Busy hospitals best for some surgeries: report

It pays off to have certain types of surgery performed in a hospital that does a high volume of that kind of operation, says a new report from the Canadian Institute for Health Information released Wednesday.

Survival rates were higher for Canadian patients who went to high-volume hospitals to undergo three of nine procedures studied for the report, which covers the years 1998 to 2003.

There was no statistically significant difference between high-volume and low-volume hospitals when it came to the other six procedures studied for the report, which looked at a total of 180,000 surgeries.

"In no cases was smaller better that we had better outcomes for hospitals that did fewer of the surgeries," said Glenda Yeates, the president of the institute.

She said government officials might want to look at the findings when discussing whether some surgeries should be offered at so-called "centres of excellence," and not provided at all in smaller hospitals.

Yeates added that some of the types of surgery studied for the report, such as heart bypass operations, are already concentrated in larger hospitals.

The surgeries for which a difference was found were:

• Angioplasty procedures, which involve inserting a catheter into the plugged-up portion of an artery, then inflating a tiny balloon that squeezes open the artery to restore circulation to the heart.
• Esophagectomy procedures, which remove part of the esophagus to treat cancer of that digestive organ that connects the throat to the stomach.
• Whipple procedures, designed to treat pancreatic cancer by removing the gallbladder, common bile duct, duodenum, part of the jejunum, and the head of the pancreas.

Patients having angioplasty procedures in hospitals that perform a lot of them were less likely to die within 30 days of the surgery, the report found after looking at 35,710 such procedures.

For every 10 extra angioplasties the hospital performed each year, the patient mortality rate showed a reduction of one per cent.

The average death rate for patients in the month following their angioplasties was very low to begin with, just 0.2 per cent for the six years studied.

The study also suggests that angioplasty patients were more likely to die if they were treated at low-volume hospitals near their homes than if they travelled to a high-volume hospital further away. Then mortality rates in those cases were 1.6 per cent and 0.7 per cent, respectively.

But centralizing complex surgery in a few major centres isn't always best, since local and regional hospitals must maintain some surgical programs or risk losing the ability to respond to emergencies, said Dr. David Urbach, a surgeon at Toronto's University Health Network.

"I think you have to look at a lot of these types of surgeries on a case-by-case basis because for a lot of them there really is a role to have some access at a regional level."

Cancer procedures much more rare

The two types of cancer procedures showed more dramatic differences, but the institute's report pointed out that they are relatively rare, with only a few of Canada's 744 active hospitals performing more than 30 a year.

The risk of an esophagectomy patient dying within 30 days dropped by 44 per cent with every 10 extra esophagectomies a hospital performed. The average mortality rate for that procedure is 4.3 per cent.

Patients having Whipple procedures experienced a 46-per-cent decline in death rates for every 10 additional surgeries a hospital did.

The Canadian Institute for Health Information, a not-for-profit organization established by the nation's health ministers, also released a new review of international studies looking at the same topic and covering a variety of surgeries.

They found that two-thirds of the 300 studies showed patients did better when they were operated upon at high-volume hospitals.