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Why volume matters

Blog  /  Why Volume Matters

Everyone knows the saying “practice makes perfect”. We all understand the link between achieving excellence, or even being good at a task and performing it regularly. In his book Outliers Martin Gladwell popularised the concept of the 10,000 rule in mastering playing the violin.

He asserted that the key to achieving true expertise in any skill is simply a matter of practicing for at least 10,000 hours. Although this rule has been to some extent subsequently de-bunked in so far as the quality of practice is as important as the absolute time spent, nonetheless it’s clear that mastering a practical skill without practice and performing it regularly is difficult.

In medicine, complex surgical procedures such as for oesophageal and pancreatic cancer were centralised to high volume centres in the UK 20 years ago as it was shown that when surgeons performed only small numbers outcomes were poor. This model is universally adopted in many countries. In the UK there are volume thresholds for instance for endoscopic procedures such as colonoscopy in both the NHS and private sectors and clinicians not meeting these are encouraged or asked not to perform them for the same reason; high volume, all things being equal is associated with better outcomes.

And yet, in the treatment of patients with reflux symptoms this has not happened.

In 2023 a survey throwing light on anti-reflux surgical practice in the UK was published. 155 surgeons responded to a series of questions Arrow Survey Summary and the results were amazing. The median (similar to average) number of cases performed each year privately was just 6. Yes, that’s one just every 2 months. The numbers were higher in the NHS but still only one per month. The majority were performing less than 20 operations per year and only a handful averaging one per week. Interestingly many surgeons performing anti-reflux surgery didn’t contribute their data to the survey but it’s a reasonable assumption their volumes may well be even smaller.

Furthermore, only 14% (yes that’s right one in seven!) reported that they collected post-operative quality of life data. So, they couldn’t know whether what they were doing was achieving what most anti-reflux surgery aims to do, that is improve quality of life.

Does this matter? Well 5 years ago a large study by Schlottmann and colleagues looked at this question in detail':' Antireflux Surgery in the USA':' Influence of Surgical Volume on Perioperative Outcomes and Costs-Time for Centralization?. The records of over 75,000 patients who had undergone anti-reflux surgery in the USA over nearly 15 years were analysed. Yearly surgical volume was categorized as low (less than 10 operations per year), intermediate (10–25 operations per year), or high (25 or more operations per year). When operations were performed at low-volume hospitals, postoperative bleeding, cardiac failure, renal failure, respiratory failure, and inpatient mortality were more common. In intermediate-volume hospitals, patients were more likely to have postoperative infection, oesophageal perforation, bleeding, cardiac failure, renal failure, and respiratory failure. The length of hospital stay was longer at low and intermediate volume hospitals (1.08 and 0.55 days longer, respectively). And the associated costs were higher in intermediate and low compared to high volume centres. Overall, the complication rate was nearly twice as high in low compared to high volume centres.

Interestingly a subsequent UK study Reintervention After Antireflux Surgery for Gastroesophageal Reflux Disease in England which reviewed over 22,000 patients again demonstrated the link between volumes and outcome. Specifically, patients were less likely to require a further operation following an anti-reflux operation when their initial procedure was undertaken at high volume centres (in this case defined as more than 15 operations per year, which you might argue is setting the bar low) compared with a low volume centre.

All this is common sense. Like any complex procedure, anti-reflux surgery requires skill and regular high volumes to achieve good outcomes. In our opinion it’s far from optimal that surgeons performing small volumes of operations per year offer these procedures. The bar defining adequate volume isn’t clear, but in our view using the threshold of 25 per year employed in the Schlottmann study seems reasonable.

As things stand while many surgeons agree with this principle, both the NHS and private medical insurers continue to commission and pay for anti-reflux surgery from low volume hospitals and surgeons. This has to change and hopefully will. But in the meantime, it’s up to patients to march with their feet. If you’re considering surgery we suggest that you ask your surgeon how many procedures they perform each year and if they record post-operative outcome data. If not and/or the volumes are low- think again.

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