Surgical volume and outcome relationship in pediatric cardiac surgery

A significant inverse relationship between surgical institutional and surgeon volume and patient outcome has been demonstrated in many high-stakes surgical specialties. By in large, the same results were found in pediatric cardiac surgery, where a more thorough analysis has demonstrated that this relationship is mediated by case complexity and the type of surgical procedures. Lower-volume programs tend to underperform in comparison to larger programs as case complexity increases. High-volume pediatric cardiac surgeons have better results compared with low-volume surgeons, especially with complex procedures such as with the Norwood procedure. Nevertheless, this trend towards lower mortality at larger centers is not universal: All larger programs do not perform better than all smaller programs. Moreover, surgical volume seems to account for only a small proportion of the overall between-center variation in outcome. Thus the use of center-specific risk adjusted outcomes as a tool for quality assessment may be more reliable than relying upon surgical volume alone. Indeed, a patient’s risk factors and their level of disease severity may play a more important role in determining their individual outcome than the impact of the surgeon or program’s volume. Nevertheless, the relationship between surgical volume and outcome in pediatric cardiac surgery is strong enough that it ought to shape and influence public policy around the decision to centralise pediatric cardiac surgery and support strategies that support higher center and surgeon volumes and their impact on patients and providers.