Quality vs. Volume

For certain procedures or conditions, it appears that high-volume centers usually provide better quality than low-volume facilities.  This finding is behind the concept of Centers of Excellence for everything from cancer to weight reduction.  However, there is an interesting inconsistency when applying such concepts to Trauma Centers.

I was more than a little confused about 10 years ago when the American College of Surgeons amended the requirements for Level I Trauma Center designation to include a volume requirement.  That is, unless a trauma center admitted a specific minimum number of trauma patients, they would not be designated as a Level I Trauma Center.  Currently, the requirement stands at “a total of 240 admissions with an ISS [Injury Severity Score] >15 or an average of 35 patients with an ISS>15 for the ‘core’ trauma surgeons on the trauma call panel.”  Because a high volume of severely injured patients is generally more likely to insure that the resources are available in such a facility to deal effectively with those patients, this seems, on the surface, to be an entirely reasonable requirement.

There is serious inconsistency, however, in requiring a minimum patient volume for trauma centers.  And that is that another requirement for Level I Trauma Centers is that they must have an active trauma prevention program consisting of “prevention activities that center on priorities based on local data.”

Given these two requirements for Level I Trauma Center designation, it is apparent that such trauma centers must have a trauma prevention program in place — they just have to make sure that it is not very effective. 

Obviously, the problem is that volume is being used as a stand-in for quality.  This approach has been easier for health care in general because quality is very difficult to measure.  Given the various pre-existing conditions and uncontrolled degrees of disease and injury, it has been difficult to compare outcomes on a case-by-case basis.  However, through the use of statistical standardization tools present in the National Surgical Quality Improvement Program (NSQIP) and the Trauma Quality Improvement Program (TQIP) developed by the American College of Surgeons, it is likely to be increasingly possible to grade quality performers for designation purposes.  The paradigm shift in medicine will be to seek appropriate indicators other than volume to determine high-quality centers.  Such a move will promote a migration to effective health care through active prevention.