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Interpreting the Volume–Outcome Relationship in the Context of Cancer Care

Maria Hewitt and Diana Petitti, Editors

National Cancer Policy Board



Division on Earth and Life Studies


Washington, D.C.

The National Academies of Sciences, Engineering, and Medicine
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Page i Interpreting the Volume–Outcome Relationship in the Context of Cancer Care Maria Hewitt and Diana Petitti, Editors National Cancer Policy Board INSTITUTE OF MEDICINE and Division on Earth and Life Studies NATIONAL RESEARCH COUNCIL NATIONAL ACADEMY PRESS Washington, D.C.

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Page ii NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the National Cancer Institute; the Centers for Disease Control and Prevention; the American Cancer Society; American Society of Clinical Oncology; Abbott Laboratories; Amgen, Inc.; and Aventis. The views presented in this report are those of the National Cancer Policy Board of the Institute of Medicine and the National Research Council and are not necessarily those of the funding agencies. International Standard Book Number 0-309-07586-6 Additional copies of this report are available for sale from the National Academy Press , 2101 Constitution Avenue, N.W. , Box 285, Washington, D.C. 20055 . Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's home page at . The full text of this report is available at . For more information about the Institute of Medicine, visit the IOM home page at Copyright 2001 by the National Academy of Sciences . All rights reserved. Printed in the United States of America .

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Page iii THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

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Page v NATIONAL CANCER POLICY BOARD Arnold J. Levine (Chair), President, The Rockefeller University, New York Joseph Simone (Vice Chair), Medical Director, Huntsman Cancer Foundation and Institute, University of Utah, Salt Lake City Ellen Stovall (Vice Chair), Executive Director, National Coalition for Cancer Survivorship, Silver Spring, MD Diana Petitti (Vice Chair), Director, Research and Evaluation, Kaiser Permanente of Southern California, Pasadena Tim Byers, Professor of Epidemiology and Program Leader, Clinical Cancer Prevention and Control, University of Colorado Health Sciences Center, Denver Vivien W. Chen, Epidemiology Section Chief and Professor, Louisiana State University Medical Center, New Orleans Susan Curry, Professor of Health Policy and Administration and Director, Health Research and Policy Centers, University of Illinois at Chicago Norman Daniels, Professor of Philosophy, Tufts University, Boston (member through April 2001) Kathleen Foley, Director, Project on Death in America, The Open Society and Memorial Sloan-Kettering Cancer Center, New York (member through April 2001) Thomas Kelly, Professor and Chairman, Department of Molecular Biology and Genetics, The Johns Hopkins University School of Medicine, Baltimore (member through April 2001) Mark McClellan, Assistant Professor of Economics, Stanford University (member through March 2001) William McGuire, Chief Executive Officer, UnitedHealth Group, Minnetonka, MN John Mendelsohn, President, University of Texas M.D. Anderson Cancer Center, Houston Monica Morrow, Professor of Surgery and Director, Lynn Sage Comprehensive Breast Program, Northwestern University Medical School, Chicago

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Page vi Nancy Mueller, Professor of Epidemiology, Harvard University School of Public Health, Boston Pilar Ossorio, Assistant Professor of Law and Medical Ethics, and Associate Director for Programming, Center for the Study of Race and Ethnicity in Medicine, University of Wisconsin Law School, Madison Cecil B. Pickett, Executive Vice President for Discovery Research, Schering-Plough Research Institute, Kenilworth, NJ John Seffrin, Chief Executive Officer, American Cancer Society, Atlanta Sandra Millon Underwood, ACS Oncology Nursing Professor, University of Wisconsin School of Nursing, Milwaukee Frances Visco, President, National Breast Cancer Coalition, Washington, D.C. (member through April 2001) Susan Weiner, President, The Children's Cause, Silver Spring, MD Study Staff Maria Hewitt, Study Director Florence Poillon, Editor NCPB Staff Roger Herdman, Director, National Cancer Policy Board Nicci T. Dowd, Administrator Jennifer Cangco, Financial Associate

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Page vii REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: John Cameron, Department of Surgery, The Johns Hopkins University School of Medicine Jeffrey Crane, Rex Cancer Center Edward Hannan, Department of Health Policy, Management, and Behavior, State University of New York at Albany Arthur Levin, Center for Medical Consumers Arnold Milstein, William M. Mercer, Inc. Scott Parker, Retired, Intermountain Health Care, Inc. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Sheldon Greenfield, The Primary Care Outcomes Research Institute, New England Medical Center Hospitals, appointed by the Institute of Medicine and Joe Newhouse, Department of Health Policy and Management, Harvard University, appointed by the NRC's Report Review Committee, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring board and the institution.

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Page ix Contents INTERPRETING THE VOLUME–OUTCOME RELATIONSHIP IN THE CONTEXT OF CANCER CARE 1     Background, 1     The Volume–Outcome Relationship in the Context of Health Care Quality Measurement, 2     Evidence of a Volume–Outcome Relationship for Cancer Interventions, 3     Interpreting the Volume–Outcome Relationship, 5     Potential Impact of Policies to Concentrate Cancer Care in High-Volume Hospitals, 6     National Cancer Policy Board Recommendation, 8     References, 12 APPENDIX A     13     Volume and Outcome in Cancer Surgery, 13     Summary, 19     Criteria for Rating the Quality of Published Studies, 20     References, 31

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