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Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature

Ethan A. Halm, MD, MPH; Clara Lee, MD, MPP; and Mark R. Chassin, MD, MPP, MPH
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From Mount Sinai School of Medicine and Cornell Medical Center, New York, New York.


Note: An earlier version of this work was presented at Interpreting the Volume–Outcome Relationship in the Context of Health Care Quality, an Institute of Medicine and National Cancer Policy Board, National Academy of Sciences workshop, on 11 May 2000 in Washington, D.C.

Grant Support: Dr. Halm was supported in part by a Robert Wood Johnson Generalist Physician Faculty Scholars award.

Requests for Single Reprints: Ethan A. Halm, MD, MPH, Mount Sinai School of Medicine, Department of Health Policy, Box 1077, One Gustave L. Levy Place, New York, NY 10029; e-mail, ethan.halm@mountsinai.org.

Current Author Addresses: Drs. Halm and Chassin: Mount Sinai School of Medicine, Department of Health Policy, Box 1077, One Gustave L. Levy Place, New York, NY 10029.

Dr. Lee: New York Weill Cornell Medical Center, Department of Surgery, 525 East 68th Street, New York, NY 10021.


Ann Intern Med. 2002;137(6):511-520. doi:10.7326/0003-4819-137-6-200209170-00012
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Purpose: To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them.

Data Sources: The authors searched MEDLINE from January 1980 to December 2000 for English-language, population-based studies examining the independent relationship between hospital or physician volume and clinical outcomes. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies.

Study Selection: Of 272 studies reviewed, 135 met inclusion criteria and covered 27 procedures and clinical conditions.

Data Extraction: Two investigators independently reviewed each article, using a standard form to abstract information on key study characteristics and results.

Data Synthesis: The methodologic rigor of the primary studies varied. Few studies used clinical data for risk adjustment or examined effects of hospital and physician volume simultaneously. Overall, 71% of all studies of hospital volume and 69% of studies of physician volume reported statistically significant associations between higher volume and better outcomes. The strongest associations were found for AIDS treatment and for surgery on pancreatic cancer, esophageal cancer, abdominal aortic aneurysms, and pediatric cardiac problems (a median of 3.3 to 13 excess deaths per 100 cases were attributed to low volume). Although statistically significant, the volume–outcome relationship for coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery, and orthopedic procedures was of much smaller magnitude. Hospital volume–outcome studies that performed risk adjustment by using clinical data were less likely to report significant associations than were studies that adjusted for risk by using administrative data.

Conclusions: High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of these findings is complicated by the methodologic shortcomings of many studies. Differences in case mix and processes of care between high- and low-volume providers may explain part of the observed relationship between volume and outcome.

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Summary for Patients

Does Quantity Mean Quality in Medical Procedures?

The summary below is from the full report titled “Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature.” It is in the 17 September 2002 issue of Annals of Internal Medicine (volume 137, pages 511-520). The authors are EA Halm, C Lee, and MR Chassin.

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