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Doctors perform a surgery at Mount Saint Joseph Hospital in Vancouver on Sept. 22, 2010. (JOHN LEHMANN/John Lehmann/The Globe and Mail)
Doctors perform a surgery at Mount Saint Joseph Hospital in Vancouver on Sept. 22, 2010. (JOHN LEHMANN/John Lehmann/The Globe and Mail)

More (volume) is better in health care Add to ...

One of the most important medical findings of the past decade is the growing evidence that more is better for patients. Not more money or more administration, but more volume.

The higher the rate at which an individual doctor does a procedure, the better the health outcomes for the patients they see.

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This notion makes sense on an intuitive level: a doctor who does 30 cataract operations a day will be more deft, practiced and poised than a doctor who does one cataract operation a year.

Like any process, repetition gives opportunities to find efficiencies, improvements and ultimately approach perfection. But the evidence is more than just intuition and logic.

Study after study finds patients receive far better care when surgeons perform procedures in high-volumes.

A team at Yale University Hospital looked at U.S. national data from 1999 and 2005 for a number of surgeries, including colorectal procedures, esophagectomy, gastrectomy, pancreatectomy, thyroidectomy, coronary artery bypass graft surgery, and carotid endarterectomy. “Overall, unadjusted mortality and LOS [length of stay]were significantly lower for high-volume surgeons compared with low-volume surgeons in 1999 and 2005.”

In other words, when a surgeon is able to specialize significantly fewer patients died and their recovery was much faster.

Another study looked at cancer surgeries in low-volume hospitals and high-volume hospitals.

It found far lower mortality rates in hospitals where a large number of the same procedure was performed over and over. “The most striking results were for esophagectomy, for which the operative mortality rose to 17.3% in low-volume hospitals, compared with 3.4% in high-volume hospitals, and for pancreatectomy, for which the corresponding rates were 12.9% vs 5.8%.”

If you are getting surgery, you want the person who does the procedure constantly. You will live longer.

These findings are relatively new, and they turn aspects of the health system on their head. Hyper-specialization becomes much more critical, allowing surgeons to focus on perfecting the same treatment, rather than generally approaching a wide range of surgeries that result from one disease.

Small rural populations will find better service can come by relying on specialists. For instance, in the fall out to the crisis around breast cancer misdiagnosis, Newfoundland shipped its pathology data to Mt. Sinai Hospital in Toronto to ensure sufficient volumes to provide specialization and higher certainty.

The next step is virtualization.

The University Hospital Network in Toronto is working with the Timmins hospital and nine others surrounding it to examine the use of tele-pathology: digital slide scanners, workstations and workflow software that’s designed to improve the speed and quality of diagnosis, and to enhance patient safety. This replaces the cumbersome microscope and physical sample work with faster service that will make national specialization a reality that will improve results.

These kind of practices should be more common and will provide higher safety and improved quality of life to Canadians.

As we move toward the renegotiation of the federal-provincial-territorial health accord in 2014, the federal government should be working to enable provinces to share specializations and facilitate patient transfers more easily. Lives will literally be saved.

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