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Research has demonstrated that there is lower operative mortality at hospitals with higher surgical volume. Using administrative data from Medicare, this study found lower mortality associated with each of eight procedures when performed by surgeons who undertook the operation more frequently. Lower mortality with surgeons who operate frequently. For many surgical procedures, patients at hospitals where a high number of such procedures are performed (high-volume hospitals) have lower mortality rates than those at hospitals that are less experienced with the procedures. 1 – 4 In one recent study of the national population of Medicare recipients, we found strong relations between hospital volume and operative mortality associated with 14 high-risk cancer resections and cardiovascular procedures. 5 Despite the considerable body of research in this area, little is known about the mechanisms underlying the observed associations between volume and outcome. Because they tend to be much larger facilities, high-volume hospitals have a broader . . .

For surgical procedures, operative mortality varies inversely with the number of procedures performed at a hospital. This study quantified the relation between volume and outcome among Medicare patients for 14 different surgical procedures. The relative effect of surgical volume on outcome varied markedly among types of procedures. For pancreatic resection, the absolute difference in mortality rates between the highest-volume and the lowest-volume hospitals was over 12 percent, whereas for carotid endarterectomy, the difference was only 0.2 percent. This study quantified the relation for 14 surgical procedures in Medicare patients. Over the past three decades, numerous studies have described higher rates of operative mortality with selected surgical procedures at hospitals where few such procedures are performed (low-volume hospitals). 1 – 4 Several recent reviews suggest that thousands of preventable surgical deaths occur each year in the United States because elective but high-risk surgery is performed in hospitals that have inadequate experience with the surgical procedures involved. 5 – 7 As part of a broader initiative aimed at improving hospital safety, a large coalition of private and public purchasers of health insurance — the Leapfrog Group — is encouraging patients undergoing one of five high-risk . . .

The volume–outcome hypothesis has created a policymaker's dilemma. In 1979, Luft and colleagues 1 reported in the Journal that the number of procedures performed at a hospital (hospital volume) and mortality rates for many surgical procedures were inversely related. Since then, this relation has been documented many times, 2 fueling a persistent debate about whether health care should be regionalized and certain sorts of complex, elective care restricted to high-volume medical centers. 3 – 5 Two studies reported in this issue of the Journal will undoubtedly fuel this controversy. In the first, Birkmeyer and colleagues 6 used Medicare claims data from 1994 through 1999 to . . .

There is considerable evidence that patients undergoing various types of complex treatments or high-risk surgical procedures have lower mortality rates and otherwise better outcomes if care is provided in hospitals that have a high caseload of patients with the same condition than if care is provided by institutions with low caseloads of such patients. Notwithstanding the fact that some low-volume institutions have good outcomes and some high-volume hospitals have relatively poor outcomes, this relation between high volume and better outcomes is strong and persistent, with approximately 300 studies on the subject having been reported in the English-language literature since the . . .

Cardiovascular disease represents the main health problem for women as it is the leading cause of death and morbidity. In recent years, technological advances and experience gained by surgeons and cardiologists has resulted in a significant improvement of percutaneous coronary procedures, which has been demonstrated to be safe and effective for both men and women. However, gender disparities in the management of coronary artery disease, specifically in the rate of use of these interventional procedures, as well as in the incidence of cardiovascular events have been reported. Treatment inequalities may also impact on outcomes. Possible reasons for treatment bias include a patient s preferences, a physician s decisions, biological and pathophysiological gender differences and inadequate evidence-based medicine among women.

Because time to presentation to the hospital affects time to treatment and is known to be important in acute myocardial infarction, we evaluated this variable in patients with unstable angina/non-ST segment elevation myocardial infarction (UA/NSTEMI). Among 2909 consecutive patients with UA/NSTEMI admitted to 35 hospitals in 6 geographic regions of the United States, we compared patients with acute (onset of pain <12 hours before admission) and subacute (onset >12 hours) unstable angina. Patients with \"hot\" (acute) unstable angina presented more often to the emergency department and were subsequently admitted more often to an intensive care unit. Hospital administration of medications did not differ between the two groups, with the exception of heparin, which was paradoxically used more often in subacute patients (p<0.001). All cardiac invasive procedures were undertaken less often in the acute patients (catheterization, 41.4% vs. 58.7%, p=0.001; percutaneous coronary intervention, 11.3% vs. 21.1%, p=0.001; coronary artery bypass grafting, 5.6% vs. 12.0%, p=0.001). A greater percentage of acute patients were found to have no significant coronary artery disease at cardiac catheterization (20.1% vs. 15.0%, p=0.006). Mortality did not differ between the two groups; however, the composite endpoint of death and MI favored the acute patients (1.3% vs. 2.2%, p=0.032). Contrary to our initial hypothesis, \"hot\" UA patients tended to be at lower risk than patients with subacute presentation, highlighting the fact that patients with UA/NSTEMI remain at high risk even after the initial 12-hour period.

The Food and Drug Administration stands ready to OK a highly anticipated drug-eluting stent as early as this week, but revenue at hospitals may fall as a result of declining volumes in cardiovascular surgeries, a lucrative service. The problem comes \"because hospitals are stuck in the middle,\" says Jeffery Morneault (left), an executive at Health Alliance of Greater Cincinnati.