Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery from unsafe hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume.
We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for major lung cancer surgery, splitting the data into training (2010–2015) and validation sets (2016–2018). We calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modelled a market exit of low-performing hospitals and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance/time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure.
Between 2016 and 2018, 28,647 patients were treated in 974 hospitals. 71.4% of all high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In a RSMR centralization model, an average of 33 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, while 48 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery was 16 minutes. Centralization based on RSMR compared to volume would ensure lower median travel times, and these times would be lower than those observed.
RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.
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All authors have declared no conflicts of interest.