World Journal of Surgery

, Volume 29, Issue 10, pp 1230–1233 | Cite as

How are Volume–Outcome Associations Related to Models of Health Care Funding and Delivery? A Comparison of the United States and Canada

  • David R. Urbach
  • Ruth Croxford
  • Nancy L. MacCallum
  • Thérèse A Stukel
Article

Abstract

How models of health care financing and delivery affect patterns of procedure volumes, outcomes, and volume–outcome associations is not known. We compared volume–outcome studies done in Canada, which provides residents with universal, single-payer health care, with those done in the United States, to determine whether there was a difference in the likelihood of finding statistically significant volume–outcome associations. We analyzed 142 articles, most (90.1%) of which were from the United States. The articles described a total of 291 separate analyses. After adjusting for the clustering of multiple analyses in the same study, the likelihood of finding a statistically significant volume–outcome association was substantially lower in Canadian studies as compared with those from the United States (odds ratio 0.24, 95% confidence interval 0.08 to 0.74, p = 0.01). This result persisted after adjustment for the procedure/condition studied, and the number of study subjects. Canadian volume–outcome analyses are less likely to identify statistically significant volume–outcome associations than US studies, possibly because of the smaller size of some Canadian studies. It is also possible that different models of health care financing and delivery affect patterns of procedure volumes and volume–outcome associations. By promoting competition between hospitals and providers, market-based models may exacerbate existing variations in the quality of hospital care.

References

  1. 1.
    Luft HS. The relationship between surgical volume and mortality: an exploration of causal factors and alternative models. Med. Care 1980;18:940–959PubMedGoogle Scholar
  2. 2.
    Birkmeyer JD, Siewers AE, Finlayson EVA, et al. Hospital volume and surgical mortality in the United States. N. Engl. J. Med. 2002;346:1128–1137CrossRefPubMedGoogle Scholar
  3. 3.
    Dudley RA, Johansen KL, Brand R, et al. Selective referral to high volume hospitals: estimating potentially avoidable deaths. J. A. M. A. 2000;283:1159–1166PubMedGoogle Scholar
  4. 4.
    Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann. Intern. Med. 2002;137:511–520PubMedGoogle Scholar
  5. 5.
    Epstein AM. Volume and outcome —it is time to move ahead. N. Engl. J. Med. 2002;346:1161–1164PubMedCrossRefGoogle Scholar
  6. 6.
    Birkmeyer JD. Should we regionalize major surgery? Potential benefits and policy considerations. J. Am. Coll. Surg. 2000;190:341–349CrossRefPubMedGoogle Scholar
  7. 7.
    Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N. Engl. J. Med. 2003;349:2117–2127CrossRefPubMedGoogle Scholar
  8. 8.
    Urbach DR, Baxter NN. Does it matter what a hospital is “high volume” for? Specificity of volume-outcome associations for surgical procedures: analysis of administrative data. B. M. J. 2004;328:737–737CrossRefGoogle Scholar
  9. 9.
    US Congress Office of Technology Assessment. Hospital Financing in Seven Countries. 1995;OTA-BP-H-148Google Scholar
  10. 10.
    Zeger SL, Liang K-Y, Albert PS. Models for longitudinal data: a generalized estimating equation approach. Biometrics, 1988;44:1049–1060Google Scholar
  11. 11.
    Grumbach K, Anderson GM, Luft HS, et al. Regionalization of cardiac surgery in the United States and Canada. Geographic access, choice and outcomes. J. A. M. A. 1995;274:1282–1288PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2005

Authors and Affiliations

  • David R. Urbach
    • 1
    • 2
  • Ruth Croxford
    • 1
  • Nancy L. MacCallum
    • 1
  • Thérèse A Stukel
    • 1
  1. 1.Institute for Clinical Evaluative SciencesToronto OntarioCanada
  2. 2.Toronto General HospitalTorontoCanada

Personalised recommendations