In a retrospective study reported in the Journal of Clinical Oncology, Farjah et al found that patients who underwent resection for lung cancer at hospitals and with surgeons meeting Volume Pledge criteria did not have better short-term outcomes compared with patients who received care from hospitals and surgeons not meeting those criteria.
As noted by the investigators, “In 2015, several health systems announced that they would take the Volume Pledge, which restricted high-risk cancer resections to hospitals that meet procedure-specific hospital and surgeon volume thresholds.”
“The Volume Pledge was not associated with better outcomes except for a marginally shorter length of stay. A reexamination of volume-outcome relationships for hospitals and surgeons yielded mixed results that did not reveal a practical alternative for volume-based quality improvement efforts.”— Farjah et al
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Study Details
The study involved data from the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database for patients undergoing resection for lung cancer between 2015 and 2017. Outcomes were compared for hospitals and surgeons who did vs did not meet the Volume Pledge criteria of ≥ 40 patients per year for hospitals and ≥ 20 patients per year for surgeons.
Adjusted analysis of outcomes controlled for age; sex; body mass index; hypertension; steroid use; congestive heart failure; coronary artery, peripheral, and/or cerebrovascular disease; previous cardiothoracic surgery; diabetes; predicted forced expiratory volume in 1 second; induction therapy; renal failure/dialysis; smoking status; Zubrod and American Society of Anesthesiologist scores; incisional approach; extent of resection; and pathologic stage.
Key Findings
Among 32,183 patients, 465 surgeons, and 209 hospitals included in the analysis, 16,630 patients (52%) received care from both a hospital and surgeon meeting Volume Pledge criteria.
In adjusted analysis, there were no significant differences for meeting vs not meeting criteria for any complication (38% vs 38%, odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.93–1.10), major morbidity (7.4% vs 8.0%, OR = 0.98, 95% CI =0.87–1.09), STS major morbidity-mortality composite endpoint (1.2% vs 1.3%, OR = 0.99, 95% CI = 0.89–1.10), operative mortality (death within 30 days of resection or during the index admission; 7.7% vs 8.4%, OR = 1.04, 95% CI = 0.84–1.27), or failure to rescue (2.7% vs 2.9%, OR = 1.03, 95% CI = 0.82–1.31).
Meeting of criteria was associated with a significant 0.5-day reduction in median hospital stay (OR = 0.91, 95% CI = 0.86–0.96).
A nonlinear relationship between hospital volume and complications was observed, in which intermediate-volume hospitals had the highest risk of complications.
Surgeon volume showed an inverse linear relationship with major morbidity, the STS composite endpoint, and length of hospital stay. For major morbidity and the STS composite endpoint, surgeon annual volumes of ≥ 60 patients (8% of surgeons in cohort) were associated with a significantly lower risk of adverse events. Surgeons with more than 115 patients were associated with significantly lower risk of operative mortality.
The investigators concluded, “The Volume Pledge was not associated with better outcomes except for a marginally shorter length of stay. A reexamination of volume-outcome relationships for hospitals and surgeons yielded mixed results that did not reveal a practical alternative for volume-based quality improvement efforts.”
Farhood Farjah, MD, MPH, FACS, of the University of Washington, Seattle, is the corresponding author for the Journal of Clinical Oncology article.
Disclosure: For full disclosures of the study authors, visit ascopubs.org.
