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Assessing the Volume-Outcome Hypothesis and Region-Level Quality Improvement Interventions: Pancreas Cancer Surgery in Two Canadian Provinces

  • Healthcare Policy and Outcomes
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

The volume-outcome hypothesis suggests that if increased provider procedure volume is associated with improved patient outcomes, then greater regionalization to high-volume providers should improve region-level outcomes. Quality improvement interventions for pancreas cancer surgery implemented in year 1999 in Ontario, Canada were designed to regionalize surgery to high-volume hospitals and decrease operative mortality. Similar interventions were not used in Quebec, Canada. We assessed the volume-outcome hypothesis and the impact of the Ontario quality improvement interventions.

Materials and Methods

Administrative databases helped identify pancreatic resections from years 1994 to 2004 and relevant patient and hospital characteristics. Hospitals were high-volume if they provided ≥10 procedures in a given calendar year. Outcomes were regionalization of surgery to high-volume providers and rates of operative mortality.

Results

From 1994 to 2004 the percentage of cases in high-volume hospitals increased from 33 to 71% in Ontario and from 36 to 76% in Quebec. Annual rates of operative mortality dropped in Ontario (10.4–2.2% or less) and changed little in Quebec (7.2–9.8%). Changes in measures over time in both provinces were similar before and after year 1999.

Conclusions

Regionalization was associated with improved operative mortality in Ontario but not in Quebec, undermining the volume-outcome hypothesis. The Ontario quality improvement interventions likely were of little influence since patterns in regionalization and operative mortality were similar before and after year 1999.

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Acknowledgment

We gratefully acknowledge contributions of the following individuals, Nathalie Vandal, Eric Pelletier, Feng Qiu, and Refik Saskin for their contributions to the statistical analysis and interpretation of the data. This research was funded by the Canadian Cancer Society grant No. 016273. The Canadian Cancer Society, which oversees the awarding of these grants, had no role in the planning, execution, interpretation, or writing of the study. This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.

Authors’ Contribution

The following outlines the contributions of each author to the preparation of this manuscript. The was study conceptualized and designed by MS, DU, DM, RS, NB, TT, AB, DD, and MNL. MS, DU, DM, RS, and NB acquired the data. Data analysis and interpretation was done by MS, DU, DM, RS, NB, TT, AB, DD, and MNL. MS, DU, DM, and NB drafted the manuscript, and all authors helped with revisions to the manuscript for important intellectual content. MS, DU, DD, and MNL obtained funding for the study. The study was supervised by MS, DU, RS, DM, and MNL. All authors have seen and approved the final version of the manuscript.

Access to Data

Dr. Simunovic had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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Authors and Affiliations

  1. Department of Surgery, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada

    Marko Simunovic MD

  2. Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada

    Marko Simunovic MD & Mark N. Levine MD

  3. Juravinski Cancer Centre, Hamilton, ON, Canada

    Marko Simunovic MD & Mark N. Levine MD

  4. Division of Clinical Decision-Making and Health Care, Toronto General Research Institute, Toronto General Hospital, Toronto, ON, Canada

    David Urbach MD

  5. Direction Systemes de soins et Politiques publiques, Institut national de sante publique du Quebec, Quebec, QC, Canada

    Diane Major PhD

  6. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

    Rinku Sutradhar PhD

  7. Division of General Surgery, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada

    Nancy Baxter MD

  8. Public Health Sciences, Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Teresa To PhD

  9. Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Adalsteinn Brown DPhil

  10. Health System Strategy Division, Ontario Ministry of Health and Long-Term Care, Toronto, ON, Canada

    Adalsteinn Brown DPhil

  11. Continuing Medical Education Section, Association of American Medical Colleges, Washington, DC, USA

    Dave Davis MD

  12. Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada

    Mark N. Levine MD

Authors
  1. Marko Simunovic MD
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  2. David Urbach MD
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  3. Diane Major PhD
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  4. Rinku Sutradhar PhD
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  5. Nancy Baxter MD
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  6. Teresa To PhD
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  7. Adalsteinn Brown DPhil
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  8. Dave Davis MD
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  9. Mark N. Levine MD
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Corresponding author

Correspondence to Marko Simunovic MD.

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Simunovic, M., Urbach, D., Major, D. et al. Assessing the Volume-Outcome Hypothesis and Region-Level Quality Improvement Interventions: Pancreas Cancer Surgery in Two Canadian Provinces. Ann Surg Oncol 17, 2537–2544 (2010). https://doi.org/10.1245/s10434-010-1114-0

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  • DOI: https://doi.org/10.1245/s10434-010-1114-0

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