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    1. review evidence of the relationship between volume of services and health-related outcomes for cancer and other conditions;

    2. discuss methodological issues related to the interpretation of the association between volume and outcome;

    3. assess the applicability of volume as an indicator of quality of care; and

    4. identify research needed to better understand the volume—outcome relationship and its application to quality improvement.

The workshop was structured around presentations of two commissioned papers:

    1. “How Is Volume Related to Quality in Health Care? A Systematic Review of the Research Literature,” by Ethan A. Halm, Clara Lee, and Mark R. Chassin; and

    2. “When and How Should Purchasers Seek to Selectively Refer Patients to High-Quality Hospitals?” by R. Adams Dudley, Richard Y. Bae, Kirsten L. Johansen, and Arnold Milstein.

The workshop was jointly sponsored by IOM's Committee on Quality of Health Care in America and the National Cancer Policy Board, with financial support from the Agency for Healthcare Research and Quality (AHRQ). The board discussed volume-related policy issues at their October 2000 board meeting with three participants of the IOM workshop, Colin Begg, R. Adams Dudley, and Edward Hannan. This White Paper briefly summarizes the findings from the workshop and presents board recommendations for implementing volume-based policies relevant to cancer care.


The National Cancer Policy Board concluded in its 1999 report Ensuring Quality Cancer Care that, based on the best available evidence, some individuals with cancer do not receive care known to be effective for their conditions. The magnitude of the problem is not known, but the board believes it is substantial. Evidence points to underuse of some interventions known to be effective (e.g., radiation therapy, adjuvant chemotherapy after surgery), overuse of interventions for which evidence supports alternative interventions (e.g., mastectomy versus breast conserving surgery), and misuse of effective interventions (e.g., administering inappropriate doses of chemotherapy). Despite compelling evidence of quality problems, it is difficult for individual consumers, health care purchasers, and others to make informed choices about cancer care, in part because the data needed to provide quality information specific to a particular physician or hospital are generally not available (IOM, 2000b). To ascertain

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