal interactions, your writings, and your support. For all you have done, I am eternally grateful. Presidential talks vary in theme from personal messages to lifelong research projects, from philosophy to biologic topics. I have chosen to talk on volume, outcome, and specialty training as a means to expand from my personal observations to public policy issues and from individual education to a commitment toward societal good. Just as “a journey of a thousand miles starts with a single step,” so too, a large clinical database starts with a single patient. In 1997, a young woman was found clinically to have a large pelvic and abdominal mass. She and her family were frightened. They had no specific knowledge of a hospital’s outcome results with this problem; they sought help on the basis of institutional reputation and physician availability. After preoperative testing, the woman underwent a total abdominal hysterectomy, a bilateral oophorectomy, an appendectomy, and an abdominal staging procedure. An adenocarcinoid tumor of the appendix was the primary culprit, and this situation represented stage 4 disease. Subsequently, a catheter was placed for intraperitoneal chemotherapy, followed by intravenous therapy, although definitive outcome data were not available for this tumor type and stage. A major pulmonary embolus occurred after hospital discharge, requiring readmission. During this time, knowing the prognosis, the patient and her family sought additional treatment options. Eight months after the first procedure, a second-look staging operation and hyperthermic intraperitoneal infusion were done, followed by additional intraperitoneal and intravenous chemotherapy for a total treatment period of 2 years. Institutional volume in this instance was a single case, but surgeon experience was extensive. After the patient’s chemotherapy was completed, she went on to receive experimental vaccine therapy, knowing again that results for this tumor type were unclear. What does this individual patient teach us? First, institutional and surgeon reputations, not outcomes data, play major roles in an individual’s treatment selection. Second, complications do occur after hospital discharge and may not always be recorded in certain databases. Third, the benefits of certain treatment options relate to averages and are not specific to individuals. Finally, hospital and surgeon volumes, along with specialty training, may influence patient outcome, but the processes of care that are most important are not always clear. Concern over quality in health care has seen dramatic resurgence in recent years. Underuse, overuse, and misuse of hospitalized patient care continues to occur. Gawande et al., in a study of adverse events in Colorado and Utah, noted that 54% of surgical adverse events were preventable, and 6% of these adverse events resulted in death.1 Unfortunately, the availability of objective data on the quality of care delivered by individual surgeons and hospitals has remained limited. For this reason, patients, insurers, corporate purchasers, and policymakers look increasingly to provider volume as a surrogate indicator for quality of care (Table 1). In May 2000, for example, the Institute of Medicine convened a workshop to discuss hospital and surgeon volumes and clinical outcomes, along with recommending public policies for selective patient referral to institutions.2 A growing body of literature finds a positive association between hospital and surgeon volumes and clinical outcomes in surgery (Table 2).3 The magnitude and the Received April 14, 2003; accepted December 19, 2003. Address correspondence and reprint requests to: John M. Daly, MD, Temple University School of Medicine, 3420 North Broad Street, Room 102, Philadelphia, PA 19140; DalyJ@mail.temple.edu.